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About Face

Chapter Four Acne Scarring Types of Scars Scar Treatments Dermabrasion Injections Dermal Punch Grafting Excision Face-lift

Dermal Punch Grafting

Dermal punch grafting, the third technique in a surgeon’s arsenal against the effects of acne scarring, is ideal for some ice pick scars. The “punch” is a tiny round cylinder, and it comes in a variety of sizes up to about five millimeters in diameter. The cylinder has a wickedly sharp edge at the bottom, just like a razor, and I apply this edge to the skin while rotating the cylinder between my thumb and forefinger. The cylinder punches through the surface of the skin and bores through the dermis to neatly cut out the scar tissue in a kind of core drilling exercise. (Hair transplants are punched out using the same technique, though a surgeon will usually resort to a motor-driven attachment if he’s doing a lot of grafts at once.)

Once the punch has been made, the skin graft to be applied to the site is “harvested” from behind the ear. The skin high on the bone behind the ear is ideal for grafts because it is one of the few places on the human body that doesn’t grow any hair. (You don’t want great long hairs sprouting from your face, especially if you’re a woman.) This skin also presents a good color match (but not perfect) with facial skin. Generally speaking, dermal punch grafting is used on scars, ice pick and otherwise, with a diameter of between three and five millimeters. If an ice pick scar is smaller, say two millimeters wide, I might just take a stitch and close up the hole without bothering to graft. Otherwise, Histoacryl is applied to the graft; we no longer have to bother with sutures.

Sometimes, grafting becomes a two-stage procedure: the graft heals into a tiny bump slightly higher that the surrounding skin; this bump is then removed with a more general dermabrasion procedure. The two-stage approach is taken over a six-month or year-long period of time, to allow for complete healing before deciding whether the dermabrasion is necessary.

Patients with acne scarring so severe that it requires grafting are often slow to heal from the grafts. This is because they have such troubled skin to begin with: the oiliness, or sebaceousness, means that the composition of their skin makes it more prone to infection. As a result, we often must prescribe tetracycline or minocycline - antibiotics - for a period of time to help decrease the bacteria, P. Acnes, that is causing the recausing infection. Some patients are allergic to such medication, so their ability to heal from grafting might be limited.

If the patient’s skin shows pit-type scars greater in circumference that five millimeters, it is still possible to try grafting, but it might result in a shallow depression when the graft heals. Overall, this produces what we call a “cobblestone” effect, especially if there have been several such grafts - the skin looks faintly like the surface of a cobblestone driveway. If this occurs, the condition can be improved with dermabrasion, or even collagen injections. But usually, it is necessary.

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