Sir,

The revision of a depressed scar is more difficult because it does not follow the line of relaxed skin tension. Several measures have been proposed for the recovery of this type of scar, yet they have a number of limitations, complications, and disadvantages. The combination of punch elevation, fractionated carbon dioxide laser, and trichloroacetic acid (TCA) touches offer satisfactory results.

This was a twenty-year-old female of phototype III, with no medical history, who consulted for a scar at the tip of the nose that had been evolving for the previous four months following the manipulation of a button. A clinical examination revealed the presence of two contiguous, 2.5 mm, irregular, depressed, and atrophic scars of normal skin color at the tip of the nose (Fig. 1a), for which the patient initially benefited from punch elevation of 3 and 4 mm (Fig. 1b) performed under local anesthesia with well-coded, post-surgical scar support based on the placement of Steri-Strips, the twice-daily application of fusidic acid, preventive valaciclovir, and a healing cream. A significant improvement was observed in the depressed scar during the 24-month post-operative follow-up without complications or pigmentation disorders (Fig. 1c).

Figure 1: (a) The two depressed scars at the tip of the nose. (b) Punch elevation of 3 and 4 mm. (c) Control one year after laser and TCA touching.

Johnson stated the punch elevation method for the remedy and repair of deep pimples and scars with Steri-Strips and other strategies [1]. This approach is undertaken for scars 3 mm in diameter or larger with true shade matching and directly walls [2]. It involves the use of a punch barely larger than the scar to be handled, besides that the scar that is being punched is not always disposed of. The cylinder of tissue is incised down to the extent of the subcutaneous fat. The incised scar is authorized to flow till it is far with the encompassing pores and skin. If it does not thrust upward easily, it may be launched at the level of the fat with an excision, as was the case of our patient. The cylinder of tissue may be kept in place by means of the patient’s serum and rest as if it was a graft, by a surgical tape [2,3], or by stitches.

Some scars will heal at the same level of the skin surface and some will be raised [3], hence the value of combining other resurfacing techniques to treat superficial irregularities, dermal fillers to replace lost volume in large atrophic areas, and surgical procedures, such as punched excision and remodeling, such as fractional CO₂ laser, which allows more precise control of ablation, especially for certain deeper scars requiring several passages [4,5].

The deep penetration of high-concentration TCA focal peel has produced extraordinary clinical effects and rare complications. Similarly, to a 3–5-day shorter recuperation time than with laser resurfacing, there was no need for preconditioning or anesthesia as only a small vicinity of pores and skin became unsatisfactory. Moreover, the simplicity of the method, similarly to the excessive charge of satisfaction said with the aid of sufferers and its low cost, confirms that the use of a concentration of more than 70% of TCA is a safe and powerful method for the treatment of atrophic scars [6].

Our case illustrated the amazing success of a simple and rapid procedure based on punch elevation in combination with 100% TCA touches and fractional CO₂ laser in the management of depressed nasal scarring in a young female.

Fractional CO₂ laser treatment in combination with punch elevation and TCA touching improves the results of treating depressed facial scars. This combination offers the benefit of increased patient satisfaction without increased side effects.

REFERENCES

1. Hirsch RJ, Lewis AB. Treatment of acne scarring. Semin Cutan Med Surg. 2001;20:190-8.

2. Goodman GJ. Postacne scarring:A review of its pathophysiology and treatment. Dermatol Surg. 2000;26:857-71.

3. Dreno B. Acne:Physical treatment. Clin Dermatol. 2004;22:429-33.

4. Grevelink JM, White VR. Concurrent use of laser skin resurfacing and punch excision in the treatment of facial acne scarring. Dermatol Surg. 1998;24:527-30.

5. Magnani LR, Schweiger ES. Fractional CO2 lasers for the treatment of atrophic acne scars:A review of the literature. J Cosmet Laser Ther. 2014;16:48-56.

6. Barikbin B, Saadat N, Akbari Z, Yousefi M, Toossi P. Focal High-concentration trichloroacetic acid peeling for treatment of atrophic facial chickenpox scar:An open-label study. Dermatol Surg. 2012;38:1662-7.