Part III: Atrophic- and acne scars and Stretch marks before after treatment
Treatment of atrophic scars has its own characteristics and depends on the type of scars, their age, as well as the qualifications of the doctor. Today there is no universal method of getting rid of atrophic scars after acne, accidents or operations.
Treatment of atrophic scars with microdermabrasion
Tretment of atrophic scars with microdermabrasion consists of polish the edges of the scar with aluminium sand (aluminum oxide microcrystals – Al2O3) and tightens the atrophic scar bottom to the skin surface with vacuum (Fig.1).
The microdermabrasion method be able to remove atrophic scars after acne, chickenpox, road accident or after surgery. This method is excellent to elevate such type of atrophic scars as a Boxсar, Ice pick and Rolling, if they are fresh. Old atrophic scars can be significantly improved and smoothed. However, microdermabrasion can not lift the bottom of the old (mature) scar to the skin’s surface, since it is firmly fixed deep in the dermis.
Fig.1. Treatment of atrophic scars with microdermabrasion (fresh scar on the forehead)
Removal of atrophic scars by microdermabrasion does not require anesthesia, the recovery period being 4-10 days. Patients retain social activity. In some countries this method is called “A weekend procedure”. To archive tangible results, 3-5 procedures are required with a 3-4 week interval (Fig.2).
Fig.2. Microdermabrasion of fresh scars on the forehead before and after
Correction of atrophic scars by deep rotational dermabrasion
Correction of atrophic scars by deep rotational dermabrasion (surgical dermabrasion) with special rotational discs was first described by Kromayer in 1905. The abrasive fraises with 20 000 – 60 000 r / min were introduced in the 60`s of the last century (Fig.3). These devices are used for the correction of hypertrophic, atrophic and normotrophic scars, but cannot be used for active keloids. Papillary derma layer is the application point.
Fig.3. Deep rotational dermabrasion with rotating fraise
In relation to old scars, we not use the term “treatment of atrophic scars”, but only the “correction”, because the scar is already mature. Correction of atrophic scars by deep rotational dermabrasion consists in removing not so much direct the scar tissue than the normal skin surrounding the scar (Fig. 4). Thus, deep rotational dermabrasion cannot remove scars after acne. It is used to smooth the difference between the bottom of the atrophic scar and normal skin. Deep rotational dermabrasion applies only for old scars correction.
Fig.4. Correction of atrophic scars by rotational dermabrasion. Scheme
Fig.5. Old atrophic scars before and after deep rotational dermabrasion
Treatment of atrophic scars with microneedling
Microneedling is also known as collagen induction therapy with a dermaroller (Fig.6), dermapen or dermashtamp as well as RF microneedling. With the help of microneedling it is possible to remove or minimisate atrophic scars of the such types as Boxcar and Rolling, if they are fresh (before 1 year old). Chances increase when microneedling is combined with other treatment of atrophic scars methods. Microneedling as an independent method practically does not work on old atrophic scars. Therefore, it is impossible to remove scars after acne, accidents and operations which are older than 1 year. Collagen induction therapy also does not work to Ice pick scars.
Fig.6. Microneedling or collagen induction therapy of atrophic scars
The mechanism of action of microneedling
When micro needles penetrate into the dermis, hundreds of microscopic channels form in the skin (Figure 7). In response to this microinjuries a whole cascade of complex sequential reactions of the healing process is activated. The special skin cells, fibroblasts, begin to patch and darn those microscopic channels which made by microneedles. Fibroblasts make synthesise of collagen islands in the lumen of micro-channels. These islands stretch to each other, and gradually bring the edges of scars together (Fig.9). Thus, atrophic scars become smaller and narrower (Fig. 10).
Fig.7. Atrophic scars before microneedling procedure
Fig.8. Micro-needles in the skin
Fig.9. Collagen synthesis in the lumen of micro-channels
1-2. Atrophic scars
3. Collagen fibers
Fig.10. Reduction of atrophic scars
Fig.11. Treatment of atrophic acne scars before and after microneedling
Treatment of atrophic scars with scar removal creams and gels
Of course, no creams or gels can remove scars after acne, accidents or surgery completely. Each individual case surely requires a consultation with the attending physician to select the necessary scar cream or scar gel, because some products are capable of not only improving, but as well as of worsening the scar condition. The appointment of Contractubex for atrophic scars and stretch marks is completely erroneous and undesirable (Fig.12). The same can be said about silicone gels from scars: Kelo-cote, Dermatix, Strataderm, MedGel, Scarguard. They can be used for the prevention and treatment of hypertrophic scars, and for the prevention of keloid scar (not for treatment or removal!). Attempts to treat or remove scars after acne with silicone gels and contractubex contribute to sagging them even more!
Fig.12. Contractubex is intended only to prevent keloid scars
Reduction of atrophic scars by subcision
Subcision (subcision) in Latin means subcutting. Subcision can improve or remove scars after acne, injuries and surgeries. This method was developed by american dermatologist David S. Orentreich specifically for the correction of old atrophic scars (Fig.13).
The principal of this method is as follows. The process of scar maturation is accompanied by the development of connective tissues that fixate the scar bottom in the dermis. Connective bridles are subcised by the special needle and the released scar bottom elevates to skin surface. The defect aligns.
Fig.13. Subcision of atrophic scars. Scheme
Reduction of atrophic scars by subcision requires certain skills and practice. Subcision of atrophic scars performs under a local anesthesia, as this is a microsurgical intervention (Fig.14).
Complications of subcision are:
– violation of innervation due to the intersection of the nerve;
– massive bleeding as a result of crossing vessels;
– bacterial infection.
Fig.14. Subcision for atrophic scars
Fig.15. Subcision for atrophic scars after injury before and after
Subcision can be combined with other methods of atrophic scars correction. There are lots of options for this! For example, subcision and microneedling. The combination of subcision and microneedling can improve old scars after acne, injuries, operations (Fig.16).
Fig.16. Atrophic scar before and after combined procedure of subcision and microneedling
Correction of a atrophic scar by punch excision
Punch – excision is application of a round knife for remove atrophic scars after acne or chicken pox (Fig. 17).
Fig.17. Punch-excision of a atrophic scar
Surgical intervention is performed under local anesthesia. The cut-off skin cylinder is lifted with tweezers and cut out with scissors. Then the edges of the wound are close with stitches. Thus, the round scar is transformed into a linear one.
Treatment of atrophic scars with fillers
Boxcar and Rolling type of atrophic scars can be treated with hyaluronic acid fillers. But it is useless to use fillers for improve Ice-pick scars. This is because that the bottom of the ice-pick scar is so narrow that it is impossible to squeeze it out to the skin surface with the help of fillers. Filler injections are often combined with subcision, which supposedly improves the effect. In fact, there is scientifically confirmed evidence that the combination of subcision of atrophic scar and using of hyaluronic acid filler in one procedure is ineffective.
Fig.18. Combined correction of the scar on forehead with filler and Botox
Laser treatment of atrophic scars
For laser treatment of atrophic scars ablative and non-ablative lasers are used. Ablative lasers heat and evaporate water that is contained in epidermal cells. Non-ablative lasers influence on the dermis, leaving the epidermis intact.
Carbon dioxide laser (ablative CO2 laser), a wavelength of 10,600 nm is the most aggressive. Carbon dioxide laser has all side effects and complications, such as hyperpigmentation, transformation of atrophic scar to keloid, lasting redness.
Fractional ablative laser (Fraxel) is a type of CO2 laser. It is necessary multiple repeated procedures (minimal 7-8 times) with an interval of 3-5 weeks to remove scars after acne by fractional laser. Fractional laser for treatment of fresh atrophic scars is much more effective than for correction old scar. OLD atrophic scars (older than 1 year) DO NOT respond to fractional laser!
Fig.19. Treatment of fresh atrophic scars with an ablative fractional laser (Fraxel)
Erbium laser (Er: YAG, ablative) has a wavelength of 2940 nm. It in exactly the same way as the carbon dioxide laser is absorbed by the water in the skin cells and is used for resurfacing and reducing the depth of atrophic scars. When water is evaporated from the reticular layer of the dermis, the collagen fibers become more compact and make room for synthesize new collagen to the free space by fibroblasts. Unlike a CO2 laser the Er: YAG laser has a very low thermal effect. This is the so-called. cold ablation with minimal thermal damage.
Vascular laser (pulsed dye laser – PDL, non-ablative). For the correction of erythematous atrophic scars, pulsed dye lasers with a wavelength of 585-595 nm are used. The mechanism of action is the elimination of the vascular component (bleaching). The point of application lies in the impact of high energy on red blood cells in the lumen of blood vessels, which are the substrate of the red scar. Vascular (non-ablative) laser – simply “glues” the vessels in the scar (Fig.20). During treating scars with the vascular laser complications as a rule is not observed.
Fig.20. Treatment of the atrophic scars with vascular laser.
Treatment of atrophic scars with chemical peels
Depending on the depth of impact, all chemical peels are divided into:
- superficial – several layers of cornified epidermal cells;
- median – the entire depth of the stratum corneum;
- deep – to the entire depth of the epidermis, to the border of the basal layer and papillary dermis.
Alpha hydroxy acid does not have any significant effect, so their use for the treatment and correction of scars is impractical.
TCA chemical peels are used for fresh and old atrophic scars types Boxcar and Rolling. For fresh scars the concentration of 15% TCA peels is sufficient, for old scars – 25-35%. After an chemical peel the skin gets a powerful boost to regeneration. This is due to the influx of stem cells necessary for recovery. However, there is an opinion that the resource of stem cells is not infinite, and the more often chemical peels are perform, the faster their resource is exhausted.
Fig.21. Removal of atrophic scars by chemical peels. Post-accident scars before and after the TCA peel
Fig.22. TCA cross
Reduction of atrophic scars by TCA cross (cross – chemical reconstruction of skin scars)
For removing scars after acne using concentrated TCA 50-80% (trichloroacetic acid). TCA cross must be apply exclusively to ice pick scars. In essence, TCA cross is not a peel, because no exfoliation (peeling) is not here. Acid is applied dotted on each atrophic acne scar. Due to its increased fluidity, trichloroacetic acid penetrates to the bottom of the ice pick scar. As a result of such local burns and local inflammation, the walls of the scar in the depth stick together, and the scar gradually decreases. The result can be assessed after 3-4 TCA cross procedures.