Saline injections prove effective for reducing post-acne marks
National report - Saline injections provide a safe, simple and cost-effective solution for post-acne scarring - particularly atrophic, shallow boxcar scars, according to two dermatologists.
"For years, we had used saline injections to treat people who had atrophy from steroid injections in the skin," says David J. Sire, M. D., director, Advanced Skincare Surgery & Medcenter, Fullerton, Calif. The saline injections facilitated quicker resolution of this lipoatrophy, he says. About 10 years ago, at the suggestion of his senior partner David Homme, M. D., Dr. Sire says he tried the technique with acne scars and found similar results.
"We've had good luck with it for atrophic scars, as well," particularly those that have left some dermal atrophy and perhaps subcutaneous tissue loss, Dr. Sire says. "We're treating primarily the deep dermis, perhaps into the reticular dermis. It's been an easy, relatively inexpensive and painless way to deal with traumatic, surgical, laser and dermabrasion-induced scars, also."
Other advantages include the fact that the procedure introduces no foreign material into the skin, he says. Therefore, the procedure avoids immediate and delayed reactions, such as granuloma formation, which can occur with some dermal fillers and other scar repair techniques.
To optimize results, Dr. Sire says he recommends that patients use a topical retinoid for at least two weeks preprocedure to "prime" the skin. Scars of long duration are generally less vascular and composed largely of tightly packed collagen bundles, he says. "The tissue is not very active metabolic ally." Retinoids help to stimulate collagen production and can help to normalize keratinization in patients with active acne, he says.
During the procedure, backlighting is important for creating shadows that highlight scars' appearance. With such lighting, "You can see changes in the surface of the skin to pinpoint where exactly the scars are," Dr. Sire says.
As for technique, he says, "Usually I inject into the scar itself, creating a bleb or bolus of saline, which then expands the scar. Typically, there's only one injection into each scar," using a 30-gauge needle.
"Benzyl alcohol, the preservative in normal saline, acts as a local anesthetic," he says. "So the area you're working in quickly becomes pretty well numb. We've also used a topical anesthetic prior to the injection for people who are more sensitive."
For patients who tend to bruise, "To be safe, we apply ice to the skin before and after treatment, as we do with dermal filler injections," he says. Saline injection volume varies from 0.5 cc to 1 cc per injection site, Dr. Sire says. Each treatment takes about 15 minutes, and most patients see 20 to 80 percent improvement after five or six sessions.
After several sessions, injecting becomes easier, as the tissue texture softens, allowing the dermis to expand. "As we inject, we notice a softening of the tissue and the scar, so that there's less pressure when you inject with a needle and syringe," Dr. Sire says.
Results typically last one to two years. Scars don't completely disappear, Dr. Sire says, but they diminish gradually over time. Accordingly, "We try to have patients come in for a 'booster' treatment once or twice a year."
Side effects include shortterm bruising and mild swelling that usually disappears in two to three hours, Dr. Sire says. Some patients experience a tiny amount of bleeding, as with any skin injection.
How it works
Dr. Sire proposes that the treatment's mechanism of action stems from the fact that stretching and physical stimuli provoke fibroblasts to produce collagen and various growth factors.13
"The brisk dermal injection elevates the skin in a wheal-like fashion, initiating a wound-healing process that provokes the production of subtle amounts of collagen" and other extracellular matrix components, he says. "This promotes a layering of collagen, which fills in the contour defect." Moreover, the saline solution's buoyancy functions like a balloon, tenting the fibers that have been bound down by the scarring process.
"As with most scars, we get slightly faster results if they're relatively fresh and still have some inflammatory reaction in the skin, which I believe the treatment triggers a bit," Dr. Sire says. The treatment has worked, however, for patients who have spent years trying many other treatments with other physicians. "That's a common scenario that we've seen," he says.
Regarding cost, Dr. Sire says his practice charges $100 to $150 per treatment. "We like to do a series of six to nine, about two weeks apart. We've tried many different time intervals, and that seems to give the best chance of letting the body settle down a bit between injections." To date, he estimates that his practice has performed the treatment on more than 100 patients. Because the procedure is relatively low-risk, his physician assistant sometimes performs these injections as well, he says.
Dr. Sire also has used the technique in combination with other scar treatments.
"I typically start with saline injections to try to get the body to respond. Then, for deeper scars such as boxcar scars, we sometimes add subcision" at the same time as the injection procedure, or a dermal filler if six to nine saline injections don't produce satisfactory results. "We have also used intralesional steroids for thickened scars and pulsed dye laser for erythematous scars," he says.
In the eyes of peer-reviewed medical-journal editors, Dr. Sire says, the saline procedure's simplicity is perhaps a disadvantage. "I've submitted it before, and it's been ignored." Perhaps these editors believe that "something this simple can't be that great," he says, "but it actually is."
Tried and true
W. Philip Werschler, M.D., F.A.A.D., F.A.A.C.S., assistant clinical professor of medicine/ dermatology, University of Washington, Seattle, says, "I believe the concept is valid. In this day of high-technology lasers, tissue activators and engineered fillers, it's important not to forget older, proven technologies."
Decades ago, Dr. Werschler says, physicians performed subcision using large-bore coreless needles that functioned somewhat like chisels. "Basically, you would go underneath the tissue and cut under acne scars, surgical scars or traumatic scars to improve their appearance," he says. Sometimes, physicians would also inject isotonic saline during this procedure to lift the scars upward and outward from the dermis.
"Then a fibrin clot would develop underneath the scar," Dr. Werschler says. "The fibrin clot would stimulate the development of new collagen." The process of breaking up scar tissue and injecting it with saline probably produces some irritation, fibrinogen, scar tissue formation and eventually collagen, Dr. Werschler says. He says he sees no downside to the treatment - provided the clinician is aware of the anatomy and patients bring reasonable expectations.
"I see this as a modern-day version of an age-old treatment technique that seems to have withstood the test of time," he says. "It seems effective, safe, relatively easy and inexpensive."
References: 1 Koo J. J Am Acad Dermatol. 1995 May;32(5 Pt 3):S26S30. 2 Tan JK. Skin Therapy Lett. 2004 Aug-Sep;9(7):1-3, 9. Review. 3 Mulder MM, Sigurdsson V, van Zuuren EJ, et al. Dermatology. 2001;203(2):124-130.
By John Jesitus Senior Staff Correspondent Copyright Advanstar Communications, Inc. Jun 2011
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