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Aesthetics Journal
Aesthetics
Treating acne scarring with fillers Dr RenĂŠe Hoenderkamp discusses the treatment of acne scarring with dermal fillers Introduction Acne scarring can be distressing and stigmatising, especially when affecting the face. Whilst there are a multitude of treatment options available, I do see patients who have tried everything including combinations of lasers, peels, retinoids and needling, but are still searching for a solution. I therefore decided to try and treat some atrophic scars with hyaluronic acid (HA) fillers and witnessed some excellent results. When treating acne scarring with fillers, I use one of two techniques depending on the scar type and number. Injecting filler carefully into the dermis/epidermis underneath atrophic scars lifts them and improves the overall look of skin blighted by acne scarring. This can be done by either individually targeting pitted scars with a plumping filler or approaching an entire area with a lighter filler, used mainly as a skin booster for hydration and skin conditioning. Having said this, all filler types are being used to treat acne scarring.1 Anatomy of acne scarring Acne scars occur when pustules go on to form nodules and cysts. Scarring is the result of skin damage during the healing of active acne. This process produces two typical scar types; atrophic and hypertrophic scars, depending on whether there is a net gain or loss of collagen in the healing process.2 A net loss forms an atrophic scar (80-90%) and a net gain a hypertrophic or keloid scar (10-20%).2 Both processes arise from the same pathophysiology, involving a transition through three stages of damage and healing. The damage caused initially by inflammation of a blocked sebaceous gland causes blanching and vasoconstriction. The immune response floods the area with granulocytes, macrophages, neutrophils, lymphocytes, fibroblasts, and platelets, preparing for granulation via immune mediator release. As granulation progresses the final stage is seen: matrix remodelling. The area is then flooded with enzymes, released from fibroblasts and keratinocytes, which determine the final structure of the extracellular matrix (ECM). Any imbalance in the enzymatic breakdown and rebuild of tissue results in scarring.2 When using fillers to treat acne scarring, only atrophic scars can be treated, because they are the only scars which are depressed, and these are generally classified into three types; boxcar, ice-pick and rolling (Figure 1):
Pros and cons Procedurally, the biggest consultation discussion point is permanence. Using semi-permanent fillers means improvement will gradually wear off and need repeating. My experience is that scars rarely return to their previous state due to a degree of subscision that occurs (and can be actively carried out) during administration. Filler type will dictate longevity, but I use HA fillers, so six to 12 months is the norm.3 Results are instant and improve over the following weeks. I often address specific scars for patients preparing for a big event, so timing is key and having the treatment a few weeks before the event, and not a few days, is always advisable. The procedure is painful but bearable. Some practitioners use lidocaine cream, but I find the associated local oedema is detrimental to scar visualisation, so I avoid using anaesthesia. Anecdotally, it appears to be less painful than lip fillers and these patients have often had many painful procedures to treat the indication previously, so may be more tolerant than other filler patients. Injection site redness and bruising is a possibility, as with all filler procedures, so careful consenting is key to managing expectations and guiding patients on how long potential side effects may last. Is it effective? Certainly my experience suggests the use of fillers is an effective solution for atrophic scar reduction. Results are seen instantly and improve over weeks as there is a double effect from the procedure: physical lifting up and out of the scar, and collagen development that often follows from fibroblast stimulation in the dermis by the needle. Not all scars respond equally, and response is governed by type and depth of scar and how disrupted the underlying tissue is; this dictates filler placement and can’t be predicted. I have found broad rolling scars that are distensible when the skin is stretched respond best to fillers, but I have also had success with box car and ice pick scars that are not too narrow. The improvement, whilst varied, is always in my experience evident, and, however slight, is of psychological benefit. These patients have often struggled for years to improve their scars, and resulting expectations are lower than the usual filler patient. They are often so appreciative of small improvements that it is humbling and a useful reminder of the stigma suffered.
Reproduced from Aesthetics | Volume 2/Issue 8 - July 2015