ment. The overall appearance assessed by reports of patient satisfaction was statistically significant (P=.015) compared with the 3-physician committee’s assessment.
Side effects were minimal and are summarized in Table 1.
DISCUSSION
There are multiple treatment modalities for acne scar treatment, and a combination of these is usually required for the optimum effect. In the present study, the effect of fat grafting on atrophic facial acne scars was compared with the use of fractional ablative
CO2 laser. A review of the literature shows that a similar study has not been conducted.
The patients had mixed types of atrophic acne scars (rolling, boxcar, and icepick). The patients with icepick scars (2 patients in group A) showed no improvement from the fat grafting. The recent recommendation is to treat icepick scars with punch excision or chemical reconstruction of skin scars techniques.1 Similar recommendations have been given for icepick scars in combination with fractional ablative laser treatment.2
Patients with boxcar scars in group B showed no improvement, but increasing the parameters of these patients might have been of benefit. In group B, in the 3-month follow-up after the last session, less than 20% of patients graded as having excellent
scar improvement (75%-100%), 0 as marked (50%-75%), almost 70% as moderate (25%-50%), and less than 10% as mild (Figure 5). A single pass was used at 15 W with spacing 800 μm in all patients to standardize the comparison, regardless of the thickness of the skin or scar depth. Most of the patients had thick skin, which might have needed higher power or more passes. Thickness should be noted, and sebaceous skin is usually thicker. Smooth skin may be thin and atrophic from previous therapeutic interventions or advancing age.17
A study found that higher fractional ablative CO2 laser treatment
densities were better than low densities at the same energy 15 mJ and resulted in more inflammatory response
and improved results.18 Others have used a single pass on 20 patients with acne scars, with 10 patients treated at a fluence of 50 mJ to 70 mJ and 10 patients at 15 mJ to 35 mJ. There was a 50% to 70% improvement in the high energy group and a 10% to 40% improvement in the low energy group.19 A study on Asian patients used a 15 W fractional CO2 laser on 12 patients
with skin type IV in a single pass with high pulse energy (105 mJ/MTZ) in deeper scars and lower pulse energy (75-90 mJ/MTZ) in mild to moderate scars, with no concurrent cooling.
Follow-up at 3 months was 0 excellent, 31% good, 38% fair, 31% slight. Follow-up at 6 months was 8% excellent, 38% good, 38% fair, and 15% slight.4
On the other hand, in group A, the scar and overall improvement
were graded as 30% excellent, 30% marked, 20% moderate, and 20% mild (Figure 4). The improvement seen in group A represents graft survival and proves the ability of fat to produce adipokines that help the viability of the preadipocytes
and probably the ability for neovascularization and collagen synthesis. This needs to be further investigated by biopsy in future studies.
Despite controversies in the literature over several points, eg, the effect of anesthesia on fat viability, the fat-grafting technique proved to be successful, starting with its harvesting. A recent study by Keck showed that with the exception of bupivacaine, all local anesthetics significantly reduced cell viability, but to differing degrees
as determined directly after treatment and compared with a saline control treatment. However, during long-term cultivation, none except articaine plus adrenaline had any impact on viability.
The differentiation was assessed by adiponectin expression. With the exception of articaine plus adrenaline, no differences in cell size or lipid droplet formation were detectable between the control and local anesthetic-treated cells. Most surgeons wait 30 minutes after tumescence for the infiltration fluid to percolate properly and for its full pharmacologic actions to occur. Harvest-
