Fractional CO₂ Laser Treatment vs Autologous Fat Transfer in the Treatment of Acne Scars: A Comparative Study

and for its role in collagen synthesis and angiogenesis.¹⁰ This close relationship is underlined by the potent proangiogenic factors released by adipose lineage cells (monobutyril, vascular endothelial growth factor [VEGF], and leptin), causing the differentiation of preadipocytes to endothelial cells under hypoxic conditions.¹¹Fat grafting has become a standard technique in plastic surgery. Improvement of skin texture has been noticed along with its filling effect. Various studies on the physiology of fat and the histological changes have hypothesized, for example, that the fat graft induces neoangiogenesis and collagen synthesis due to secreted adipokines.¹² Other studies have assumed that matricryptins produced because of collagen destruction are powerful inductors of collagen synthesis.¹³ Older hypotheses include synthesis by preadipocytes or fibroblasts formed by transformed stem cells.^14,15 Skin texture improved due to thickening of the dermis with skin softness and skin color or reduced pore diameter. Skin suppleness improved due to increased ease of gliding between subcutaneous layers. Skin color and scar quality showed marked improvement after fat graft. Histologic and immunohistologic studies comparing biopsies taken from nude mice before and after fat grafting showed an increased density of extracellular matrix surrounding the fatty tissue and between the fatty tissue and the dermis.¹⁶

In the present study, the effect of fat grafting on atrophic facial acne scars was compared with fractional ablative CO₂ laser treatment. A review of the literature indicates that no similar study has been done.

With approval from the Dermatology Research Ethics Committee (Derma REC), Faculty of Medicine, Cairo University, this study was performed at the dermatology outpatient clinic and surgical operation room at Kasr Al-Ainy Hospital at Cairo University in the period between March 2011 and October 2011.

The study included 20 patients with acne scars. Inclusion criteria were males and females older than 18 years with atrophic acne scars. Excluded from the study were patients younger than 18 years, and patients with retinoid use in the past 6 months, systemic disease (diabetes or hypertension), collagen disease, malignancy, photosenstivity, and keloidal tendencies.

The patients were assessed by a committee of 3 physicians, a single-blinded physician, and reports of patient satisfaction, through pretreatment and posttreatment digital photos. The improvement was described in the following scale:+: 0% to 25% (mild), ++: 25% to 50% (moderate), +++: 50% to 75% (marked), ++++: 75% to 100% (excellent)

All patients gave informed consent and their full history, and they were photographed before and after each session. Their age ranged from 18 to 38 years. Their skin type ranged between III and IV, and they were divided into 2 groups in a blinded randomized study. Group A, consisting of 10 patients (5 female and 5 male), all with mixed atrophic acne scars, were subjected to fat grafting. Group B, consisting of 10 patients (6 female and 4 male), all with mixed atrophic acne scars, were subjected to fractional ablative CO₂ laser treatment.

Ten patients were subjected to fat grafting. The procedure was done under local anesthesia in a surgical operation theater with complete aseptic precautions. Fat was harvested using tumescent anesthesia (20 cc xylocaine 2% + 20 cc saline + 1/200,000 adrenaline) and injected at the iliac crest region using 20 cc syringes. A 0.5 cm stab incision was made at the donor site to introduce a cannula connected to 60 cc syringe, the fat was aspirated by steady movements in subcutaneous tissues, and the end point was the appearance of blood. The fat was placed in vacuumed laboratory plain tubes. The tubes were inserted in centrifuge at a speed of 3,000 rpm for 7 minutes and 3 layers were formed —an oily layer on top, blood and fluid at the bottom, and the fat in between. All layers were disposed of except the fat layer, which was placed in 3 cc syringes with a screw lock. The whole face was sterilized by alcohol. Infraorbital nerve block was done using 1 cc (lidocaine 2% and 1/200,000 adrenaline) through buccal mucosa. A 0.5 cm stab incision was made preauricular in the hairline or in an already existing scar. The 3 cc syringe with the fat was connected to an injection cannula that was inserted at the incision. Fan-shaped subscision of the scars was done, creating tracts for fat placement in subdermal regions. Fat was placed during cannula retraction in its bed created by the subscision tracts. Molding was done against the zygoma and maxilla.

The procedure was a surgical day case, and the patient was prescribed antibiotics and anti-inflammatory drugs for a week. A compression garment was used at the site of harvesting for 48 hours, as well as a dressing with topical antibiotics. Steristrips at the injection site were also used.

Follow-up took place after 1 week and over the following 3 months. Results were gathered through photographs, patient satisfaction, and single-blinded assessment.

Ten patients were treated with a fractional ablative CO₂ laser (DEKAâ„¢ SmartXide, Florence, Italy). Asepsis of the face was done using an alcohol swab. Four of 10 patients received a local anesthetic. Each session was performed with a single pass