surgical treatment of facial acne scars based on morphologic

Surgical Treatment of Facial Acne Scars Based onMorphologic Classification: A Brazilian ExperienceBOGDANA VICTORIA KADUNC, PHD, AND ADA REGINA TRINDADE DE ALMEIDA, MD

Dermatologic Clinic, Hospital do Servidor Publico, Municipal de Sao Paulo, Brazil

BACKGROUND. Acne scar treatment remains a challenge in the

medical literature. It is very difficult to compare the efficacy ofdifferent therapeutic approaches because of the lack ofconsensus regarding acne scar description and classification.

OBJECTIVE. To establish a morphologic classification of acnescars and to assess the efficacy of different therapeutic optionsbased on scar type.

METHODS. During an 8-year period, 228 patients were prospec-tively studied. Their acne scars were morphologically classifiedand customized, staged rehabilitation programs were established

for each patient. The assessment of treatment efficacy wasconducted 18 months after the end of treatment and was based

on patients’ and physicians’ opinions ranked on a semiquanti-tative basis as percentage of improvement from baseline.

RESULTS. Among the 168 patients who finished the study, 26completed three stages of the treatment plan, and 142 weresubmitted to one or two therapeutic stages, depending on lesion

types. Eighty-six percent of the patients considered the resultsexcellent or good compared with 76% by the authors and 78%by three independent dermatologic surgeons.

CONCLUSION. The classification and the staged therapeutic planfor acne scarred patients facilitated treatment and improvedoutcomes and may allow development of protocols by

comparing results among different authors.

B. V. KADUNC, PHD, AND A. R. TRINDADE DE ALMEIDA, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITHCOMMERCIAL SUPPORTERS.

ACNE IS an extremely common pilosebaceous dis-order. In spite of the numerous therapeutic options,undesirable sequels are frequent and interfere inpatients’ psychological profile.

Acne scars were traditionally and indiscriminatelytreated by ablative techniques, such as chemicalpeels1 and dermabrasion,2 but soon it was noticedthat some patients did not show any improvement,even after aggressive procedures. The disappointmentled the surgeons to search for new options; varioussurgical techniques, including laser resurfacing,3–5

have been used to treat acne scars. However, nostandardized method has ever been followed. As aresult, it is impossible to compare treatment ap-proaches, mainly because of lack of consensus in theliterature, concerning acne scars nomenclature andclassification.

The objectives of this article are to propose amorphologic acne scar classification and to assess theefficacy of different therapeutic options based on acnescar types.

Methods

During an 8-year period (from January 1, 1993, toJanuary 30, 2001), 228 consecutive patients with mildto severe facial acne scars referred to the DermatologicClinic of Hospital do Servidor Publico Municipal, SaoPaulo, Brazil (86 patients), and to the private practiceof the authors (142 patients) were enrolled in thisprospective study. The exclusion criteria were recentsystemic therapy with isotretinoin or previous proce-dures to repair acne scars. Patients’ age ranged from16 to 54 years; 137 were female subjects (60%), and91 patients were male (40%). The Fitzpatrick photo-types varied from II to VI. An informed consent formwas signed by all patients before entering the study.

Previous, intermediate, and posttreatment photo-graphs were taken using the same camera and lightingsettings, type of film, patient positioning, and devel-oping process.

At the first visit, patients were examined withoblique and superior light sources and had their acnescars evaluated regarding the following aspects: loca-tion, number, shape (linear, round, star-like, puncti-form), consistency (soft, hard, fibrotic), color,distensibility, and relationship to the surrounding skin(depressed or elevated).

Based on these characteristics and using termscollected from the literature, acne scars were classified

r 2003 by the American Society for Dermatologic Surgery, Inc. � Published by Blackwell Publishing, Inc.ISSN: 1076-0512/03/$15.00/0 � Dermatol Surg 2003;29:1200–1209

Correspondence and reprint requests to: Bogdana Victoria Kadunc,

PhD, Rua Gaivota 91, apto 71, CEP 04522-030, Moema, Sao Paulo, SP,

Brazil, or e-mail: [email protected].

as (1) elevated, (2) dystrophic, and (3) depressed. Someof them were further subdivided in order to facilitatethe indication of specific treatments, resulting in 11distinct morphologic types.

Description of Acne Scars and SpecificTreatments Reported

1. Elevated scars. a. Hypertrophic lesions are raisedabove the skin surface and are limited to the originalinsult area. They are frequent in the mandibular,malar, and glabellar regions (Figure 1) and can be re-duced by steroid injections, direct or tangential exci-sions, or 585-nm flash-pumped pulsed dye laser sessions.6

b. Keloidal scars are found in patients with geneticpredisposition. Their dimensions exceed the initialinjury, and the scar grows to the side ‘‘in the shape of acrab claw.’’7 They are common in the mandibulararch, shoulders, and sternal region and are prone to

recur. Keloidal scars are very difficult to deal withbecause of their proliferating characteristics (Figure 2).The therapeutic options are intralesional steroid orbleomycin sulfate8 injections, subtotal excisions,9

cryotherapy,10 and X or b radiotherapy.c. Papular are soft elevations, like anetodermas, that

are frequently observed on the trunk11 and mental area(Figure 3). They can be treated by controlled CO2 laservaporization or light electrodesiccation of each papule.

d. Bridge is a fibrous string over healthy skin. Thiskind of scars is common on the face and is treated bytangential excision (Figure 4).

2. Dystrophic scars. These types of scars may haveirregular or star-like shapes with a white and atrophicfloor (Figure 5). They can also be represented byfibrotic masses with multichanneled tracts that retainsebaceous or pustular material. Direct excision5 underprimary elliptical or broken lines or even ‘‘M,’’ ‘‘Z,’’ or‘‘W’’ plasties is required for their treatment.

Figure 1. Hypertrophic scars: clinical and diagrammatic characterization.

Figure 2. Keloidal scars.

Dermatol Surg 29:12:December 2003 KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS 1201

3. Depressed scars. They are contour or volume de-fects that can be (a) distensible and (b) nondistensible.

3.a.1 Distensible retractions After skin distension,they remain attached only by the centralportion (Figure 6) through myofascial attach-ments that have to be released by underminingor subcision.12 If necessary, a filling agent isthe next step of treatment.

3.a.2 Distensible undulations (valleys) They disap-pear completely after skin distension (Figure 7)and are the best indication for dermal orsubdermal filling techniques, performed in oneor more sessions.

3.b Nondistensible depressions These do not disap-pear after skin distension and are characterized assurface defects. These types of scars accumulatemake-up and sunscreen lotion, and the projection

Figure 3. Papular scars.

Figure 4. Bridge.

Figure 5. Dystrophic scar.

1202 KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS Dermatol Surg 29:12:December 2003

of their margins casts a dark shadow on thebottom. They can be subdivided into the follow-ing: (3.b.1) Superficial (dish-like) are shallowdefects (Figure 8) in which the only usefultherapeutic approach is isolated use of ablativemethods, including phenol chemical peeling,1

dermabrasion,2–13 chemabrasion,14 and CO23–15

or pulsed Erbium YAG4–16 laser abrasion. (3.b.2)Medium (crater-like) has a scar base that isrelatively smooth and has normal color and

texture and wide diameter (Figure 9) and can betreated by either of two ways: (1) the base issurrounded and cut by biopsy punches17 or miniblades, followed by elevation with forceps untilthe clot formation, to keep it in the new positionor (2) the shoulders can be sculpted and beveledto the peripheral skin by razabrasion18 (using therazor blade as abrader), electrodesiccation19 orCO2 laser vaporization. (3.b.3) Deep (ice-pick orpitted scar) are narrow and fibrotic scars, with

Figure 6. Distensible retractile scars.

Figure 7. Distensible undulated scars.

Figure 8. Nondistensible superficial scars.


sharp shoulders perpendicular to the skin. Theyare epithelial invaginations that can reach thesubcutaneous layer (Figure 10). They have to beexcised by cylindrical punches, which have to belarge enough to involve the entire lesion. Theycan be left to second intention healing or bereplaced by full-thickness grafts from the post-auricular area, which are 25% to 50% larger

than the defect (punch graft technique).20–23

Direct closure of these small holes very frequentlyleads to enlarged and unpleasant scars, unlessthey are submitted to deep intradermal sutures.(3.b.4) Tunnels are constituted of two or more icepicks connected by an epithelized tract (Figure11). They have to be excised but can also berepaired by punch grafting.22

Figure 9. Nondistensible medium scars.

Figure 10. Nondistensible deep scars.

Figure 11. Tunnel.


Study Design

After the morphologic classification, all studiedpatients were submitted to skin conditioning withsunscreens, a-hydroxy acids, and/or tretinoin agentsand then enrolled in a three-staged rehabilitationprogram (Table 1).

Stage I: complementary techniques. In this stage,patients were submitted to one or more of thefollowing procedures: intralesional steroid injectionsaddressing erythematous hypertrophic or keloidalscars; focal light electrodesiccation to treat the papularones; tangential excisions to eliminate bridges andnonerythematous hypertrophic lesions; direct (ellipti-cal, broken lines, or W-plasty) excisions to improvedystrophic areas; subcision to release distensibleretractions; punch elevation to raise medium nondis-tensible depressions; and punch grafting to correctdeep nondistensible scars and tunnels.

These techniques were performed in one to threesessions (30 days apart) at least 6 to 8 weeks beforestage II intervention.

Stage II: ablative techniques. They were indicated totreat patients whose scars presented nondistensiblesuperficial depressed pattern or to complement stage Itechniques. The methods used were as follows:

1. Chemabrasion: A full-face 35% TCA chemicalpeeling was followed by regional motor-drivendermabrasion on the most scarred cosmetic units.This combined procedure facilitated mechanicalexfoliation and was useful to blend dermabradedand nondermabraded regions, reducing demarca-tion lines, mainly on the eyelids and neck area.

2. Full-face resurfacing: We performed two or threepasses using high-energy pulsed CO2 laser(Coherent Laser Corporation, Palo Alto, CA)equipped with computer pattern generator hand-piece (CPG) in the Ultrapulse mode at 300 mJs,60 W, with a density of 4 to 6. This method wasindicated mainly to flaccid skin patients.

Punch elevations or excisions frequently completed theablative processes, aiming at achieving the bestleveling grade. Antiviral and antibiotic systemictherapy and semiocclusive dressings employing ster-ilized veil fabric and petrolatum jelly were used in thepreoperative and postoperative periods.24

In spite of the use of complementary techniques,some severely scarred patients had to be submitted totwo ablative processes, with a 6-month intervalbetween them. In general, these patients had a largenumber of dystrophic scars, ice picks, and tunnels.

Stage III: filling techniques. To correct distensibleundulated scars, we chose to use hyaluronic acid25

injections (Perlane and Restylane; Q-Medical, Inc.,Uppsala, Sweden) to treat superficial (dermal) tissueloss or microlipoinjections to treat deep (subcuta-neous) tissue loss. This stage of treatment took fromone to several sessions or served as a sequential stepafter the other previous ones.

Evaluation

As a follow-up procedure, all patients were examinedand photographed at 2-month intervals. The finalevaluation for assessment of treatment efficacy tookplace 18 months after the beginning of the procedures

Table 1. Morphologic Classification of Acne Scars and Specific Procedures Employed in the Three-Staged Treatment Plan in228 Patients

Scar Types Specific Procedures

1. Elevated

a. Hypertrophic Intralesional steroid injections/tangential excisions (stage I)

b. Keloidal Intralesional steroid injections (stage I)

c. Papular Focal light electrodesiccation (stage I)

d. Bridges Tangential excision (stage I)

Elliptical, broken lines, or W-plasty excisions (stage I)2. Dystrophic

3. DepressedSubcision (stage I)3.a.1 Distensible retractions

3.a.2 Distensible undulations Hyaluronic acid/fat injections (stage III)

3.b.1 Nondistensible superficial Ablative techniques (stage II)

3.b.2 Nondistensible medium Punch elevation (stage I)

3.b.3 Nondistensible deep (ice picks) Punch grafting (stage I)

3.b.4 Tunnels Punch grafting (stage I)


(Figures 12–14) and collected the opinions of patients,the authors, and three dermatologic surgeons notdirectly involved in the study.

Patient self-assessment consisted of their subjectiveimpression of the percentage of improvement of four

analyzed variables: (1) a reduction in number of scars,(2) a reduction in deepness of scars, (3) an improve-ment of color uniformity, and (4) a reduction inretention of sebaceous material. The authors and theindependent dermatologic surgeons assessed improve-ment similarly, except for item four. The authors basedtheir judgement of improvement on clinical data andphotographic evaluation, whereas the surgeons notinvolved in the study based their opinions on blindanalysis of pretreatment and posttreatment photo-graphs.

The final results were rated as excellent, good,unchanged, or poor, as a percentage of improvementfrom baseline, based on a semiquantitative scale (Table2). Chi-square statistical analysis was used to comparethe three treatment efficacy evaluations.

Results

Out of 228 patients initially enrolled in the series, 168(74%) completed the study. Forty patients (24%) wereclassified as phototype II, 58 (34%) as group III, and70 (42%) as groups IV, V, and VI. The majority of thepatients presented morphologically heterogeneousacne scars, but type 3 (the depressed scars) was

Figure 12. Dark-skinned patient with nondistensible medium scars.

Figure 13. Postinflammatory hyperpigmentation after dermabrasion.

Figure 14. Final results after punch elevation and dermabrasion.

Table 2. Evaluation of Acne Scar Improvement

Excellent: when improvement of 75% or more was observed in all

four analyzed variables

Good: when improvement between 50% and 75% was observed in

all four analyzed variables

Unchanged: when improvement below 50% was observed in all

four analyzed variables

Poor: worsening of the characteristics of the four variables


predominant in this population. The elevated anddystrophic types were less frequently seen.

Table 3 shows the number of patients in eachtreatment stage. Out of the 168 patients who finishedthe study, 46 (27%) were treated with complementarytechniques, and 40 (24%) were submitted to resurfa-cing or chemabrasion only, whereas 21 (13%) receivedsoft-tissue augmentation. Thus, 107 (64%) patientscovered only one step of the treatment plan. Thirty-five (21%) patients were treated using two of thetherapeutic stages, and 26 (15%) completed the threestages. Of 89 (53%) patients that needed ablativemethods, including the 12 (7%) most severely scarredsubjects, who required two sessions, 25 were classifiedas phototype II, 30 as type III, and 34 were included inIV, V, and VI Fitzpatrick groups.

The results analyzed by the overall impressions ofpatients, the authors and the dermatologic surgeonsare presented in Table 4. In their self-evaluation, 144patients (86%) considered the results excellent or goodcompared with 128 (76%) by the authors and 131(78%) by the panel of dermatologic surgeons.

Based on chi-square analysis, there were nostatistically significant differences (P5 0.3113) amongthe evaluations of the three groups.

Common adverse events assessed on the 2nd monthwere observed in 54 (32%) patients and includedherpes simplex flares (5 patients), milia formation (11

patients), and transient postinflammatory hyperpig-mentation. The later was observed in 38 (42%) of the89 patients submitted to ablative methods. Amongthem,8 patients were classified as phototype III and 30as IV, V, and VI Fitzpatrick types. Stage II procedureswere more frequently associated with adverse effects.

True complications assessed on the 18th monthwere observed in 14 (8%) patients and includedpostexcision widening of scars (10 patients), demarca-tion lines (3 patients), and residual hypopigmentation(1 patient).

Discussion

Treating acne scars, according to Fulton, ‘‘is perhapsthe most difficult cosmetic surgery procedure thatexists.’’26 It is really challenging to achieve totalcorrection of tissue destruction caused by severeinflammatory acne, which can destroy the epidermis,dermis, and the underlying fat. The main treatmentgoal is to obtain as much improvement as possiblerather than perfection.

After studying acne scars in different articles, wenoticed that authors have been using their own acnescar denominations. There is no reproducible methodthat encompasses the majority of acne scar types andcorrelates the lesions and the specific techniques usedto repair them.

Ellis and Mitchell27 suggested the use of the wordsice picks, craters, undulations, tunnels, shallow-typeand hypertrophic scars, whereas Koranda7 referred tocraters or pits, ice picks, keloidal and hypertrophicscars. Goodman,28 based on pathophysiologic find-ings, suggested that atrophic postacne scarring couldbe divided into superficial macular, deep dermal,perifollicular scars, and fat atrophy. Langdon,29 inturn, described three types: I, small diameter shallowscars; II, ice picks; and III, distensible scars. Jacob etal.30 referred to other three different subtypes: ice pick,rolling, and boxcar.

The most frequently described lesions are thedepressed ones, indiscriminately referred as pitted oratrophic acne scars,3–20 with few references to othermorphologic patterns.

Historically, acne sequels have been treated byablative techniques such as deep chemical peels,1–19

dermabrasion,2–5 and more recently, resurfacing pro-cedures with CO2

3,15,31,32 and Er:YAG4–16 lasers ortheir combination.33 However, according to theliterature, the results of isolated ablative techniquesare extremely variable, presenting outcomes that rangefrom 25%,34 40%4 to 81.4%.3

In 1941, Eller and Wolff,19 after performing phenolpeelings to treat acne scars, noticed this fact and

Table 3. Number of Patients Submitted to Each TreatmentStage

Stage I 46 patients527%

Stage II 40 patients524%

Stage III 21 patients513%

Stages I1II 16 patients510%

Stages I1III 12 patients57%

Stages II1III 7 patients5 4%

Stages I1II1III 14 patients58%

Stages I1II1II1III 12 patients57%

Table 4. Impressions of 168 Patients, Authors, and ThreeDermatologic Surgeons Not Directly Involved in the Studyon Efficacy of Acne Scar Treatment Based on MorphologicClassification

Patients Authors Independent

Dermatologic

Surgeons

Excellent 45 (27%) 33 (20%) 41 (24%)

Good 99 (59%) 95 (56%) 90 (54%)

Unchanged 17 (10%) 25 (15%) 25 (15%)

Poor 7 (4%) 15 (9%) 12 (7%)


recommended beveling the ‘‘cuplike scars’’ edges byelectrodesiccation or shaving. Nowadays, the consen-sus is that acne scars cannot be effectively corrected byone single treatment modality because of the widevariety. Multiple other methods have been added toablative techniques, including injections of collagen,35

silicone,36 or fat,37 excision with primary closure,5

facelifts,27,28 punch elevation,5–17 and punch excisionwith full-thickness graft replacement.20–23

Different authors have also tried to facilitate acnescar treatment by suggesting schematic diagrams thatcorrelate scars morphology and treatment,21,30–38

whereas others have used sequential therapeutic plansin treating theses scars. Whang and Lee32 suggestedthree stages: 1, 50% TCA focal chemical peeling inpitted areas; 2, CO2 laser vaporization 1 to 3 monthslater, and 3, full-face dermabrasion 6 to 8 weeks later.Conversely, Jacob et al.30 did not suggest definitestages, as they considered that by performing punchexcision, punch elevation, subcision, and laser skinresurfacing would be enough to reach good results inany type of acne scars.

Fulton and Silverton37 preferred multiple ap-proaches such as subcision, small-volume fat transfer,laser resurfacing, dermabrasion, excision, and graft-ing—all of them performed at the same surgical time.

In this study, we proposed a more comprehensiveclassification, encompassing most of the different typesof acne scars and unifying the literature terminology.In our three-staged treatment plan, we used at leasteight different therapeutic modalities to reach appro-priate improvement of acne-scarred patients. In ouropinion, it is safer to perform the procedures atdifferent times, which allows better understanding ofpatients’ psychological profile and guarantees theircompliance and confidence.

Another difficult issue is the evaluation of the results.Reviewing the literature, we found that Jordan et al.39

tried to assess the effectiveness of laser resurfacingtreatment for facial acne scars. They concluded thatthere is a need of ‘‘good quality randomized controlledtrials with standardized scarring scales’’ in order tocompare treatment results among different articles.

Objective methods such as comparative countingand measuring of lesions in specific areas13 andanalysis of textural skin changes applying opticalprofilometric programs3 were recently introduced inthe medical literature. Nevertheless, we noticed thatmost of the studies published on acne scars treatment,ranked the improvement in scales that translatedopinions of authors and independent physicians.4,16,31

This is a result of the difficulty to count theinnumerous lesions that can be present in acne scarredfaces. For this reason, in our study, which was initiated8 years before, we chose the same criteria.

Considering the 168 (74%) patients that completedthe staged treatment plan and returned for the finalevaluation, it was observed that acne scar improve-ment caused a very positive psychologic impact onthese frequently stigmatized people, building their self-esteem.

Seventy-nine (47%) patients with predominantdistensible lesions, craters, or ice picks were treatedby filling or focal techniques and did not undergoablation. This possibility enhanced treatment compli-ance because patients did not have to be away fromtheir professional or social activities, and no pigmen-tary alterations occurred, even in dark-skinned in-dividuals.

Conversely, the most commonly observed adverseevent (transient postinflammatory hyperpigmentation)was observed in 42% of the 89 patients submitted tochemabrasion or laser resurfacing. The problem wasalways detected by the 3rd week after the ablativeprocedure and occurred in 27% of the patientsclassified as phototype III and in 88% of patientswho were phototypes IV, V, and VI. These values maybe explained by the high percentage of mixed ethnicityand dark-complexion people in the Brazilian popula-tion; the problem was easily solved within 30 dayswith tretinoin-hydroquinone combined creams. No stu-died patient presented long-lasting hyperpigmentation.

Although the three independent treatment efficacyevaluations classified the outcomes as excellent orgood improvement in more than 76% of the patients,our results cannot be compared with the literaturebecause of lack of standardized and worldwideaccepted acne scars classification.

We believe that the systematic application of thestaged treatment program in 228 patients, followed bylong interval evaluations, provided good experienceand improved the authors’ clinical and surgicalaccuracy. The unified classification of scar typesfacilitated the correct selection of the best therapeuticoption for each specific scar.

Conclusion

The classification based on morphologic patterns andthe staged therapeutic plan for acne-scarred patientsfacilitated the treatment, improved the final outcomes,and may allow development of protocols comparingresults among various therapeutic approaches anddifferent authors.

Acknowledgment The authors thank Maria Helena Kiss, MD,PhD, for her suggestions and Luciana Gadelha, MD, for thedrawings.


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surgical treatment of facial acne scars based on morphologic

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