F or most, acne is a passing phenomenon of adolescence, just another obstacle on the path to adulthood. However, some unfortunate individuals are forever scarred by the process. Such acne scarring is variable in terms of intensity and morphology, but all scarring shares the feature of indefinite persistence. Many affected patients seek intervention to address the defects created by acne scarring. In this article, we describe an approach that addresses acne scarring with a combination of CO2 laser skin resurfacing and microdroplet silicone injection. An Overview of Acne Scarring Acne is a disease of the pilosebaceous unit. While the pathogenesis of acne is not fully understood, one important component is inflammation. Left unchecked the inflammatory mediators induced by acne can damage dermal and subcutaneous structures resulting in permanent scarring.1 This process can result in a wide range of clinically apparent scars. Acne scarring is difficult to precisely define and classify, but dermatologists “know it when they see it.” Some scars have a narrow, deep, punched-out appearance, commonly referred to as ice pick scars. Other scars present as ill-defined depressed dermal troughs. These are sometimes referred to as rolling scars or atrophic scars. Other scars have different morphologies including hypertrophic scars and multi-channeled fistulas.2 No widely accepted classification system exists, but clinical experience affirms that there is a spectrum of scars that may result from acne. Just as there are many types of scars that may eventuate from acne, many treatments have been described that aim to correct these flaws. As with any medical condition, primary prevention of acne scarring is the most effective treatment. We, as dermatologists, are uniquely qualified and positioned to serve patients in this regard. However, many patients present for treatment only after scarring has occurred. And, for these patients, there are many effective treatment options. Treatments include dermabrasion, chemical peeling, laser resurfacing, non-ablative laser treatment, rhytidectomy, subcision, excision, punch grafting, fat transfer, filling agents and combinations of these treatments.3 (See table 1 ) Most practitioners match various treatment modalities with clinical scar variants. Here, we will describe the successful outcomes we have achieved with concurrent CO2 laser resurfacing and microdroplet silicone injection. CO2 Laser Resurfacing Facial skin resurfacing for the treatment of acne scarring has been practiced for decades. Initially, resurfacing was accomplished through dermabrasion and chemical peeling. Beginning in the 1980s some practitioners began using ablative CO2 lasers to perform skin resurfacing.4 Since then laser technology has advanced, and the advent of improvements such as the computerized pattern generator have made CO2 laser resurfacing more reproducible and less operator dependent. In our practice, CO2 laser resurfacing has largely replaced dermabrasion and chemical peeling because it produces a more predictable depth of skin injury, leading to more consistent results. CO2 laser skin resurfacing has been used extensively in skin rejuvenation. The laser targets intracellular and extracellular water and produces a controlled thermal injury to the epidermis and superficial dermis. This injury stimulates the skin’s healing mechanisms to produce new collagen thereby rejuvenating sun-damaged skin.5 The same principles apply in treating acne scarring. You can target the surface texture irregularities of acne scarring by implementing the laser. Most patients achieve significant improvement. Studies suggest that the range of improvement is 25% to 90% after a single treatment,5,6 and almost 90% of patients note improvement in their final appearance.7 (See figures 1A and 1B.) Microdroplet Silicone Injection In our experience, CO2 laser resurfacing works the best for acne scarring with superficial skin irregularities. Laser resurfacing is less effective for broader zones of atrophic scarring. These scars, characterized by loss of tissue and depression of the affected skin, are better suited to treatment with filler substances. We have found microdroplet silicone injection to be a useful therapy for this type of acne scar. Silicone, in some form, has been used for soft tissue augmentation for many decades. There are currently two FDA approved silicones available for use in the United States: Silikon 1000 (Alcon Laboratories, Inc., Fort Worth, TX) and Adatosil 5000 (Bausch and Lomb Surgical, Claremont, CA). These two silicones are classified as medical devices and are indicated for ophthalmologic use for intraocular injection in the treatment of complicated retinal detachments.8 They were approved by the FDA in 1997 and 1994, respectively. The availability of highly purified, medical- grade silicone has supported the use of silicone as a soft tissue filler as a legitimate off-label use of the substance. Silicone has many desirable attributes as a material for soft tissue augmentation. Silicone refers to a group of polymers based on the element silicon. Degree of cross-linking and other chemical attributes determine the physical properties of silicone.9 Medical grade silicone is a clear, viscous, highly stable liquid. When injected into the skin in minute quantities, silicone induces fibroplasia.10 This natural host response uses the body’s own collagen to generate volume resulting in natural, supple tissue augmentation. Furthermore, the results last many years. When treating acne scarring with silicone injections, we use the microdroplet technique. A small volume of 0.005 ml to 0.01 ml or less of silicone11 is injected into the deep dermis of each targeted acne scar. The scars that are most responsive to this treatment are the broad, rolling, atrophic scars characteristic of some patients with acne scarring. Remember that the filling effect of the treatment comes from the body’s response to the silicone, not from the volume of the silicone itself. We recommend that you retreat the patient at no shorter than 3-month intervals as needed until the desired level of correction has been obtained. Three to six treatment sessions are average for optimal response. (See figure 2A and 2B.) Silicone injection is effective and well tolerated by the majority of patients, but as with any treatment there are potential adverse effects. Common side effects include bruising, swelling and pain. These are minor and self limited and related to the injection process rather than the substance injected. As with any cosmetic procedure there is the potential for over-correction, under-correction or asymmetry. As the results of silicone augmentation are long lasting, so is any perceived over-correction. The most worrisome potential complication is the development of persistent inflammatory lesions at the sites of silicone injection. These may occur years to decades after treatment with silicone.12 The incidence of such reactions appears to be less than 1% and seems to correlate with the injection of adulterated material or possibly improper injection technique, especially large volume injection.13 Still, the true incidence and etiology of such reactions remain unknown and patients must be properly advised of this risk. Combination Approach Patients with acne scarring often have a mixture of types of scars. It’s common to find surface irregularities and broad atrophic scarring together in the same patient. In such cases, we use a combined approach with concurrent silicone microdroplet augmentation of the atrophic scars and CO2 laser resurfacing of the affected zones in the same operative treatment session. This stimulates collagen formation in the deeper portions of the dermis by the silicone and in the upper portions by the laser. This results in a tightening of the skin and a diminishment of visible scarring. This combined procedure can be supplemented by further silicone treatments as needed in future sessions. By pairing these individually permanent interventions, many patients can attain satisfactory improvement of acne scarring. (See figures 3A and 3B.) Long-Term Results Acne scarring is a challenging dermatologic problem and a perfect solution remains elusive. With skill and careful consideration the dermatologic surgeon can successfully intervene and mitigate the effects of this lifelong condition. Combined CO2 laser skin resurfacing and microdroplet silicone injection is another tool that can provide patients with long-term relief from the disfigurement of acne scars. Disclosure: The authors have no conflict of interest with any subject matter discussed in this article.
A Combination Approach to Treating Acne Scarring
F or most, acne is a passing phenomenon of adolescence, just another obstacle on the path to adulthood. However, some unfortunate individuals are forever scarred by the process. Such acne scarring is variable in terms of intensity and morphology, but all scarring shares the feature of indefinite persistence. Many affected patients seek intervention to address the defects created by acne scarring. In this article, we describe an approach that addresses acne scarring with a combination of CO2 laser skin resurfacing and microdroplet silicone injection. An Overview of Acne Scarring Acne is a disease of the pilosebaceous unit. While the pathogenesis of acne is not fully understood, one important component is inflammation. Left unchecked the inflammatory mediators induced by acne can damage dermal and subcutaneous structures resulting in permanent scarring.1 This process can result in a wide range of clinically apparent scars. Acne scarring is difficult to precisely define and classify, but dermatologists “know it when they see it.” Some scars have a narrow, deep, punched-out appearance, commonly referred to as ice pick scars. Other scars present as ill-defined depressed dermal troughs. These are sometimes referred to as rolling scars or atrophic scars. Other scars have different morphologies including hypertrophic scars and multi-channeled fistulas.2 No widely accepted classification system exists, but clinical experience affirms that there is a spectrum of scars that may result from acne. Just as there are many types of scars that may eventuate from acne, many treatments have been described that aim to correct these flaws. As with any medical condition, primary prevention of acne scarring is the most effective treatment. We, as dermatologists, are uniquely qualified and positioned to serve patients in this regard. However, many patients present for treatment only after scarring has occurred. And, for these patients, there are many effective treatment options. Treatments include dermabrasion, chemical peeling, laser resurfacing, non-ablative laser treatment, rhytidectomy, subcision, excision, punch grafting, fat transfer, filling agents and combinations of these treatments.3 (See table 1 ) Most practitioners match various treatment modalities with clinical scar variants. Here, we will describe the successful outcomes we have achieved with concurrent CO2 laser resurfacing and microdroplet silicone injection. CO2 Laser Resurfacing Facial skin resurfacing for the treatment of acne scarring has been practiced for decades. Initially, resurfacing was accomplished through dermabrasion and chemical peeling. Beginning in the 1980s some practitioners began using ablative CO2 lasers to perform skin resurfacing.4 Since then laser technology has advanced, and the advent of improvements such as the computerized pattern generator have made CO2 laser resurfacing more reproducible and less operator dependent. In our practice, CO2 laser resurfacing has largely replaced dermabrasion and chemical peeling because it produces a more predictable depth of skin injury, leading to more consistent results. CO2 laser skin resurfacing has been used extensively in skin rejuvenation. The laser targets intracellular and extracellular water and produces a controlled thermal injury to the epidermis and superficial dermis. This injury stimulates the skin’s healing mechanisms to produce new collagen thereby rejuvenating sun-damaged skin.5 The same principles apply in treating acne scarring. You can target the surface texture irregularities of acne scarring by implementing the laser. Most patients achieve significant improvement. Studies suggest that the range of improvement is 25% to 90% after a single treatment,5,6 and almost 90% of patients note improvement in their final appearance.7 (See figures 1A and 1B.) Microdroplet Silicone Injection In our experience, CO2 laser resurfacing works the best for acne scarring with superficial skin irregularities. Laser resurfacing is less effective for broader zones of atrophic scarring. These scars, characterized by loss of tissue and depression of the affected skin, are better suited to treatment with filler substances. We have found microdroplet silicone injection to be a useful therapy for this type of acne scar. Silicone, in some form, has been used for soft tissue augmentation for many decades. There are currently two FDA approved silicones available for use in the United States: Silikon 1000 (Alcon Laboratories, Inc., Fort Worth, TX) and Adatosil 5000 (Bausch and Lomb Surgical, Claremont, CA). These two silicones are classified as medical devices and are indicated for ophthalmologic use for intraocular injection in the treatment of complicated retinal detachments.8 They were approved by the FDA in 1997 and 1994, respectively. The availability of highly purified, medical- grade silicone has supported the use of silicone as a soft tissue filler as a legitimate off-label use of the substance. Silicone has many desirable attributes as a material for soft tissue augmentation. Silicone refers to a group of polymers based on the element silicon. Degree of cross-linking and other chemical attributes determine the physical properties of silicone.9 Medical grade silicone is a clear, viscous, highly stable liquid. When injected into the skin in minute quantities, silicone induces fibroplasia.10 This natural host response uses the body’s own collagen to generate volume resulting in natural, supple tissue augmentation. Furthermore, the results last many years. When treating acne scarring with silicone injections, we use the microdroplet technique. A small volume of 0.005 ml to 0.01 ml or less of silicone11 is injected into the deep dermis of each targeted acne scar. The scars that are most responsive to this treatment are the broad, rolling, atrophic scars characteristic of some patients with acne scarring. Remember that the filling effect of the treatment comes from the body’s response to the silicone, not from the volume of the silicone itself. We recommend that you retreat the patient at no shorter than 3-month intervals as needed until the desired level of correction has been obtained. Three to six treatment sessions are average for optimal response. (See figure 2A and 2B.) Silicone injection is effective and well tolerated by the majority of patients, but as with any treatment there are potential adverse effects. Common side effects include bruising, swelling and pain. These are minor and self limited and related to the injection process rather than the substance injected. As with any cosmetic procedure there is the potential for over-correction, under-correction or asymmetry. As the results of silicone augmentation are long lasting, so is any perceived over-correction. The most worrisome potential complication is the development of persistent inflammatory lesions at the sites of silicone injection. These may occur years to decades after treatment with silicone.12 The incidence of such reactions appears to be less than 1% and seems to correlate with the injection of adulterated material or possibly improper injection technique, especially large volume injection.13 Still, the true incidence and etiology of such reactions remain unknown and patients must be properly advised of this risk. Combination Approach Patients with acne scarring often have a mixture of types of scars. It’s common to find surface irregularities and broad atrophic scarring together in the same patient. In such cases, we use a combined approach with concurrent silicone microdroplet augmentation of the atrophic scars and CO2 laser resurfacing of the affected zones in the same operative treatment session. This stimulates collagen formation in the deeper portions of the dermis by the silicone and in the upper portions by the laser. This results in a tightening of the skin and a diminishment of visible scarring. This combined procedure can be supplemented by further silicone treatments as needed in future sessions. By pairing these individually permanent interventions, many patients can attain satisfactory improvement of acne scarring. (See figures 3A and 3B.) Long-Term Results Acne scarring is a challenging dermatologic problem and a perfect solution remains elusive. With skill and careful consideration the dermatologic surgeon can successfully intervene and mitigate the effects of this lifelong condition. Combined CO2 laser skin resurfacing and microdroplet silicone injection is another tool that can provide patients with long-term relief from the disfigurement of acne scars. Disclosure: The authors have no conflict of interest with any subject matter discussed in this article.
F or most, acne is a passing phenomenon of adolescence, just another obstacle on the path to adulthood. However, some unfortunate individuals are forever scarred by the process. Such acne scarring is variable in terms of intensity and morphology, but all scarring shares the feature of indefinite persistence. Many affected patients seek intervention to address the defects created by acne scarring. In this article, we describe an approach that addresses acne scarring with a combination of CO2 laser skin resurfacing and microdroplet silicone injection. An Overview of Acne Scarring Acne is a disease of the pilosebaceous unit. While the pathogenesis of acne is not fully understood, one important component is inflammation. Left unchecked the inflammatory mediators induced by acne can damage dermal and subcutaneous structures resulting in permanent scarring.1 This process can result in a wide range of clinically apparent scars. Acne scarring is difficult to precisely define and classify, but dermatologists “know it when they see it.” Some scars have a narrow, deep, punched-out appearance, commonly referred to as ice pick scars. Other scars present as ill-defined depressed dermal troughs. These are sometimes referred to as rolling scars or atrophic scars. Other scars have different morphologies including hypertrophic scars and multi-channeled fistulas.2 No widely accepted classification system exists, but clinical experience affirms that there is a spectrum of scars that may result from acne. Just as there are many types of scars that may eventuate from acne, many treatments have been described that aim to correct these flaws. As with any medical condition, primary prevention of acne scarring is the most effective treatment. We, as dermatologists, are uniquely qualified and positioned to serve patients in this regard. However, many patients present for treatment only after scarring has occurred. And, for these patients, there are many effective treatment options. Treatments include dermabrasion, chemical peeling, laser resurfacing, non-ablative laser treatment, rhytidectomy, subcision, excision, punch grafting, fat transfer, filling agents and combinations of these treatments.3 (See table 1 ) Most practitioners match various treatment modalities with clinical scar variants. Here, we will describe the successful outcomes we have achieved with concurrent CO2 laser resurfacing and microdroplet silicone injection. CO2 Laser Resurfacing Facial skin resurfacing for the treatment of acne scarring has been practiced for decades. Initially, resurfacing was accomplished through dermabrasion and chemical peeling. Beginning in the 1980s some practitioners began using ablative CO2 lasers to perform skin resurfacing.4 Since then laser technology has advanced, and the advent of improvements such as the computerized pattern generator have made CO2 laser resurfacing more reproducible and less operator dependent. In our practice, CO2 laser resurfacing has largely replaced dermabrasion and chemical peeling because it produces a more predictable depth of skin injury, leading to more consistent results. CO2 laser skin resurfacing has been used extensively in skin rejuvenation. The laser targets intracellular and extracellular water and produces a controlled thermal injury to the epidermis and superficial dermis. This injury stimulates the skin’s healing mechanisms to produce new collagen thereby rejuvenating sun-damaged skin.5 The same principles apply in treating acne scarring. You can target the surface texture irregularities of acne scarring by implementing the laser. Most patients achieve significant improvement. Studies suggest that the range of improvement is 25% to 90% after a single treatment,5,6 and almost 90% of patients note improvement in their final appearance.7 (See figures 1A and 1B.) Microdroplet Silicone Injection In our experience, CO2 laser resurfacing works the best for acne scarring with superficial skin irregularities. Laser resurfacing is less effective for broader zones of atrophic scarring. These scars, characterized by loss of tissue and depression of the affected skin, are better suited to treatment with filler substances. We have found microdroplet silicone injection to be a useful therapy for this type of acne scar. Silicone, in some form, has been used for soft tissue augmentation for many decades. There are currently two FDA approved silicones available for use in the United States: Silikon 1000 (Alcon Laboratories, Inc., Fort Worth, TX) and Adatosil 5000 (Bausch and Lomb Surgical, Claremont, CA). These two silicones are classified as medical devices and are indicated for ophthalmologic use for intraocular injection in the treatment of complicated retinal detachments.8 They were approved by the FDA in 1997 and 1994, respectively. The availability of highly purified, medical- grade silicone has supported the use of silicone as a soft tissue filler as a legitimate off-label use of the substance. Silicone has many desirable attributes as a material for soft tissue augmentation. Silicone refers to a group of polymers based on the element silicon. Degree of cross-linking and other chemical attributes determine the physical properties of silicone.9 Medical grade silicone is a clear, viscous, highly stable liquid. When injected into the skin in minute quantities, silicone induces fibroplasia.10 This natural host response uses the body’s own collagen to generate volume resulting in natural, supple tissue augmentation. Furthermore, the results last many years. When treating acne scarring with silicone injections, we use the microdroplet technique. A small volume of 0.005 ml to 0.01 ml or less of silicone11 is injected into the deep dermis of each targeted acne scar. The scars that are most responsive to this treatment are the broad, rolling, atrophic scars characteristic of some patients with acne scarring. Remember that the filling effect of the treatment comes from the body’s response to the silicone, not from the volume of the silicone itself. We recommend that you retreat the patient at no shorter than 3-month intervals as needed until the desired level of correction has been obtained. Three to six treatment sessions are average for optimal response. (See figure 2A and 2B.) Silicone injection is effective and well tolerated by the majority of patients, but as with any treatment there are potential adverse effects. Common side effects include bruising, swelling and pain. These are minor and self limited and related to the injection process rather than the substance injected. As with any cosmetic procedure there is the potential for over-correction, under-correction or asymmetry. As the results of silicone augmentation are long lasting, so is any perceived over-correction. The most worrisome potential complication is the development of persistent inflammatory lesions at the sites of silicone injection. These may occur years to decades after treatment with silicone.12 The incidence of such reactions appears to be less than 1% and seems to correlate with the injection of adulterated material or possibly improper injection technique, especially large volume injection.13 Still, the true incidence and etiology of such reactions remain unknown and patients must be properly advised of this risk. Combination Approach Patients with acne scarring often have a mixture of types of scars. It’s common to find surface irregularities and broad atrophic scarring together in the same patient. In such cases, we use a combined approach with concurrent silicone microdroplet augmentation of the atrophic scars and CO2 laser resurfacing of the affected zones in the same operative treatment session. This stimulates collagen formation in the deeper portions of the dermis by the silicone and in the upper portions by the laser. This results in a tightening of the skin and a diminishment of visible scarring. This combined procedure can be supplemented by further silicone treatments as needed in future sessions. By pairing these individually permanent interventions, many patients can attain satisfactory improvement of acne scarring. (See figures 3A and 3B.) Long-Term Results Acne scarring is a challenging dermatologic problem and a perfect solution remains elusive. With skill and careful consideration the dermatologic surgeon can successfully intervene and mitigate the effects of this lifelong condition. Combined CO2 laser skin resurfacing and microdroplet silicone injection is another tool that can provide patients with long-term relief from the disfigurement of acne scars. Disclosure: The authors have no conflict of interest with any subject matter discussed in this article.
