Fig. 8.4 Rolling scars amenable to subcision can occur periorally, on the upper and lower cheeks, and at the temples. Subcision can also be highly effective for nasal scars (not shown).
Apart from ablative, partially ablative, and nonablative external smoothening techniques, cutting surgery can be used to treat acne scars. One minimally invasive surgical technique for rolling scars is subcision, which is preceded by instillation at the site of scarring of anesthesia – local for small areas and tumescent for larger areas. Developed by Norman and David Orentreich, subcision (Figs. 8.4 and 8.5) requires insertion of an 18–26-gauge Nokor or similar needle, or even a blunt canula, into the superficial subcutis. Depth of insertion is contingent on the degree of scar indentation, with intradermal positioning more appropriate for shallow scars and deep dermal placement for deeper scars. The needle is then rotated so that the spearlike tip is parallel to the skin, and the needle is used to tent the skin. Back-and-forth rasping movement of the needle along the underside of the dermis releases fibrous attachments holding down scars and stimulates the growth of reactive fibrosis that gradually fills the deadspace underlying newly loosened scars. In a manner similar to liposuction, fanning movement of the needle and triangulation of each scar from different entry sites helps elevate scars. Especially if widespread treatment is being performed, intraoperative bruising and bleeding is minimized by using tumescent needle insertion. Postoperative ecchymoses and edema can last 1–3 weeks.To avoid a flare of cystic acne after treatment, susceptible patients with some active acne may be treated with oral tetracyclines for several weeks before and after subcision.
Fig. 8.5 (a) In subcision, the rasping needle is used to release the fibrous bands connecting rolling scars to the deep skin structures. (b) Simultaneous tenting of the skin with the needle minimizes the risk of injury to neurovascular structures.
Individual deep boxcar or ice-pick scars can be resistant to nonsurgical treatment. At times, the best approach can be to cut these out.A time-honored technique uses a biopsy punch to treat such scars. If the targeted scar fits precisely within the punch, circumferential cutting with the punch can cause elevation of the scar as lateral and deep fibrous bands are severed and the plug containing the scar spontaneously elevates. This is referred to as punch elevation. Alternatively, if the scar is very deep and well embedded, the central plug may be removed, as in the case of a punch biopsy. Then the created defect may either be sewn end-to-end, to create a slit-like scar (i.e., punch excision), or filled with a similar shaped plug harvested from an uninvolved scar (i.e., punch grafting). At times, a series of deep scars may be present in a linear or curvilinear array. Such scars may be revised by removal of a strip of epidermis and dermis using the techniques of elliptical excision and bilayered closure with eversion. If a patient requires punch or linear excision as well as resurfacing for treatment of acne scars, it is preferable to perform the excisions first, as the re-epithelialization following the ablative procedure will conceal the excision lines.
Perifollicular hypopigmentation of acne scars, especially those of the trunk, remains highly resistant to treatment. If papular and facial, hypopigmented scars may be treated with fine-needle diathermy, and grafting procedures useful in vitiligo may also be considered. Minigrafting is limited in efficacy, since the spread in pigment from the graft sites to the surrounding scars appears to be restricted, but epidermal suspensions of cultured and noncultured cells are promising new therapies. Newly available automated commercial kits for trypsin epidermal separation (Re-Cell) may simplify the grafting process.
Continue Reading
For treatment of acne scars, resurfacing provides maximal improvement and nonablative therapy offers the promise of convenience and safety. To wed these two desirable outcomes in a single therapy, so-called ‘partially ablative’ treatments have been devised. These methods are used to resurface only a portion of the skin area treated, thus allowing maintenance of skin [...]
Continue Reading
Nonablative therapy can also be performed with RF devices, including those using monopolar and bipolar technologies. RF energy, in cadaver skin, can shrink the fibrous septae,20 and may also have collagen-remodeling effects. While it is typically used for tightening sagging facial or body skin rather than for rectification of acne scars, RF treatment, like treatment [...]
Continue Reading
During the past 5 years or so, nonablative therapy has largely replaced ablative therapy for the treatment of acne scars. In nonablative therapy, directed energy, usually thermal, is used to induce tissue modification and collagen remodeling in the dermis. The benefits compared with ablative therapy are that skin deepithelialization does not occur, and nonablative therapy [...]
Continue Reading
A more recent variant of resurfacing is plasma resurfacing. This uses the ‘fourth state of matter’ to precisely injure epidermis and underlying dermis without inducing immediate sloughing of the epidermis. As such, plasma resurfacing has similarities to single-pass CO2 laser resurfacing. A plasma cloud of electrons removed by radiofrequency sparking of nitrogen gas is absorbed [...]