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COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE
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CHAPTER 26 Facial Scar Revision
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Suzan Obagi, MD Angela S Casey, MD
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Facial scarring is a common complaint among patients seen by cosmetic dermatologic surgeons Several etiologies, including inflammatory acne, trauma, previous surgical procedures, and viral infections such as varicella or herpes simplex, can lead to permanent scarring Treatment of scarring remains an evolving subject among dermatologic surgeons In order to better understand the optimal treatments for facial scarring, we first explore the different morphologies of facial scars This is followed by a review of treatments grouped according to each distinct type of scar We conclude with a discussion of combination treatments and how to apply these modalities to the patient with acne scarring to achieve the maximum results
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CHAPTER 26 FACIAL SCAR REVISION
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FIGURE 26-2 Valley scars viewed in direct light (left) and indirect light (right) cally small (1 2 mm) and have a wide aperture with steep edges that taper to a single point at the base, as if the skin has been pierced by an ice pick An epithelial tract forms along the sides of the opening within the scar These scars may be shallow or deep, and may extend as far as the dermal subcutaneous junction Boxcar scars are round to oval in shape with well-defined vertical edges and a flat base, as if the scar has been punched out of the skin They typically range from 01 to 05 mm in depth and are usually widely spaced out on the skin surface, occurring as solitary scars Unlike ice pick scars, this type of scar does not converge to a single point Shallow/atrophic scars present as a cluster of miniaturized boxcar scars They usually emerge in groups of four or more and occur mainly on the cheeks Valley scars ( rolling scars) are deeper and have an undulating appearance that is best appreciated in indirect lighting (Fig 26-2) Valley-shaped scars arise from a variable loss of dermis and/or subcutaneous tissue Because acne and varicella scars are dermal defects, they require a treatment modality that reaches the dermis in order to achieve clinical improvement
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Pretreatment Considerations
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Open communication and good rapport with the patient cannot be emphasized enough Patients paying for cosmetic procedures tend to have high expectations of the results; therefore, realistic outcomes of the various treatment modalities must be discussed in detail with the patient prior to the procedure Potential side effects and adverse outcomes must also be revealed to the patient prior to the procedures Additionally, it is important to discuss expected downtime and possible discomfort during the recovery period Furthermore, pre- and postoperative skin conditioning regimens as well as necessary time and monetary investment should be covered in detail during the patient consultation Finally, assessment of the patient s pain threshold and discussion of topical, local, or oral analgesia should be initiated Pre- and postoperative photographs are mandatory as these photographs serve as an important source of documentation Patients should remove their makeup prior to having the photographs taken, and all photography should be performed in a standardized manner with constant lighting, settings, and views A complete and thorough discussion of these issues, while important, is beyond the scope of this chapter; therefore, we direct readers to several references by the senior author2 6
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MORPHOLOGY OF ATROPHIC SCARS
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There are two broad classifications of facial scarring: atrophic and hypertrophic This review focuses on atrophic facial scarring We expand upon the classification previously proposed by Jacob et al1 by dividing atrophic facial scarring into four main types: ice pick, boxcar, shallow/atrophic, and valley/rolling scars (Fig 26-1) Ice pick scars are typi-
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Ice pick scar
Rolling scar
Boxcar scar
Epidermis Shallow/Atrophic
Dermis
Fatty tissue
FIGURE 26-1 Schematic illustrating the different types of acne scars
ALGORITHM FOR ATROPHIC SCARS
Ice Pick Scars
Because of the deep and steeply sloped morphology of ice pick scars, fillers do not typically produce significant cosmetic improvement7 Likewise, resurfacing is not optimal since the depth of the scar usually far exceeds that which can be safely reached with resurfacing procedures Therefore, the treatment choices include punch excisions, punch grafts, and spot trichloroacetic acid (TCA) peels (Fig 26-3)
trephine The donor grafts are typically obtained from the postauricular skin Donor grafts are taken 05 mm larger than the excision, which allows for optimal alignment after healing and scar contraction take place The graft is placed so that it is level with the surrounding skin, and it may be held in place with Steri-Strips (3M, St Paul, MN) The donor site is bandaged as described earlier Approximately 6 weeks following graft placement, the area can be leveled with dermabrasion, if necessary SPOT TRICHLOROACETIC ACID Another effective treatment for ice pick scar revision is spot treatment with TCA TCA causes precipitation of proteins and coagulative necrosis of cells in the epidermis and collagen necrosis in the papillary and upper reticular dermis Dermal collagen production and remodeling occurs over several months and results in dermal thickening Lee et al described the technique of using a sharpened wooden applicator to firmly and directly apply 65% to 100% TCA into the ice pick scar They found that the application of a higher TCA concentration was more effective in treating atrophic acne scars11 Based on our experience with this method, extreme caution must be used since the application of such a strong concentration of TCA can actually cause deepening and widening of scars We prefer using 30% to 50% TCA These treatments can be repeated at 6-week intervals until satisfactory results are achieved
skin or that the surrounding skin be planed down to the level of the scar base Options for treating this type of scarring include punch elevation or resurfacing with dermabrasion, laser, or modified phenol peels (Fig 26-4) These scars do not respond well to superficial or medium-depth peels because of the depth of the scar when compared to the surrounding skin Additionally, the underlying fibrosis of the dermis in these scars prevents the scar from stretching and smoothing out with peels PUNCH ELEVATION Punch elevation describes the technique of elevating tissue within a depressed scar so that it is level with the normal skin surface surrounding it When choosing a site to be punch elevated, it is essential that the scar have a smooth, normal base and sharp vertical edges Using a trephine that is equal in size to the inner diameter of the scar, the inner aspect of the scar is excised down to subcutaneous fat The tissue is then elevated to sit slightly above the surface level of the skin to overcome the retraction that occurs during the healing phase The tissue may be held in place with Steri-Strips (3M, St Paul, MN) or 5-0 or 6-0 polypropylene (Prolene, Ethicon, Inc) The area is bandaged as discussed previously, and the patient is seen in follow-up 1 week later for suture removal/evaluation DEEP PEELS/PHENOL PEELS Phenol peels are deep peels that quickly penetrate the skin to the level of the reticular dermis12; the efficacy of the phenol is due to the resulting protein denaturation and coagulation as well as induction of new collagen synthesis13 Phenol requires hepatic metabolism followed by renal excretion Systemic absorption of phenol can directly cause arrhythmias, so patients must be on a cardiac monitor throughout the procedure One of the significant risks of phenol peels is permanent hypopigmentation 14; therefore, careful patient selection is essential The original formulation of phenol and croton oil has been modified to prevent the peel from penetrating as deeply as the Baker-Gordon formulation Both Hetter and Stone independently described a modification of phenol peels that yields better control over depth of penetration14,15 This has allowed patients with various skin types to be treated with favorable results16 While laser resurfacing with CO2 and Er:YAG (erbium:yttriumaluminum-garnet) has largely replaced
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