All acne scar revision treatments depending on the acne scar type, downtime, and skin type or skin colour of the patient. Lets briefly discuss these 3 factors so you have an understanding of scar revision.
Identification of acne scars– this is the most important aspect of scar revision. Acne scars can be sub typed into box scars, ice-pick or deep scars, rolling scars, atrophic, hypertrophic or lumpy scars, pigmented scars, and anchored or tethered scars. Each type of scar will have an optimal treatment. Post acne scars are polymorphic and various types of scars usually coexist in the same individual. It is very important that each scar be assessed individually and treated accordingly. The method of the intervention depends on the types of the scars, overall appearance of the face and budgets of the patient
Depressed Scars / Atrophic Scars
Examples include –
Ice pick Scars
- Ice pick scars – best treated with TCA CROSS and combination of Fraxel laser / laser or RF resurfacing and RF Microneedling. Ice pick scars are narrow (less than 2 mm), deep sharply marinated epithelial tracts that extend vertically to the deep dermis or subcutaneous tissue. The skin looks as if it has been pierced by an ice pick or sharp instrument. Ice picks scars seem to make a small, deep, “hole” in the skin. They are the most common acne scars that occur on the cheeks and have a “punctate” appearance. Ice pick scars develop after an infection from a cyst or other deep inflamed skin tissue and its way to the surface leaving a column-like scar. TCA CROSS, or Trichloroacetic Acid Chemical Reconstruction of Skin Scars, uses up to 100% strength TCA in minute doses. These drops are placed precisely into icepick scars to stimulate healing within the narrow scars, resulting in resurfacing of these scars over several treatments.
- Rolling scars – best treated with Fraxel and Fractional laser resurfacing & RF Microneedling as well as EndyMed FSR (fractional skin resurfacing). These are distensible, depressed scars with gentle sloping edges. Roling scar are shallow depressions that are best appreciated with a change in surface lighting. They can vary in size and often coalesce with neighboring rolling scars. Rolling scars are shallow, wide (more than 4 to 5 mm) and have a subdermal fibrous tether. These scars are caused by damage under the surface of the skin. They give the skin a wave-like appearance
- Box car scars – can be treated with TCA CROSS and laser resurfacing or RF (radiofrequency) Microneedling or EndyMed FSR (fractional skin resurfacing). Boxcar scars are angular scars with sharp vertical edges, and resemble the scars left by chicken pox. They may be shallow or deep, punched out, wide at the surface and at the base are most often found on the cheeks and temples
- Shallow depressed scars resulting from tissue destruction following inflammation and infection. Treated with Fractional Lasers such as PicoWay, Fraxel 1550 or Microneedling, EndyMed FSR (fractional skin resurfacing) and to a lesser degree with Chemical Peels.
- Atrophic scars – best treated with Fillers, lasers can only help partially. RF Micronedling can also be a good option.
Of the 3 main types of indented acne scars (ice-pick, boxcar or rolling) each might be tethered (anchored) to deeper structures of the hypodermis, and require more invasive procedures to release them from their anchoring scars. This is shown below where a needle is used to release the scars in a procedure known as subcision. This is can be the first step in a series of acne scar treatments where subsequent techniques are used to resurface the more superficial skin and improve its appearance and quality.
- Tethered scars – Scars that are stuck to deeper layers will require subcision – best treated surgically with subscion by a doctor. It is a minor dermatological surgical procedure that uses a needle or blunt cannula to break these anchoring scars. RF Microneedling can also be a solution for tethered scars.
Brown, Pigmented Scars or PIH (Post Inflammatory Hyperpigmentation)
- Pigmented scars / PIH Post Inflammatory Hyperpigmentation Scars – best treated with Carbon Laser Peel, PicoWay Laser, Medical Facials such as Oxygeneo, Chemical Peels, Microneedling, Clear and Brilliant or EndyMed FSR (fractional skin resurfacing).
Red Flat Scars
- Red flat “scars” resulting from capillary expansion following any inflamed acne. Treated with BBL, chemical peels and/or MediSpa Facials as well as RF Microneedling.
- Hypertrophic: These are elevated, fibrotic scars, more common in males and frequently seen in the mandibular area of the face and back of the chest. Often the result of severe acne (cysts or nodules), they generally stay within the boundary of the original wound, and may decrease in size over time
- Keloid scars – raised, firm “hypertrophic scars” – are an occasional response to acne. Keloid scars are not treated with lasers and typically treated with cortisone injections to the scars. These keloids developing in acne lesions. They are seen more often in acne lesions. They are seen more often in males, on the back and chest
Downtime of procedure– this refers to the time taken off by the patient due to recovery. Some acne scar revision procedures are associated with a long recovery time, some with no downtime. Examples include-
- Fillers for acne scars- no downtime
- RF Microneedling or PicoWay Laser – 12- 36 hours downtime
- TCA CROSS- 5-7 days downtime
- Fractional and Fraxel laser- 3-6 days downtime
- Fully ablative laser resurfacing – 7- 10 days downtime
- Carbon Peels, Mild Chemical Peels, Facials or Microneedling – none to 1 day
Skin colour of the patient- this is very important as darker skin patients such as ethnic skin, will need more conservative settings compared to fair patients. This is because darker skin patients can pigment or darken with laser treatments and TCA peels a lot easier than fair skin patients.
Most patients will have multiple scar types, and hence several treatment sessions are needed for the very best results. If you are fortunate enough to have scars such as shallow to medium depth box car scars with fair skin type, then you may only require one treatment.
FILLER SKIN BOOSTERS
Hyaluronic acid fillers can be used in conjunction with subcision or lasers. Used during subcision, these fillers separate the upper from lower skin and prevent it from re-attaching, increasing the efficacy of each session. Used after lasers, the V2 skinbooster with Redensity 2 with its proprietary nutritious cocktail of aminoacids aids in recovery of the skin and optimizes the end results.