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DERMATOSURGICAL PROCEDURES FOR ACNE SCARS
DR SWATHY LEKSHMI J L
PATHOGENESIS
Inflammation
Granulation tissue formation
Matrix remodelling
• Proliferation of P.acne
• Stimulation of innate immune response
• Activation of complement
• Inflammation
• Inflammation extends to dermis
• Degradation of dermal matrix
GRANULATION TISSUE
Shift in the balance of collagen type
Type 1 collagen- 80%
MATRIX REMODELLING
 Activation of Nf-kb & Aps
 Up regulation of MMPs
 Procollagen synthesis
CLASSIFICATION OF ACNE SCARS
 MACULAR
Erythematous
Hyperpigmented
 Depressed
Ice pick- Depressed scars
wider at surface
narrower at base
 Rolling- Distensible,
depressed scars with
sloping edges
 Boxcar – Shallow or
deep, punched out
scars, wide at
surface and base
 ELEVATED
Hypertrophic-Elevated fibrotic scars
Mandibular area, back
 Keloidal-Back and
chest
 Papular-Raised,
papular and fibrotic
Chin and nose
 Bridging scars and sinus tracts-
Multiple linear scars , joined by
epithelial tracts
Surgical procedures
PREOPERATIVE ASSESSMENT
 HISTORY
 HSV infection
 Recent use of Isotretinoin
 Keloidal tendency
 Current medication
 Previous surgery
 Degree of sunexpusre
 Immunocompromising condition
EXAMINATION
 General
 Skin type
 Keloid or Hypertrophic scar
 Presence of infection
 Activity of acne
 Antiviral therapy 2 days prior and for 7-10 days after
procedure
 Sun screen, HQ, Glycolic acid
 Consent form
 Photograph- mandatory for resurfacing with laser,
dermabrasion, chemical peels
 Microneedling
 Subcision
 Punch technique
 TCA CROSS
 Dermal grafting
Indication
 Rolling and Boxcar scars
MICRONEEDLING
CONTRAINDICATION
 Active herpes labialis
 Keloidal tendency
 Isotretinoin therapy in the preceeding 6 months
 Bleeding disorders
DERMAROLLER
 Drum shaped roller
 192 microneedles of 0.1 mm dia.
 Needle length 0.5 – 2 mm
 Motorised Dermastamps &
Home care dermastamps
PROCEDURE
 Topical anaesthesia
 Stretch the skin perpendicular to direction of
movement of derma roller
 Roll the tool 4 times in 4 different directions
 250-300 Pricks/cm sq.
 Needle penetrates at an angle, then goes deeper, and
extracted at a converse angle
 End point- uniform bleeding points over scarred area
POST PROCEDURE
 Clean with NS
 Oral analgesic
 No need of phtoprotection
 3-4 sessions at 4-8 wks intervals
SUBCISION
HISTORY
1957- Spangler
1995- David Orentreinch and Norman Orentreinch
Subcutaneous incisionless surgery
PRINCIPLE
 Releasing fibrotic strands underlying scars
 Organization of blood in the induced dermal
pockets
 Connective tissue formation in the area
INDICATION
 Rolling scars
PROCEDURE
 Mark the scar
 Local infiltration anaesthesia
 18 G,1.5 inch Nokor Admix
needle
 Insert the needle at periphery of scarred area
 Move back and forth, fanlike motion
 Firm pressure for 5 mts.
 Avoid preauricular, temporal and mandibular
areas
 Repeat at 6 wkly intervals
 2-3 sessions
 COMPLICATIONS
 Bleeding
 Hematoma
 Hypertrophic scarring
 Scar recurrence
PUNCH EXCISION AND CLOSURE
 Ind- Ice pick and Boxcar scars
PROCEDURE
 Local anaesthesia
 Select appropriate size punch
 Traction at right angles to RSTL
 Descend upto s/c fat and excise scar plug
 Undermine the wound edges
 Suture
PUNCH INCISION AND ELEVATION [Punch floatation]
Depressed scars with normal surface texture
Boxcar scar>3mm
PROCEDURE
 Punch that match to inner dia. of crateriform scar
 Rotating motion release bound down scar
 Elevate the plug and free from underlying tissue
 Elevate the plug and position to lie slightly higher than
surrounding skin
 Secure in position by cyanoacrylate tissue adhesive
PUNCH REPLACEMENT AND GRAFTING
 INDICATION
 Deep irregular pits
 Tethered boxcar scars with altered skin
texture
PROCEDURE
 Scar plug is removed and graft is transferred to
the plug site
 Donor site- post auricular area and inner arm
 Donor punch graft size> 0.5mm larger
CROSS
 Technique using high strength TCA focally on atrophic
acne scars to induce collagenisation and cosmetic
improvement
 PRINCIPLE
 Precipitation of proteins
 Coagulative necrosis of epidermal cells and collagen
 Dermal remodelling
INDICATION
 Ice pick scars
PROCEDURE
 Mark the scar
 Clean with spirit and degrease with acetone
 Patient in sitting position
 Stretch the skin and apply 100% TCA focally
 Avoid spillage
 Keep the skin stretched until frosted
 Wash the face
 Photo protection
 3 sessions , 4 wkly intervals
COMPLICATIONS
 Transient post inflammatory hyper& hypo pigmentation
 Priming skin with HQ and tretinoin for 2 wks
DERMAL GRAFTING
 Placing dermal grafts into precise pockets under skin
ADVANTAGES
 Not susceptible to infection
 Can be tailored accurately
 Creates a permanent space
 Readily available
 Easy to perform
PROCEDURE
 Conventional
 Enzymatic
CONVENTIONAL
 Local anaesthesia
 Subcsion 10- 14 days before
 Donor tissue from post auricular area or from
dermabraded site
 Defective area is tunnelled
 Trim the grafts according to shape
 Insert the graft and suture slit
ENZYMATIC TECHNIQUE
 Graft in 0.25% trypsin in EDTA solution
 Incubate at 37⁰ C for 75 mts.
 Transfer to phosphate buffered saline and
remove epidermis
 Insert the graft by conventional technique
or inject using a wide bore needle
RESURFACING TECHNIQUES
CHEMICAL PEELING
 Salicylic acid 20-30%- active acne and
superficial scars
 TCA 10%, 15%, 25%
 Glycolic acid 25-35%
 Jessener’s peel
 Medium depth & deep phenol peels –
effective but not recommended
 ABLATIVE
 DERMABRASION
 Ind- superficial acne scars
 Spot dermabrasion can be done in office setting
 Full face dermabrasion needs an operation theatre facility
 Topical or infiltrative anaesthesia
 Mark scars and stretch the skin
 Dermabrade till the base of scars
 Maximum level- Jn of upper and mid reticular dermis
 Manual dermabrader to feather the edges
 Hemostasis
 Non adherent dressing for 1 wk
COMPLICATIONS
 Infections
 Persistent dyschromia
 Hypo/ hyper pigmentation
 Erythema & scarring
LASER ABLATION
 CO2 laser (10,600nm)
 Er: YAG laser (2940nm)
RESUEFACING – NON ABLATIVE OR MINIMALLY
ABLATIVE
MICRODERMABRASION
Superficial minimally invasive technique of mechanical
abrasion of skin using a pressurised stream of abrasive
particles
 Aluminium oxide crystals
 Disposble diamond tip
 Ind- Superficial scars
 CI- Active infection
Concurrent dermatoses on face
 Eye protection
 Set machine parameters with pr. level 10-30 mm of Hg
 Stretch the skin under tension
 Move the hand piece in a sweeping, outward motion
 2nd pass in a direction perpendicular to first pass
except in neck
 End point- erythema
 Topical antibiotic
 Repeated weekly
COMPLICATION
 Erythema, oedema, infection, purpura,
pigmentary changes and scarring
 Conjunctival congestion
 Crystal adherence to cornea
 SPK
DISADVANTAGES
 Does not improve deep scars
 Multiple sittings
 Maintenance therapy
NON ABLATIVE RESURFACING LASERS
 Ind- atrophic acne scars
 Nd :YAG LASER(1320 nm, 1064 nm)
 Diode laser(1450 nm)
 Flash lamp pumped pulsed dye laser(585 nm)
 Er: glass laser
SOFT TISSUE AUGMENTATION
 Ind- soft atrophic scars with loss of dermal tissue
 Dermal filers are placed under scars
 Elevate and bring the surface of scar in level with
surrounding skin
 Subcsion or microneedling can be done prior
 Hyalouronic acid fillers
 Autologous fat
 PLLA
 Calcim hydroxyapatite
INTRALESIONAL STEROIDS AND CYTOTOXICS
Ind- Hypertrophic and keloidal scars
Triamcinolone 10-20 mg/ml + 5FU
SILICONE GEL SHEETING
 Useful in flattening keloid and hypertrophic scars
 SCAR REVISION
 Ind- Linear and extensive scarring
 Z, M and Y Plasty
CRYOTHERAPY
 Cryoslush
 Cryopeel method
FRACTIONAL PHOTOTHERMOLYSIS
 Non injured part of skin is the source of
keratinocytes
 Migration begins within 24 hrs
 Keratinocytes facilitate removal of MENDs
NON ABLATIVE
 1550nm erbium doped fibre laser
ABLATIVE
 Fractional CO2laser
 Direct vaporizing effect on epidermis and some part
of dermis
 Free of any active acne lesions
 No history of keloidal tendency
PROCEDURE
 Clean the skin with 70% alcohol
 LA cream for 1 hr
 No. of passes and fluence depending on skin
type & severity of scarring
 Cool the skin with ice packs after procedure
 Non comedogenic Abs for 3-5 days +sunscreen
COMPLICATIONS
 Erythema and crusting
 PIH
 Dryness of skin
 Pruritus
 Bronzing of skin
 Aggravation of acne
THANK YOU

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acne.pdf

  • 1. DERMATOSURGICAL PROCEDURES FOR ACNE SCARS DR SWATHY LEKSHMI J L
  • 3. • Proliferation of P.acne • Stimulation of innate immune response • Activation of complement • Inflammation • Inflammation extends to dermis • Degradation of dermal matrix
  • 4. GRANULATION TISSUE Shift in the balance of collagen type Type 1 collagen- 80%
  • 5. MATRIX REMODELLING  Activation of Nf-kb & Aps  Up regulation of MMPs  Procollagen synthesis
  • 6. CLASSIFICATION OF ACNE SCARS  MACULAR Erythematous Hyperpigmented  Depressed Ice pick- Depressed scars wider at surface narrower at base
  • 7.  Rolling- Distensible, depressed scars with sloping edges  Boxcar – Shallow or deep, punched out scars, wide at surface and base
  • 8.
  • 9.  ELEVATED Hypertrophic-Elevated fibrotic scars Mandibular area, back
  • 10.  Keloidal-Back and chest  Papular-Raised, papular and fibrotic Chin and nose
  • 11.  Bridging scars and sinus tracts- Multiple linear scars , joined by epithelial tracts
  • 13. PREOPERATIVE ASSESSMENT  HISTORY  HSV infection  Recent use of Isotretinoin  Keloidal tendency  Current medication  Previous surgery  Degree of sunexpusre  Immunocompromising condition
  • 14. EXAMINATION  General  Skin type  Keloid or Hypertrophic scar  Presence of infection  Activity of acne
  • 15.  Antiviral therapy 2 days prior and for 7-10 days after procedure  Sun screen, HQ, Glycolic acid  Consent form  Photograph- mandatory for resurfacing with laser, dermabrasion, chemical peels
  • 16.  Microneedling  Subcision  Punch technique  TCA CROSS  Dermal grafting
  • 17. Indication  Rolling and Boxcar scars MICRONEEDLING
  • 18. CONTRAINDICATION  Active herpes labialis  Keloidal tendency  Isotretinoin therapy in the preceeding 6 months  Bleeding disorders
  • 19. DERMAROLLER  Drum shaped roller  192 microneedles of 0.1 mm dia.  Needle length 0.5 – 2 mm  Motorised Dermastamps & Home care dermastamps
  • 20. PROCEDURE  Topical anaesthesia  Stretch the skin perpendicular to direction of movement of derma roller  Roll the tool 4 times in 4 different directions  250-300 Pricks/cm sq.  Needle penetrates at an angle, then goes deeper, and extracted at a converse angle  End point- uniform bleeding points over scarred area
  • 21. POST PROCEDURE  Clean with NS  Oral analgesic  No need of phtoprotection  3-4 sessions at 4-8 wks intervals
  • 22.
  • 23. SUBCISION HISTORY 1957- Spangler 1995- David Orentreinch and Norman Orentreinch Subcutaneous incisionless surgery
  • 24. PRINCIPLE  Releasing fibrotic strands underlying scars  Organization of blood in the induced dermal pockets  Connective tissue formation in the area
  • 25. INDICATION  Rolling scars PROCEDURE  Mark the scar  Local infiltration anaesthesia  18 G,1.5 inch Nokor Admix needle
  • 26.  Insert the needle at periphery of scarred area  Move back and forth, fanlike motion  Firm pressure for 5 mts.  Avoid preauricular, temporal and mandibular areas
  • 27.  Repeat at 6 wkly intervals  2-3 sessions  COMPLICATIONS  Bleeding  Hematoma  Hypertrophic scarring  Scar recurrence
  • 28.
  • 29. PUNCH EXCISION AND CLOSURE  Ind- Ice pick and Boxcar scars PROCEDURE  Local anaesthesia  Select appropriate size punch  Traction at right angles to RSTL  Descend upto s/c fat and excise scar plug  Undermine the wound edges  Suture
  • 30.
  • 31. PUNCH INCISION AND ELEVATION [Punch floatation] Depressed scars with normal surface texture Boxcar scar>3mm
  • 32. PROCEDURE  Punch that match to inner dia. of crateriform scar  Rotating motion release bound down scar  Elevate the plug and free from underlying tissue  Elevate the plug and position to lie slightly higher than surrounding skin  Secure in position by cyanoacrylate tissue adhesive
  • 33. PUNCH REPLACEMENT AND GRAFTING  INDICATION  Deep irregular pits  Tethered boxcar scars with altered skin texture
  • 34. PROCEDURE  Scar plug is removed and graft is transferred to the plug site  Donor site- post auricular area and inner arm  Donor punch graft size> 0.5mm larger
  • 35.
  • 36. CROSS  Technique using high strength TCA focally on atrophic acne scars to induce collagenisation and cosmetic improvement  PRINCIPLE  Precipitation of proteins  Coagulative necrosis of epidermal cells and collagen  Dermal remodelling
  • 37. INDICATION  Ice pick scars PROCEDURE  Mark the scar  Clean with spirit and degrease with acetone  Patient in sitting position  Stretch the skin and apply 100% TCA focally
  • 38.  Avoid spillage  Keep the skin stretched until frosted  Wash the face  Photo protection  3 sessions , 4 wkly intervals
  • 39. COMPLICATIONS  Transient post inflammatory hyper& hypo pigmentation  Priming skin with HQ and tretinoin for 2 wks
  • 40.
  • 41. DERMAL GRAFTING  Placing dermal grafts into precise pockets under skin ADVANTAGES  Not susceptible to infection  Can be tailored accurately  Creates a permanent space  Readily available  Easy to perform
  • 43. CONVENTIONAL  Local anaesthesia  Subcsion 10- 14 days before  Donor tissue from post auricular area or from dermabraded site  Defective area is tunnelled  Trim the grafts according to shape  Insert the graft and suture slit
  • 44. ENZYMATIC TECHNIQUE  Graft in 0.25% trypsin in EDTA solution  Incubate at 37⁰ C for 75 mts.  Transfer to phosphate buffered saline and remove epidermis  Insert the graft by conventional technique or inject using a wide bore needle
  • 46. CHEMICAL PEELING  Salicylic acid 20-30%- active acne and superficial scars  TCA 10%, 15%, 25%  Glycolic acid 25-35%  Jessener’s peel
  • 47.  Medium depth & deep phenol peels – effective but not recommended
  • 48.  ABLATIVE  DERMABRASION  Ind- superficial acne scars  Spot dermabrasion can be done in office setting  Full face dermabrasion needs an operation theatre facility  Topical or infiltrative anaesthesia
  • 49.  Mark scars and stretch the skin  Dermabrade till the base of scars  Maximum level- Jn of upper and mid reticular dermis  Manual dermabrader to feather the edges
  • 50.  Hemostasis  Non adherent dressing for 1 wk COMPLICATIONS  Infections  Persistent dyschromia  Hypo/ hyper pigmentation  Erythema & scarring
  • 51. LASER ABLATION  CO2 laser (10,600nm)  Er: YAG laser (2940nm)
  • 52. RESUEFACING – NON ABLATIVE OR MINIMALLY ABLATIVE
  • 53. MICRODERMABRASION Superficial minimally invasive technique of mechanical abrasion of skin using a pressurised stream of abrasive particles  Aluminium oxide crystals  Disposble diamond tip  Ind- Superficial scars  CI- Active infection Concurrent dermatoses on face  Eye protection
  • 54.  Set machine parameters with pr. level 10-30 mm of Hg  Stretch the skin under tension  Move the hand piece in a sweeping, outward motion  2nd pass in a direction perpendicular to first pass except in neck  End point- erythema  Topical antibiotic  Repeated weekly
  • 55. COMPLICATION  Erythema, oedema, infection, purpura, pigmentary changes and scarring  Conjunctival congestion  Crystal adherence to cornea  SPK
  • 56. DISADVANTAGES  Does not improve deep scars  Multiple sittings  Maintenance therapy
  • 57. NON ABLATIVE RESURFACING LASERS  Ind- atrophic acne scars  Nd :YAG LASER(1320 nm, 1064 nm)  Diode laser(1450 nm)  Flash lamp pumped pulsed dye laser(585 nm)  Er: glass laser
  • 58. SOFT TISSUE AUGMENTATION  Ind- soft atrophic scars with loss of dermal tissue  Dermal filers are placed under scars  Elevate and bring the surface of scar in level with surrounding skin  Subcsion or microneedling can be done prior
  • 59.  Hyalouronic acid fillers  Autologous fat  PLLA  Calcim hydroxyapatite
  • 60.
  • 61. INTRALESIONAL STEROIDS AND CYTOTOXICS Ind- Hypertrophic and keloidal scars Triamcinolone 10-20 mg/ml + 5FU
  • 62. SILICONE GEL SHEETING  Useful in flattening keloid and hypertrophic scars
  • 63.  SCAR REVISION  Ind- Linear and extensive scarring  Z, M and Y Plasty
  • 65. FRACTIONAL PHOTOTHERMOLYSIS  Non injured part of skin is the source of keratinocytes  Migration begins within 24 hrs  Keratinocytes facilitate removal of MENDs
  • 66. NON ABLATIVE  1550nm erbium doped fibre laser ABLATIVE  Fractional CO2laser  Direct vaporizing effect on epidermis and some part of dermis
  • 67.  Free of any active acne lesions  No history of keloidal tendency PROCEDURE  Clean the skin with 70% alcohol  LA cream for 1 hr  No. of passes and fluence depending on skin type & severity of scarring  Cool the skin with ice packs after procedure  Non comedogenic Abs for 3-5 days +sunscreen
  • 68. COMPLICATIONS  Erythema and crusting  PIH  Dryness of skin  Pruritus  Bronzing of skin  Aggravation of acne