Surgical Treatment of Facial Acne Scars Based on Morphologic Classification: A Brazilian Experience B OGDANA V ICTORIA K ADUNC , P H D, AND A DA R EGINA T RINDADE DE A LMEIDA , MD Dermatologic Clinic, Hospital do Servidor Publico, Municipal de Sa˜o Paulo, Brazil BACKGROUND. Acne scar treatment remains a challenge in the medical literature. It is very difficult to compare the efficacy of different therapeutic approaches because of the lack of consensus regarding acne scar description and classification. OBJECTIVE. To establish a morphologic classification of acne scars and to assess the efficacy of different therapeutic options based on scar type. METHODS. During an 8-year period, 228 patients were prospectively studied. Their acne scars were morphologically classified and customized, staged rehabilitation programs were established for each patient. The assessment of treatment efficacy was conducted 18 months after the end of treatment and was based on patients’ and physicians’ opinions ranked on a semiquantitative basis as percentage of improvement from baseline. RESULTS. Among the 168 patients who finished the study, 26 completed three stages of the treatment plan, and 142 were submitted to one or two therapeutic stages, depending on lesion types. Eighty-six percent of the patients considered the results excellent or good compared with 76% by the authors and 78% by three independent dermatologic surgeons. CONCLUSION. The classification and the staged therapeutic plan for acne scarred patients facilitated treatment and improved outcomes and may allow development of protocols by comparing results among different authors. B. V. KADUNC, PHD, AND A. R. TRINDADE DE ALMEIDA, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS. ACNE IS an extremely common pilosebaceous disorder. In spite of the numerous therapeutic options, undesirable sequels are frequent and interfere in patients’ psychological profile. Acne scars were traditionally and indiscriminately treated by ablative techniques, such as chemical peels1 and dermabrasion,2 but soon it was noticed that some patients did not show any improvement, even after aggressive procedures. The disappointment led the surgeons to search for new options; various surgical techniques, including laser resurfacing,3–5 have been used to treat acne scars. However, no standardized method has ever been followed. As a result, it is impossible to compare treatment approaches, mainly because of lack of consensus in the literature, concerning acne scars nomenclature and classification. The objectives of this article are to propose a morphologic acne scar classification and to assess the efficacy of different therapeutic options based on acne scar types. Correspondence and reprint requests to: Bogdana Victoria Kadunc, PhD, Rua Gaivota 91, apto 71, CEP 04522-030, Moema, Sa˜o Paulo, SP, Brazil, or e-mail: [email protected] Methods During an 8-year period (from January 1, 1993, to January 30, 2001), 228 consecutive patients with mild to severe facial acne scars referred to the Dermatologic Clinic of Hospital do Servidor Publico Municipal, Sa˜o Paulo, Brazil (86 patients), and to the private practice of the authors (142 patients) were enrolled in this prospective study. The exclusion criteria were recent systemic therapy with isotretinoin or previous procedures to repair acne scars. Patients’ age ranged from 16 to 54 years; 137 were female subjects (60%), and 91 patients were male (40%). The Fitzpatrick phototypes varied from II to VI. An informed consent form was signed by all patients before entering the study. Previous, intermediate, and posttreatment photographs were taken using the same camera and lighting settings, type of film, patient positioning, and developing process. At the first visit, patients were examined with oblique and superior light sources and had their acne scars evaluated regarding the following aspects: location, number, shape (linear, round, star-like, punctiform), consistency (soft, hard, fibrotic), color, distensibility, and relationship to the surrounding skin (depressed or elevated). Based on these characteristics and using terms collected from the literature, acne scars were classified r 2003 by the American Society for Dermatologic Surgery, Inc. Published by Blackwell Publishing, Inc. ISSN: 1076-0512/03/$15.00/0 Dermatol Surg 2003;29:1200–1209 Dermatol Surg 29:12:December 2003 as (1) elevated, (2) dystrophic, and (3) depressed. Some of them were further subdivided in order to facilitate the indication of specific treatments, resulting in 11 distinct morphologic types. Description of Acne Scars and Specific Treatments Reported 1. Elevated scars. a. Hypertrophic lesions are raised above the skin surface and are limited to the original insult area. They are frequent in the mandibular, malar, and glabellar regions (Figure 1) and can be reduced by steroid injections, direct or tangential excisions, or 585-nm flash-pumped pulsed dye laser sessions.6 b. Keloidal scars are found in patients with genetic predisposition. Their dimensions exceed the initial injury, and the scar grows to the side ‘‘in the shape of a crab claw.’’7 They are common in the mandibular arch, shoulders, and sternal region and are prone to Figure 1. Hypertrophic scars: clinical and diagrammatic characterization. Figure 2. Keloidal scars. KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS 1201 recur. Keloidal scars are very difficult to deal with because of their proliferating characteristics (Figure 2). The therapeutic options are intralesional steroid or bleomycin sulfate8 injections, subtotal excisions,9 cryotherapy,10 and X or b radiotherapy. c. Papular are soft elevations, like anetodermas, that are frequently observed on the trunk11 and mental area (Figure 3). They can be treated by controlled CO2 laser vaporization or light electrodesiccation of each papule. d. Bridge is a fibrous string over healthy skin. This kind of scars is common on the face and is treated by tangential excision (Figure 4). 2. Dystrophic scars. These types of scars may have irregular or star-like shapes with a white and atrophic floor (Figure 5). They can also be represented by fibrotic masses with multichanneled tracts that retain sebaceous or pustular material. Direct excision5 under primary elliptical or broken lines or even ‘‘M,’’ ‘‘Z,’’ or ‘‘W’’ plasties is required for their treatment. 1202 KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS Dermatol Surg 29:12:December 2003 Figure 3. Papular scars. Figure 4. Bridge. Figure 5. Dystrophic scar. 3. Depressed scars. They are contour or volume de- fects that can be (a) distensible and (b) nondistensible. 3.a.1 Distensible retractions After skin distension, they remain attached only by the central portion (Figure 6) through myofascial attachments that have to be released by undermining or subcision.12 If necessary, a filling agent is the next step of treatment. 3.a.2 Distensible undulations (valleys) They disappear completely after skin distension (Figure 7) and are the best indication for dermal or subdermal filling techniques, performed in one or more sessions. 3.b Nondistensible depressions These do not disappear after skin distension and are characterized as surface defects. These types of scars accumulate make-up and sunscreen lotion, and the projection Dermatol Surg 29:12:December 2003 KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS 1203 Figure 6. Distensible retractile scars. Figure 7. Distensible undulated scars. Figure 8. Nondistensible superficial scars. of their margins casts a dark shadow on the bottom. They can be subdivided into the following: (3.b.1) Superficial (dish-like) are shallow defects (Figure 8) in which the only useful therapeutic approach is isolated use of ablative methods, including phenol chemical peeling,1 dermabrasion,2–13 chemabrasion,14 and CO23–15 or pulsed Erbium YAG4–16 laser abrasion. (3.b.2) Medium (crater-like) has a scar base that is relatively smooth and has normal color and texture and wide diameter (Figure 9) and can be treated by either of two ways: (1) the base is surrounded and cut by biopsy punches17 or mini blades, followed by elevation with forceps until the clot formation, to keep it in the new position or (2) the shoulders can be sculpted and beveled to the peripheral skin by razabrasion18 (using the razor blade as abrader), electrodesiccation19 or CO2 laser vaporization. (3.b.3) Deep (ice-pick or pitted scar) are narrow and fibrotic scars, with 1204 KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS Dermatol Surg 29:12:December 2003 Figure 9. Nondistensible medium scars. Figure 10. Nondistensible deep scars. Figure 11. Tunnel. sharp shoulders perpendicular to the skin. They are epithelial invaginations that can reach the subcutaneous layer (Figure 10). They have to be excised by cylindrical punches, which have to be large enough to involve the entire lesion. They can be left to second intention healing or be replaced by full-thickness grafts from the postauricular area, which are 25% to 50% larger than the defect (punch graft technique).20–23 Direct closure of these small holes very frequently leads to enlarged and unpleasant scars, unless they are submitted to deep intradermal sutures. (3.b.4) Tunnels are constituted of two or more ice picks connected by an epithelized tract (Figure 11). They have to be excised but can also be repaired by punch grafting.22 Dermatol Surg 29:12:December 2003 Study Design After the morphologic classification, all studied patients were submitted to skin conditioning with sunscreens, a-hydroxy acids, and/or tretinoin agents and then enrolled in a three-staged rehabilitation program (Table 1). Stage I: complementary techniques. In this stage, patients were submitted to one or more of the following procedures: intralesional steroid injections addressing erythematous hypertrophic or keloidal scars; focal light electrodesiccation to treat the papular ones; tangential excisions to eliminate bridges and nonerythematous hypertrophic lesions; direct (elliptical, broken lines, or W-plasty) excisions to improve dystrophic areas; subcision to release distensible retractions; punch elevation to raise medium nondistensible depressions; and punch grafting to correct deep nondistensible scars and tunnels. These techniques were performed in one to three sessions (30 days apart) at least 6 to 8 weeks before stage II intervention. Stage II: ablative techniques. They were indicated to treat patients whose scars presented nondistensible superficial depressed pattern or to complement stage I techniques. The methods used were as follows: 1. Chemabrasion: A full-face 35% TCA chemical peeling was followed by regional motor-driven dermabrasion on the most scarred cosmetic units. This combined procedure facilitated mechanical exfoliation and was useful to blend dermabraded and nondermabraded regions, reducing demarcation lines, mainly on the eyelids and neck area. KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS 1205 2. Full-face resurfacing: We performed two or three passes using high-energy pulsed CO2 laser (Coherent Laser Corporation, Palo Alto, CA) equipped with computer pattern generator handpiece (CPG) in the Ultrapulse mode at 300 mJs, 60 W, with a density of 4 to 6. This method was indicated mainly to flaccid skin patients. Punch elevations or excisions frequently completed the ablative processes, aiming at achieving the best leveling grade. Antiviral and antibiotic systemic therapy and semiocclusive dressings employing sterilized veil fabric and petrolatum jelly were used in the preoperative and postoperative periods.24 In spite of the use of complementary techniques, some severely scarred patients had to be submitted to two ablative processes, with a 6-month interval between them. In general, these patients had a large number of dystrophic scars, ice picks, and tunnels. Stage III: filling techniques. To correct distensible undulated scars, we chose to use hyaluronic acid25 injections (Perlane and Restylane; Q-Medical, Inc., Uppsala, Sweden) to treat superficial (dermal) tissue loss or microlipoinjections to treat deep (subcutaneous) tissue loss. This stage of treatment took from one to several sessions or served as a sequential step after the other previous ones. Evaluation As a follow-up procedure, all patients were examined and photographed at 2-month intervals. The final evaluation for assessment of treatment efficacy took place 18 months after the beginning of the procedures Table 1. Morphologic Classification of Acne Scars and Specific Procedures Employed in the Three-Staged Treatment Plan in 228 Patients Scar Types 1. Elevated a. Hypertrophic b. Keloidal c. Papular d. Bridges 2. Dystrophic 3. Depressed 3.a.1 Distensible retractions 3.a.2 Distensible undulations 3.b.1 Nondistensible superficial 3.b.2 Nondistensible medium 3.b.3 Nondistensible deep (ice picks) 3.b.4 Tunnels Specific Procedures Intralesional steroid injections/tangential excisions (stage I) Intralesional steroid injections (stage I) Focal light electrodesiccation (stage I) Tangential excision (stage I) Elliptical, broken lines, or W-plasty excisions (stage I) Subcision (stage I) Hyaluronic acid/fat injections (stage III) Ablative techniques (stage II) Punch elevation (stage I) Punch grafting (stage I) Punch grafting (stage I) 1206 Dermatol Surg 29:12:December 2003 KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS Figure 12. Dark-skinned patient with nondistensible medium scars. Figure 14. Final results after punch elevation and dermabrasion. Table 2. Evaluation of Acne Scar Improvement Excellent: when improvement of 75% or more was observed in all four analyzed variables Good: when improvement between 50% and 75% was observed in all four analyzed variables Unchanged: when improvement below 50% was observed in all four analyzed variables Poor: worsening of the characteristics of the four variables analyzed variables: (1) a reduction in number of scars, (2) a reduction in deepness of scars, (3) an improvement of color uniformity, and (4) a reduction in retention of sebaceous material. The authors and the independent dermatologic surgeons assessed improvement similarly, except for item four. The authors based their judgement of improvement on clinical data and photographic evaluation, whereas the surgeons not involved in the study based their opinions on blind analysis of pretreatment and posttreatment photographs. The final results were rated as excellent, good, unchanged, or poor, as a percentage of improvement from baseline, based on a semiquantitative scale (Table 2). Chi-square statistical analysis was used to compare the three treatment efficacy evaluations. Figure 13. Postinflammatory hyperpigmentation after dermabrasion. Results (Figures 12–14) and collected the opinions of patients, the authors, and three dermatologic surgeons not directly involved in the study. Patient self-assessment consisted of their subjective impression of the percentage of improvement of four Out of 228 patients initially enrolled in the series, 168 (74%) completed the study. Forty patients (24%) were classified as phototype II, 58 (34%) as group III, and 70 (42%) as groups IV, V, and VI. The majority of the patients presented morphologically heterogeneous acne scars, but type 3 (the depressed scars) was Dermatol Surg 29:12:December 2003 KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS predominant in this population. The elevated and dystrophic types were less frequently seen. Table 3 shows the number of patients in each treatment stage. Out of the 168 patients who finished the study, 46 (27%) were treated with complementary techniques, and 40 (24%) were submitted to resurfacing or chemabrasion only, whereas 21 (13%) received soft-tissue augmentation. Thus, 107 (64%) patients covered only one step of the treatment plan. Thirtyfive (21%) patients were treated using two of the therapeutic stages, and 26 (15%) completed the three stages. Of 89 (53%) patients that needed ablative methods, including the 12 (7%) most severely scarred subjects, who required two sessions, 25 were classified as phototype II, 30 as type III, and 34 were included in IV, V, and VI Fitzpatrick groups. The results analyzed by the overall impressions of patients, the authors and the dermatologic surgeons are presented in Table 4. In their self-evaluation, 144 patients (86%) considered the results excellent or good compared with 128 (76%) by the authors and 131 (78%) by the panel of dermatologic surgeons. Based on chi-square analysis, there were no statistically significant differences (P 5 0.3113) among the evaluations of the three groups. Common adverse events assessed on the 2nd month were observed in 54 (32%) patients and included herpes simplex flares (5 patients), milia formation (11 Table 3. Number of Patients Submitted to Each Treatment Stage Stage I Stage II Stage III Stages I1II Stages I1III Stages II1III Stages I1II1III Stages I1II1II1III 46 patients 5 27% 40 patients 5 24% 21 patients 5 13% 16 patients 5 10% 12 patients 5 7% 7 patients 5 4% 14 patients 5 8% 12 patients 5 7% Table 4. Impressions of 168 Patients, Authors, and Three Dermatologic Surgeons Not Directly Involved in the Study on Efficacy of Acne Scar Treatment Based on Morphologic Classification Excellent Good Unchanged Poor Patients Authors Independent Dermatologic Surgeons 45 (27%) 99 (59%) 17 (10%) 7 (4%) 33 (20%) 95 (56%) 25 (15%) 15 (9%) 41 (24%) 90 (54%) 25 (15%) 12 (7%) 1207 patients), and transient postinflammatory hyperpigmentation. The later was observed in 38 (42%) of the 89 patients submitted to ablative methods. Among them,8 patients were classified as phototype III and 30 as IV, V, and VI Fitzpatrick types. Stage II procedures were more frequently associated with adverse effects. True complications assessed on the 18th month were observed in 14 (8%) patients and included postexcision widening of scars (10 patients), demarcation lines (3 patients), and residual hypopigmentation (1 patient). Discussion Treating acne scars, according to Fulton, ‘‘is perhaps the most difficult cosmetic surgery procedure that exists.’’26 It is really challenging to achieve total correction of tissue destruction caused by severe inflammatory acne, which can destroy the epidermis, dermis, and the underlying fat. The main treatment goal is to obtain as much improvement as possible rather than perfection. After studying acne scars in different articles, we noticed that authors have been using their own acne scar denominations. There is no reproducible method that encompasses the majority of acne scar types and correlates the lesions and the specific techniques used to repair them. Ellis and Mitchell27 suggested the use of the words ice picks, craters, undulations, tunnels, shallow-type and hypertrophic scars, whereas Koranda7 referred to craters or pits, ice picks, keloidal and hypertrophic scars. Goodman,28 based on pathophysiologic findings, suggested that atrophic postacne scarring could be divided into superficial macular, deep dermal, perifollicular scars, and fat atrophy. Langdon,29 in turn, described three types: I, small diameter shallow scars; II, ice picks; and III, distensible scars. Jacob et al.30 referred to other three different subtypes: ice pick, rolling, and boxcar. The most frequently described lesions are the depressed ones, indiscriminately referred as pitted or atrophic acne scars,3–20 with few references to other morphologic patterns. Historically, acne sequels have been treated by ablative techniques such as deep chemical peels,1–19 dermabrasion,2–5 and more recently, resurfacing procedures with CO23,15,31,32 and Er:YAG4–16 lasers or their combination.33 However, according to the literature, the results of isolated ablative techniques are extremely variable, presenting outcomes that range from 25%,34 40%4 to 81.4%.3 In 1941, Eller and Wolff,19 after performing phenol peelings to treat acne scars, noticed this fact and 1208 Dermatol Surg 29:12:December 2003 KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS recommended beveling the ‘‘cuplike scars’’ edges by electrodesiccation or shaving. Nowadays, the consensus is that acne scars cannot be effectively corrected by one single treatment modality because of the wide variety. Multiple other methods have been added to ablative techniques, including injections of collagen,35 silicone,36 or fat,37 excision with primary closure,5 facelifts,27,28 punch elevation,5–17 and punch excision with full-thickness graft replacement.20–23 Different authors have also tried to facilitate acne scar treatment by suggesting schematic diagrams that correlate scars morphology and treatment,21,30–38 whereas others have used sequential therapeutic plans in treating theses scars. Whang and Lee32 suggested three stages: 1, 50% TCA focal chemical peeling in pitted areas; 2, CO2 laser vaporization 1 to 3 months later, and 3, full-face dermabrasion 6 to 8 weeks later. Conversely, Jacob et al.30 did not suggest definite stages, as they considered that by performing punch excision, punch elevation, subcision, and laser skin resurfacing would be enough to reach good results in any type of acne scars. Fulton and Silverton37 preferred multiple approaches such as subcision, small-volume fat transfer, laser resurfacing, dermabrasion, excision, and grafting—all of them performed at the same surgical time. In this study, we proposed a more comprehensive classification, encompassing most of the different types of acne scars and unifying the literature terminology. In our three-staged treatment plan, we used at least eight different therapeutic modalities to reach appropriate improvement of acne-scarred patients. In our opinion, it is safer to perform the procedures at different times, which allows better understanding of patients’ psychological profile and guarantees their compliance and confidence. Another difficult issue is the evaluation of the results. Reviewing the literature, we found that Jordan et al.39 tried to assess the effectiveness of laser resurfacing treatment for facial acne scars. They concluded that there is a need of ‘‘good quality randomized controlled trials with standardized scarring scales’’ in order to compare treatment results among different articles. Objective methods such as comparative counting and measuring of lesions in specific areas13 and analysis of textural skin changes applying optical profilometric programs3 were recently introduced in the medical literature. Nevertheless, we noticed that most of the studies published on acne scars treatment, ranked the improvement in scales that translated opinions of authors and independent physicians.4,16,31 This is a result of the difficulty to count the innumerous lesions that can be present in acne scarred faces. For this reason, in our study, which was initiated 8 years before, we chose the same criteria. Considering the 168 (74%) patients that completed the staged treatment plan and returned for the final evaluation, it was observed that acne scar improvement caused a very positive psychologic impact on these frequently stigmatized people, building their selfesteem. Seventy-nine (47%) patients with predominant distensible lesions, craters, or ice picks were treated by filling or focal techniques and did not undergo ablation. This possibility enhanced treatment compliance because patients did not have to be away from their professional or social activities, and no pigmentary alterations occurred, even in dark-skinned individuals. Conversely, the most commonly observed adverse event (transient postinflammatory hyperpigmentation) was observed in 42% of the 89 patients submitted to chemabrasion or laser resurfacing. The problem was always detected by the 3rd week after the ablative procedure and occurred in 27% of the patients classified as phototype III and in 88% of patients who were phototypes IV, V, and VI. These values may be explained by the high percentage of mixed ethnicity and dark-complexion people in the Brazilian population; the problem was easily solved within 30 days with tretinoin-hydroquinone combined creams. No studied patient presented long-lasting hyperpigmentation. Although the three independent treatment efficacy evaluations classified the outcomes as excellent or good improvement in more than 76% of the patients, our results cannot be compared with the literature because of lack of standardized and worldwide accepted acne scars classification. We believe that the systematic application of the staged treatment program in 228 patients, followed by long interval evaluations, provided good experience and improved the authors’ clinical and surgical accuracy. The unified classification of scar types facilitated the correct selection of the best therapeutic option for each specific scar. Conclusion The classification based on morphologic patterns and the staged therapeutic plan for acne-scarred patients facilitated the treatment, improved the final outcomes, and may allow development of protocols comparing results among various therapeutic approaches and different authors. Acknowledgment The authors thank Maria Helena Kiss, MD, PhD, for her suggestions and Luciana Gadelha, MD, for the drawings. Dermatol Surg 29:12:December 2003 References 1. Mackee GM, Karp FL. The treatment of post-acne scars with phenol. Br J Dermatol 1952;64:456–9. 2. Kurtin A. Corrective surgical planning of the skin. Arch Dermatol 1953;68:389–95. 3. Alster TS, West TB. Resurfacing of atrophic facial acne scars with a high-energy, pulsed carbon dioxide laser. Dermatol Surg 1996;22:151–5. 4. Kye YC. Resurfacing of pitted facial scars with a pulsed Er:YAG laser. 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