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  1. Presented by Dr Rubeena Bano Moderator Dr Neerja Puri
  2.  Scars are an indelible reminder of acne  can play havoc with the social functioning of the patient leading to stress and anxiety  reduce QOL as great as that with epilepsy, asthma, diabetes or arthritis.  Limited treatment options for acne scars leave prevention as the best remedy for scar prone patients.
  3.  Atrophic and Hypertrophic (3 : 1).  Atrophic Acne Scars: 3 types;  Icepick- 60–70% of total scars, the boxcar 20–30% and rolling scars 15–25%.
  4. INFLAMMATION  Of pilosebaceous follicles.  Dermal inflammation greater potential for scarring. GRANULATION TISSUE FORMATION  Normal wound- type III collagen  Mature scars - type I collagen. MATRIX REMODELING  Scar prone patients- prolonged cycles of MMPs procollagen synthesis
  5. Goodman and Baron devised a qualitative scarring grading system that is simple and universally applicable except in severe cases where different patterns are simultaneously present in a patient
  6.  Combination of medical and surgical approaches  Communication with patients- gain trust and confidence  Counseling  Understanding patients’ expectations  Informed consent  Pre and post-treatment photographs.  Examination of skin- scar type, extent, tendency for pigmentation and keloid formation.
  7. 1. Aesthetic approach: Chemical peels, microdermabrasion, dermal fillers 2. Surgical approach:  Punch techniques, subcision,  dermal grafting,  fat transfer, implantation of autologous collagen,  cultured and expanded autologous fibroblasts,  focal treatment with TCA,  microneedling, dermabrasion, scar revision  cryoslush 3. Laser resurfacing: ablative, nonablative and fractional resurfacing.
  8.  Skin Needling Therapy, Dermaroller Therapy Or Collagen Induction Therapy (CIT)  Dermaroller- drum shaped roller, studded with 192 microneedles in eight rows.  Needle length ranging from 0.5 to 2 mm.  1.5 mm- mc used. 2 mm- deeper atrophic scar.  Motorized dermastamps- needle cartridges attached to a motor device having a to- and-fro movement inducing pricks.  Home care dermastamps. Indications  Grade 3 and 4 scars-- rolling and boxcar scars. C/I  Active herpes labialis  Keloidal tendency  Patients on isotretinoin therapy within 6m  Bleeding disorders.
  9. Procedure  Disinfection and anesthetization with EMLA  Rolled four times in four different directions: horizontally, vertically, and diagonally right and left.  To ensure even pricking pattern, resulting in about 250–300 pricks/cm2.  Endpoint- uniform bleeding points.  Skin stretched perpendicular to direction of dermaroller movement to reach the base of the scars.
  10. Postprocedure Care  Mild swelling and superficial bruising.  Oral analgesics for needle size is >2 mm.  A total of 3-4 treatment sessions, repeated at 4–8 weeks interval. Outcome  Full result in 8–12 months  Improvement in acne scar continues even after 6 months after the last dermaroller therapy.  Combine with other techniques for better results. Studies G Fabbrocini et al. confirms that dermaroller therapy was highly effective in treatment of rolling acne scars. A recent Indian study by Majid I, found that, in 21 patients with Grade 3 scarring treated with microneedling, an excellent response was noted in 16 patients (reduction to Grade 1 or less). Overall, 26 out of the total of 36 patients (72.2%) showed an excellent response to dermaroller treatment while 6 others achieved a good response (16.7%).
  11.  Release subcutaneous fibrotic strands in a rolling scar that improve with stretching the skin The mechanisms of scar improvement in subcision are:  Releasing fibrotic strands underlying scars  Organization of blood in the induced dermal pocket  Connective tissue formation in the area.
  12. Treatment Procedure  Area is marked and subcutaneous anesthesia given.  Best needle- 1.5 inch Nokor Admix needle.  16 to 23G inj needles can be used.  Done in 2 directions, larger scars- multiple puncture sites.  The needle can be fixed on a 2cc syringe so that the syringe works as a handle.  Firm pressure applied postop for 5 min to achieve hemostasis.  Repeated at 6 weeks for up to 2- 3 successive treatments. NOKOR NEEDLE Needle inserted from periphery with blade facing upward Tip turned parallel to skin surface Sweep gently at dermal subdermal jxn snapping sound heard as the bands break
  13. Complications  Bleeding  Hematoma  hypertrophic scaring  scar recurrence  Bluish discoloration and swelling persists for 5–7 days. Practical Tips  For multiple scars, start with the most dependent area and work upward  Mild bleeding is expected and beneficial.  large hematoma allow blood to flow out  combined with subdermal implants Autologous fat or dermal tissue Superior results can be achieved by combination therapy.
  14. Includes: 1. punch excision 2. punch flotation or punch elevation 3. punch replacement grafting Punch Excision  For ice pick scars and deep boxcar scars less than 3.5 mm diameter  Scar excised with 1.5- 3 mm biopsy punch as per size of the scar  Traction applied perpendicular to the skin lines changes circular wound into an ellipse parallel to the relaxed skin tension lines.  Scar tissue is removed and wound sutured with interrupted sutures
  15. Punch Flotation  Best for wide (> 3 mm) boxcar scars  Punch equal to scar size is selected  Bound-down scar is released and freed from the underlying tissue positioned to lie slightly higher than the surrounding skin.  Secured in position by cyanoacrylate tissue adhesive Punch Replacement Grafting  For deep, irregular pits and tethered boxcar scars with altered skin texture.  similar to that of a punch flotation,  Plug replaced with donor plug obtained from the postauricular area or inner arm  Donor punch graft should be 0.5 mm larger than the punch used to excise the scar.
  16.  Punch replacement and flotation techniques are successful for scars on less mobile regions such as the malar and forehead area  less successful in perioral sites Complications  poor graft take, graft extrusion and graft visibility.  Poor color and textural mismatch  Dermabrasion after excision, but before closure, improves the subsequent scar appearance  Recently, simultaneous resurfacing with a CO2 laser and punch excision has been advocated.
  17.  Uses high strength TCA focally on the atrophic acne scars to induce collagenization and cosmetic improvement. MOA  Best t/t for ICE PICK scars TCA precipitates proteins and cause coagulative necrosis Induction of collagen production and reorganization of dermal collagen. Remodelling of type III collagen by type I collagen Improvement of scars
  18. Complications  Transient PIH and hypopigmentation Practical Tips  Priming the skin with hydroquinone and tretinoin cream for 2 weeks  Strict Photoprotection  Avoid accidental spillage of TCA  Application limited to scar base and not to rim of the opening of the pit.
  19. Advantages 1. Not susceptible to infection 2. Can be tailored for a variety of defects 3. Creates a permanent spacer between skin and underlying fibrous band 4. Readily available 5. Easy to perform  Two different techniques- conventional and enzymatic separation. Conventional Technique  Subcision done  Donor tissue is harvested using biopsy punches/ dermatomes from the post auricular site.  Epidermal part and excess fat is trimmed and tissue transferred to saline.  Scar area is tunneled to create a space for the graft.  Graft is inserted using a forceps through small slit  slit is sutured with proline
  20. Enzymatic Technique  FTSG harvested  transferred 0.25% of trypsin in EDTA solution Incubated at 37º C for 75 minutes.  Tissue is transferred to phosphate buffered saline and the epidermis is manually separated.  Soft, flexible and easily moldable dermal tissue  Filled into the defect as in case of conventional technique.  Or it can be transferred into 1 cc syringe and pushed into the defect.  Area molded by external manipulation.
  21. Chemical Peeling  Peeling agents used- 1. salicylic acid 20–30% 2. TCA 10% 3. 15% and 25% 4. glycolic acid 25–35% 5. Jessner’s peel  TCA 35%- used for deeper scars  Salicylic acid 20–30%- peeling agent of choice in active acne Microdermabrasion  Easy technique, safe in darker skin and low cost.  Indicated for superficial scars and is ineffective for deeper scars.  Repeated weekly until the desired result is obtained.
  22. Soft Tissue Augmentation (Fillers)  T/t of scars with loss of dermal tissue elevate them and bring the surface of the scars in level with the surface of surrounding skin  Preparations used- hyaluronic acid fillers, autologous fat, PLLA (Sculptra), calcium hydroxyapatite (CaHA, Radiesse) and Liquid injectable silicon.  High cost and temporary duration of result is a disadvantage. Scar Revisions  Scar revision techniques such as Z, M and Y plasty  Performed by a dermatosurgeon properly trained in performing these procedures.
  23. Cryotherapy  Cryoslush and cryopeel nodulocystic acne, inflammatory papule and pustule.  Cryoslush method, solid CO2 is crushed and a few drops of acetone are added to make a paste applied to the lesions with a gauze ball for 2–10 seconds.  Superficial peeling is achieved due to epidermal necrosis, which causes desquamation of comedones, resolution of inflammatory papules, pustules, nodules and cysts.  Cryopeel method, spray of liquid N2 used for 2–3 sec.  Pigmentary changes are common, esp in darker-skinned patients  Persistent erythema and scarring may also occur
  24.  Grade 2 and Grade 3 scars are ideal candidates for laser treatment.  Rolling and superficial boxcar scars respond the best  Lasers Used for Acne Scars 1. Ablative lasers 2. Nonablative lasers
  25.  Ablative lasers cause injury or ablation of epidermis and dermis with resultant collagen deposition.  The two main ablative lasers used are; CO2 laser  emits light at 10,600-nm wavelength.  causes vaporization of epidermis and papillary dermis to a depth of about 20–60 µm.  Additionally, there is thermal injury up to another 20– 40 µm zone around the vaporization zone. Erbium Yttrium Aluminum Garnet (Er:YAG) laser  Emits light in the 2,940-nm wavelength and the depth of ablation with this laser is only 10–20 µm.  surrounding thermal damage does not exceed 15 µm.  Thus total depth of achieved is about 30–40 µm with single pass.
  26. S/E- 1. prolonged erythema 2. exfoliation of the skin 3. posttreatment hyper- and hypopigmentation 4. risk of scarring 5. secondary infections 6. prolonged downtime  Ablative lasers are most effective in treatment of post-acne scars  CO2 laser is thought to be a more effective laser as it can achieve a greater depth of ablation.  Erbium YAG laser has less risk of side effects.
  27.  MOA- controlled injury to the dermal collagen without any damage to the epidermis  Healing response with dermal collagen remodeling tightening effect on the skin with resultant improvement in the appearance of the scars  Require less downtime, less efficacious as compared to ablative lasers.  Divided into two groups: a. Infrared lasers:  1450-nm diode laser- advantage of treating active acne  1064-nm Qs Nd: YAG laser  1320-nm Nd: YAG laser  1540-nm Er: glass laser b. Visible light lasers:  IPL  pulsed dye lasers  light emitting diodes  broadband light sources • Nonablative lasers provide modest improvement. • T/t comprises of multiple sessions at 3–4 week
  28.  Minimizes adverse effects and shortens the downtime Skipped noninjured part of the skin provides the source of keratinocytes that migrate into the laser-treated injured areas.
  29. Divided into; NONABLATIVE FRACTIONAL LASERS  use wavelength of 1410– 1550 nm.  Cause nonablative columns of dermal and epidermal injury with skip areas.  Eg; 1550-nm erbium doped fiber laser known as Fraxel laser ABLATIVE FRACTIONAL LASERS  Delivers the best of both worlds by providing efficacy of ablative laser treatment but minimizes the side effects.  Eg; fractional CO2 laser.
  30.  Isotretinoin reduces acne vulgaris and prevents further scarring.  Care should be exercised in patients with recent history of isotretinoin as it delays in healing and atypical scar formation.  Earlier studies suggest 6–12 m waiting period before performing resurfacing procedures.  However, recent publications demonstrate considerable safety of different procedures in patients recently treated with isotretinoin Abrasion of a small test area is a useful predictor of wound healing, enabling earlier acne scar treatment using this procedure.
  31. “Life is so short, the craft so long to run”