Combination therapy in the management of atrophic acne scars

BACKGROUND

Atrophic acne scars are difficult to treat. The demand for less invasive but highly effective treatment for scars is growing.

OBJECTIVE

To assess the efficacy of combination therapy using subcision, microneedling and 15% trichloroacetic acid (TCA) peel in the management of atrophic scars.

MATERIALS AND METHODS

Fifty patients with atrophic acne scars were graded using Goodman and Baron Qualitative grading. After subcision, dermaroller and 15% TCA peel were performed alternatively at 2-weeks interval for a total of 6 sessions of each. Grading of acne scar photographs was done pretreatment and 1 month after last procedure. Patients own evaluation of improvement was assessed.

RESULTS

Out of 16 patients with Grade 4 scars, 10 (62.5%) patients improved to Grade 2 and 6 (37.5%) patients improved to Grade 3 scars. Out of 22 patients with Grade 3 scars, 5 (22.7%) patients were left with no scars, 2 (9.1%) patients improved to Grade 1and 15 (68.2%) patients improved to Grade 2. All 11 (100%) patients with Grade 2 scars were left with no scars. There was high level of patient satisfaction.

CONCLUSION

This combination has shown good results in treating not only Grade 2 but also severe Grade 4 and 3 scars.

A systematic review of treatments for acne scarring. Part 1: Non-energy-based techniques

Acne is a common condition that can result in permanent scarring. We have performed a comprehensive literature search of the last 10 years in order to determine the efficacy and side effects of commonly used treatments against post-acne scarring. A total of 36 relevant articles were identified on the following interventions: subcision (10), dermabrasion (one), microneedling (eight), dermal fillers (five), and chemical peeling (12). Post acne scarring is a common and challenging condition with no easy and definitive solution. The above interventions have been used with varying degrees of efficacy, each having both pros and cons. All have been deemed to be safe with few and transient adverse reactions. However, further trials with larger number of patients are necessary in order to reach more concrete conclusions regarding their efficacy.

Efficacy of fractionated microneedle radiofrequency with and without adding subcision for the treatment of atrophic facial acne scars: A randomized split-face clinical study

BACKGROUND

There is no gold standard treatment for facial acne scars, and overall, little literature exists about the combination therapy for treatment of acne scar.

AIMS

The aim of this study was to evaluate the efficacy of fractionated microneedle radiofrequency (FMR) vs FMR combined with subcision for the treatment of atrophic acne scars.

PATIENTS/METHODS

This was a randomized, split-face clinical study of 25 patients with II-IV Fitzpatrick skin types with moderate to severe facial atrophic acne scars. Initially, standard subcision by Nokor needle was performed on one side. Two weeks after subcision, FMR treatment was performed on both cheeks of each participant. Second and third FMR treatment sessions were performed within 4-week intervals. Two-blinded dermatologists performed clinical assessments using a quartile grading scale, and patients were also asked to judge their satisfaction using a visual analog scale (VAS) scoring system.

RESULTS

The age of the patients varied from 24 to 40 years (mean: 30.08±4.94 years). Only nine patients (36%) were males. Clinical assessment by two-blinded dermatologists showed statistically significant improvement in the combination (FMR+subcision) group (P=.009). Patient satisfaction was statistically significantly better in the combination group (P=.001). A darkening of skin phototype was associated with a decrease in patient's satisfaction VAS score (P=.07).

CONCLUSION

The combination of subcision and FMR is a safe and effective modality for mixed type acne scars. Additional randomized clinical study with long-term follow-up is necessary for further evaluation of FMR in combination with other procedures. The full trial protocol can be accessed in: http://www.irct.ir/searchresult.php?keyword=%20%20IRCT2016103130597N1&id=30597&number=1&field=a&prt=1&total=1&m=1. The clinical trial registration number is IRCT2016103130597N1.

A split-face comparative study to evaluate efficacy of combined subcision and dermaroller against combined subcision and cryoroller in treatment of acne scars

BACKGROUND

Acne scars occur consequent to abnormal wound healing following sebaceous follicular inflammation in acne. Various types of acne scars are icepick, rolling, boxcar, hypertrophic, and keloidal. Different modalities of treatment include subcision, dermaroller, cryoroller, punch excision, chemical peeling, and lasers.

OBJECTIVES

To compare the efficacy of combined subcision and dermaroller vs. combined subcision and cryoroller in acne scar treatment.

METHODS

Thirty patients (19 males and 11 females) with grade 2, 3, and 4 postacne scarring (Goodman and Baron qualitative grading system) were enrolled in the study. Three sittings each at 1-month interval were carried out of subcision under nerve block on the entire face followed by derma roller (2.5 mm) and cryoroller on one half of the face. Standardized digital photography was performed preprocedure and at 6 months. Grading of acne scar photographs using the Goodman and Baron qualitative and quantitative grading scale was carried out by a blinded observer pre- and postprocedure at 6 months. Patients' own evaluation based on patient scar severity perception scale of 1-10 was also taken into account.

RESULTS

Assessment using the quantitative grading scale showed a 57% improvement using combined subcision and cryoroller against 40% improvement with combined subcision and dermaroller. Average improvement perceived by the subjects was 61% with combined subcision and cryoroller against 45% with combined subcision and dermaroller. The data were analyzed using Wilcoxon signed rank test and found statistically significant. Postinflammatory hyperpigmentation on the cryoroller side and erythema, edema, and hematoma formation due to subcision was transient.

CONCLUSION

Combined subcision and cryoroller is more effective than combined subcision and dermaroller for treatment of acne scars.

Fractional Carbon Dioxide Laser and its Combination with Subcision in Improving Atrophic Acne Scars

Background:

Acne is a very common skin disease in which scars are seen in 95% of the patients. Although numerous treatments have been recommended, researchers are still searching for a single modality to treat the complication due to its variety in shape and depth. We compared the effects of fractional carbon dioxide (CO₂) laser alone and in combination with subcision in the treatment of atrophic acne scars.

Materials and Methods:

This clinical trial study was performed in Skin Diseases and Leishmaniasis Research Center (Isfahan, Iran) during 2011–2012. Eligible patients with atrophic acne scars were treated with fractional CO₂ laser alone (five sessions with 3-week interval) on the right side of the face and fractional CO₂ laser plus subcision (one session using both with four sessions of fractional CO₂ laser, with 3-week interval) on the left side. The subjects were visited 1, 2, and 6 months after the treatment. Patient satisfaction rate was analyzed using SPSS 20 software.

Results:

The average of recovery rate was 54.7% using the combination method and 43.0% using laser alone (P < 0.001). The mean patient satisfaction was significantly higher with the combination method than laser alone (6.6 ± 1.2 vs. 5.2 ± 1.8; P < 0.001). Bruising was only seen with the combination method and lasted for 1 week in 57.0% and for 2 weeks in 43.0%. Erythema was seen in both methods. Postinflammatory pigmentation and hyperpigmentation were associated with combination method. No persistent side effects were seen after 6 months.

Conclusion:

Using a combination of subcision and laser had suitable results regarding scar recovery and satisfaction rate.

Platelet-rich plasma in the treatment of scars, to suggest or not to suggest? A systematic review and meta-analysis

Despite the rising trend for applying platelet-rich plasma (PRP) in the management of various types of scars, there is no convincing evidence supporting its use. This motivated us to review the randomized clinical trials that examine the effectiveness and safety of PRP, alone or in combination with other methods, for the management of atrophic or hypertrophic/keloidal scars. The Web of Science, Scopus, Google Scholar, and Cochrane Library databases were systematically searched until September 1^st , 2020. Thirteen clinical trials were enrolled in the meta-analysis, and 10 more were reviewed for their results. The random effect meta-analysis method was used to assess the effect size of each outcome for each treatment type, and I² was used to calculate the statistical heterogeneity between the studies. Patients treated with PRP experienced an overall response rate of 23%, comparable to the results seen with laser or micro-needling (22% and 23%, respectively) When used alone, moderate improvement was the most frequently observed degree of response with PRP (36%) whereas, when added to laser or micro-needling, most patients experienced marked (33%, 43%, respectively) or excellent (32% and 23%, respectively) results. Concerning the hypertrophic/keloid scars, the only study meeting the required criteria reported a better improvement and fewer adverse effects when PRP was added to the intralesional corticosteroids. Platelet-rich plasma appears to be a safe and effective treatment for various types of atrophic scars. In addition, when added to ablative lasers or micro-needling, it seems to considerably add to the efficacy of treatment and reduce the side effects.

A Comprehensive Review of Non-Energy-Based Treatments for Atrophic Acne Scarring

Scarring is a dire consequence of acne vulgaris. Particularly, atrophic acne scarring is highly prevalent among young adults, and its physical and psychological effects can persist throughout their lives if left untreated. This literature review will analyze various non-energy-based approaches to treating atrophic acne scarring, emphasizing recent advances within the last 5 to 10 years. To accomplish this, we performed a PubMed search for various acne scar treatments such as chemical peels, dermabrasion, microdermabrasion, subcision, microneedling, punch techniques, dermal fillers, and thread lifting. Our findings and analysis show that there is no panacean solution to treating atrophic acne scars, which explains the evolving trend towards developing unique combinatorial treatments. Although a fair comparison of each treatment approach is difficult to achieve due to the studies’ varying sample sizes, strength of evidence, treatment execution, etc, there still remains a level of consensus on what treatments are well suited for particular scar types.

Efficacy evaluation of Endolift-based Subcision on acne scar treatment

BACKGROUND

People with acne scar suffer from destruction to the surface of the skin. Treating acne scars is a challenge that might need several methods.

AIMS

Subsection is a method that has been informed to be a useful method in treating rolling acne scars. While Subcision is a valued procedure, its effect is mild to moderate due to its high reappearance rate, and patients' dissatisfaction with some of the side effects such as inflammation after procedure.

PATIENTS/METHODS

In this pilot study, 9 rolling acne scar patients underwent Subcision with the Endolift (200-nm fiber) and followed up for 3 months. Outcomes were evaluated by 3 dermatologists (Blind). Also, the patients' satisfaction was assessed to compare with dermatologist's opinions.

RESULTS

Our results indicated that Subcision with the Endolift displayed good and very good improvement in about 90% of patient with a good and very good satisfaction in the patients. Photographic data evaluation indicated 100% improvement in scar depth, topography, and total acne scar appearance. The average numbers of lesions before the treatment were 25.5 ± 12.1, and after treatment, it was reduced to 11.4 ± 2.1 (P < .05).

CONCLUSION

Subcision with the Endolift seems to be a safe and effective method for acne scar treatment. It is done with a single perforation on each side (instead of several perforations), which reduces the pain and scar risk in the patients. Also, Endolift-based Subcision needs fewer surgical sessions and less recovery time with less inflammation and erythema.

Combination therapy using subcision, needling, and platelet-rich plasma in the management of grade 4 atrophic acne scars: A pilot study

BACKGROUND

Multimodality therapies including minimally invasive modalities are increasingly used in atrophic scarring.

OBJECTIVE

To evaluate the role of platelet-rich plasma (PRP) as adjunctive therapy to a combined subcision and needling treatment in severe (grade 4) atrophic acne scarring.

METHODS

A total of 30 patients with grade 4 acne scars were randomly divided into two groups, 15 patients each: Group A underwent three sequential treatments of subcision and needling while Group B, three sequential treatments of subcision, needling, and topical application of PRP that were performed at 3-week intervals. Scar grading was assessed 3 months following the final session. Participant's assessment of treatment response was registered.

RESULTS

Scar improvement ≥50% was reported significantly more often by Group B than Group A patients (P = 0.025). Regarding physician-based assessment of scar grading post-therapy (number of patients with two grades improvement vs one grade or no improvement), there was a trend toward more improvement in Group B (P = 0.195). Physician's evaluation of acne scar improvement correlated with the patient's assessment of improvement: 60% of Group A and 66.6% of Group B patients appreciated an improvement of 25%-49% and 50%-74%, respectively. Mean duration of postprocedure erythema/edema was shorter among Group B than Group A patients (16.1 vs 32.9 hours, respectively). Overall, substantial improvement was noticed in rolling and boxcar scars with only a mild change in icepick scars.

CONCLUSION

Platelet-rich plasma appears to add to the improvement of grade 4 atrophic acne scars when combined with needling and subcision. These findings require further evaluation by future studies.

Comparing cannula-based subcision with the common needle method: A clinical trial

OF TRIAL DESIGN

Treatment of depressed acne scars requires multiple modalities. Although needle subcision is a valuable method, it exhibits mild to moderate efficacy in treatment of deep acne scars owing to the high recurrence rate and other side effects. A total of 100 patients with rolling acne scars were randomly treated using the standard technique of 18 gauge cannula and 27 gauge needle subcision in two parallel groups, and the effect of cannula subcision instead of needle subcision was evaluated in the treatment of rolling acne scars.

METHODS

A total of 100 patients were randomly treated using the standard technique of 18 gauge cannula and 27 gauge needle subcision. The outcomes of these procedures were assessed by three blinded dermatologists and by patients' satisfaction.

RESULTS

Subcision using the cannula showed good and very good improvement in about 83% of patients (n = 50, P < .05) based on dermatologists investigation and almost no side effects were observed in compared with needle subcision. The response rate was significantly different while using cannula subcision.

CONCLUSION

Cannula subcision appears to be a safe and practical technique that can enhance the efficacy of subcision without considerable complications.

Subcision: Indications, adverse reactions, and pearls

BACKGROUND

Subcision, also known as subcutaneous incisionless surgery, is a surgical intervention used to treat a variety of skin conditions including atrophic acne scars, depressed scars, cellulite, and wrinkles.

AIMS

We plan to prepare a review article about the indications of subcision, its adverse reactions, and pearls.

PATIENTS/METHODS

We searched the literature for the information about subcision and its applications from papers published up to March 2019. The search was performed through the databases of the National Library of Medicine.

RESULTS

After a thorough review of the published papers about subcision, we finally chose to review 40 articles that had proper sample size and design to prepare this review article. Twenty-one papers were related to the application of subcision in the treatment of acne scar and other scars. Four articles were about the application of subcision to treat cellulite, and eight articles were related to other applications of subcision such as the treatment of striae or nasolabial fold. The remaining seven articles include published review papers about subcision or acne scar classification.

CONCLUSION

Subcision seems to be effective on various skin conditions including acne scar, other depressed scars, and cellulite. It is easy to apply and inexpensive with short downtime and no significant complications. Subcision needs proper technique and adequate experience.

Comparison of two methods of subcision Nokor and blunt blade in acne scars treatment

CONTEXT

Subcision is a simple surgical method that can be effective in treatment of acne scars.

AIMS

This study was conducted to evaluate and compare the two methods of Nokor needle and blunt blade (BB) subcision in treatment of acne scars.

SETTINGS AND DESIGN

This clinical trial study was conducted on 28 patients with acne scars.

PATIENTS AND METHODS

One side of the face was treated with BB subcision method, and the other side was treated with Nokor needle method. Followed up period was 6 months after treatment.

STATISTICAL ANALYSIS USED

Data were analyzed by Statistical Package for the Social Sciences (version 20) software using independent sample t test, Mann-Whitney test, Friedman test, and Fisher's exact test.

RESULTS

In follow-up period, the improvement of acne scars was comparable in both groups (P > 0.05). Complications were lower in BB method than another method (P < 0.05). The patient satisfaction was higher in BB method (P < 0.05).

CONCLUSIONS

Both of modalities offered similar improvement, but the complication rate was lower and the patient satisfaction was also higher in the BB method than another method.

A split-face randomized controlled study comparing the efficacy and safety of intralesional radiofrequency-assisted subcision vs conventional subcision in postacne scars

BACKGROUND

Postacne scars have significant psychosocial distress among patients. Subcision is a well-known treatment modality specially for rolling type of acne scars, but is a crude mechanical process, which carries a risk of hematoma formation.

AIMS

To compare the efficacy and safety of radiofrequency-assisted subcision (rSubcision) with conventional subcision in postacne scars.

METHODS

In this randomized, split-face study, adult patients with postacne scars were randomized to receive either conventional subcision or rSubcision in 2 sessions, 4 weeks apart and followed up for 2 months. Outcome was measured using Goodman and Baron score (GBS), investigator global assessment (IGA) by two blinded dermatologists, and patient global assessment (PGA).

RESULTS

Seventeen out of 21 patients completed the treatment. Statistical analysis of the results was performed using SPSS 15.0 statistical software (SPSS). Patients in both the groups had significant improvement from baseline according to quantitative scoring (P = .0001), number of scars (P = .0001), IGA, and PGA. The improvement was comparable in both the groups according to GBS and IGA but better on rSubcision side in terms of PGA. Two patients developed small entry point burn during rSubcision which healed in one month and one developed persistent hematoma with conventional subcision.

CONCLUSIONS

Both modalities were comparable in terms of assessment scores and investigator assessment, but patients found improvement better on rSubcision side.

Evaluating the effectiveness of stromal-vascular fraction (SVF) cells along with subcision method in the treatment of acne scars: A double-blind randomized controlled clinical trial study

BACKGROUND

Subcision method is one of the main techniques for treatment of acne scars or stromal-vascular fraction (SVF) and combined therapy can improve treatment strategy.

OBJECTIVE

To use subcision method along with SVF for treatment of acne scar and comprised with alone subcision method.

MATERIALS AND METHODS

In this double-blind clinical trial study, 10 patients with acne scars were entered into the study. Subcision technique was randomly performed on one side of the face and subcision technique plus SVF on opposite side of the face. All patients were examined before treatment and after 3 months by Visioface for volume, area, and depth of scars, as well as thickness and density of the epidermis and dermis of the scars in question. In addition, doctor's and patients' satisfaction, tolerability, and safety were determined after 3 months of treatment. Finally, statistical analysis was done by SPPS, version 25.

RESULTS

In terms of volume and area of scars, the mean percent change was 46.55 ± 13.92 and 44.60 ± 5.76, for the case group, and 13.31 ± 9.27 and 11.28 ± 9.64 for the control group, respectively. So, combined therapy led to significant recovery compared with alone subcision method (p value < 0.001). In both interventions, the increase of density and thickness was proven after treatment, also a significant difference in complete, epidermal, and dermal thickness and epidermal density variables was observed between combined therapy and alone subcision (p value < 0.05). Mean score of doctor's and patients' satisfaction in combined therapy (7.10 ± 0.74 and 7.10 ± 0.99, respectively), was also significantly higher than subcision alone (5.50 ± 0.53 and 5.30 ± 1.25, respectively). Finally, no complications were observed in the patients.

CONCLUSION

According to the acquired results, combined therapy can be considered as effective and safe treatment for acne scars with significant higher efficacy compared with subcision alone.

Subcision in acne scarring: A review of clinical trials

Post-acne scarring is the most common permanent consequence of acne vulgaris. Subcision is an intervention in which a needle or blunt cannula is inserted under the scar and moved back and forth to cut fibrotic strands and form new connective tissue, thereby elevating the atrophic scars. In this study, we reviewed the efficacy and adverse effects of different subcision techniques alone or in combination with other modalities to manage acne scars. The terms (subcision), (subcision AND acne scar), and (subcision AND scar) were searched in PubMed and Google Scholar. We included all available reports on clinical trials written in English and published before June 2022. A total of 16 relevant articles were identified after reviewing the abstracts and full texts. Four articles compared blunt cannula-based subcision as a modified technique with needle-based subcision as a conventional method, while the others investigated the combination of subcision with other modalities. According to our findings, subcision is a safe and effective method for treating atrophic acne scars. Needle-based subcision and cannula-based subcision offer comparable efficacy, with the latter causing fewer side effects and inducing greater patient satisfaction. Combining subcision with the application of autologous tissues (platelet gel) or artificial materials (hyaluronic acid gels and threads) as fillers can improve outcomes and prevent the re-depressing of scars, as can its combination with frequent suctioning. Combinations with microneedling or fractionated microneedle radiofrequency have also been safe and effective. We conclude that modifications of the subcision procedure lessen its side effects, and combination therapies improve its efficacy.

Evaluation of PSP technique including dot peeling, subcision and intradermal injection of PRP in the treatment of atrophic post-acne scars

BACKGROUND

Atrophic post-acne scars are common complications of acne. Many modalities are proposed, but each does not yield satisfactory clinical outcomes. To evaluate the therapeutic effect of PSP technique including dot peeling, subcision and intradermal injection of autologous platelet-rich plasma (PRP) for the treatment of atrophic post-acne scars.

PATIENTS AND METHODS

Twenty patients with different types of atrophic acne scars on the face were included. All patients received PSP technique in the form of dot peeling, then after 2 weeks, subcision and intradermal PRP injection were done simultaneously. PSP technique was performed for each patient every month for 3 months.

RESULTS

After 3 months of the last session, 30% of 20 patients had excellent improvement, 20% of patients had good improvement, 20% of patients had moderate improvement, and 30% of patients had mild improvement. There was statistically significant difference after treatment (p ≤ .001). Side effects were mild and tolerable and included erythema, ecchymosis, and hyperpigmentation. All types of scars showed significant improvement with no significant difference between them.

CONCLUSION

PSP technique was found to be a safe and cost-effective treatment option for atrophic acne scars.

Treatment of nasal depressed scars using micro-plasma radiofrequency technology combined with subcision

BACKGROUND

The nose is located in the middle of the face; therefore, nasal scarring will bring a significant psychological impact on patients. Although there are many treatment methods for depressed scars, these methods have varying degrees of efficacy and all carry certain adverse effects. A better treatment method is urgent to be found. In this study, the effect of micro-plasma radiofrequency technology combined with subcision to treat nasal depressed scars is evaluated.

METHODS

18 Chinese patients with nasal depressed scars participated in this study. All patients received one session of micro-plasma radiofrequency treatment first. 2 months later, subcision combined with micro-plasma radiofrequency technology was performed on them at 6-month intervals, and a total of 2 sessions of combined treatment were performed. Goodman and Baron Scale was used to evaluate nasal scars before treatment and 6 months after the final session.

RESULTS

All 18 patients in this study had Grade 4 nasal scars before treatment. 6 months after the end of treatment, 13 patients (72.2%) showed excellent or near total improvement, and 5 patients (27.8%) showed marked improvement. No adverse side effects were observed during treatment. Patient self-evaluation indicated that all patients were satisfied with the cosmetic outcomes.

CONCLUSIONS

In this study, we explored a new treatment method for nasal depressed scars. We used micro-plasma radiofrequency technology combined with subcision to treat nasal depressed scars and obtained relatively satisfactory results with no adverse effects.

Real-world effectiveness and safety of collagenase clostridium histolyticum-aaes injections for the treatment of thigh cellulite in women: An open-label study interim analysis

BACKGROUND

Collagenase clostridium histolyticum-aaes (CCH-aaes) is approved in the United States for moderate-to-severe cellulite in the buttocks of adult women.

AIM

Interim analysis to evaluate efficacy/safety of CCH-aaes in the treatment of thigh cellulite.

METHODS

Data were analyzed from a phase 3, open-label study (REAL). Women with mild-to-moderate cellulite on both thighs (Clinician Reported Photonumeric Cellulite Severity Scale score, 2 or 3) received ≤0.84 mg (volume, 18 ml) of CCH-aaes subcutaneously, in up to 12 dimples per posterolateral thigh, in up to 3 treatment sessions (Days 1, 22, and 43). Follow-up was on Day 90 (interim cutoff). A subset of women participated in the concurrent study (PIXELS), which included high-definition photography and 3D-image scanning of treatment areas.

RESULTS

Twenty-two women (44 thighs) were included in the interim analysis (mean age, 42.3 years; thighs with mild cellulite, 68.2%). Investigators reported high percentages of responders (score of "improved" or better on Investigator Global Aesthetic Improvement Scale) at Day 90 for either thigh (86.4%; primary endpoint) or both thighs (72.7%). Patient-reported bother due to cellulite was reduced at Day 90; mean change was 15.3 points (85.5% reduction) in BODY-Q Appraisal of Cellulite Scale total score (possible range, 11-44). In PIXELS analysis, Day 90 3D-image scans showed improvement from baseline in skin roughness in some of the treated thigh areas. The most commonly reported adverse events were injection-site bruising and pain (95.5% and 50.0% of patients, respectively).

CONCLUSIONS

CCH-aaes treatment of mild-to-moderate thigh cellulite was effective and generally well tolerated, with markedly reduced cellulite-related bother.

Single session of combined microfat and subcision in the treatment of Grade 4 atrophic acne scars

BACKGROUND

Severe atrophic acne scars (AAS) remain the "Achilles's heel" of AAS treatment. The combination of microfat and subcision treatment is a potential solution for severe AAS.

AIMS

This study aimed to evaluate the efficacy and safety of combined microfat and subcision treatment for severe (Grade 4) AAS.

METHODS

Data of patients with Grade 4 AAS who underwent combined microfat and subcision treatment between September 2016 and December 2020 were reviewed. Post-treatment evaluation was performed at least 3 months postoperatively. The severity of AAS was graded based on Goodman's qualitative classification. The volume of concavities was measured using an Antera 3D camera. Complications were documented.

RESULTS

A total of 42 patients received a single treatment session. Excellent response was observed in 5 (11.9%) patients, very good in 13 (31.0%), good in 22 (52.4%), and poor response in 2 (4.7%). The average reduction of the total volume of concavities was 28.0%. The most common minor side effects were mild swelling and bruising. No major complications were observed.

CONCLUSIONS

Combined microfat and subcision treatment is a safe and effective treatment for severe AAS. The approach will be a significant treatment for severe AAS.

Subcision, chemical peels, and platelet-rich plasma: Combination approaches for the treatment of striae distensae

Striae distensae (SD) are disfiguring skin condition causing cosmetic troubles and psychological distress. The aim was to compare the efficacy and safety of platelet-rich plasma (PRP) versus its combination with subcision or medium-depth peeling (glycolic acid 70% followed by trichloroacetic acid [TCA] 35%) for SD treatment. Seventy-five female patients with SD were divided into three equal groups with the contralateral side in each patients represented the control group. Group A treated with PRP, group B received PRP + subcision while group C received PRP + combined peeling (GA 70% + TCA 35%). Primary outcome included clinical improvement, patients' satisfaction, and Dermatology Life Quality Index (DLQI). Striae measurement, skin biopsies were also assessed. Very much improvement was achieved in 28%, 44%, and 36% in groups A, B, and C respectively. The combined groups (B and C) showed significantly higher patients' satisfaction and DLQI than group A (p = 0.03), (p < 0.0001). A significant decrease in all striae measurements was achieved with all groups (p < 0.001); however, groups B and C showed more decrease (p = 0.2 and 0.4). A highly significant decrease in the mean number of sessions was found in group B (p < 0.0001). All groups demonstrated improvement in dermal collagen deposition, which was higher in the combined groups. Side effects were mild and well tolerated. The combination of PRP with subcision or peeling was more effective and offered a higher therapeutic response than PRP alone. Moreover, the subcision has superior efficacy in striae albae and safer in darker skin types.

Effectiveness of subcision using carboxytherapy plus fractional carbon dioxide laser resurfacing in the treatment of atrophic acne scars: comparative split face study

Introduction: Fractional carbon dioxide laser resurfacing is the gold standard treatment for atrophic acne scars but when combined with subcision to the depressed scars it provides rapid improvement. Carboxytherapy is considered a tool for subcision via injecting the gas under pressure plus its well-known effect in rejuvenating scars.Aim: Main objective of the work is to evaluate the effectiveness of combined subcision using carboxytherapy plus fractional carbon dioxide laser resurfacing in the treatment of atrophic acne scars.Patients and method: Twenty patients with atrophic acne scars undergone three sessions of fractional carbon dioxide laser resurfacing for both sides of the face and subcision by CO₂ gas for the right side scars only. Standardized photographs were taken before and three months after the last session and evaluated by two independent blinded dermatologists for the degree of improvement.Result: The right side of the face improved better than the left side and showed excellent improvement in 10% of cases that was statistically significant (p value=.003).Conclusion: Subcision via carboxytherapy accelerate the improvement of atrophic acne scars when combined with fractional carbon dioxide laser resurfacing.

A multimodal approach to the treatment of extensive burn scars: a modified subcision technique for intralesional delivery of corticosteroid and 5-fluorouracil in combination with several procedural laser therapies; a case report

INTRODUCTION

Hypertrophic scars and keloids are challenging to manage due to recurrence and often sub-optimal response to treatment. There is a lack of both definitive treatment standards and randomised controlled trials comparing therapeutic options. While a wide array of procedures has been utilised to improve traumatic burn scars, such interventions have been used with varying degrees of success. Some reported methods include intralesional injections of anti-inflammatory and anti-mitotic medications, laser-based therapy, topical therapies, cryotherapy, silicone gel sheeting, pressure therapy, radiotherapy and reconstructive surgery.

CASE

We report a case of extensive traumatic burn scarring on the head and neck successfully treated with a multimodal approach comprised of an infrequently used modified subcision technique to deliver alternating intralesional injections of anti-inflammatory (high-dose steroid) and anti-metabolite (5-flurouracil) concurrently with a series of laser (epilatory, vascular and fractional) treatments.

METHODS

Our treatment modality utilised a subcisional technique to deliver intralesional steroid and anti-metabolite medications directly into scar tissue to downregulate inflammation and inhibit collagen synthesis. Alexandrite, fractional and pulsed dye laser therapy was employed to improve skin texture, reduce dyschromia and reduce tissue burden of hypertrophic scar and keloid tissue, resulting in improved mobility and skin elasticity.

CONCLUSION

Our case supports a combined medical and procedural, subcisional, approach to successfully treat a patient with extensive hypertrophic scarring and keloid formation with associated hair entrapment after a head and neck burn.

Autologous Smashed Dermal Graft with Epidermal Re-closure: Modified Technique for Acne Scars

Conventional technique of dermal grafting for acne scars where the source of filler material used is the patient's own dermis requires longer surgical time, recovery period and can result in unsightly scars at the donor area. Hence, it is not suitable for treating a larger number of scars. Furthermore, these dermal grafts are firm and cannot be contoured to fit all types of acne scars. Occurrence of epidermal cyst and secondary infection is another complication if epidermis is not completely removed. Enzymatic techniques need trypsinisation which is expensive and requires laboratory facilities.

The efficacy and safety of subcision using CO2 gas combined with fractional laser for acne scars: Clinical and microscopic evaluation

BACKGROUND

Various modalities have been used to treat acne scars. CO₂ fractional laser is an effective and commonly used treatment. CO₂ gas injection into the dermis by needle with high pressure can cause fibrotic collagen breakage, producing the effects of subcision. CO₂ also stimulates collagen synthesis by increasing neovascularization and releasing oxygen.

OBJECTIVE

This study evaluated the efficacy and the safety of the combined treatment with CO₂ gas subcision and CO₂ fractional laser for acne scars.

METHODS AND MATERIALS

Fourteen patients with acne scars were treated with three sessions of CO₂ gas subcision at 2-week intervals and two sessions of fractional laser at 4-week interval. The clinical improvement was assessed using a 4-point scale. For histologic analysis, punch biopsy was performed before and after treatment in 10 patients.

RESULTS

All patients experienced clinical improvements. Excellent, marked, moderate, and mild response was achieved in 1 (7%), 8 (57%), 4 (29%), and 1 patient (7%), respectively. Histologic evaluation of the biopsy specimens showed increased dermal collagen with dermal thickening and elastic fiber straightening in the reticular dermis after the treatment.

CONCLUSION

The combination therapy with CO₂ gas subcision and fractional laser was satisfactory and safe for treating acne scars. Abbreviation and acronym: CO₂: Carbon dioxide GAS: Global assessment scale H&E: hematoxylin and eosin; SD: standard deviation.