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About Face

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

Scar Treatments

There are five methods of improving the scarring left behind by acne vulgaris: dermabrasion; injectable substances; dermal punch grafting; excision; and face-lifting.

Dermabrasion

Dermabrasion, or dermal leveling, is what we call the “workhorse” technique. It involves planning the normal, unaffected skin surrounding the scar pits so that the skin is thinned to the level of the bottom of the pit - or as close to the bottom as we can get. In other words, if you dug a hole in your garden and wanted to make the hole less obvious, you could either fill is up to bring it level with the surrounding earth, or you could dig away at the earth surrounding the hole until it ceased to exist because the surrounding surface had become level with the bottom of the hole. Dermabrasion makes the scar pits so shallow that they appear to be more level with the surrounding, normal skin.

What we are doing is actually removing the top layer of skin, the epidermis, and planing down into the dermis layer. As the patient heals from the operation, new skin cells push up to the surface to create a new epidermis. Most patients with acne scarring who have undergone dermabrasion heal in about seven days, but the maturing process takes a little longer. This means that the epidermis has healed after a week or so, but the skin is still red in color because the keratin layer has yet been restored to its normal thickness. The good news is that no skin on the body regenerates faster than facial skin: it is extremely rich in pilosebaceous units. You could never, for example, dermabrade the skin on the inside of a patient’s arm. It wouldn’t regenerate quickly enough or in a great-enough quantity to prevent scarring from the process itself.

The process of dermabrasion can be used to improve the appearance of acne scarring and superficial scarring caused by accident, as well as freckles, some birthmarks and tattoos. Patients can be dermabraded under general anesthesia or under local anesthesia in a condition of conscious sedation. The skin can then be “frozen” with an anesthetic skin refrigerant called Fridgaderm. Dermabrasion is a vigorous action, and the skin must be taut or “frozen” to be worked on. Freezing keeps the bleeding to a minimum during the procedure.

According to a text on the subject, by Dr. E. Gaylon McCollough and Dr. Phillip Royal Langsdon, published by Thieme Medical Publishers in New York, carpenter sandpaper was originally used to hand-plane the skin. Then the idea of a motor-driven instrument was developed, and some surgeons tried hooking up a dental drill to sandpaper discs. Today, like me, most surgeons prefer the modern electrical units, available with a variety of tips appropriate to the task at hand, such as wire brushes, diamond fraises and serrated, stainless-steel wheels. I prefer to sue the diamond fraise, which is a round metal cylinder with diamond chips on it. Whichever implement is used, however, there’s no getting around the fact it’s a bit of a messy job that requires a steady hand.

Dermabrasion is ideally suited to patients with wide, shallow pits in the skin. This is not a procedure for ice pick scars. The idea is to round the shoulders of the pit so that there is less shadowing at the bottom of the pit. Obviously, the less severe the problem is before we start, the more effective dermabrasion will be: it isn’t safe to go too deeply through the dermis as this action itself will cause scarring. Occasionally, I’ll treat a patient with dermabrasion twice over the course of several years, which allows for healing periods of more than twelve months.

Generally speaking, it’s a good idea to dermabrade an entire regional aesthetic unit of the face at one time. By this, I mean doing the entire forehead, or an entire cheek, even if only part of the area is affected. This is because dermabrasion affects the skin’s pigmentation by making it lighter in color. The trick is to go a bit deeper in the area that needs dermabrasion, then to “feather” lightly toward the edges so that the aesthetic unit blends nicely with the rest of the face.

Many surgeons refuse to dermabrade people of Negroid or Oriental extraction because dermabrasion can make the affected areas patchy and lighter in color. But it’s been my experience that the lightened areas darken with healing and that the overall effect can be quite acceptable over a period of time in some patients. As well, I usually do a test area behind the ear to determine the degree of discoloration. If the patient is willing to accept patchy, discolored skin for up to a year after the operation, I see no reason to deny it. However, I don’t like to dermabrade Caucasian people with olive-colored skin. The dermabrasion seems to leave permanent brown and lighter colored blotches. To my eye, the blotches are usually more noticeable than the original problem of acne scarring, so it doesn’t make any sense.

Within eighteen to twenty-four hours after dermabrasion, the regeneration of skin begins. There are two ways to handle the healing process that follows dermabrasion: let a crust form (basically, a giant scab on the face) that will shed in about seven to twelve days, or keep the surface of the face moist. To keep the skin moist, Polysporin ointment, mineral oil or Crisco shortening can be applied. Most of my patients prefer the ointment because it is less messy that the other two lubricants. However I favor the covered approach using some of the new “breathing” or moist dressings: studies have shown that regeneration is speeded up with a dressing. These days I use a spray sealant called Tisseel as well.

Once the dressing comes off, in about five to seven days, the dermabraded skin will be very red at the beginning, then fade to lessening degrees of pink over the next eight weeks. It’s very important to completely avoid the sun and then to wear a broad spectrum sunscreen with an SPF (sun protection factor) of at least 15 for the next six months. Otherwise, the bright pink patches might become permanently brown.

As with the chemical peel process I described earlier, dermabrasion is likely to cause some swelling, especially if it’s been done around the eyes or lips. The swelling will be most obvious by the end of the second day after the operetta, and then if begins to subside. It helps to sleep with your head propped up by a couple of pillows at night; elevation seems to bring the swelling down a little faster as the swelling is gravity-dependent.

Also similar to the chemical peel process is the warning not to pick away any adherent crust that forms on the skin. This could damage the dermis layer and cause infection and scarring. And, as with chemical peel, about thirty percent of patients will experience some form of depression. The depression is at least partly attributable to the psychological impact of seeing your face in the early postoperative period: it’ll be messy. If it happens to you, just try to remember that it is a perfectly normal reaction and that the feeling will pass.

Several weeks or months after dermabrasion is done, some patients might experience the appearance of “milia” on the skin. These are tiny white bumps, names for their resemblance to millet seeds. They are caused by keratin plugging the sweat glands - some people, in fact, develop milia as a reaction to prickly heat. Usually, the condition disappears on its own, but if it persists, the bumps can be uncapped with a needle by your surgeon and made to disperse. In any case, milia is nothing to worry about.

Most patients can return to work or a reasonably active social life about two weeks after dermabrasion with makeup applied by an aesthetician or a camouflage makeup specialist. The redness and some splotchy patches will persist a while longer, but water-based makeup will conceal the worst of it. Very occasionally, a patient will develop fever blisters during these first weeks, and medication can be prescribed to settle them down. Patients who’ve had dermabrasion done on the nose should avoid wearing eyeglasses for at least two weeks after, so this could affect the speed with which normal life is resumed. And, a final word of advice, athletically inclined patients shouldn’t exercise strenuously for at least a month following the procedure. Extreme changes in temperature or flushing will exacerbate the redness on a temporary basis. The new skin you are growing is as delicate as a newborn baby’s. Remember to keep ultraviolet rays off your face and wear your sun bonnet!

I mentioned earlier an unusual kind of scaring caused by acne that sometimes appears on the chin: nodular scarring. These tiny bumps, measuring three to five millimeters in diameter, do not respond well to dermabrasion. It is better to apply “electrical hyfrecation”, and the results are usually good. A “hyfrecator” looks something like a ball-point pen casing, with a fine needle at one end. It is attached to a machine that emits radio waves, or electric currents, to actually “fry away” each nodular scar.

My experience has been that it is better to hyfrecate the chin over two or more sessions, doing only a small section at a time. For some reason, when the entire chin in hyfrecated, the patient can end up with what we call an “exuberant” healing process, and the end result isn’t nearly as level. Actually, exuberant healing from the inflammation of acne is exactly what caused the thickened nodular scars in the first place. So, nodular scarring is best treated in several short sessions.

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