PRESENTATION 1 includes dermatological procedures (acne surgery) Topics included - Comedone extraction Intralesional steroid injection Incision and drainage Cryo surgery Dermabrasion Microdermabrasion Phototherapy Photodynamic therapy

1. ACNE SURGERY
Dr. Smruti Ramawanshi

2. Contents
• Introduction
• Indications
• Types of acne surgery
• Comedone extraction
• Intralesional steroid injection
• Incision and drainage
• Cryo surgery
• Dermabrasion
• Microdermabrasion
• Phototherapy
• Photodynamic therapy

3. Introduction
Reasons for doing acne surgery-
1) Dissatisfying outcome of medical
management.
2) Susceptibility to develop postinflammatory
hyperpigmentation and scarring.
3) Failure of drugs to prevent sequelae.
4)Revolutionary progress in surgical techniques.

4. Indications:
• Comedonal acne-
a)Open comedones
b)closed comedones
• Papules
• Inflammory acne[pustules, cysts and nodules]
• Acne scars
• Post acne hyperpigmentation

5. Types:
• Comedone extraction
• Electrosurgery
• Incision and drainage
• Evacuation surgery
• Cryosurgery
• Chemical peel
• Subcision
• Scalpel excision techniques
• Soft tissues augmentation

6. • Intralesional Steroid Injection
• Phototherapy: A) Intense Pulsed Light
B) Lasers
• Photodynamic Therapy
• Dermabrasion
• Microdermabrasion

7. Surgical Guidelines For Active Acne
GRADE I GRADEII GRADE III GRADE IV
Comedone
extraction
Comedone
extraction
Same as grade II Same as grade III
Evacuation surgery Evacuation surgery Superficial
chemical peeling
ILS,LN2
Light
electrodessication
closed
comedones,papule
Incision and
drainagepapules,
pustules
LN2
dipstick/cryospray/c
ryoroller
Microdermabrasion cryoslush LN2 cryopeel
Light
electrodessication
microdermabrasion Therapeutic
dermabrasion

8. COMEDONE EXTRACTION

9. Procedure
• Extraction of a comedone open or closed, from the
pilosebaceous unit by using comedone extractor.
Open comedones -Firm pressure perpendicular to the direction
of the comedone is exerted against the facial bones creating
circumferential pressure in the follicle extruding follicular
content through hole in the convex cup of the extractor.
Closed comedones -top of lesion is nicked with a 26 G needle
or tip of no. 11 scalpel blade. The extractor is then maneuvered
as for open comedones.

10. Disadvantages
• Recurrence is common
Open comedones- 24-40 days
Closed comedones- 30-50 days
• Overzealous use results in increased inflammatory
response

11. ILS INJECTION

12. Indications:
- nodulocystic acne
- hypertrophic / keloidal acne scars.
Agent:
Most commonly triamcinolone acetonide
Initially in a concentration of 10mg/ml
The injection is repeated every 3 weeks depending upon the
clinical response.
• Keloidal scars: A concentration of 40mg/ml may have to be used.
• Nodulocystic acne: 2.5mg/ml is admininstered with 26 G needle

13. Procedure:
• 1-2ml suspension of inj triamcinolone acetonide is
prepared[2.5mg-5mg/ml] by diluting with distilled water for
injection.
• Skin surface overlying the cyst, surgically prepared with
cetavlon, spirit and povidone iodine
• Skin overlying cyst is stabilised with left hand.
• 26G needle attached to syringe, skin overlying the cyst is
pierced at the most non dependant point.

14. • Needle is advanced till it meets resistance which on further
pressure suddenly yields a feeling of give way, indicating one
has entered the cyst cavity.
• Quantity :0.025-0.1 ml should be injected into cyst.
• Needle is slowly withdrawn.
• Equal or lesser quantity can be injected in tissue surrounding the
cyst(4 quadrants),below the cyst for faster resolution.

15. • Tense cyst: prior aspiration of cyst contents till it collapses
partially or fully with 21G needle.
• Pressure at entry point for haemostasis and closure.
• Multiple lesions can be injected at same time.
• Injection repeated every 15-20 days interval till cyst resolves.
Complications :
• Haematoma
• Secondary infection
• Atrophy- Placement too superficial or too deep may cause

16. Pinching and incising:

17. INCISION AND DRAINAGE
• Pustules, nodules and abscesses: may be surgically incised and
drained.
• Skin overlying the follicular opening is incised with either a fine
needle tip or tip of no.11 scalpel blade
• Each lesion is drained by pinching or squeezing it. No dressing
is needed.
• Apply antibiotic cream.
• Judicious incision and drainage initiate healing, shorten the
duration of lesions.

18. EVACUATION SURGERY

19. • Useful in all stages and morphological types of acne, viz.
papules, cysts, nodules and comedones to minimise scar
formation.
• Negative pressure is applied onto the skin overlying the lesions
with the help of medium to large conical glass cups fitted at end
of suction tube.
• Large cup: for applying suction to multiple contiguous lesions
simultaneously.
• Closed comedones: surface is punctured before suction is
applied.

20. • End point- has to be judged clinically by elevation of the lesions
within the suction cup.
• Procedure: started on the forehead & continued linearly in a
sequential manner over rt cheek, chin,lft cheek etc
• At end: contents are brought out near follicular opening, followed
by incision and drainage of the contents.
• Pressure is given for adequate hemostasis ,to prevent refilling of
larger cysts and nodules.

21. • Cleansing: facial skin surface is wiped with dry gauze.
• pt is asked to wash face with soap and water.
• Ice compress: given to reduce oedema, and for early
resolution of inflammation.

22. CRYOSURGERY
Indications:
• Nodular and cystic lesions
• Hypertrophic scar
• Keloidal scars
• Extensive scarring
Three techniques are in general use-
• Cryoslush
• Cryopeel
• Cryoprobe

23. CRYOSLUSH
Cryogen: solid CO2 (dry ice)
(-78.5 C)
• Method : CO2 snow as refrigerant along with acetone, with or
without precipitated sulphur or alcohol to cause superficial
peeling with:
--desquamation of comedones,
--resolution of papules, pustules and nodulocystic acne with
avoidance or improvement in superficial acne scars

24. • LN2 ROLLER: LN2 lowers the surface temp to -196 degree C.
 Mechanism:
• I]superficial depth peeling-
1. Desquamation
2. Reduces inflammation
3.Faster resolution and minimises scars
• II] Remodels dermal collagen: improves existing scars.
 Indications
• Nodulocystic acne (grade III/IV)
• Acne scars(atrophic, superficial boxcars rolling,hypertrophic)

25. CRYOPROBE
• Indications - nodulocystic acne.
• CRYOPROBES using nitrous oxide,LN2 or CO2 used to
freeze the nodulocystic acne for 3-5secs individually without
treating the whole face.
• Larger lesions: process can be repeated at 2 or more sites.
• Schedule: repeated every 2 wks till resolution occurs.

26. CRYOPEEL
CRYOGEN - LN2 (-196 degree C)
Indication
• Severe nodulocystic acne
• Chronic/resistant acne
• Acne keloidalis nuchae
• Post acne scars.

27. • Depending on the time of contact
1.Superficial peel- 2-3secs
2.Medium depth- 5-7secs
• LN2 hand held spraying unit or
• Table top unit with special acne spray tip attachement

28. DERMABRASION
• DEFINITION
• Consist of sequential planing of the raised or otherwise
normal skin, from epidermis, through the papillary dermis, to
the desired level [max junction of upper and mid reticular
dermis] with either manual or electrical abraders, allowing
this wound to heal by secondary intention, to achieve
levelling effect, making cutaneous scars less conspicuous.
• Procedure carried out under GA,LA or RA.

29. • Preferably done – when acne is in good control
• Superficial depressed scars.
• Deep acne scars- improves more by wire brush dermabrasion as
microlacerations of wire brush can resurface deeply

30. Contraindications
• Keloidal tendency,
• Atrophic hairless scars of burns and trauma
• Bleeding disorder
• Active infections
• History of taking isotretinoin[12-18months]
Patient Selection
• Fairer the patient, better is the result
• Patient with realistic expectations

31. • EQUIPMENT:
• 1) MECHANICAL-
a) sand papers (water paper no 80,110)
b) hand held metallic dermabraders
MANEKSHA’S MANUAL DERMABRADERS

32. • ELECTRICAL:
a) wire brushes and diamond fraises (various sizes and
shapes)

34. • Cable unit or hand held machine(15000 rpm)

35. • CBC, BT, CT, PT, platelet count, blood sugar level
• X ray chest pa view
• Fitness for GA
• Screening for hepatitis B,VDRL,HIV
• Informed consent and photos
• Test spot dermabrasion at postauricular site
• Close shave or removal excess hair just before operation.
• Injection vitamin K[1ml/10mg] 1 day before surgery.
PREOPERATIVE WORKUP

36. • Removal of skin pigment[epidermis]
• Multiple tiny punctate bleeding points [Superficial papillary
dermis]
• Larger, rapidly bleeding points ( junctn of mid to deep papillary
dermis)
Assessing depth of dermabrasion

37. • Faintly visible pinkish or whitish to greyish parallel lines and
ridges[junction of deep papillary to upper reticular dermis]
• Excessive bleeding with fraying or appearance of breaks in
parallel lines and ridges with a feeling of resistance-optimal level
and adequate depth of dermabrasion [ junction of upper and mid
reticular dermis)
• Herniation of tiny yellow bits of fat( lower reticular dermis
ruptured at places)- not a good sign , stop dermabrading at this
level.

38. Procedure:
• Protective gear:cap, mask, gown, gloves and face shield.
• Marking of submandibular margin: Just beneath and parallel
to the inferior border of the mandibular ramus from infra
auricular area to centre of chin on both sides.
• GA with endotracheal tube
• Surgical preparation with marking of individual scars with
marker pen.

39. Technique:
• Face turned to one side, skin is stretched to provide a flat and
taut surface for planing.
• Using wire brush or diamond fraise endpiece , hold the hand
piece in safety razor grip.
• Direction of pull should be towards handle of hand piece i.e.
perpendicular to the axis of direction of rotating end piece.

41. • First establish the submandibular border, by smooth strokes
along the marked line from either ear to the chin.
• Individual pitted scars are moderately stretched. Using pear
shaped diamond fraise end piece, gently rotate the hand piece
clockwise in small circles to lightly abrade the base of the scar
and firmly abrade its edges.
• Smoothen out all the marked scars individually in a similar
fashion.

42. Electrical dermabrasion

43. • Electrical segmental cosmetic facial unit wise
dermabrasion:

44. Postoperative management:
• Iv fluids-1-2 bottles 5% dextrose, started intraoperatively
1st-1-2 hours,2nd over 12hrs post operatively.
• patient is admitted for 4-7 days and discharged when
oozing stops
Dressings
• Face is covered with double layer of framycetin tulle and
left with no further dressing.
• Serum is allowed to ooze.

45. Post operative dressing

46. Medications:
• Antibiotics,analgesics,short course of tapering steroids.1v -1st day.
Oral-from 2nd day.
• Inj.Vit k (1ml)continued from a day before surgery, followed by on the
day and the next day after dermabrasion (total of 3 consecutive days).
• Crusted serous discharge and gauze fall by 10-15 days.
• Emollients and sunscreens- for next 3 months
• Patient remains indoor for 1 month and avoids direct sun exposure-
next 2-3 months

47. Sequelae
pain,oedema,exudation,discomfort,erythema,milia,dyschromia.
Side Effects
hyperpigmentation, persistent erythema, permanent
hypopigmentation, exacerbation of acne.
Complications
bleeding,telangiectasias,infection,scarring,keloid,allergic contact
dermatitis, complications of LA/GA

48. MICRODERMABRASION UNIT

49. MICRODERMABRASION
• Is a resurfacing technique consisting of mechanical abrasion of
skin with pressurised stream of Al2O3 crystals so as to achieve
superficial wounding.
• PARTICLE BEAM RESURFACING: tool,useful in management
of epidermal abnormalities.[clogged pores,comedonal acne,mild
acne scarring]
• Mechanism: double system of aspiration-compression within
flexible tube,connecting machine and the hand piece.
• Aluminium oxide crystals fired from the system against the skin
through nozzel with programmed pressure,resulting in multiple
foci of microtrauma in epidermis.

50. • Used microcrystals, reabsorbed through aspiration
system to a waste container.
• Depth of injury: extends through epidermis.
• Healing: 3-5days
• Schedule: repeat sittings 1-2 wks interval for 6 sittings.
• Advantages: anaesthesia not needed.
• Complication:transient erythema,mild post inflammatory
hyperpigmentation.

51. LIGHT BASED THERAPY
• Feature of P. acnes is the endogenous production and
accumulation of porphyrins, with coproporphyrin III thought
to be the major subtype.
• These endogenous porphyrins absorb visible light
induces the formation of singlet oxygen species and
other reactive free radicals
bacterial destruction

52. BLUE LIGHT
• P. acnes colonies are reliably destroyed when exposed to
blue light in vitro due to the strong absorption and
photoactivation of endogenous porphyrins at this wavelength
(420-nm).
• However, blue light only superficially penetrates human skin
due to a high degree of light scattering, which may limit its
therapeutic effect.
• Despite this disadvantage, blue light has been demonstrated
to be effective in improving acne.

53. • Tzung et al. investigated a 420-nm light in a randomized
split-face trial.
• The blue light was administered twice weekly at a dose of
40 J/cm2 for 4 weeks.
• Significant improvement in acne noted.

54. RED LIGHT
• Though red light is less effective in activating porphyrins than blue
light, red light is able to penetrate skin to greater depths and activate
porphyrins in the sebaceous follicle.
• Red light may also induce anti-inflammatory effects via influencing
cytokine release from tissue macrophages .
• Zane et al reported the effectiveness of a 600- to 750-nm red light
administered twice weekly at a fixed dose of 20 J/cm2 in 15 patients
with moderate facial acne.
• At the end of the 4-week treatment period there was a significant
reduction in the acne which was sustained at a 3-month follow-up visit.
• The treatments were well tolerated with no significant adverse events.

55. Intense Pulsed Light
• Pulsed light sources are capable of delivering significantly more
photons at peak power than a continuous wave source, which may
enhance any therapeutic effect.
• Chang et al. investigated an intense pulsed light (IPL) source with a
530- to 750-nm filter in 30 Korean women with mild–moderate acne.
• All patients treated three IPL treatments, 3 weeks apart using fluences
of 8.0 J/cm2 for skin type III and 7.5 J/cm2 for skin type IV and a pulse
duration of 2.5 ms and a double light pulse with a 10-ms interval.
• Three weeks after the final IPL treatment, all patients had experienced
an improvement in acne lesions.

56. 532-nm KTP Laser
• The 532-nm potassium titanyl phosphate (KTP) laser targets the
chromophores oxyhemoglobin and melanin.
• Its mechanism of action in acne is presumably via activation of
porphyrins.
• However, the KTP laser may also cause mild collateral thermal
injury of sebaceous glands and
• may modify the sebaceous gland vasculature.
• fluences of 7–9 J/cm2, a spot size of 4 mm, and a pulse duration
of 20 ms.

57. Pulsed Dye Laser
• The pulsed dye laser (PDL) is also presumed to work through
endogenous porphyrin photoactivation.
• Also altering sebaceous gland microvasculature, that cause mild
collateral thermal injury to sebaceous glands, and possibly anti-
inflammatory actions.
• PDL has been investigated in acne using low-fluence.
• 585-nm PDL with a spot diameter of 5 mm and a pulse duration
350 μs, and were randomly allocated to receive 1.5 J/cm2.
• Twelve weeks after a single treatment there was a significant
improvement

58. 1,450-nm Diode Laser & 1,320-nm Nd:YAG Laser
• Damage to the duct epithelium and sebocytes of sebaceous
glands and seems to have efficacy in treating acne.
• Diode laser- fluence of 14 J/ cm2 (6-mm spot size and
dynamic cooling at 40 ms) or
• 16 J/cm2 (6-mm spot size and dynamic cooling at 45 ms)

59. 1,540-nm Erbium:Glass Laser
• Infrared laser that produces a wavelength that is
rather deeply penetrating; hence, it is able to target
sebaceous glands and the surrounding dermis.
• A potential advantage is that it seems to cause
comparatively little discomfort in contrast to the
other infrared lasers
• Active lesions should b treated with four treatments at 2-week intervals
using a 4-mm spot size, 3.3-ms pulse duration, 10 J/ cm2 , 4 passes.
• and the remaining face was treated with a single pass at 10 J/cm2.

60. PHOTODYNAMIC THERAPY
• It involves activation of a photosensitizing agent by light to
produce O2 intermediates that destroy target tissue.
• PDT is more effective than lights alone - as use of exogenous
photosensitisers maximizes singlet oxygen production and results in
more effective P. acnes photodestruction compared with treatments
that solely rely on light absorption by endogenous porphyrins.
• The rationale is based on the knowledge that aminolevulinic acid
(ALA) is preferentially taken up by the pilosebaceous units and
metabolized in the heme synthesis pathway to produce
protoporphyrin IX (PpIX), a potent photosensitizer.
• Once activated by light, PpIX produces singlet oxygen and free
radicals that cause damage to the mitochondria and cell membranes.
• ALA-PDT offers a unique way of improving acne by selectively
damaging the pilosebaceous units and killing P. acnes.

61. • ALA-PDT can be done with many light sources.
• ALA is applied on the areas to be treated as a 20% cream. The light
sources can be: red-light from a diode laser (635 nm), pulse excimer
dye laser (634 nm), or a broadband halogen source (600-700 nm).
• Noncoherent light sources have a number of advantages over
coherent light, including larger illumination fields, lower cost, and
possible photoactivation of photoproducts, which may result in
additional PDT effects
• Blue light PDT does not seem to be significantly better than blue light
alone, which is probably due to the shallow depth of penetration of
light at these wavelengths

62. Photosensitizer
• ALA and m-ALA are commercially available at concentrations of
20% and 16%, respectively.
• Both agents are generally used with 3–4 h of contact time before
light exposure previously; however,now there has been great
interest in shorter contact times of 15–90 min.
• which may result in milder adverse events.
• ALA and m-ALA, have absorbance and photoactivation at
wavelengths in the 650- to 850-nm range.
• This allows longer wavelengths with deeper penetration

63. • ADVERSE EFFECTS
• fairly common with PDT
• include - erythema, edema, blistering, crusting, acneiform
eruptions, and post-inflammatory hyperpigmentation.
• Treatment-related pain is also very common and can limit
the utility of PDT.

64. THANK YOU