As discussed in chapter 6, resurfacing with the erbium:YAG laser is a very effective treatment for facial scars. Resurfacing is most effective for small diameter, superficial scars. Large-diameter, deeper scars require adjunctive treatments that result in elevation of the scar or thickening of the depressed skin within the scar. One such treatment is subcision, a minor surgical procedure done under local anesthesia. In this process, a hypodermic needle is used as a small surgical scalpel to slice through scar tissue bands below the type III scar. Releasing the scar tissue allows the "bound down" skin to elevate. The injury produced by subcision heals with the production of additional dermal tissue (collagen), which also contributes to thickening of the skin within the depressed scar, thus elevating the depression. Because the skin surface is essentially undisturbed by subcision, these treatments produce little immediately noticeable effect other than minor bruising or swelling. All the healing takes place beneath the skin surface. These treatments can be done anytime before or after laser resurfacing.
Another method of elevating type III depressed scars is injection of a filler material. Bovine collagen is widely used for this purpose. I prefer injecting Fascian to provide filling. Fascian is composed mainly of human collagen derived from fascia obtained from tissue donors. Unlike bovine collagen, there is virtually no risk of an allergic reaction from human collagen. The human material also persists longer after injection—generally six months, compared to three months for bovine collagen.
Small-diameter, deep acne scars are not amenable to laser resurfacing. These scars are classified as type II acne scars and are sometimes called "ice pick" scars because of their shape. Type II acne scars are best treated by total removal, usually done with a small, round punch biopsy instrument using local anesthesia (fig. 6.2). The punch instrument removes a small cylinder of skin, including the entire scar. If the removed scars are small, the remaining normal skin is simply stitched together. Larger scars leave a larger punch defect and may require filling with a small skin graft, which is also obtained with the punch biopsy instrument, usually from skin behind the ear (of the same patient). Punch removal of type II acne scars is usually performed several weeks prior to laser resurfacing.
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