Before and after treament at Dr. Naomi for acne scarring, with fractional laser, skinbooster, dermal fillers and Qswitched laser
Acne scar removal requires patience and persistence, but can be life changing for the patient. The international maestro of acne scarring, Assoc. Prof Goodman, is back to answer my questions on this topic. Assoc Prof Goodman, is also the developer of Facecoach, an online training site for cosmetic doctors
What is your systematic approach to acne scarring?
A/Prof. G: For acne scarring you need to think in the same terms that you think about all rejuvenative work. For some reason there is this mind block that happens where all we think about is the surface – which laser or gizmo to use on this. I look at the patient’s scars as issues of surface (colour, minor texture changes), Volume (either deficiency in the case of atrophic scarring or excess in terms of hypertrophic scarring) and movement (whether expressions are worsening the scarring in the upper face frown and forehead or particularly lower face). I then endeavour to work out a plan that will encompass all these things explaining to the patient that this will take significant time to achieve.
What is your satisfaction rate with punch grafting?
A/Prof. G: I don’t do a lot of punch grafting for acne scarring – I do for pigment transfer where it is good. Amongst the punch techniques I much prefer the less arduous and more satisfying technique of punch elevation or fillers into these sort of scars. For punch elevation the technique is the same as a punch biopsy. It is important to be on the outside of the scar and to take it down to the sub cutis where it is not held laterally by the tissues but after this it is the same – you just don’t detach the punch – just let it float to sit at its new position. I used to do a lot more punch grafting but found it always required a second procedure and was difficult to get the grafts to sit perfectly flat.
Do you use needling to treat acne scarring? If so what length of needle? Which patients?
A/Prof G: Yes we do – we use a popular needling vibrating device and a stamping device. Generally the depth mirrors the problem. The older rollers used to have a fixed 3mm but mostly now the range is 1-2.5mm. Good patients are those with pores, and shallower scarring but even ice pick scars may respond.
Needling vs ablative fractional laser for acne scarring, please discuss.
A/Prof. G: Ablative fractional lasers are more serious business as far as downtime is concerned, whether depth or surface is your target. Needling is easier on patients, ablative lasers a harder road. Generally ablative lasers are better for the more severe “corrugated iron roof” or rolling scars that are not amenable to lesser techniques. Both these techniques are best delivered alongside other options. Ablative techniques are our best offering for those who suffer from ageing changes alongside acne scarring
I assume that you commonly use ablative fractional laser? Do you also use non ablative fractional laser to treat acne scarring?
A/Prof G: We use a lot of non ablative techniques for acne scarring and in fact fractionated radio frequency is our current favourite for many types of scarring.
Do you ever use full field laser resurfacing for acne scarring?
A/Prof G: No not often. Fully ablative field treatment for perioral with Erbium being my most common, but no CO2 or combination CO2 Erbium much at all anymore. I never thought it was a great technique for acne scarring as the maximum depth is only about 300 microns versus fractional ablative and non ablative technlogies that get down 3-4 times that depth.
Dermal fillers still seem so underused for the treatment of acne scarring, yet in the right cases, the results can be instantaneous, and almost miraculous. Why do you think patients can go to multiple clinics and have laser after laser and never be offered a dermal filler, when it would be of such benefit?
A/Prof. G: I don’t think they know how to do this or what to expect. This is dealt with in detail in Facecoach and it is an article coming up in the next Australasian Journal of Dermatology by me and Amanda Van Den Broek.
You do need to know how to do it but I agree it is so miraculous and accurate.
Do you use only HA dermal fillers for acne scarring, or do you use other types of dermal filler?
A/Prof. G: I have used fat a lot but I prefer HA because of its immediacy, adequate longevity and great accuracy. I would suggest their reversibility is useful too.
I love skinboosters for acne scarring, do you?
A/Prof. G: For gently rolling scars, I think this useful but for deeper scars I use a vertical “pillar of Filler” with high G prime fillers for most of my scarring work.
In my practice, I have noticed an anecdotal increase in dermal filler infections in patients with a history of acne scarring. Have you as well? If so, can you offer a possible explanation why this could be the case?
A/Prof. G: No I haven’t really, but I will look out for it. I don’t think infections are common with fillers, at least not acute infections. Biofilms are more so but I haven’t noticed a difference with acne scarring patients.
As a patient with acne scarring ages, I personally consider volume replacement an important treatment to contribute to the improvement of their scarring, or to at least prevent worsening of their scarring. Do you use this regularly in your treatment protocol for acne scarring?
A/Prof. G: So true. Volume here is absolutely required and is dealt with in one of the Facecoach modules. Acne will often devastate volume through cystic disease, inflammation and destruction of deeper tissues. This destruction makes the skin less able to put up with the volume loss of ageing. It also makes it less resistant to movement related lines especially in the lower face.
Does Facecoach have an acne scarring treatment module?
A/Prof. G: Sure does and will have more soon. We anticipate making this a focus in Facecoach.