Antiviral drugs are not routinely given unless there is a positive history of herpes infection.30
All laser patients had a downtime of 1 week. There was insignificant
healing time reported between Er:YAG laser and CO2 laser.31 Conversely, patients in group A had only 1 day, which favors fat grafting in terms of patient appeal.
Acne flares occurred in 2 patients in group B (Figure 7), and have been previously reported with CO2 lasers.32 Moreover, there were also reports of suppurative diseases, including acne vulgaris,33 and further studies are needed to explain the contradiction.
The only patient with active acne to show improvement was in group A. Further studies are needed to confirm these results. In group A, 3 patients developed malar fullness, but were not annoyed by it. Fat is liable to hypertrophy due to the adipokines released from adipocytes and the angiogenesis that results for graft survival and may occur with weight gain.34
A major drawback in group B was the development of a pixilated
pattern on the cheeks of 4 patients, which affected their cosmetic appearance (Figure 8). This remained for the whole month between sessions, continued for 3 months after the final session, and was not relieved by topical retinoids. No other studies reported this side effect, so more reports are needed on the side effects of fractional CO2 laser procedure, as it is still in its infancy.
A problem we faced with some patients in group A during harvesting
was that they were too thin to have sufficient fat at the iliac crest, which necessitated using both sides to harvest a sufficient
amount of fat. Another problem that must be considered with fat grafting is that it needs a skilled doctor, because it is a surgical procedure, unlike laser treatment where the skills can be acquired more quickly.
In conclusion, fat grafting proved to be more effective than ablative
fractional CO2 laser in the treatment of acne scars. Fat grafting has many points in its favor, the main one being the clinical improvement of the scars and texture. Other advantages
may include it requiring only a single session with a 30% excellent improvement after 3 months with minimal downtime and almost no complications when administered in the proper setting, technique, and patient selection. By contrast, 70% of group B had mild improvement with several complications and prolonged downtime, which supports the stem cell theory of fat grafting. A second session of fat grafting is recommended for those who show mild to moderate improvement.
Laser parameters should consider skin thickness in acne scar patients and the variability of the lesions within the same cheek. These may increase or decrease the number of passes,
the power or fluence, and the treatment density, so the physician can use variable parameters in the same patient according
to their assessment of the condition. Further studies
