Sunday, March 31, 2019
Comparison of Techniques in Acne Scar Treatment
Comparison of Techniques in Acne Scar TreatmentPunch cut techniques ar utilized for depressed marks such as ice fragmentise and boxcar scars. According to the diameter of the scar, a biopsy punch of appropriate surface is employ to excise the scar.If the scar is 3.5 mm in size, it is excised and sutured after undermining, in a direction parallel to the relaxed grate tension lines.Procedure Surgical eagerness is done. Local anaesthesia infiltration and marking of the scar is done. Initial undermining of the scar is done. Based on the diameter of the scar, a biopsy punch of appropriate size is inserted till the hypodermic fat layer and the punch graft is remove and discarded. After removal of the plug, the bea becomes elliptical. Undermining with an artery forceps is done and is followed by seam with 6-0 prolene. (Illustration 33.5) A linear scar ensues lying along the RSTL. preparation is done. Antibiotics and NSAIDs are administered for 7 daylights.Depressed pitted ice pick scars up to 4 mm in diameter, are excised and replaced with an autologous, full-thickness punch graft. The sponsor site is usually the stead-auricular region or the gluteal region. Care should be taken to block cobblestoning, which is a common complication.Procedure Surgical preparation is done. Local anaesthesia infiltration and marking of the scar is done. Initial undermining of the scar is done. Based on the diameter of the scar, a biopsy punch of appropriate size is inserted till the subcutaneous fat layer and the punch graft is removed and discarded. From the donor site, a full thickness punch graft 0.5 mm than the excised scar is taken. This is then travel into the recipient area( Area of excised scar), if compulsioned it is trimmed. Sutures or functional glue is applied. (Illustration 33.6) Dressing is done. Antibiotics and NSAIDs are administered for 7 days.All the punch techniques require a operative follow up after 1 workweek to check for the donor/ recipien t site and removal of sutures, if infallible.In selected cases, when scarring is linear and extensive, scar fiat techniques such as Z, M and Y plasty whitethorn be useful. These need to be performed by a dermatosurgeon properly trained in execute these procedures. 41, 42Various techniques such as microneedling, threadlifts are cosmos utilize in atrophic acne scars. Intralesional steroids and cytotoxics along with silicone sheets are the mainstay for hypertrophic scars.Skin needling, overly called collagen induction therapy or needle dermabrasion is the technique of rolling a crook composed of a barrel studded with hundreds of needles, which create thousands of micropunctures in the skin to the level of the papillary to mid-dermis. 43 The optimum scars to treat with skin lesion are the similar as fractional laser resurfacing rolling acne scars, trivial boxcar scars, or erythematous or hypopigmented macular scars. A dermaroller device is used with needles of length 1.5 to 2.5 mm is rolled crosswise the skin with pressure in multiple directions until the area demonstrates uniform pass with flying colors bleeding with thousands of micropuncture sites. One study describes rolling the device quaternion times in four different directions (horizontally, vertically, and diagonally right and left) for a total of 16 passes. 44 In the authors experience, the number of passes required to achieve uniform pinpoint bleeding of the manipulation area is varying and is inversely proportional to the density of the needles on the rolling barrel. Usually, three or much treatments are required to achieve optimal clinical benefit, detached by four-week intervals. Figure 33.6 shows mature results with dermaroller microneedling.Microneedling with fractional radiofrequency (MFR) technology is now be used for acne scars. MFR is useful for distensible scars and non- distensible scars with associated volume loss. The procedural expound and clinical studies nourish been d etailed in Chapter 10.Non-surgical face lifts with threads are also being used for acne scar treatment. Polydioxanone (PDO) threads are used for lifting and tissue tightening and scar resurfacing it stimulates production of collagen and fibroblasts in response to its implantation. Threadlift with PDO is indicated in tolerants of scars who cannot come repeatedly for multiple number of sittings for derma roller, or do not want to undergo laser/ lights or radiofrequency treatments. Evidence found studies are lacking with this technique. The procedure has been detailed in chapter 15.Intralesional triamcinolone 10-40 mg/mL with or without cytotoxics, like 5-fluorouracil, is indicated for the treatment of hypertrophic scars and keloids. These are repeated at 3-4 weekly intervals until resolution fear is taken to avoid atrophy. 45, 46, 47, 48Administration of fluorouracil (5-FU) or bleomycin into the scars, results in gradual flattening of the scars. 49, 50, 51 5-FU inhibits rapidly pro liferating fibroblasts found in dermal wounds. 52The therapy is effectual for facial acne scars as monotherapy, 53, 54 and in combining with intralesional corticosteroids and a 585 nm pulsed disgrace laser. 50 Studies with 5-FU use a concentration of 50 mg/mL with a total dose per session ranging from 50 mg to 150 mg and can be given multiple times a week to increase treatment efficacy. Bleomycin is another antineoplastic agent that inhibits collagen synthesis through cytotoxic effects on rapidly dividing fibroblasts. 55, 56Silicone dressings are chemically and biologically inert silicon sheets or gels are found to be useful in flattening keloids and hypertrophic scars, reducing discoloration and making scars cosmetically acceptable. 57, 58Scarring in areas which are subjected to repeated movements (chin, marionette lines) are prone to become more obvious with aging. The synergistic combination of botulinum toxin and fillers may prove to be a useful modality in these scars. Botul inum toxin relaxes the muscles and hence decreases the plastic forces surrounding the scar. 20Combining 2 or 3 modalities of acne scar treatment in a single session or nonparallel think of the procedure can prove advantageous to a monotherapy. Various combination therapies are practiced. Combination of different interventions can result in copasetic improvement of acne scarring.It is useful to combine subcision with various modalities. Subscision treatments followed by microneedling performed immediately the day after and TCA 15% peel done a fortnight ulterior was found to improve the grade of scar. 59 Another sequential combination therapy is TCA peeling, subcision, and accompanying fractional laser irradiation. Dot peeling and subcision is done twice at an interval of 2-3 weeks and fractional laser irradiation is done every 3-4 weeks. The continuation of therapy is 12 months. A marked decrease in acne scar moroseness was noted. 60 Combination of PRP with microneedling, frac tional CO2 and erbium YAG also constitutes an effective substitute(a) that produces synergistic benefits with fewer adverse effects. 61, 62, 63The aim of good postoperative care is to prevent or minimize complications and ensure early recovery. Preventive actions must(prenominal)(prenominal) be taken promptly to avert complications, which may lead to inconceivable aesthetic or functional result. This is most important in ablative case resurfacing procedures, particularly in darker skinned patients, where pigmentary alterations are common. Supportive medical examination therapy and a careful maintenance program are substantial to maintain results of surgical treatment in most patients.Complications related to individual procedures are discussed in details in respective chapters. In general, the complications include conditions such as expeditious herpes simplex, immunosuppressive conditions, which may predispose to infection and hold up healing. Post inflammatory hyperpigment ation is a common and dreaded complication of acne surgery, in particular in dark skinned patients. Patients with unrealistic expectations or uncooperative patients who do not follow treatment regimens are more prone to win complications. Adequate counselling, priming the skin and supportive medical therapy, apart from good intra- and postoperative care are essential for satisfactory surgical outcomes.The tips for heed based on the authors experience are describe in Box 33.4Box 33.4 Pearls and PitfallsProcedural treatment in acne provides perfumed results. These are an adjunct treatment in active acne, however post acne scarring is being better managed with the advent of various procedural interventions. Fractional resurfacing lasers have proven to be one of the most beneficial technologies for post acne scarring. keen-witted use of combination therapies in a single or sequential sessions have a synergistic role and are increasingly being used in clinical practice. Appropriate patient selection and a good understanding of patient expectations are vital to achieve an optimal therapeutic outcome.Acne surgery involves the use of appropriate surgical interventions for treatment of active acne as well as improving cosmetic outcomes in postacne scarring. In active acne, surgical intervention is used as an adjunctive to medical therapy. The treatment of post acne scars involves a multimodal approach as different types of scars may exist in an individual. Each scar and each patient must be evaluated and treated accordingly. The main goal of treatment is to achieve maximal improvement rather than perfection. The procedures can be classified as resurfacing, lifting, excisional modalities.For superficial scars, non-invasive or minimally invasive techniques such as microdermabrasion, superficial chemical peels or the newer non ablative lasers, are better treatment options. For deeper scars, a have approach with subcision, punch excision techniques in conjunction w ith resurfacing procedures, are essential to achieve optimum results. Many complications can be prevented by everlasting(a) preoperative evaluation, sound surgical technique, and careful follow-up care. Good patient rapport and effective communication with patients are invaluable.