Dermal Grafts for Acne Scars At A Glance
- Best Results3-8 sessions (outdated)
- Treatment Recovery4-6 days
- Procedure Time30-80 min
- Skin SpecialistNot performed as treatment outdated
- Duration of ResultsLife
- Back to Work2-6 days
- Cost$$ Partial Medicare rebate in most cases
Dermal Grafting Acne Scars
Dermal grafting involves harvesting of autologous collagen. This collagen or dermal graft is then placed in atrophic acne scars. This procedure can be used for isolated scars with low volume deficits. This procedure has now been largely replaced with fat & stem cell transfer & collagen stimulating dermal fillers.
FactsFacts on Dermal Grafts For Acne Scars
- This is a form of autologous collagen transfer
- In theory it also transfers stems & fibroblasts to atrophic scars
- The donor site is the back of the ear
- Each scar is incised down to the fat layer
- Tiny fragments of collagen is then inserted
- Laser resurfacing months after can reduce scar lines formed by incisions
- I reserve this procedure for isolated liner scars only
- Dermal fillers, adipose stem cells & autologous fat transfer has largely replaced dermal grafting
What is dermal grafting?
This procedure is over two decades old. Newer techniques such as dermal smashing have been recently described. There are many spins on this technique, including autologous cell transfer & stem cell therapy & transplantation. Dermal grafting is essentially removing dermis from one part, processing the matrix, then re-implanting it in atrophic scars, including acne & chicken pox scarring.
Dr Rob Sinclair in Brisbane is probably one of the most experienced surgeons in the field of dermal grafting. I was fortunate enough to be taught by him.
How is this procedure performed?
The procedure is divided into harvesting, recipient site preparation & graft insertion.
Harvesting is from behind the ear. CO2 laser is used to destroy the upper part of skin, known as the epidermis. This donor is excised, and the site sutured. The donor is chopped up (literally) into many fragments.
Scar site preparation: A tiny nick is made aligned at the 3 to 9 oclock orientation, it is often elliptical in design. A pocket is made down to the fat layer.
Graft insertion: tiny fragments of dermis is placed into the atrophic scar, & sutured with a 6’0 nylon suture. Each and every atrophic scar is treated with this similar procedure.
After correction (usually 3-24 months after the journey began), the areas are resurfaced with either CO2 or erbium ablative lasers. This decreases the visibility of scar lines caused by insertion.
How many sessions will it take to treat my acne scars?
Grafting has limits, especially in the context of large volume deficits – namely highly atrophic acne scars. In this context, it may not be practical or feasible to correct. The number of sessions required is based upon adding up ALL the volume deficits. This ranges from one session (for mild atrophic scar) to over 40 sessions for multiple scars.
What are the limitations of dermal grafting?
Dermal grafting is limited by both dermal donor sites & practically of treatment when it comes to extensive scarring.
The classic donor site is postauricular or behind the ear. The total area is about 4 by 1 cm by two. Or about 8-10 cm2. Preauricular donor sites are less preferred due to the scar line, however if required, this is another option.
The practical aspect of say 200 to 400 individual atrophic scars are limited by time constraints. If 10 scars are treated per session, 30-40 sessions may be required. The greatest rate limiting factor is volumetric deficits. Some scars have deficits of over 3-4 mls (that is per scar). This is where autologous fat transfer has some merit.
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What are the side effects of dermal grafting?
The biggest problem with dermal grafting is what happens many years down the road. Each graft is placed in the high subcutaneous layer causing what is known as an iatrogenic scar. Over time, volume loss is experienced as this is part of the ageing process. This pulls down on the scar tissue, exposing incision scars (puckers). These puckers can however be treated with multi-level subcision.
Acute effects include inclusion cysts, essentially when a foci of epidermis is carried with the graft. This is mostly due to epidermal cells in the follicle (hence why postauricular skin is preferred). In most cases steroid injections or 5FU can settle down these cysts, not infrequently they need to be re-excised.
Other aspects such as hypertrophic scars (donor site), scar dehiscence, infection etc.. pertain to surgical procedures.
What has largely replaced this procedure?
With the event of dermal fillers, especially collagen stimulating fillers, dermal grafting has taken a step back in the past five years, at least in my practice. Fillers have several advantages over dermal grafts including-
- Treatment of large volume deficits
- Treatment of multiple scars
- Relative safety & longevity
- Lack of iatrogenic scarring
- Ability to combine with procedure such as surgical subcision
Autologous stems & fat transfer are alternatives to dermal grafting & exogenous fillers. Fat can replace volume deficits well over 20 mls on the face. Additionally ASC or adipose stem cells can provide seeding for collagen formation.
Another factor to understand in the context of acne scarring is to treat age related changes. This provides support for the overlying skin & scars. Probably the hardest concept to get through to patients.
What types of scars do I still perform dermal grafting on?
I still think there is time & place for dermal grafting. Atophic linear scars with dermal atrophy may benefit from this treatment. In theory AMVC may also benefit, however logically a test spot with close follow up is needed. I do not treat AMVC in private practice. This should be investigated & treat in a public hospital as other causes need to be ruled out.
Thin (less than 2 mm), long atrophic scars can benefit from strip collagen. This can be inserted with a needle, longer strips are threaded through with a fine suture. This is probably the only time I employ dermal grafting in my practice.
How much does this procedure cost?
Dermal grafts are partially covered by Medicare. Other surgical procedures such as subcision are also partially covered, providing the scars are severe. Additionally, it has to be done by a dermatologist or a plastic surgeon & not by cosmetic general practitioners.
Davin’s viewpoint on dermal grafting & acne scars
I was fortunate enough to have gone through the process of dermal grafting two decades ago. Prior to the rise of dermal fillers, this was probably one of the only methods to correct atrophic scars. Fat transfer at that stage of the game gave dismal results with very high reabsorption rates.
Grafting is still useful for isolated scars, especially atophic linear scarring where stip harvesting can give good correction. I have largely replaced large volume correction with either collagen stimulating fillers (PLLA – Ca OH) or ASC – fat transfer.
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