Scars are divided into 3 groups: atrophic, hypertrophic and keloidal.

Hypertrophic scars and keloids are caused by increased formation of scar tissue and they are raised above the skin.

Atrophic scars are the most common; they are depressed as they heal below the normal layer of the skin.

There are 3 main types of atrophic scars: rolling, ice-pick and boxcar scars.

Rolling scars are most commonly seen. They are soft, deep or superficial and they are often linear or circular. They have sloping edges that make the skin appear uneven and wavy. They appearance improve with manual stretching of the skin. The lower part of the scar is connected to the subcutaneous layers by fibrous tissue.

Ice-pick scars are small, usually less than 2 mm, deep and V- shaped. They look as if a sharp object, like an ice-pick, has punctured a hole into the skin. Sometimes they look like a large, dilated pore.

Boxcar scars look like a crater in the skin, they are often round or oval with sharp vertical edges. They are wider than ice-pick scars.

Treatments options:

As mentioned before post acne scars are permanent and complete removal is not possible.

All treatments aim at improving their appearance.

The type of treatment is individually chosen depending on the patient’s skin conditions and the type of scars.

The following procedures are offered to the patients in Art of Aging Aesthetic Medical Practice: Chemical peels, micro-needling, PRP, CROSS technique /dot peeling with TCA and subcision, intralesional steroid injections, dermal fillers.

CROSS technique

CROSS technique (chemical reconstruction of skin scars) has been found to be effective and simple procedure to be performed in the medical practice. It is best suited to treat ice-pick and boxcar scars. The CROSS technique entail stretching the skin and using a fine wooden tooth pick to apply highly concentrated (90%) TCA (Trichloroacetic acid) to the bottom of the scar. This leads to destructions of the skin and fibrous tissue. As the wound heals, new collagen fibres form inside the scar, helping to reduce its appearance. TCA CROSS can cause mild, temporary burning sensations, but anaesthesia is usually not necessary. A single session of TCA CROSS may improve the appearance of ice pick scars by around 25%. Patients can undergo 3-6 additional sessions at 4 weeks intervals.

After the procedure

- Frosting of the scar surface lasts up to 12 hours
- The skin around the treated sites becomes red and sore for 24-48h
- Small scabs develop after 2-3 days and fall off after 3-7 days
- Make-up may be applied from 3rd day
- Sunscreen is compulsory to reduce the risk of pigmentation

Possible complications and side effects of TCA CROSS

- Prolonged local irritation and erythema
- Damage to mucosal surface , lips, nostril, conjunctiva leading to painful ulceration and potential scarring if TCA is inadvertently deposited on these site
- Post inflammatory hyperpigmentation ( usually transient) or hypopigmentation ( this may be permanent)
- coalescence of adjacent scars to form a larger scars
- Sub-optimal response or lack of improvement

Other treatments combined with TCA CROSS

- Topical retinoid
- Micro-needling (Dermapen, Dermaroller)
- Subcision

Subcision

Subcisionis performed using a hypodermic needle inserted through a puncture in the skin surface. The sharp edge of the needle is used to break fibrotic strands that are tethering the scar to the underlying tissue. The release of the fibrotic strands and new collagen formation caused by wound healing leads to aesthetic improvement of the scar.

Contraindications to Subcision include:

- Patients with a history of hypertrophic or keloid scars
- Current or recent (within 12 months ) oral retinoid (Roaccutane/ Oratane)
- Bleeding or blood clotting disorders
- Active bacterial or viral infection

How is Subcision performed?

After cleaning and disinfecting the skin the treated area is infiltrated with a local anaesthetic (lidocaine). A sterile needle is inserted to the scar and parallel to the skin surface. The needle is advanced thought the dermis and moved back and forth in a fan-like motion. A snapping sound is heard as fibrous bands are transected.

Manual pressure is applied to the wound at the end of the procedure.

After the procedure

Pressure and ice are applied. Make-up can be applied the following day to camouflage bruised area.

The number of treatments required to achieve desired results depends on the type, locations and severity of the depression. 3-6 treatments might be needed in moderate scarring.

Possible complications and side effects of subcision:

- Hematoma due to bleeding (small haematoma is normal)
- Pain and tenderness of the treated sites
- Hypertrophic scars (5-10%) or keloid scars, mostly in periorbital skin, glabella, labial commissure and upper lip.
- Infection
- Post – inflammatory pigmentation
- Injury to the nerve, blood vessel

Other treatments combined with subcision:

- Topical retinoids
- Micro-needling (Dermapen, Dermaroller)
- Chemical peels
- TCA CROSS

Intralesional steroid injections

Hypertrophic scars and keloids are treated with corticosteroids which are directly injected into the scar. These injections often improve the appearance of the keloids and hypertrophic scars by flattening them. A series of 6-8 monthly treatments are often necessary to achieve results. Some keloids and hypertrophic scars may be treated with steroid combined with Botox injections.

Contraindications:

- Active tuberculosis
- Systemic fungal infection
- Active peptic ulcer
- Uncontrolled diabetes mellitus, heart failure and severe hypertension
- Severe depression
- Extensive psoriasis

Possible complications and side effects:

- Pain at the injections sites, bruising
- Infection
- Cutaneous and subcutaneous lipoatrophy ( skin dimples around the injection sites a few weeks after treatment, these may be permanent)
- Telangiectasia ( dilated capillaries)

Dermal fillers

Dermal fillers can be used to treat depressed acne scars, such as rolling and boxcar scars. Dermal fillers help to raise the indentations and volume loss caused by acne, creating a smoother appearance. For more information regarding dermal fillers please look at “Dermal fillers” under Procedures.

Other procedures

Chemical peels (Glycolic Acid, Jessner peel, TCA, Pyruvic Acid , Salicylic Acid ), Dermapen ( micro-needling) , PRP (Platelets Rich Plasma) are described separately, please look under Procedures .