Surgical Treatments

Treatments for Post-Acne Scarring

Acne is almost always treatable and early intervention is recommended to avoid the complication of scarring. An array of treatments exists, reflecting the diversity of acne and post-acne scarring conditions.

Acne is aesthetically unpleasant and embarrassing and may cause severe physiological distress. According to several studies, employment prospects can be decreased and interpersonal difficulties are common.

Acne is so common that it is often thought of as a normal stage in human development but with early treatment, subsequent scarring can be averted. Post-acne scarring is particularly devastating and often represents the failure of adequate and timely medical treatment.

The nature of post-acne scarring

Acne scarring is either a problem of excess tissue (hypertrophy) or of loss of tissue (atrophy). In addition, scars may be obvious because of their colour.

Scars with excess tissue are seen in people who are predisposed to this type of scarring. They are difficult to treat, and many different types of treatment may be necessary.

Scars that result in a loss of tissue are much more common. Post-acne scarring often involves the deeper structures, rather than the surface of the skin, leading to the appearance of indentations. These indentations may appear as depressed scars, or as sharp-walled 'ice-pick' scars. There may also be pigmentation changes in the skin. Hyperpigmentation (an increase in colour) is more common in olive-skinned patients, and will fade in 3-18 months if sun protected. New scars may also be red and will mature in time, losing their colour.

Treatments for post-acne scarring

A number of different procedures may be employed in the treatment of indented acne scarring. Laser resurfacing of the area is commonly performed; often in conjunction with other techniques such as fat transplantation, photodynamic therapy, blood transfer, punch grafting and skin rolling. If the scars are particularly indented or are in areas with a loss of tissue, subcision or Fraxel® laser treatment may be favoured.

Laser Blepharoplasty

The surgical correction of excess fullness or bagginess of the upper eyelid, or of 'bags' beneath the eye

As we age, the delicate skin of the eyelid loses its elasticity and may hang down in a fold, giving a hooded look to the eyes. In the most extreme cases, the sagging skin rests on the eyelashes and partially obscures peripheral vision. In the lower eyelid, the pocket of fat that normally sits behind the eye protrudes forward through a weakened septum, causing the "bags" under the eyes. This is commonly an inherited tendency and may cause an appearance of perpetual tiredness. The upper and lower eyelids may be affected separately or together, but the lower lids are frequently worse.

The procedure

Upper Eyelids

An incision is made in the natural crease of the upper eyelid. Excess skin and protruding fat are removed, and the skin edges are closed with fine, dissolving stitches. A very fine scar results, which fades with time and is hidden in the eyelid crease.

Lower Eyelids

The technique for the lower eyelids is different for scalpel and laser. The scalpel method involves an incision along the lower eyelid margin, then excess skin and fat are removed, and the skin edges are closed with fine stitches. This sometimes drags down the lower eyelid and produces an unusual appearance. Laser blepharoplasty of the lower eyelid has the advantage of having no skin incisions or stitches. Excess fat is removed through the inside surface of the lower eyelid. Wrinkles or crow's feet beneath the eye may be removed very effectively by resurfacing this area with the laser. The deepest expression lines at the sides of the eyes may be softened but not totally removed by this method.

Blepharoplasty procedures are performed in a day surgery or small hospital under a light general anaesthetic. You may go home following the procedure accompanied by a friend, but you are often advised to stay overnight in hospital. You should not drive on the day of the surgery.

The use of lasers for eyelid surgery

A laser is a very powerful light beam that is able to be used as a precise cutting tool or to remove fine layers of tissue. Used in blepharoplasty procedures, its advantages over the scalpel technique are that:

it leaves no visible scar on the lower eyelid;
no ectropion (dragging down of the eyelid) occurs, which is common with other methods;
there is virtually no bleeding with the laser, and therefore minimal bruising or swelling;
a shorter recovery time is required, allowing for an early return to work and social commitments.

The healing process

Normal activities may usually be recommenced two-three days following the lower eyelid procedure and eye make-up may be worn after this time. Stitches in the upper eyelid either dissolve or are removed by 7 days, and one or two weeks off work may be required.

Fat Transplantation

Fat is taken from an area where there is too much and is placed in other areas where there is too little, such as the ageing or post-acne-scarred face.

It is a useful procedure for:

severe acne scarring, where the fat layer under the skin is affected, causing the skin to sink in some areas;
fat loss in the face as part of the normal ageing process. This happens especially in the cheeks and temples. People with a gaunt face from birth often benefit from having their own fat transplanted into these depressed areas;
major expression lines may be attempted by fat transplant. These transplants are more likely to be temporary as these lines are strongly bound down to underlying tissues;
hand augmentation. This is quite a good treatment for ageing hands which tend to lose fat as ageing occurs. This may need to be repeated periodically to maintain the correction;
upper & lower lips. The upper and lower lip often loses volume with ageing and this may be supplemented by fat. A technique of lengthening the lower lip by fat injection tends to correct the droopy corners of the mouth. This is often temporary but may be long lasting.

The procedure

Some fat is removed from an area of plenty with a thin cannula. Local anaesthetic is used to remove the fat painlessly. The removed fat is washed to remove any broken cells, then re-injected into the area where it is required.

For how long does the fat last?

On average, 40-60% of the fat survives one year. In certain areas, such as the upper lip and cheek hollows, the long-term results are substantially better than this, however in scars and expression lines, the fat may need topping up to achieve the desired result. Usually 2-3 injections, 6-8 weeks apart are recommended for these areas. There is often some loss after each injection and a satisfactory result is gradually built up rather than produced in the first injection.

Suture Lifting

With very little risk or downtime, and no need for general anaesthetic, this is a very clever, alternative face lifting procedure for a subtle and very natural lift to the face.

With ageing and sun damage, the face takes on different appearances. Often, this involves a change in skin texture with a development of blotchy pigmentation and fine lines. This may be more prominent around the eyes and mouth. For those at this stage, laser resurfacing can produce a smooth and rejuvenated appearance with some skin contraction and elevation.

In the next stage, the skin starts to droop from the facial structures, requiring some form for lifting. Until this point there have been two types of facial lifts. The classic face lift that involves cutting and removing skin, and the face skin lift, which is less invasive and has less risks associated with it, but which still involves cutting and pulling that can produce scarring.

How does the suture lift differ from the more traditional face lifts?

Facial suture lifting requires no cutting (except two small incisions behind the ears) and the skin is lifted with sutures (seams) alone. The sutures are made from a nylon-type material and are placed under the skin and left in place permanently. After a few weeks the skin is held in position by tissue which forms around the sutures.
Suture lifting is a reversible and less invasive procedure that is performed under local anaesthetic in the rooms.

To whom might this procedure be suited?

Patients who are not yet ready for face lift surgery.
Patients who have previously had a face lift and want to improve the residual loose or drooping areas that remain.

Contour Thread Lift

A Contour Threadlift™ with patented Contour Threads™ is a minimally invasive, safe and effective non-surgical procedure that offers subtle, natural-looking, facelift-like results.

A Contour ThreadLift™ utilises tiny surgical sutures to lift and support the droopy areas of the brow, cheeks, face and neck. Contour threads™ have tiny, teeth-like (barb-like) cogs that will grasp on to and lift the soft tissues. The threads are inserted in precise locations using a long needle, and once inserted under the skin, they open in an umbrella like fashion to form a support structure that gently lifts and repositions the tissues into a more vertical and youthful position. With the lift effect secured, the needle is removed, the end of the thread is cut and knotted, allowing it to retract deep under the skin where it cannot be felt or seen. The non-absorbable threads stay within the deep tissues and provide support.

Pain and discomfort are very minimal with this technique and most patients need only take mild pain relief. In most cases, ice compresses are recommended for the first 24-48 hours.

Following a Contour ThreadLift™ procedure, there are some practical instructions and care that must be followed to avoid dislodging the threads from their supportive tissue whilst the collagen reaction takes place. Some of these instructions include avoidance of forceful facial rubbing (massage), strong active movement (support brow if coughing/sneezing), sleeping on the side of your face, avoiding excessive mouth opening (eating apples, for example) and some sporting activities.

The Contour ThreadLift™ is a stand-alone procedure. However, it is not uncommon to have this procedure combined with treatments to reduce facial muscle activity, dermal fillers to enhance volume, or peels and laser therapy to improve skin texture.

Mohs Micrographic Surgery

The most effective and precise surgical technique for curing more severe types of skin cancer

In this highly specialised procedure, difficult or recurrent skin cancers are removed and evaluated using microscopic control and careful mapping techniques. The major advantage of Mohs surgery over other methods of surgery is that, because of microscopic control and the step-wise process, the tumour can be removed with the maximum cure rate (98%), with the smallest possible hole and, therefore, the least possible scar.

The procedure

The cancerous lesion is removed in layers, which are immediately colour coded, mapped and microscopically examined. It is then determined whether any more tissue needs to be taken and, if so, from where. If necessary, further layers of skin are then removed, mapped and microscopically examined. This step-wise procedure continues until the cancer is gone.

The healing process

The hole produced from removal of the cancer is then repaired in the appropriate manner - with either a skin graft or skin flap - to reduce the degree of scarring.

Laser-Assisted Punch Grafting

Scarred areas of the face are released or replaced with healthy skin from another site.

The best scars to treat by punch grafting are small (less than 3-4mm) deep, and sharp-walled, e.g. the ice-pick scars of acne of chicken pox. This procedure gives a permanent correction if the graft survives in its new location.

The procedure

Under local anaesthetic, the scar is removed with a punch biopsy. This instrument cuts out the scar, leaving a small circular wound. This is then filled with a piece of skin taken from another area [usually behind the ear]. The recipient site usually has a dressing, while the donor site will have some stitches.

Any number up to about 25 grafts may be placed at one time. If more grafts are required, this is usually best divided into two procedures. One to two months later, a resurfacing laser procedure may be necessary to merge the grafts into the surrounding skin.

The healing process

After one week, dressings and stitches are removed. The little grafts look like small bumps on the face until the area is lasered 1-2 months later, and will require some make-up for several months until the merging process with the surrounding skin is complete. During this phase, the grafts may look different in colour (usually pinker), and the edges may be visible. These aspects settle during the healing process.

Subcision

Subcision involves undermining scars, wrinkles or cutaneous depressions to release their attachment to deeper structures. New connective tissue is then formed which helps to 'lift out' these contour abnormalities.

Many types of defects respond to this treatment, including depressed scars, skin grafts, surgical wounds and wrinkles.

The procedure

Subcision is performed in the rooms under local anaesthetic. A small probe is inserted under the depressed area and moved back and forth to release the attachment. The depression will visibly lift and the procedure is then complete. There is often some bleeding, but this is considered beneficial in preventing early reattachment. It may also be responsible for the development of new collagen.

Successive treatments often produce further improvement.

Excisional Surgery

The process of cutting away unwanted lesions

Excision is a traditional dermatological method for removing skin cancers and other unwanted spots. The name refers to the cutting away of unwanted lesions. Often, sutures (stitches) are required to assist the healing process. Some operations, such as some skin cancer treatments, may require a second procedure, usually performed at six weeks following the initial surgery.

The healing process

Scarring results from the wound incurred during the procedure. It will look red until healing has completed, at which point, it will assume its final pale appearance. This process may take 1-2 years

Bruising and/or Swelling can occur in some instances. Usually this is minor, but where the skin is loose (e.g. eyelids or cheeks), this may be more noticeable.

Weakness of the area. Once the sutures are removed, the wound is not as strong as prior to the excision, but it gains strength over the 3 months following the procedure.

Pain. Post-operative pain is usually only minor. Pain-killers may be taken to minimise this.

Sundry Procedures

Minor and adjunct procedures that are also used in the practice

Fine wire diathermy

This treatment works by passing a small electric charge down a hair-like needle into an unwanted spot, causing the spot to shrivel and disappear. It does so over the following few days to weeks depending on the body part treated and the amount of current used. It should not be confused with the rather gross diathermy delivery systems of the past. Correctly used, this is a most elegant technique and one that gives uniformly good results.

Fine wire diathermy may be used in many situations. These include the treatment of dilated blood vessels on the face and any fine vessels on the upper limbs or trunk. It has a major role in the treatment of minor skin blemishes such as small skin tags, milia, syringomas, seborrhoeic warts and sunspots. In this role, it is similar to a CO2 laser in its effects (see page 00). It is also used effectively as part of a hair removal technique called epilation (see page 00).

The healing process

Wounds and scabbing. After the procedure with non-insulated needles, a scab forms after an initial sore. This wound is usually inconsequential, but if a larger area has been treated then a significant sore may be seen and this may need a night-time topical antibiotic or antiseptic ointment (preferably greasy) for seven to ten days on the face or longer if elsewhere.

Makeup and sunscreen are usually permissible after the procedure.

Sun avoidance. It is important to protect this treated area from the sun whilst the spot is healing. Otherwise the spot may preferentially tan and stay that way for weeks.

Side-effects

Scarring and other side effects are very unusual.

Hearing aid and pacemaker malfunction. Caution is usually advised for people who use these devices as some of the older diathermy units have been known to stop them from working. The newer diathermy machines, which we use, don't really have this problem and most modern pacemakers also protect the patient from this rather nasty situation.

Cautery

Hot cautery is similar to diathermy except instead of electricity this technique uses straight heat to remove lesions. A wire loop is heated to red hot and, usually with local anaesthetic, the spot is cooked and left to fall off over time. This is an effective technique for treatment of brown spots on hands or anything that is entirely growing on the surface of the skin.

Another very good use for the hot cautery is in the treatment of skin cysts. With this type of spot the cautery tip is inserted into the cyst centre and the contents of the cyst melted. The lining also comes away with this technique and the cyst is often able to be delivered through a very small cut which becomes virtually invisible.

Side-effects

White spots may be left behind when hot cautery is used upon darker-complexioned patients. It is considered a less useful procedure for this group.

Liquid nitrogen

This chemical is most natural: it is around us all the time and represents 80% of the air that we breathe. The only difference is that once made into a liquid it has an incredibly low temperature of close to -200ºC. This low temperature allows us to selectively destroy anything that we aim it at. It affects the top layer of skin much more than the second layer, and given that scars are formed from injury to the second layer of skin, this approach can successfully treat large surface spots without scarring if correctly applied.

Liquid nitrogen is a traditional dermatologist's tool and is used widely to remove all sorts of lesions but especially sunspots and seborrhoeic keratoses. It is also particularly good at treating brown age spots on the backs of hands and faces. It is either applied with a swab on a stick dunked into the liquid nitrogen or it is sprayed on or applied with a cold probe.

The healing process

Blistering and scabbing. Whichever delivery method is used, the end result is the same. It produces localised frostbite which readily forms a thick blister that may break or remain intact and slowly evolve into a scab. This scab lifts in a week on the face and longer if applied elsewhere or for a longer time.

Colour resolution. After the healing time, the patch is often transiently red then white and finally in most cases returns to its normal skin colour.

Side-effects

Pain. There is some discomfort with liquid nitrogen application; a peculiar sensation whereby the body can't quite work out if this substance is cold or hot or just painful. The pain, however, is fleeting.

Scarring and changed skin colour. These undesired effects are not common if the procedure is carefully performed.

Skin shaving, snipping

These are two extremely simple but very effective techniques used for skin lesions such as acrochordans, seborrhoeic warts, cherry angiomas and moles.

Skin shaving is a technique in which the skin is inflated a little with local anaesthetic and the razor bowed so that it takes off the spot with a minimum surround of normal skin. The level of control that one can exert using this simple but exquisitely sharp instrument is very fine indeed. The edges of the wound are sometimes further bevelled with fine wire diathermy if necessary and the result, if the removal is kept superficial, is excellent. This technique is particularly effective on the nose and on the concave areas of the face such as the temples, around the nose, eyes and ears.

The snipping procedure is appropriate for any spot that has begun to hang from the skin surface such as a mole or skin tag. It is often done without local anaesthetic as the snip is so swift that it is not felt. This painlessness is also attributed to the extreme sharpness and special design of the scissors.

Spot peeling

This technique uses strong caustic substances such as Trichloacetic acid and Phenol usually in relatively high concentrations. The substance may either be painted on the skin such in treating xanthelasma around the eyelids or it may be applied in point fashion down the centre of either a dilated oil gland (sebaceous hyperplasia) or down a dilated pore or deep ice pick scar.

The healing process

Time. If painted on, the resulting healing will generally follow the same time frame as that seen with the more general chemical cosmetic peeling process.

Scabbing. If point peeling is performed healing will produce a very small sometimes miniscule scabbing.

The painting is usually performed with a cotton swab after cleansing of all skin oils with acetone. The point peel is often done with a sharp instrument such as a toothpick dipped in the peeling solution.

Side-effects and complications

Side-effects are rare.

Scarring is occasionally seen with painting but such a small area is being done that this is not usually visually obvious even if it occurs.

A need for repetition. The main problem with point peeling is that it doesn't always work and it may need to be repeated.

Curettage

This instrument is very versatile despite being mainly used for skin cancer treatment. It has been used for acne cysts and its newer use is in lipoma removal. It gently scrapes away seborrhoeic warts and other surface lesions that have been loosened with glycolic acid or other peeling agents or after fine wire diathermy.

The curette can not be used in areas of loose or very thin skin such as around the eyelid. But correctly used in the treatment of non-cancerous spots, it is a very useful instrument.

Cortisone injections

This very simple technique is useful in the therapy of scars and cysts.

A dilute local mixture of local anaesthetic and cortisone is sufficient treatment for early scars after sugery or acne or other inflammatory cysts. More entrenched or thickened scars may require stronger concentrations of cortisone to settle these down.