Acne Scar Revision

Introduction

There are comparatively few methods of treating an acne scar and often several selected methods will need to be combined in the one patient to treat one difficult area of scarring and sometimes to treat different scars in the same patient. Simply put, one can:

• 1.

  Alter the color: Color may be the main visual clue to the presence of macular, atrophic or hypertrophic scarring. The technique employed is dependent on the offending color. Post-inflammatory hyperpigmentation is often the cause of brown marking perceived as “scarring” by the patient and is responsive to medical therapy with bleaching preparations and time, light chemical skin peeling, a variety of pigment lasers, light sources and the advent of fractionated lasers ( Fig. 20.1 ). Home skin care, vascular lasers or intense pulsed light and time may be all that is required for erythematous marking or scarring ( Fig. 20.2 ). Hypopigmented marking is more difficult and may require pigment transfer techniques although fractionated lasers have also been found useful ( Fig. 20.3 ).

  
  
  

• 2.

  Induce (or reduce) collagen: This is the most common method utilized in the treatment of post-acne scars. Inducing new collagen formation is a common pathway used by all resurfacing techniques from the most minor home care to superficial treatments such as microdermabrasion, light chemical skin peeling through to the deeper resurfacing techniques represented by medium and deep chemical peeling including the “CROSS” technique, skin needling or rolling, dermabrasion, ablative laser skin resurfacing (CO ₂ , erbium), plasma skin resurfacing and fractional resurfacing. When treating hypertrophic and keloid scars, multiple and often periodically repeated therapies are required to change the excessive collagen production by the fibroblasts

• 3.

  Fill the scar: This includes autologous (autologous collagen, dermal and fat grafting) and non-autologous temporary, semi-permanent and permanent augmentation techniques and agents ( Fig. 20.4 ).

  

Surgical Options

Classification of Acne Scarring by Burden of Disease

In search of a practical way of approaching a patient with post-acne scarring, a grading system has been devised that is based on the overall burden of disease the patient must bear. No practitioner can totally understand what an acne scarred patient experiences on a day-to-day basis, but there is value in an objective scale of severity for comparison and research purposes and for planning therapies ( Tables 20.1–20.4 ).

In essence:

• 1.

  Surface treatment revolves around altering the color of the scar as well as inducing or reducing collagen in the underlying tissue.

• 2.

  Volume requires augmentation or filling to increase volume deficits or sometimes decrease the volume in terms of hypertrophic scarring.

• 3.

  Movement involves neurotoxins to minimize the action of muscle on diseased, atrophic or sometimes hypertrophic scarring.

• 4.

  Surgical options include punch techniques, excision or subcision.

This chapter will attempt to view and utilize the reconstructive schema above and methods of assisting acne scars within the classification of scarring framework looking at the burden of disease ( Tables 20.1–20.4 ). Most appropriate treatments for each classification will be outlined for each scar type within these classifications and when that treatment is best applied will be described in detail. For example, ablative non-fractional laser skin resurfacing may be applicable for Grades III or IV scarring but would be described in the Grade III section; similarly, bulk filling may have applicability to Grades III or IV scarring but is at its best when employed in Grade IV, grossly atrophic scarring disease.

Grade I Scarring ( Table 20.1 )

This pattern is all about the surface, and macular scarring can be erythematous, hyperpigmented or hypopigmented and is visible to an observer at any distance.

Movement, volume or surgical options have no bearing with this level of scarring. In this level of scarring the facial reconstruction paradigm focuses on improvement in the skin's surface. Color is highly important to patients, as we tend to judge the health and age of an individual based partly on the evenness of skin color. This type of scarring, although flat, is distressing to patients as it is obvious without make-up. Many female patients will apply concealers and thick make-up to camouflage marks but render themselves liable to secondary comedonal changes of acne cosmetica.

Grade II Scarring ( Table 20.2 )

Grade II acne scarring ( Fig. 20.5 ) is again mainly concerned with the skin surface. It is mild, atrophic or hypertrophic disease, which may not be obvious at a social distance (such as talking to someone in normal lighting) and is easily covered with make-up.

This type of scarring alters collagen reflectance in the scarred dermis, causing the loss of an even skin glow from shadows cast by the scars. This is particularly obvious to patients looking in the mirror or with lighting from above. Usually this is mild atrophic disease but occasionally mild papular acne scarring will produce small protuberances especially on the nose or chin.

In the facial reconstruction paradigm, skin surface improvement is achieved by increasing or reducing collagen. Mild volume changes such those offered by superficial dermal fillers like hyaluronic acids are also useful. Using our paradigm of surface, volume, movement, and surgical approaches, all of the approaches below are possible either as isolated treatments, or in combination. Most require multiple treatments and all may be used for multiple scars or localized areas although fillers are more applicable for localized disease.