Treatment of depressed cutaneous scars with gelatin matrix implant: a multicenter study

Subcision for Atrophic Acne Scarring: A Comprehensive Review of Surgical Instruments and Combinatorial Treatments

Subcutaneous incisionless surgery, also known as subcision, is a minimally invasive procedure that is commonly indicated for the treatment of atrophic acne scars. In recent years, many new techniques have been developed to maximize results from this procedure. This review article aims to identify an updated list of instruments and combinatorial treatments available for atrophic acne scar patients undergoing subcision. We constructed a comprehensive PubMed search term and performed triple-blinded screening on all resulting studies for mentions of subcision as indicated by acne scarring. Our results show that there are four main categories of subcision tools that are commonly employed to treat atrophic acne scars: needles, cannulas, wires, and blunt-blade instruments. Usage of these devices varies by scar depth, personal preference, and combinatorial treatment options. Overall, subcision is a particularly effective treatment for atrophic acne scars, and there is vast potential for further innovation with this technique.

History of Dermatologic Cosmetic Surgery

Dermatology has been one of the major disciplines that has contributed to the rapid advancement of cosmetic surgery. Various cosmetic procedures including chemical peel, dermabrasion, hair transplantation, laser surgery, soft-tissue augmentation, and liposuction have been refined or developed by dermatologists. This article describes the involvement by dermatologists in these cosmetic procedures.

Update on Soft Tissue Augmentation

This article reviews all of the materials currently available for soft tissue augmentation as well as those that have recently been available and those undergoing current evaluation for possible use in the future. Techniques, side effects, and tips on the use of each of the substances are described, and the future of soft tissue augmentation is discussed.

The management of postacne scarring

BACKGROUND

Therapeutic intervention for postacne scarring has historically been limited by the considerable morbidity of most treatments for only marginal disease improvement. Within the past decade, however, a greater understanding of the pathogenesis of acne scarring has led to the development of techniques that offer more favorable risk-benefit profiles.

OBJECTIVE

The aims of this article are to highlight a number of newer techniques and to assign their appropriateness to particular grades of acne scarring.

MATERIALS AND METHODS

Current modalities are discussed as they relate to disease process and specific acne scar types. Techniques are presented in order of most effectual therapeutic interventions for defined grades of acne scarring. Acne scarring grades have been described previously in terms of disease load, severity, and lesion morphologies.

RESULTS

A comprehensive discussion of updated therapeutic techniques and their biologic rationales in the treatment of acne scarring is presented. These include targeted interventions of inflammatory and postinflammatory processes, angiogenesis, immunologic processes, dermal and subcutaneous fibrosis, hypertrophy, and keloid scarring.

DISCUSSION

A requirement for developing successful treatments for postacne scarring is a greater understanding of its pathogenesis, variability among afflicted individuals, and the inflammatory mediators and immunology of the scarring process. Many innovative techniques introduced in the past decade attempt to counteract these pathologic processes while keeping the procedural and postoperative risks to a minimum.

Historie und Anwendung der Filler zur Faltenbehandlung

The development of injectable fillers for filling in depressions or wrinkles in the face is reviewed. After the hesitant interest on fillers to correct scars and depressions which started at the end of the 19th century, the development of new substances continued at a dizzying pace when public demand to treat the signs of aging increased dramatically starting in the mid 1980s. This led to a countless number of different substances. To obtain an optimal result in treating facial wrinkles or depressions the appropriate filler must be injected with a technique that suits best the individual indication. Fillers are classified in resorbable and non-resorbable permanent fillers. With resorbable fillers only a temporary result can be obtained, which means that the patient has to undergo repetitive treatments. With permanent, non-resorbable fillers long lasting results can be obtained that may last for years and even decades. All fillers may have side effects like swelling, erythema, nodules right after treatment and in very rare cases years after the injection foreign body granulomas may develop that may be resistant to treatment.

Post acne scarring: a review

Historically, post acne scarring has not been well treated. New techniques have been added and older ones modified to manage this hitherto refractory problem. The patient, his or her expectations and overall appearance as well as the morphology of each scar must be assessed and treatment designed accordingly. Upon reaching an understanding of what the pathology of the scar is and where it resides in the skin, the most pertinent treatment for that scar may be devised. Post acne scars are polymorphous and include superficial macules, dermal troughs, ice picks, multi-channelled fistulous tracts and subcutaneous atrophy. The wide variety of new methods includes the latest resurfacing tools such as CO(2) and erbium infrared lasers, dermasanding and possibly some future techniques such as non-ablative and radiofrequency resurfacing. Dermal and subcutaneous augmentation with autologous (including fat and blood transfer) and non-autologous tissue augmentation and the advent of tissue undermining has greatly improved the treatment of atrophic scars. Use of punch techniques for sharply marginated scars (such as ice picks) is necessary if this scar morphology is to be treated well. One should attempt to match each scar against an available treatment as far as possible. Many of these techniques may be performed in a single treatment session but repeat treatments are often necessary. The treatment of hypertrophic acne scarring remains difficult, but silastic sheeting, vascular laser and intralesional cytotoxics are interesting developments. Most often occurring extra-facially and in males, these distressing scars often require multiple treatments and modalities before adequate improvement is achieved.

Blood transfer: the use of autologous blood as a chromophore and tissue augmentation agent

BACKGROUND

Atrophic scars, whether traumatic, postsurgical, or postacne, are distressing and difficult to treat. A freely available autologous agent that provides medium- to long-term correction of this problem would be welcome. There are very few endogenous chromophores in the skin for laser or light energy to target. A benign exogenous pigment implanted in superficial scars may be useful in presenting such a target for light energy, allowing selective injury to these scars and the possibility of new collagen formation.

OBJECTIVE

To report five representative case reports that describe elements of two new techniques that may be useful in the management of atrophic acne scarring.

METHODS

After drawing blood from the patient, this was immediately reinjected into premarked areas of atrophic scars. If there was substantial tissue deficit, this was either followed by repeated injections of whole blood at monthly intervals on three occasions or until adequate correction was attained and oral antifibrinolysis medication dispensed in addition to the blood transfer (hematogenous augmentation of tissue or the HAT technique). In the other circumstance, where the deficit was superficial, blood was implanted high in the tissue and used as a target for vascular laser or intense pulsed light in a technique termed the blood augmentation (with or without) stimulation of tissues by irradiation with light or laser energy or the Bastille technique. This is again repeated as required.

RESULTS

Reasonable short- to medium-term correction has been attained in all five cases and there seemed to be a progressive improvement with each injection session. With the Bastille technique case there seemed to be progressive improvement with time, with the result at 4 weeks being substantially better than that at 2 weeks or at baseline.

CONCLUSION

These case reports suggest that blood may be a worthwhile augmentation agent and chromophore. Both these techniques deserve further investigation to determine the optimum parameters. They are so simple in their concept and technique that should they help to provide a medium- to long-term correction for atrophic scars and other depressions, such as expression lines and wrinkles, they would be worthwhile additions to existing dermatologic techniques.

Therapeutic undermining of scars (Subcision)

Two patients are described with depressed atrophic scars. The first patient had undergone skeletal traction around the knee and the second patient developed an apparent anetoderma of the left side of the nose. Dermal undermining was performed as the only treatment with successful resolution of their contour abnormalities. Only a single treatment session was required in each case. A brief review of this technique is presented.

Postacne scarring: a review of its pathophysiology and treatment

BACKGROUND

There has been a largely unheralded revolution in the number of techniques that can now be used in the treatment of atrophic postacne scarring. Atrophic scarring is the more common type of scarring encountered after acne.

OBJECTIVE

To illustrate the range of techniques useful in the therapy of postacne scarring, their relative advantages and disadvantages, and their place in treatment.

METHOD

A review of available techniques is used to illustrate the treatment of indented or atrophic acne scars.

RESULTS

The individual architecture of the indented scar must be assessed so that treatment may be designed to maximize its improvement. A variety of new methods now exist, including newer resurfacing tools such as infrared lasers, dermasanding, and others in their infancy such as nonablative resurfacing and radiofrequency methods. A true explosion in autologous and nonautologous tissue augmentation and the advent of tissue undermining and the use of punch replacement techniques has added more precision and efficacy to the treatment of these scars.

CONCLUSION

Atrophic postacne scars may be satisfactorily treated in many patients, but multiple methods are often required to ensure the best results.

Management of post-acne scarring. What are the options for treatment?

Post-acne scarring is a very distressing and difficult problem for physician and patient alike. Recently, newer techniques and modifications to older ones may make this hitherto refractory problem more manageable. Options for dealing with post-acne scarring are explored. The patient, his or her overall appearance and the morphology of each scar must be assessed and treatment designed accordingly. To adequately address the patient with scarring, a thorough knowledge of the pathophysiology and anatomy of the different types of scars should be sought. Once an understanding of what the pathology is and where it is occurring is attained, the most pertinent treatment for that scar may be devised. A variety of post-acne scars is produced including superficial macules, dermal troughs, ice picks, multi-channelled fistulous tracts and subcutaneous atrophy. The wide variety of new treatment methods for post-acne scarring includes newer resurfacing tools such as CO2 and erbium infrared lasers, dermasanding and possibly some future techniques such as non-ablative and radiofrequency resurfacing. Dermal and subcutaneous augmentation with autologous and nonautologous tissue augmentation and the advent of tissue undermining have greatly improved treatment of atrophic scars. Use of punch techniques for sharply marginated scars (such as ice picks) is necessary if this scar morphology is to be treated well. One should attempt to match each scar against an available treatment as far as possible. Many of these techniques may be performed in a single treatment session but repeat treatments are often necessary. The treatment of hypertrophic acne scarring remains difficult, but silastic sheeting, vascular laser, and intralesional cytotoxics are interesting developments. Most often occurring extra-facially and in males these distressing scars often require multiple treatments and modalities before adequate improvement is achieved.

Foreign body granulomas due to injectable aesthetic microimplants

We present two types of "new" foreign body granulomas caused by the injectable aesthetic microimplants Bioplastique and Artecoll. We report the clinical and histopathologic findings in five patients who had undergone treatment of mainly facial contour abnormalities with one of these implants. All patients were women, and the mean age was 45 years (age range 24-72 years). Two patients presented after treatment with Bioplastique; in three patients, augmentation was achieved by using Artecoll. Unsatisfactory cosmetic effects led to excision of the implants in four patients; in one patient, parts of the implant were excised during another cosmetic intervention. Subsequent histopathologic examination showed features of foreign body granulomas with distinctive cystic spaces. The clue to the diagnosis is the particular configuration of these cystic spaces and the characteristic shape of the foreign bodies. Bioplastique granuloma presents with irregularly shaped cystic spaces of varying size containing jagged, translucent, nonbirefringent foreign bodies whereas Artecoll granuloma shows numerous round vacuoles nearly identical in size and shape enclosing round and sharply circumscribed, translucent, nonbirefringent foreign bodies. These specific histopathologic findings unequivocally allow the correct diagnosis in spite of sparse clinical information.

Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles

BACKGROUND

A new method of subcuticular underming for the treatment of depressed cutaneous scars and wrinkles is introduced.

OBJECTIVE

To define the newly coined term "Subcision" and to describe this minor surgical procedure for treating depressed scars and wrinkles.

METHODS

A tri-beveled hypodermic needle is inserted through a puncture in the skin surface (hence, "incisionless" surgery), and its sharp edges are maneuvered under the defect to make subcuticular cuts or "-cisions."

RESULTS

The depression is lifted by the releasing action of the procedure, as well as from connective tissue that forms in the course of normal wound healing.

CONCLUSION

This technique is useful in treating a variety of cutaneous depressions, including scars and wrinkles.

The Fibrel mechanism of action study. A preliminary report

BACKGROUND

Fibrel is a medical implant device that has demonstrated use in the correction of cutaneous depressions from acne scars and wrinkles.

OBJECTIVE

Mechanisms of actions have been proposed that have theorized the production of new collagen over time as a result of the Fibrel implant. The present study utilized human volunteers to study the histologic response of Fibrel over time.

METHODS

Fibrel was injected into tattoo sites behind the ears of human volunteers; skin biopsies were taken at various time intervals and studied histologically by a clinical pathologist.

RESULTS

An overall increase over time was noted with regard to production of collagen and inflammatory response. No change in elastic tissue was found.

CONCLUSIONS

Fibrel does promote new collagen synthesis and inflammatory response and thus is useful to correct cutaneous depressions via soft tissue augmentation.

A 5-year safety and efficacy evaluation with fibrel in the correction of cutaneous scars following one or two treatments

In a multicenter clinical trial 300 patients were treated with Fibrel, 4 weeks following a negative skin test, for the correction of cutaneous scars. Fibrel treatment was restricted to one or two implants in a maximum of four scars. The scar corrections were evaluated by the physician, the patient, and also via an objective photogrammetric method. At the end of 1 year the percentage of scars with moderate, marked, or complete correction were 65, 63.3, and 85.8% according to physician, patient, and photogrammetric evaluations, respectively. A cohort of 111 patients were followed for up to 2 years and 87 patients were followed up to 5 years postimplantation. The physician and patient evaluations showed 55.1 and 50.6%, respectively, of the scars in the moderate, marked, or complete correction category at the end of 5 years with only one or two treatments. Safety evaluations included tests for antinuclear antibodies, rheumatoid factor, and presence of antibodies to Fibrel and their crossreactivity to human collagen I and III. These tests did not show any causal relationship to Fibrel treatments and the patients did not have any untoward immunologic symptoms. The data from these patients demonstrate that one or two Fibrel treatments are effective in maintaining greater than 50% correction of depressed cutaneous scars up to 5 years with negligible adverse sequelae and no untoward immunologic symptoms.

Silicone, fibrel, and collagen implantation for facial lines and wrinkles

In recent decades, cutaneous surgeons have contributed to the development of a number of implantable materials useful in the management of facial lines and wrinkles. Among these, the most effective are injectable liquid silicone, bovine collagen implant (Zyderm/Zyplast, Collagen Corporation, Palo Alto, CA) and gelatin matrix implant (Fibrel, Mentor Corporation, Goleta, CA). Each of these treatments carries its own balance of efficacy, safety, and ease of use. Clinicians are encouraged to evaluate each of these treatments in order to be able to offer a full range of injectable therapy for the aging face.

Experimental effects of graft revascularization and consistency on cervicofacial fat transplant survival

An experimental study evaluating the contributions of graft composition (particulate vs. whole) and revascularization (immediate reanastomosis vs. delayed) to cervicofacial fat transplantation was conducted in rats. Distant (inguinal fat) grafts were bilaterally transplanted to a muscular bed in the cervicofacial region as a free flap (anastomosis to carotid and jugular vessels) or as a free graft (either particulate or whole). Postoperative assessment was made by comparison of pre- and post-operative weights and histologic examination of all specimens, and by acrylic microangiography in select animals of each group. The fat flaps exhibited minimal loss of tissue volume, and showed a normal histologic appearance of the adipocytes and extensive vascular elements within the grafts. Conversely, considerable volume loss occurred in both the particulate and whole fat grafts. Histologically, the free graft was characterized by cellular disruption, atrophic adipocytes, and areas of acellularity. Whole grafts had histologic evidence of vessels located primarily at the periphery, whereas particulate grafts had increased intragraft vessels. Only the fat flaps showed observable intragraft vasculature by microangiography. These findings suggest that reduction of fat grafts into smaller components, eg, by liposuction harvesting, does not improve graft survival or decrease posttransplant resorption.

Dermal implants: safety of products injected for soft tissue augmentation

Soft tissue augmentation is a frequently performed outpatient operation. Products available for soft tissue augmentation vary in chemistry, clinical indications, and toxicity. This review examines safety and efficacy data for collagen implants (Zyderm and Zyplast), gelatin matrix implants (Fibrel), and injectable silicone. Soft tissue augmentation requires excellent technique to achieve excellent clinical efficacy. When used appropriately, the available products for soft tissue augmentation have few complications or adverse reactions.

Long-term safety and efficacy with Fibrel in the treatment of cutaneous scars--results of a multicenter study. Multicenter study group

Three hundred patients were treated with Fibrel (Serono Laboratories, Randolph, MA) for the correction of cutaneous scars. Fibrel treatment was restricted to four scars with one or two treatments following a negative skin test. The scar corrections were evaluated by the physician, the patient, and also via an objective photogrammetric method. At the end of 1 year, the percentages of scars with moderate, marked, or complete correction were 65.0%, 63.3%, and 85.8% according to physician, patient, and photogrammetric evaluations, respectively. A cohort of 111 patients from the 1-year study were followed for up to 2 years postimplantation to evaluate safety and efficacy. These patients had similar demographic and scar characteristics as the total patient population in the initial study. The efficacy evaluation at the end of 24 months indicated that successful correction was maintained in 64.4%, 58.9%, and 78.9% of scars for physician, patient, and photogrammetric evaluations, respectively. There were no severe hypersensitivity reactions following treatment with Fibrel. The data from these patients demonstrate that one or two Fibrel treatments are effective in maintaining the correction of depressed cutaneous scars for up to 2 years with negligible adverse sequelae.