Combining different treatment modalities in management of post acne scarring

Combining different  treatment modalities in management of post acne scarring

Yasser Abdallah Aboelatta,MD, MRCS; Mohammed Mahmoud Abdelaal,MD, ABLS; Nada Abdelsatar Bersy,MD

Department of Plastic and Reconstructive Surgery, Ain Shams University, Cairo, Egypt.

Abstract

Background: Acne is a very  common  disease  affecting both sexes.  The most  important complication following active acne inflammation is post acne scars.

Patients and methods: This study included treatment of 30 patients suffering.from post acne scarring. Patients were divided into 3 groups; group I had erbium YAG laser resuifacing, group II had subcision  and fat transfer, and group  III received  triple  therapy;  laser  resurfacing, subcision, and fat injection.

Results:  The triple treatment  modality showed overall  better outcome without significant complications.

Conclusion:  The triple treatment  modality  is a good and safe modality. Other treatment modalities  can   be   added  to   this  combined  modality  to   be   more effective.

Key words: Acne, subcision, fat injection, laser resuifacing.

Introduction:

Acne is a chronic inflammatory disease of the  pilosebaceous units.l Scarring is a consequence following damage of sebaceous follicle  during  acne  inflammation. A cell­ mediated immune response has been found to be involved  in these  inflammatory events.2

Acne scarring was found in 1.7 per 1000 for both sexes; 2.0 per 1000 in men and boys and

1.3 per 1000 in women  and girls.3 Of those

with acne, 74% wait greater than 1 year before seeking evaluation. Delay  in treatment is thought to increases the probability of scarring.4

Inflammatory lesions may be superficial or deep, and many arise from non-inflamed lesions.5  Scarring usually follows deep inflammatory lesions,  but may happen  after superficial lesions in scar-prone patients.6 Close inspection of acne can reveal some scarring in up to 90% of patients7 but significant scarring occurs in about 22% of sufferers.l  Acne and post  acne  scarring lead to significant psychological problems.8

Acne scars  are broadly  categorized as a result  of increased tissue  formation or, the more common, tissue loss.9 Atrophic scars are subdivided  into 3 primary types by Jacob et aJlO icepick, rolling, and  boxcar scars.

The diversity of treatment of post acne scars actually reflects that the wide variations of the scars and the difficulty  of a single treatment alone to solve the problem. The aim of this study is to present the effectiveness of the triple therapy composed of subcision, fat injection, and  laser  resurfacing in improving acne scarnng.

Patients and methods:

The study was done over a period of 4 years

(2007-2010) at the Plastic Surgery Department, Ain  Shams  University. Thirty  patients (24 females and 6 males) suffering from atrophic facial acne scars were included. Patients' age ranged between 22-38 years with  skin phototypes III-IV. Patients  with infective or hypertrophic (keloidal) acne  scars  or with

history  of isotretinoin use, filler  substance injection, within the previous year were excluded from the study.

Patients were divided randomly into three groups, ten in each group. Patients of the first group(!) were  treated by external laser resurfacing using Er:YAG  laser (2,940  nm, wavelength, 350 f.1Sec pulse-width with energy fluence ranging from 10-15 J/cm2) in a single treating session. Er:YAG laser was used to ablate the acne scars with the surrounding normal skin  (3-5  passes), till  reaching macroscopic safe depth (upper reticular dennis).

Second group(II) were treated by lipo-filling the base of the scars at subdermal plane after subcision of scar tissue using long hi-forked needle by sweep it back and forth repeatedly to free the skin from the underlying scar tissue. Fat was harvested without tumescent usually from abdomen or trochanteric areas as available in each patient. No tumescent was used. Fat was allowed to sink down in liposuction syringe with no centrifugation or washing. Then fat was injected using injection canula. The amount of injected fat ranged from 10-20cc in each patient. Fat injection overcorrection  by about

10-20% was done.

Patients in third group(III) were treated by combining both  modalities of the first  and second group (Er:YAG laser for resurfacing plus subcision of scar tissue with lipofiling at

Results:

Table (1): Summary  of results in all groups.

subdennal plane) at same session plus injecting more fat  at deep subcutaneous and intramuscular layers  for augmentation and stretching the skin.

Group  I patients were  done  under  local anesthesia, while patients of group II and III were done under general anesthesia. Extra-thin Duoderm dressing was  applied after  laser ablation for 5-7  days. Sunblock creams  or lotions were  advised to  all  patients after complete  healing for three to six months. In addition, oral antibiotics and analgesics were used  during the  first  week  postoperative.

All patients were followed up for a period ranging  from six to twelve  months. Results were interpreted by comparing pre-treatment and post-treatment digital  pictures  taken at least six months after treatment session and every  six months using Nicon-Coolpex 995 digital camera (3.3 Mpx, 5X optical  zoom). Panel of three observers (physician, nurse, and patient relative) evaluated the  degree of improvement by comparing the results without knowing the treatment modality that was used Results were graded as excellent(> 75%), good  (51-75%), fair  (26-50%), and  poor (<25%) based  on  degree  of improvement. Complications (erythema, dyspigmentation, scarring, ....) were graded into either absent (0),  mild  (1),  or  moderate to severe (2).

Patients of group III had an overall improvement better than the other two groups Table(l). Eight patients  (80%)  in group  III had good and excellent results compared to 3 (30%) patients in group I and 5 (50%) patients in group II. Group II patients had better results than Group I patients especially for deep scars. There was no correlation  between treatment

response and  patients' age,  sex,  previous treatment  or   duration  of   acne scars.

There was no difference in healing time of

resurfaced skin in group I and group III (6-8 days). The recovery time was longer inpatients who received laser treatment (group I and III). These patients took about 12-18 days to return to their work after resolution of erythema. In

group II, patients could return to work in 7-9 days after edema and mild bruising resolved.

Only 2 patients experienced mild transient hyperpigmentation for 4 weeks (1 patient in

group I and I patient in group III) that resolved by conservative treatment (topical hydroquinone and retinoic acid). No complications were recorded  in group  II.

Figure (1): 24 years old female patient received laser resurfacing (group/).

Figure (2): 27 years old male patient underwent subcision and fat injection (group II).

Figure (3): 25 years old male patient received triple therapy technique (group III).

Discussion:

Acne is a common disorder experienced by up to 80% of people between age of 11 and

30 years and by up to 5% of older adults.11,12

For most patients acne remains a nuisance with occasional flares of lesions. Furthermore, the severe inflammatory response  results in permanent scars.  Post  acne  facial  scarring affected up to 95% of both sexes.6 Acne scars can lead to severe psychologic problems.n Once scarring  has occurred, patients  and physicians are left to struggle with the options available  for improving  skin  appearance.lO Acne scars are either tissue hypertrophy or more commonly  tissue atrophy  which often

worsens by age.14

Atrophic scars  are  3 primary types  as described by Jacob et al.lo icepick, rolling, and boxcar. The icepick scars are usually smaller in diameter and deep to the dermis or subcutaneous tissue. Treatment is frequently done  by punch excision and closure by nonabsorbable suture.15   Boxcar  scars  are shallow or deep and have almost vertical walls. Shallow  scars can be treated by resurfacing techniques or punch elevation.Deep  scars are managed by punch excision, elevation, or other modality. Soft rolling scars can be circular or linear  and have  gently  sloped  edges.  There may  be dermal  or subdermal tethering, so treatment is commonly by subcision. Many combining treatment modalities have  been described including laser, surgery, peels, skin needling,  fillers  and dermabrasion.9,13,16-22

A well  known  approach to treat  acne is resurfacing of the epidermis and tightening of dermal collagen. This included dermaplan:ing23 dermabrasion, and laser  skin resurfacing.n The  limited efficacy of dermabrasion and microdermabrasion in deep  scarsl3 and postoperative complications of dermabrasion24 limited their use. Full-face laser skin improves overall texture and produces a homogeneous skin appearance.13 Nonablative and fractional lasers gained acceptance  in the treatment  of acne  scars  and  photo-damaged skin.25-32

However their results do not approach those of ablative  lasers.16 Ablative  lasers  in acne

:included carbon dioxide laser33-35 Erbium:YAG laser36-38 and combine Erbium and C02 lasers.39,40 The Er:YAG laser is a more gentle

ablative therapy than the carbon-dioxide laser in treatment of acne scars. The Erbium YAG laser with long pulse duration achieved better results than short pulse mode.41 In addition, traditional resurfacing is more effective than the  new  fractional resurfacing systems.42

For these reasons, we used ablative Erbium YAG laser in our study (group I and III). It showed better results in superficial scars than deep scars. It also showed low complication rate supporting its efficacy and safety. Lesions were  treated  as aesthetic units  containing normal and scarred areas to obtain homogenous improvement.

Tissue augmentation is another alternative for managing acne  scarring. This  includes numerous substances such  as collagen, hyaluronic acid, synthetics, silicone, implants, and fat.9,43,44 Autologous  fat was first noted

in 1893  to improve  acne scars.45 Fat  is an excellent augmentation material. It is cheap, available in most  patients and  will not  be rejected nor  suffer  allergic  reactions.21

For all these reasons, we chose fat injection for  tissue  augmentation. Fat  was  injected subcutaneous as suggested by many authors21 as  well  as  intramuscular injection which showed good fat survival and less resorbtion in other studies.46-49 Lipofilling  was done in superficial and deep planes to add more stretch of the skin that makes scars less noticeable. Fat over-injection was performed by about 10-

20% to overcome fat resorbtion. This mild overcorrection gave us good results and seems a good choice. Fat resorbtion  reached about

20-25% after 1 year; although higher resorbtion

(70%) was reported in other studies.43 Despite fat resorbtion, no patient in our study needed other cessions of fat injection.

Subcision alone as a corrective technique was  first described by  Orentreich and Orentreich  50 in 1995 as a summation of the word "subcutaneous :incisionless". In addition to scar  release, controlled trauma and organization of  hematoma are  thought to stimulate connective tissue formation. However, it carries the  risk  of excess fibroplasias leading to nodule formation.9,21

The technique of scars undermining has been used widely as an adjunct to other maneuvers.21

In our study, subcision was combined with

fat injection (group IT and Ill). This combination was  more  effective in deep  scars than superficial scars. The  complication of hematoma or nodule formation was  not recorded in patients of group II or group III. However, direct  scar  excision seems  more effective  in very deep scars than subcision. This  seems  to produce more  linear less noticeable scars.

Although attacking skin from above by laser

resurfacing and from below by subcision and fat injection seems very risky, we did not report any   case  with skin  flap compromise.

It is clear now that acne scars show great variability. Addressing all these variable types of scars using single treatment seems illogic. This explains our approach using triple therapy composed of subcision to release fibrotic bands from below, fat injection in 2 planes (subdermal and deep subcutaneous)  to fill the tissue loss and contour  skin, and laser resurfacing that treats surface irregularities and improves skin quality via stimulation of new collagen production.  It must be clear for patients that scar improvement rather than total elimination is the ultimate goal.

Conclusion:

The combined treatment modality composed of simultaneous short pulse Erbium YAG laser resurfacing, subcision, and fat injection  is a safe and effective treatment modality of post acne scarring.The addition of selective excision of deep scars and variable pulse Erbium YAG laser to the used modality may help in obtaining better and long lasting results.

References:

1- Simpson NB, Cunliffe WJ: Disorders ofthe sebaceous glands. In: Rook's Textbook of Dermatology. Tony Burns, Stephen Breathnach, Neil Cox, Christopher Griffiths (Editors); Blackwell Science (Publisher);

7th edn.; 2004, chapter 43.

2- Cowin AJ, Brosman MP, Holmes TM, Ferguson MWJ:Endogenous inflammatory response to dermal wound healing in the fetal and adult mouse. Dev Dyn 1998; 212:

385-93.

3- Johnson MT, Roberts J: US Department of

Health, Education and Welfare, Vital and

Health  Statistics: Skin  conditions and related need  for medical care  among persons 1-74 years: United States, 1971-

1974. Washington, DC; November 1978; Series 11 no. 212.

4- Tan JK, Vasey K, Fung KY: Beliefs and

perceptions of patients  with acne.  JAm

Acad   Dermatol  2001;  44:  439-445.

5- Orentreich N, DwT NP:The natural evolution of comedones into inflammatory papules and pustules. J Invest Dermato/1914; 62:

316-320.

6- Layton AM, Henderson CA, Cunliffe WJ: A clinical evaluation of acne scarring and its incidence. Clin Exp Dermato/1994; 19:

303-308.

7- Varadi  DP, Saqueton AC: Perifollicular elastolysis. Br J Dermato/1910; 83: 143-

150.

8- Koo J: The psychosocial impact of acne: Patients' perceptions. JAm Acad Dermatol

1995; 32(Suppl): 26-30.

9- Rivera AE, Missouri K: Acne scarring: A review and current treatment modalities. J Am   Acad Dermatol  2008; 59(4).

10-Jacob  CI, Dover JS, Kaminer  MS: Acne scarring: A classification system and review of treatment options.JAm Acad Dermatol

2001; 45: 109-117.

11-Kraning KK, Odland  GF: Prevalence, morbidity, and cost of dermatological diseases. J  Invest  Dermatol  1979;

73(Suppl): 395-401.

12-Goulden V,  Stables GI,  Cunliffe WJ: Prevalence of facial acne in adults. JAm Acad   Dermatol 1999;  41:  577-580.

13-Koo JY, Smith LL: Psychologic aspects of acne. Pediatr Dermato/1991; 8: 185-188.

14-Kromayer E: Die Heilung der Akne durch

ein neues nabenloses Operations verfahren.

Munchn Med Wochenschr 1905; 52: 943.

15-Jemec JB, Jemec B: Acne: Treatment  of scars. Clin Dermato/2004; 22: 434-438.

16-Fulchiero G, Parham-Vetter P, Obagi S: Subcision  and  1320-nm Nd:Y AG nonablative laser resurfacing for the treatment  of acne scars: A simultaneous split-face single  patient  trial.  Dermatol Surg 2004; 30: 1356-1360.

17-Gold MH:Fibrel. Dermatol Clin 1995; 13:

353-361.

18-Pinski     KS,   Coleman   WP: Microlipoinjection and autologous collagen. Dermatol Clin   1995; 13:  339-351.

19-Capon  A, Mordon  S: Can thermal  lasers promote skin wound healing? Am J Clin Dermato/2003; 4:1-12.

20-Souil E, Capon  A, Mordon S, et al: Treatment with 815-nm diode laser induces long-lasting expression of 72-kDa  heat shock  protein in  normal  rat  skin.  Br J Dermato/2001; 144: 260-266.

21-Goodman G, Baron J: The management of postacne  scarring. Dermatol Surg 2007;

33: 1175-1188.

22-Whang KK, Lee M: The principle of a

three-staged operation in the surgery  of acne scars. JAm Acad Dermato/1999; 40:

95-97.

23-Malherbe WD, Davies DS: Surgical treatment of acne scarring by a dermatome. Plast Reconstr Surg 1971; 47: 122-126.

24-0rentreich D, Orentreich N: Acne  scar revision  update. Dermatol Clin 1987; 5:

359-368.

25-Kim KH,  Geronemus RG: Nonablative laser and  light therapies for  skin rejuvenation. Arch Facial Plast Surg 2004;

6:398-409.

26-Sadick NS, Schecter  AK: A preliminary study  of utilization of the 1320-nm Nd: YAG  laser  for the treatment of acne scarring. Dermatol Surg 2004; 30: 995-

1000.

27-Chua SH, Ang P, Khoo LS, Goh CL: Nonablative 1450-nm  diode laser in the treatment of facial atrophic acne scars in type IV to V Asian  skin: A prospective clinical  study. Dermatol Surg 2004; 30:

1287-1291.

28-Tanzi EL, Alster TS:Comparison of a 1450- nm diode laser and a 1320-nm Nd: YAG: A prospective clinical and histologic study. Dermatol Surg 2004; 30(2 Pt 1): 152-157.

29-Chan HH, Lam LK, Wong DS, et al: Use of 1,320 nm Nd: YAG  laser for wrinkle reduction and the treatment of atrophic acne scarring in Asians. Lasers Surg Med

2004; 34: 98-103.

30-Alster TS, Tanzi EL, Lazarus M: The use of fractional laser phothermolysis for the treatment of atrophic scars. Dermatol Surg

2007; 33: 295-299.

31-Goldberg DJ: Full-face nonablative dermal remodeling with a 1320- mn Nd:YAG laser. Dermatol  Surg   2001; 26:   915-918.

32-Ang P,  Barlow RJ:  Nonablative laser resurfacing: A systematic review  of the literature. Clin Exp Dermato/2002; 27:

630-635.

33-Goodman GJ: C02  laser  resurfacing: A subjective study  100 patientsi attitudes outcomes. Dermatol Surg 1998; 24:665-

672.

34-Dover JS: C02 laser resurfacing: Why all the fuss?  Plast Reconstr Surg 1996; 98:

506-509.

35-Alster TS, West TB: Resurfacing of atrophic facial acne scars with a high-energy, pulsed carbon dioxide laser. Dermatol Surg 1996;

22: 151-154.

36-Fitzpatrick RE,  Goldman MP: Skin resurfacing with carbon dioxide and Erbium lasers. In: Cutaneous laser surgery, the art and science of selective photothermolysis. Goldman MP, Fitzpatrick RE (Editors); St Louis: Mosby (Publisher); 2nd edn.; 1999; p. 339-436.

37-Tanzi  EL, Alster TS: Single-pass  carbon

dioxide versus multiplepass Er:YAG laser skin  resurfacing: A  comparison  of postoperative wound  healing  and  side­ effect rates. Dermatol Surg 2003; 29: 80-

84.

38-Zachary CB:Modulating the Er:YAG laser.

Lasers  Surg  Med  2000;  26:  223-226.

39-McDaniel DH, Lord J, Ash K, Newman J: Combined C02/Erbium: YAG  laser resurfacing of perioral rhytids and side to side comparison with carbon dioxide laser alone. Dermatol Surg 1999; 25: 285-293.

40-Collawn SS:  Combination therapy:

Utilisation of C02 and Erbium:YAG lasers for skin resurfacing. Ann Plast Surg 1999;

42: 21-26.

41-Walia S, Alster TS: Prolonged clinical and histological effects from  C02 laser resurfacing of atrophic acne scars.Dermatol Surg 1999; 25: 926-930.

42-Alexiades-Armenakas MR, Dover JS, Arndt KA:The spectrum oflaser skin resurfacing: Nonablative, fractional, and ablative laser resurfacing. J American Academy Dermatology 58(5): 719-737.