J AM ACAD DERMATOL
VOLUME 59, NUMBER 4
Table II. Surgical management
Skin graft ‘‘Subcision’’
Another treatment modality used that focuses on hypertrophic scars and, although less effective, keloids is silicone dressing. There is variable support to the silicone itself, with results more likely attributable to occlusion or hydration. Pressure was also one supported mechanism along with other rationales that include temperature, increased oxygen tension, electrostatic properties, or immunologic effects. There are conflicting reports as to its efficacy. One study noted improved pruritus, pain, and pliability but found no improvement in pigmentation, average elevation, or minimum elevation of scars.35 A separate review of effects, efficacy, and safety determined that ‘‘although the mechanism of action of silicone elastomer sheeting has not been completely elucidated. . .it appears to be an effective means of treating and preventing hypertrophic and keloid scars and can be used with little risk of serious adverse effects.’’ The included commentary pointed out that ‘‘they work clinically and are safe and quite frankly should be part of all hypertrophic scar and keloid therapy.’’36 Rarely, side effects include pruritus, contact dermatitis, maceration, skin breakdown, xerosis, and odors.
Surgical management is an essential tool in the armamentarium against acne scarring. The icepick, boxcar, and rolling scars are frequently addressed by surgery (Table II). Punch or elliptical excision to the subcutaneous level is preferred for icepick scars. A scar ‘‘requiring a punch larger than 3.5 mm is repaired by elliptical excision or punch elevation because these larger defects lend to ‘dog ear’ formation on the face.’’19 The goal is to trade a larger, deeper scar for a smaller, linear closure that will hopefully be less noticeable and possibly fade with time. Rarely, a skin graft may be required rather than primary closure. This usually only applies if a sinus tract or wide-based lesion is unroofed. A second alternative, punch elevation, is a method of treatment for depressed boxcar scars. The biopsy tool shouldmatch the inner diameter of the lesion and the base should appear normal because it will be elevated to the skin surface. After the punch is done and the base elevated, it is sutured flush with the normal-appearing skin and allowed to heal in place. Finally, the surgical choice for rolling or depressed scars (definitely not for icepick or atrophic scars or infected areas) is ‘‘subcision.’’ This was first described by Orentreich and Orentreich37 in 1995 as an original word created from ‘‘subcutaneous incisionless.’’ A tri-bevel needle is probed under the lesion through the needle’s puncture so it is not a true incision. This movement results in the releasing of papillary skin from the binding connections of the deeper tissues and creates controlled trauma that leads to wound healing and associated additional connective tissue formation in the treated location. It may be necessary to perform variable depths of sweeping, fanning, or lancing to disrupt the fibrous connections and multiple attempts or sessions may be required. Although uncommon, there is the potential for bruising, hypertrophy, cysts from pilosebaceous unit disruption, infection, additional scar, or worsening of the scar.
Intervention for hypertrophic scars or keloids must be done with care because the patient is known to have a propensity for that type of response. There is argument regarding the appropriateness of surgery with both types of scars but more so with keloids. If undertaken, some say that the incision must be within the lesion boundaries to prevent further extension. In addition, steroids are commonly administered locally. Therefore, the goal would be more to reduce overall size or debulk rather than completely excise. Secondary, refining procedures may also be used in the areas if desired or needed. It was found in a study of 21 patients (10 male, 11 female; age 17-59 years, mean age 35.52 years; Fitzpatrick skin I-III) that there was good improvement, as rated by both independent assessors and patients, when laser resurfacing was done after punch excision of scars.38 The noted advantage was that punch excision eliminates the deeper components and allows for only superficial laser treatment with fewer passes. So, if surgery is done, laser resurfacing may also be a Table II. Surgical managementconsideration because the chance of unwanted side effects could be reduced. Medical, additional surgical, or other procedural interventions are also available after any surgical management and may be appropriate.
Acne Scarring A review and current treatment modalities BACKGROUND and ACNE SCARS ACNE SCARS page 2 ACNE SCAR TREATMENT and MEDICAL MANAGEMENT SURGICAL MANAGEMENT PROCEDURAL MANAGEMENT PROCEDURAL MANAGEMENT page 2 TISSUE AUGMENTATION TISSUE AUGMENTATION page 2 TISSUE AUGMENTATION page 3 TISSUE AUGMENTATION page 4 Light, laser, and energy therapy Light, laser, and energy therapy page 2 Light, laser, and energy therapy page 3 Light, laser, and energy therapy page 4 Conclusion and REFERENCES Manufacturers of brand name drugs mentioned in this article