Surgical therapy of acne scars in pigmented skin

Journal of Drugs in Dermatology, Jan, 2007 by James M. Swinehart

Abstract

Problem: Surgical therapy of moderate or severe acne scars in African-Americans, Hispanics, and other individuals with darkly pigmented skin.

Challenges: Dyspigmentation in more darkly complected individuals following surgical or resurfacing operations creates an additional risk in an already difficult series of procedures. Other challenges include the lack of response of deep acne scars to lasers in general, the unpredictability of various techniques, and the long learning curve involved with dermabrasion.

Methods: Case reports are presented in which chemical peeling, punch grafting, punch elevation, subcision, dermal grafting, and wire brush and diamond fraise dermabrasion were employed in one Hispanic and one African-American patient.

Results: A satisfactory outcome was attained in each patient.

Introduction

The dearth of advertisements in the cosmetic surgery yellow pages for treatment of acne scars attests to the challenges facing the dermatologic surgeon interested in the correction of this postacne malady. Ultrapulsed or other lasers generally do not go deep enough into the skin to correct acne scars, since the maximum depth of 60 microns will certainly not be expected to provide much improvement in a scar one or 2 mm in depth. The same (unknown) factors that cause the patient's skin to heal abnormally following bouts of acne often presage unpredictable healing from the various types of acne scar surgery.

Rotating brush or diamond fraise dermabrasion has long been the standard of care for acne scars; however, Fluroethyl Spray is now hard to obtain. Currently, dermabrasion is not necessarily taught in residency programs. Without excellent hemostasis, dermabrasion can be a messy procedure and definitely has a long learning curve. The risk of increased or decreased pigmentation following resurfacing in ethnic skin may be compounded by a lack of familiarity with treatment of darker complexions due to various socioeconomic factors.

Test spots with dermabrasion and chemical peeling should always be performed prior to resurfacing of pigmented skin. (1,2) Test areas should be strongly considered with respect to dermal grafting, subcision, punch grafting, and punch elevation. The development of tumescent anesthesia by Klein, Coleman, and others has provided an excellent means for the performance of this procedure in the outpatient setting. (3) The techniques employed and discussed by John Yarborough, one of the all time masters of dermatologic surgery, should be employed. (4) These include the "triangular stretch" method and the "triple crisscross" method. (5) Newer bleaching agents for postinflammatory hyperpigmentation have been discussed extensively in this and other journals.

I do not feel that there are any significant anatomic differences in pigmented skin that would affect the choice of surgery for acne scars. Of course, both patient and physician would like some assurance as to the final status of skin pigmentation once complete healing has taken place. Medical history is important, but the healing from unrelated types of injury may not be relevant. Therefore, test spots to the proposed modalities are of paramount importance. The absence of an untoward test spot result, of course, does not preclude the possibility of a scar or uneven pigmentation when the full face is treated. However, it is nearly always preferable to have a test spot rather than to skip it, even if it means delaying the definitive procedure by several weeks.

Patient selection and management of patient expectations in the initial and subsequent consultations are perhaps more important than any group of methods. (6,7) Patients must understand that, in general, the attainment of perfection is not possible in cosmetic surgery and in treatment of acne scars in particular. I tell them that the percentage of improvement will always be "some number between 0 and 90%" and that 40% to 50% improvement is a good result. Indeed, reputable physicians never guarantee results. Also, beauty is in the eye of the beholder, and patients should never compare themselves to others or to their prepubertal skin texture. Most operations will need secondary or ancillary procedures and/or touch-ups, always at an additional cost. The outcomes depicted in the photographs here, while pleasing, are certainly not to be expected in every case.

Case Report 1

A 35-year-old Hispanic male presented with very deep pitted and fibrotic scars on the face and both cheeks. Initially, a dermabrasion test spot was performed on the right cheek, which healed well. Four months later, punch elevation was performed on the left cheek on 63 scars and punch grafts were placed into an additional 8 scars. Three months after this, 6 dermal grafts (8) and 27 punch grafts were inserted into and under acne scars on the right cheek. Two months later, the punch-float technique was used on 35 scars on each cheek. Two months subsequent to this, a full-face dermabrasion with Fluroethyl Spray was performed utilizing soft and coarse wire brushes to the cheeks as needed, with fine and medium diamond fraises to the periorbital region, chin, and nose. Sedation was provided with 15 mg Valium, 50 mg Dramamine, and 10 mg Percocet, as well as with tumescent solution with 0.1% Xylocaine plus Epinephrine 1:1,000,000 with sodium bicarbonate. For nerve blocks throughout the face, 1% Xylocaine plus Epinephrine 50/50 with 0.5% Marcaine was used. The immediate periorbital region was treated with a combination of Jessner's solution and 20% trichloroacetic acid.