Acne scars are a notoriously difficult problem to treat. Many older therapies relied on deep removal of layers of skin, long healing times, and potential pigmentation (skin color) difficulites. In addition, many of the older therapies could not be used in darker pigmented patients. Luckily, over the last several years, some new and exciting acne scar therapies have come to fruition. Dr. Shah offers the latest in acne scar treatments.
Dr. Shah uses a symbiotic approach to acne scars. He has found that more than one mode of treatment provides the best results. This approach involves switching between techniques to avoid acne scar plateau.
Philosophy
Dr. Shah uses a symbiotic approach to acne scars. He has found that more than one mode of treatment provides the best results. This approach involves switching between techniques to avoid acne scar plateau
Before and After
Lips are the most sensual feature of the face. Patients seeking lip augmentation can be as young as in their twenties to much older patients. Younger patients are often seeking a more seductive look to their face and more volume.
Post-acne scarring is quite common. An atrophic acne scar is where permanent, postinflammation degradation of the dermal surface.
About 95% of acne patients will have some degree of acne scarring. Acne scarring tends to look worse with aging.
There are said to be three different phases of acne scarring:
- Inflammation- this is where inflammatory mediators are brought about and swelling and localized inflammation is seen.
- Granulation Tissue Formation.
- Matrix remodeling- imbalance of metalloproteinases and mmp inhibitors.
The scars occur as there is degradation of collagen fibers and subcutaneous fat. There is also thought to be a genetic disposition of some patients to scar versus others.
Click Here For More Before and After Pictures.
What causes Acne Scars to occur?
Acne is typically a localized skin infection of the face. The infection can lead to redness, inflammation and sometimes scarring.
Acne is thought to occur because the oil in the skin, called sebum, feeds the bacteria that cause acne. The most common type of acne is from the bacteria, Propionibacterium acnes. More severe variants of acne, particularly pustular acne, can be caused by other types of acne, including Staphylococcus Aureus.
When the body has a vigorous response, almost inappropriately strong, to acne bacteria, this can lead to inflammation. Intense inflammation over time cause scarring. Some people are more prone to scarring than others. Some patients with intense inflammation can end up with significant disfiguring scars.
Acne scars treatments
The term ‘acne scar’ does not describe most patient’s skin accurately. Rather than a series of raised lesions, most acne scars are depressions within the skin. It is not known why some patients are predisposed to these depressions in the skin while others do not but some research hints at a genetic component. Treating these “acne depressions” often involves using techniques used to stimulate the body’s collagen fill in the depressions and textural abnormalities. Procedures such as laser resurfacing stimulate the dermis to create more collagen. Specific treatments such as Cross TCA and Pinpoint irradiation use a focused treatment to the scar itself in an effort to create collagen. Other techniques such as undermining the depressed area with a needle and using a longer lasting filler can be helpful as well to improve textural appearance.
Acne scars are often a difficult area to treat. While all these treatments can help to improve the appearance of acne scarring, they do not completely remove or eliminate them. Here are the techniques that are used to help treat acne scars.
LASER RESURFACING
Lasers can be helpful in improving texture and lessening scars in some patients. They are an alternative to dermabrasion. Dr. Shah uses a combination of erbium, fractionated erbium, C02, and fractionated C02 to resurface the face. A laser is a relatively superficial resurfacing modality but can improve texture with multiple treatments.
PINPOINT IRRADIATION
Pinpoint irradiation is a novel approach to acne scars. Traditionally, LASER resurfacing has focused on resurfacing the whole face, including the areas not affected by scarring. Pinpoint irradiation works by discretely treating the acne scar with a single C02 LASER beam, sparing the surrounding tissues. This discrete treatment allows for a faster recovery by keeping the skin intact. In a way this technique is like targeted fractionated C02 treating only the acne scars and not random locations. The benefit of fractionated C02 is quicker recovery and less chance of adverse risks.
COMBINATION OF RESURFACING AND PINPOINT IRRADIATION
Dr. Shah uses a combination of erbium, fractionated erbium, C02, and fractionated C02 to resurface the face. The benefit of combining modalities is that more than 1 effect is created. The focused treatment of pinpoint is enhanced by creating overall improved texture with a fractionated laser treatment to the surrounding area, making the scars themselves more difficult to distinguish.
FRACTORA
Fractora is a novel approach in that needles are placed deep into the dermis and treating the skin with a bottom up approach. The benefit is that the epidermis can be spared if desired leading to faster recovery. Fractora uses radiofrequency needles that will improve texture and appearance of scars.
SUBCISION
Subcision in of itself is the use of a needle to undermine the scar to improve its appearance. Blood from the needling as well as the mechanical trauma has been theorized to create collagen. In Dr. Shah’s experience, this technique WITHOUT FILLER is NOT effective. The benefit of subcision with filler is that a matrix or spacer of material is placed in the subcised area, using a specialized subcision needle. The space is then filled with a longer lasting filler product to raise the scar from a depressed area to a flatter appearance. Histological studies of fillers has demonstrated that fillers often are replaced in the body with collagen, making subcision and filler an excellent technique for some types of acne scars.
CROSS (CHEMICAL RECONSTRUCTION OF SKIN SCARS)
CROSS is a new approach to acne scars. Using the strength of a deep peel, Dr. Shah selectively targets acne scars while sparing the remainder of the skin. He treats specific scars in a highly technical and specific manner. The stimulation of the deep peel encourages collagen formation, flattening acne scars and improving skin texture. The benefit of targeted selection is that the recovery period of chemical peel is limited to the treated areas. In addition, many drawbacks of deep chemical peels can be avoided including pigmentary abnormalities, erythema, and scarring. This technique can be used in all skin types including Caucasian, Asian, African American.
CROSS TCA works with specific types of acne scars. Icepick, pores, and some boxcars respond best to this approach. Recovery from this technique often involves the early formation of a white spot which is replaced by a scab. The scab falls off and then underlying redness can be seen in the area treated with the CROSS TCA. The redness typically dissipates in a week but can last longer in select patients. Patients typically repeat multiple treatments for optimal results.
MEDICAL ROLL CIT
The medical roll CIT (collagen induction therapy) is a procedure developed to promote collagen deposition in the dermis, just below the surface of the skin. It is an effective procedure for acne scarring and upper lip wrinkles.
The developers of the medical roll CIT found that tattooed skin was smoother than non-tattooed skin. They found that the stimulation of the needles created focal areas of stimulation to the dermis, inducing the creation of collagen. In order to further stimulate collagen, topical vitamin A and C are applied before and after the roll CIT therapy. Vitamins A and C can more effectively penetrate the deeper layers of the dermis after medical roll CIT session.
While other modalities target collagen by removing lasers of skin, the Medical Roll CIT can stimulate collagen while leaving the majority of the superficial skin intact. The benefit to the patient is less pain in recovery, quicker recovery, and less chance of scarring or pigmentation changes than ablative skin therapies. In addition, the medical Roll CIT can be used all skin types safely.
The roll CIT is a highly stimulating procedure which requires a combination of a light sedative, anesthetic blocks and topical anesthesia. Most patients opt to have this procedure done in the office setting. Recovery involves swelling and in some cases bruising which typically resolves over a period of 4 to 5 days. Medical Roll CIT is effective in all acne scar types.
DR. SHAH uses two modalities for mechanical stimulation of scars. The medical roll cit is used for acne scars that are deeper in nature and needle penetration can be as deep as 3 mm. When the needle has penetrated the scar itself can be broken up and improved in appearance. A mechanized needling device is also used where penetration can be done rapidly (adjusted to over 100 oscillations per second) at a depth of 2 mm to create another method of penetration of acne scars. Different scars will utilize different approaches and may benefit from either of these techniques.
The science of acne
Acne is a common skin inflammation. When hair follicles or pores in the skin get trapped, the acne bacteria (Propionibacterium acnes) multiply in the pit and become inflamed. There are many other factors in the acne story such as hormones. When hormonal changes at puberty create excess oil, pores become blocked and are an open invitation to Acne bacteria. Commonly, patients are placed on systemic agents such as birth control antibiotics or oral antibiotics. The problem with such treatments is that it effects the entire body, can be cumbersome and inconvenient to the patient. In addition, long term systemic antibiotics can lead to antibiotic resistance.
Click Here to read more about the Science of Acne.
The types of acne scars
There are different kinds of acne scars: ice pick, atrophic, and hypertrophic. Ice pick scars are deep pitted scars with steep edges. Atrophic scars are pitted but have smooth borders and are not as deep. Hypertrophic scars, more common on the back and chest, are thick, lumpy scars that sit above the surface of the skin.
- Box Car Scar: The box car scars or boxcar scars can be treated with a variety of techniques including CrossTCA or Medical Roll-CIT
- Icepick Scars: The icepick scars can be either deep or shallow pits. The scars can be treated by direct excision, Cross TCA.
- Rolling Scars: Rolling scars usually are tissues which appear normal but have undulations within the skin. The can respond to Medical Roll-CIT or subcision with filler placement
- Raised Scars: Raised scars can be a result of acne and occur on nose/chin and torso. Larger scars may respond to intralesional steroid injection.
- Large Pore: Large Pores are very difficult to treat but some modalities which can benefit this include intradermal botulinim toxin and facial resurfacing.
Acne Scar Classification
- Grade 1 Maccular scarring or flat scarring that is charcterized by flat area of increase or decreased pigmentation visible from a distance of >500mm
- Grade 2 Mild disease that is visible at distances of >500 mm and can be covered up by make-up
- Grade 3 Moderate disease that is visible at > 500 mm and is not easily covered up by make-up or the normal shadow of a shaved beard. Stretching the skin can flatten the scar.
- Grade 4 Severe disease as in Grade 3 but is not flattened out by stretching the skin
Recovery Time
The recovery time can vary from treatment to treatment and the level of intensity. Patients wanting more aggressive treatments may want to have stronger settings at the expense of longer downtimes and more skin abnormalities. Patients can fine tune their experience to maximize their results while achieving a level of recovery acceptable to their work and social schedule. As every patient heals at a different rate, patients should be cautious about exact recuperation times.
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Frequently asked questions
The downtime is typically about 4 days.
You are able to wear makeup after one week once you have healed.
Overall the Medical Roll CIT procedure is very safe. However, realistic side effects that you may expect are prolonged swelling and redness.
The most safe and effective treatment for the majority of patients with acne scars is the Fractional CO2 Laser. This laser is a new, so called “fractional” laser. This means that the laser works by resurfacing only a “fraction” of the skin at a time, leaving the surrounding area intact for faster healing. This vastly reduces the incidence of side effects and has given us the ability to treat all skin types.
The CO2 fractional laser pokes tiny microscopic holes in the skin down past the epidermis and into the dermis. These holes cause new collagen to be generated which fills in the acne scars and creates rejuvenated smoother skin.
Most patients start to notice improvements in their skin as early as 1 week after the treatment. Continued improvements occur for the next 6 months and peak at around month 6. Most patients notice between 50-70% improvement of the condition treated. However, results vary by individual.
The vast majority of patients require only 1 treatment to achieve the desired results. Since the treated area continues to improve for the 6 months following the laser treatment, we re-evaluate the need for any additional treatments at that time. All treatments are performed in our practice located off Michigan Avenue in Chicago.
Dr. Shah safely treats acne scars in patients with all skin types including Asian, Indian, and African-American skin. An experienced laser surgeon is needed to treat darker skin types safely.
The fractional CO2 laser causes a wound in the skin which means you will have three to four days of downtime when the skin is healing. During that time you have to apply an ointment frequently to your face keep the skin greasy, which makes healing faster.
The main risks are temporary or long-lasting light or dark spots from treatment. Very rarely scarring can still result. For these reasons it is important to be treated by an experienced laser surgeon.
The whole procedure is done under local or topical anesthesia. You are awake and comfortable the entire time. Prior to the procedure, topical numbing cream is applied for 60-90 minutes. In addition, valium is given prior to the procedure to facilitate relaxation. Using these measures there is usually minimal discomfort during the resurfacing procedure.
About Us
Dr. Shah is a double board certified facial plastic surgeon who has written over 50 scientific articles including three landmark articles about facial anatomy revolutionizing the way plastic surgery is performed. Dr. Shah specializes in Acne Scars Treatment and takes an analytical approach to patient recovery after the procedure. Based in Chicago, IL; Dr. Shah is not only recognized as one of the top plastics surgeon not only in the city of Chicago, but in the world.
Related procedures: Picosure Laser, Skin Care.