Roundtable Participants W. Philip Werschler, MD Associate Clinical Professor University of Washington School of Medicine Seattle, Washington Author disclosures: Dr. Werschler received an honorarium for his participation in this roundtable.

Richard S. Herdener, MD Assistant Professor of Medicine University of Washington School of Medicine Seattle, Washington; School of Medicine Seattle, Washington Dermatology Specialists of Spokane Spokane, Washington Author disclosures: Dr. Herdener received an honorarium for his participation in this roundtable.

E. Victor Ross, MD Scripps Clinic San Diego, California Author disclosures: Dr. Ross received an honorarium for his participation in this roundtable.

Edward Zimmerman, MD Clinical Faculty Touro University School of Osteopathic Medicine Las Vegas, Nevada Author disclosures: Dr. Zimmerman is on the Speakers Bureau for Suneva and received an honorarium for his participation in this roundtable.

Introduction Acne scarring, which occurs in 95 percent of all people with acne vulgaris,1 can be challenging to treat.2 Severely inflamed lesions may leave permanent scars, which can be associated with psychological pain, low self-esteem, and reduced quality of life.2 Moreover, the clinical severity of acne scars is not necessarily an accurate measure of the patient’s distress (i.e., mild scarring may result in significant distress), just as the clinical severity of the acne vulgaris may not be correlated to the incidence or severity of scarring. General dermatologists are frequently presented with acne scarring and asked to counsel patients with regard to their treatment options. As acne scars often worsen over time, many of these patients are beyond the “acne age” of late teens into the early twenties and are middle-aged. Scar formation is the normal and natural response of tissue to wound healing following an injury that is significant enough to elicit this host tissue response. The incidence of acne scarring may be increased above the background injury with manipulation or “picking” by the patient. These scars may be aesthetically unappealing, and if hypertrophic, they may be painful as well.3 Even relatively minor scarring can have a profoundly adverse psychological impact on the patient. Some patients with acne scarring may become despondent, and the emotional impact can last a lifetime.

During the 2015 Aesthetic & Medical Dermatology Symposia in Coeur d’Alene, Idaho, four dermatology thought leaders convened for a roundtable meeting to discuss acne scarring. The primary objective of this meeting was to bring together a panel of experts in acne scars to discuss types of acne scars, treatment considerations, and current treatment options, as well as the new nonconsumable dermal filler Bellafill. The panel discussed the importance of combination therapy in the treatment of acne scars as well as how to incorporate dermal fillers to treat acne scars into a dermatology practice. The roundtable discussion and this supplement were supported by Suneva Medical, Inc.

Treating Acne Scars: What’s New? Consensus From the Experts

Treating Acne Scars: What’s New? Consensus from the Experts Types of Acne Scars The nomenclature for categorizing types of acne scars has not been entirely settled in the literature. For our purposes, it is useful to recognize three main categories of depressed acne scars—icepick scars (deeper than wide), boxcar scars (wider than deep with distinct edges), and rolling atrophic scars (these can be smoothed out if stretched).4 Atrophic acne scars are the most common and are likely caused by inflammatory processes leading to the enzymatic degradation of the collagen fibers and subcutaneous fat.5 There may be an inflammatory component to some acne scars. Clinicians may also encounter scars with more than one physical characteristic, such as pigmentation or erythema, in addition to being atrophic or hypertrophic. These may be termed “hybrid” scars. Some acne scars are elevated above the surface of the surrounding skin and may be hypertrophic, but not quite keloidal. Other characteristics that can help define acne scars include textural irregularities, depression, aberrant pigmentation, erythema, vascular dilatation, unclear or irregular borders, and papules. There are several ways to classify acne scars. In one method, acne scars may be graded on a four-point scale with grade 1 describing macular (flat) scars (erythematous hyper- or hypopigmented marks) and 4 being severe disease including scarring that is not flattened when the skin is manually stretched.6 The treatment of acne scars must be customized to meet the needs of the patient (age, skin type, extent, type, and nature of scars), the patient’s goals, and the patient’s lifestyle (downtime). See Table 1 for a short summary of main types of acne scars and treatment considerations.

Treatment Considerations The size, type, and severity of the scar will be primary considerations in treatment. The anatomic location of the scar and the patient’s skin type may also be important considerations. The scar’s etiology and prior treatments should be assessed at the patient’s initial evaluation. Patient education should be provided to manage expectations and design a treatment program that does

not exceed the patient’s comfort level for risk. There have been concerns that patients taking oral isotretinoin for acne are at risk for delayed healing after invasive scar treatments. Current clinical practice recommendations recommend that patients wait 6 to 12 months after completing isotretinoin therapy for any aggressive scar revision. However, those recommendations are being challenged by recent studies. In a retrospective study (n=110), patients taking oral isotretinoin (0.5 mg/kg/day) for acne scars or hirsutism were compared to those receiving only topical acne medications. Both groups underwent invasive treatment for acne scars and/or laser hair removal.7 Isotretinoin did not appear to delay wound healing nor was it associated with any adverse effects. There were no cases of atypical scarring, delayed wound healing, keloids, or hypertrophic scars in patients in this study. In another study, 35 patients who had taken low-dose oral isotretinoin (10mg/day) for at least one month were treated with a 1550nm erbium-doped fiber laser to reduce acne scars. In this study, 80 percent of patients exhibited better than “fair” improvement and no aggravated acne scars, hypertrophic scars, or keloids were observed.8

Current Treatment Options Multimodal approaches can often be effective in treating acne scars.9 These procedures, such as resurfacing, lifting, excisions, and filling,2 may be performed at the same time in a single procedure or in sequence. Dermatologists should individualize the best treatment options for each patient. Resurfacing. Resurfacing procedures are perhaps the most common interventions for treating acne scars and include chemical peels, dermabrasion, and laser resurfacing (ablative and nonablative laser resurfacing, plus fractional laser resurfacing). Resurfacing involves removing skin layers from the top down. Originally, dermabrasion was the main approach to treating acne scars. Dermabrasion and other resurfacing techniques help to blend acne scars into the surrounding skin by modifying the contours of the scar.3 As a mechanical procedure, the goal is to reduce the crateriform appearance of scars by smoothing sharp edges. Dermabrasion is particularly useful for treating rolling and superficial boxcar scars. While effective, to achieve

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TABLE 1. Main types of acne scars and considerations by the dermatologist in treatment DESCRIPTION

THERAPY

CONSIDERATIONS

COMMENT

Filler and/or ablative resurfacing

Resurfacing will smooth out the scar but a dermal filler is necessary to help support it after the energy device treatment.

The initial appearance following resurfacing will be good, but as undulations start to reform, their smoothness will diminish over time.

Isolate the boxcar scars and treat them individually. Treat the edges to create more of a saucer shape. Turn a crevasse into an undulation. Remove the edge (shadow effect)

Test behind ear or in inconspicuous place first for darker skin types. Asian and Spanish patients may experience transient hyperpigmentation and should be told in advance. There may be a need for volume (filler) underneath the scar to help support it after treatment

ROLLING ATROPHIC SCARS

Rolling atrophic scar

BOXCAR SCARS

Boxcar scar

CO2 laser or erbium-YAG laser, treat individual scars to efface edges and then use a fractional ablative or nonablative technology for global improvement

ICEPICK SCARS Icepick acne scar where lesion runs up and down

Surgical or punch excision

Icepick acne scar where lesion does not run up and down but may fan out

excellent results, traditional dermabrasion requires a great deal of experience and the number of physicians skilled in dermabrasion is vanishing, as newer energy-based technologies have evolved over the past 20 years. Microneedling with and without various topical applications may help smooth skin contours and blend pigmentation. Energy devices. Another frequently employed acne scar treatment involves energy devices, such as the CO2 laser and erbium YAG lasers, with and without a scanner. The goal of treatment with any energy device is to efface the edges of the scar first and then conclude with a more global treatment and tightening. Today, laser skin resurfacing may involve traditional ablative systems or fractional nonablative and ablative resurfacing techniques.10 Fractional laser resurfacing balances the effectiveness of traditional ablative resurfacing with the greater tolerability of fractional approaches.10 A novel fractional ablative CO2 laser therapy offers fractional photothermolysis and may be effective in treating acne scars less invasively than nonfractional ablative laser therapy.11–13 Patients undergoing fractional laser therapy should be advised that it may cause an acne flare during S4

Inject numbing medicine to trace, excise,use 5-0 or 6-0 absorbable sutures (two stitches)

Stitches can be left in 8 to 10 days; if a surgical scar is left, it can be ablated

Trace the path of the pores and follow that path

the healing process. A picosecond pulse duration laser treatment with a diffractive lens represents an innovation in fractional lasers for acne scar treatment.14 Pulsed dye lasers (PDLs) may be used to flatten and reduce the volume of hypertrophic scars and may result in improved skin texture and pliability as well as decreased erythema.3 PDLs work by selectively targeting hemoglobin with minimal damage to other epidermal or dermal structures. Hypertrophic facial scars may require several treatments.3 PDLs should be used at the lowest fluence that produces mild purpura. They are sometimes employed to treat acne scars, persistent erythema, telangiectasia in both adult and pediatric patients, or in patients with active acne. As a general rule, however, the authors believe it is better to treat active acne first and then address scarring in order to avoid “fighting a war on two fronts.” Subcision. In subcision, a specialized needle, usually 18 gauge, with the lumen or core stamped shut, is inserted percutaneously to release fibrotic scar bands in the dermis and subcutaneous tissue, similar to a “mini-scalpel”. This approach results in a tethered scar being “released” and allows neocollagenesis to take place beneath the scar,

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Treating Acne Scars: What’s New? Consensus From the Experts

helping to lift and smooth the surface contour.15 Subcision is useful for any depressed scars on the face, especially those classified as rolling.3 Microsubcision (MSUBx™, Suneva Medical, Inc., San Diego, California). This technique utilizes a standard hypodermic needle instead of a true subcision needle. Essentially, the needle is “passed back and forth” underneath a depressed scar to create a potential space, or pocket. This space may fill naturally with a fibrin clot, or more commonly an injectable dermal filler is placed in the pocket. Excision. Some acne scars respond well to surgical excision, which may include punch excision, elliptical excision, or punch grafting. The advantage of surgical excision is complete removal of the scar. Punch excision with a small stitch may produce good results and is likewise a straightforward procedure. For deeper scars, particularly those around the ear, a demi-lift with tightening can be helpful following excision of tissue with acne scars. Excision may leave surgical scars, but it has been the observation of the authors that many patients accept small, flat, surgical scars more readily than acne scars. Additionally, monomorphic surgical scars are typically more predictable to repair procedures than polymorphic irregular acne scars. Punch grafting may be more cumbersome for acne scar treatment, in that it requires donor/recipient matching of color, tone, and texture, and excises tissue from a donor site as well as the scar site. Punch excisions may work well for treating acne scars and any residual rough edges can be smoothed with laser or energy device treatment that same day or subsequently. Punch grafting should be used with caution on icepick scars to assure a full-thickness dermal excision of the scar base prior to placement of the graft. Chemical peeling. Icepick scars may respond well to high-concentration trichloroacetic acid (TCA) for chemical reconstruction. In a study of 53 adult patients with atrophic acne scars, 70% TCA applied focally every two weeks using a chemical reconstruction of skin scars therapy (CROSS therapy) resulted in good or excellent improvement (defined as >50%) in 66 percent of patients based on patient and physician assessments. In that study, 81 percent of patients said they were satisfied or very satisfied with TCA treatment.16 In a study of 16 patients treated with 100% TCA, 69 percent reported excellent results (>75%), and the remainder reported good results.17 High-strength TCA is thought to cause remodeling of the dermal collagen. TCA treatment is relatively inexpensive and seems well-tolerated by patients. However, TCA should be done as a stand-alone therapy or, if in multimodal approaches, be done before laser treatments and allowed to “set.” Moisture induced/generated by ablative and fractional laser treatments can dilute or spread the effect of the TCA beyond the desired boundaries and the penetration of TCA into freshly lasered skin may be unpredictable. Fillers. Fillers offer an important nonsurgical

technique to correct acne scars and improve skin texture. Since many types of filler treatments are available, clinicians should discuss with patients their various treatment options and associated risks and benefits. Many fillers are injected using the so-called linear threading method. The length of the needle is inserted into the middle of the scar or depression and the product is slowly injected as the needle is advanced or retracted, allowing product to be distributed in small amounts along the length of the scar. Fanning is a similar technique, in which the needle is inserted as for linear threading, but before the needle is removed, it is drawn back and the direction changes, enabling another line of injection. Fillers may be used to treat deep, rolling acne scars. The staging of the procedure depends on the patient and types of scars. For example, a deep rolling scar may be first treated with an energy device, then filler applied in specific regions. For a severely atrophied scar with wasting, fillers may be used first and then an energy device. In some instances, fillers might be used in the same procedure or staged for a separate procedure. Subcision, punch elevation, and dermal fillers may all be considered “lifting procedures.” Lifting procedures try to draw the base of a deep scar toward the surface and, in so doing, smooth out the skin. Fat transplantation. Autologous fat transplantation may be suitable for the treatment of severely depressed scars or scars with abnormal contours in which there is a loss of subcutaneous fat.3 Hyaluronic acid. Non-animal stabilized hyaluronic acid (NASHA) in a low-viscosity liquid can be injected into the mid-to-superficial dermis as a dermal filler.18 This treatment may be particularly useful to the correction of individual, depressed acne scars. Hyaluronic acid may be described as a consumable filler and will be resorbed by the body over a relatively brief (6–12 months) time. Additionally, when most hyaluronic acid fillers are placed superficially into the dermis in fair-skinned (Fitzpatrick 1 and 2) individuals, a bluish discoloration termed the Tyndall or Rayleigh effect may occur. This may not be the case for a unique hyaluronic acid, which is produced using a specialized production process termed “cohesive polydensified matrix,” which allows for greater dermal tissue integration of the HA. Thus, even successful treatment with hyaluronic acid will only provide temporary rather than durable results.

A New Treatment Option Nonconsumable dermal filler. The ideal filler should be free of adverse side effects, well-tolerated, safe, effective, and offer durable results. Bellafill™ (Suneva Medical, Inc., San Diego, California), originally introduced to the United States market as Artefill™, is a filler originally US Food and Drug Administration (FDA) approved for correction of nasolabial folds (smile lines)

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TABLE 2. Pearls and pitfalls in the use of nonconsumable dermal fillers Treat filler injection as a surgical procedure; prep the skin as you would for a surgical procedure. Avoid filler injections when the patient has any active inflammatory process in the treatment area, such as sunburn, active acne, inflammatory seborrhea, herpes simplex virus eruption, etc. Photograph, mark treatment areas and consider lidocaine injections prior to placement of filling agent for patient comfort. Recognize that acne scarring can distort the anatomy of tissue planes (dermis, fat, muscle). For instance, the dermis may atrophy and sit on the subcutis in some patients, but in other patients, the dermis may be thick and heavily fibrosed. Be aware of nerves and vasculature in the treatment area. The risk of granulomas and nodules is very small. Granulomas are a distinct histological event. Not every bump or nodule is a granuloma. Correct to optimal surface contour or slightly under-correct; it is easy to use a secondary injection later, if needed. Swelling may occur within the treatment area. If clinical evaluation is obscured, consider a “time out” from injection for 10 to 15 minutes, use cold packs to reduce edema and if unsuccessful, consider rescheduling injections at a later date. Ask patients to gently massage the injection sites for two minutes each morning and night for one to two weeks to help maintain even distribution of the microspheres within the treatment area(s).

and has recently been approved as the first dermal filler in the United States for treatment of acne scars. This new product is indicated for the correction of moderate-tosevere atrophic distensible facial acne scars on the cheeks in adults.19 Bellafill, a dermal filler, is bovine collagen solution (80%) with nonresorbable polymethylmethacrylate (PMMA) microspheres (20%) and 0.3% lidocaine. The collagen portion of the product initially acts as a volumizer and supports collagen production. This nonconsumable dermal filler can be used on distensible scars. It provides support/scaffolding and may help normalize reflective optics (reflection/refraction) of the skin surface by reducing shadowing of the base of the scar. Treating physicians have in the past expressed concerns about the use of a nonconsumable filler because it represents a permanent treatment and theoretically a risk of permanent complications. Clinical trial safety data from a five-year safety study as well as the pivotal acne scar study and nasolabial fold study confirm the low adverse event occurrence of Bellafill across 1,542 subjects, as well as the clinical manageability of the minor adverse events. The authors shared some of their pearls and pitfalls in Table 2. Note that when filler is injected into the skin, it will travel along the path of least resistance, so it may not go precisely where expected. Only very small amounts of nonresorbable dermal filler are needed, typically one- to two-tenths (0.1–0.2) of a milliliter per scar per treatment session. These small amounts make it difficult to overfill a scar, but even if that happens, it may be possible to squeeze or “milk out” excess filler or, if need be, use a punch excision to extract it. Note that too much filler may result in a palpable lesion before it is visible. Dermal filler can be applied using microsubcision for S6

depressed acne scars and can be evenly dispersed since the filler is formulated as suspended microspheres. Having the patient massage the injection sites following injection can further aid in even distribution (see Table 2). Note that Bellafill’s product labeling recommends intradermal skin testing and observation for 28 days to assure there is no sensitivity to bovine collagen or lidocaine. This pretest may not always be practical or feasible particularly for patients who find a visit to the dermatology clinic to be a hardship or have time or travel issues. However, remember that this pre-treatment skin testing is part of the FDA labeling for Bellafill, and is for patient safety. Some patients may “cool off” in 28 days and decide they no longer want to undergo treatment. An innovative strategy to deal with this issue is to consider skin testing at the time of consultation, plus selective mapping, photography, and perhaps microsubcision or subcision in an attempt to demonstrate to the patient what the procedure will be like upon their return in 28 days.

Clinical Trials of Bellafill In a single-center, open-label, pilot study (n=14 patients, 57 scars), atrophic acne scars were subjected to subcision and then Bellafill was injected into the scar. At eight months, investigators rated 96 percent of atrophic acne scars had improved.20 No adverse events were reported. In a double-blind study of 147 patients with ≥4 moderate-to-severe atrophic facial acne scars, patients were randomized for an injection of Bellafill or saline, with a second injection four weeks later, if needed. The majority

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of patients in the active-treatment group and some in the control group (64% vs. 33%, respectively; p=0.0005) achieved the primary endpoint, a two-point improvement on the four-point validated acne scar rating scale in ≥50 percent of scars at six months. There were no significant differences in results between sexes, lighter versus darker skins, or younger versus older patients.21

Filler Complications Visible papules may occur with the use of any filler, particularly poly-L-lactic acid and may occur if the injection is too superficial or the volume of dilution is too low.22 Tissue necrosis is rare, but may occur with the intravascular injection of filler into a vessel or if the injection compresses the local vasculature.23 This may initially be evident to the clinician with blanching during injection or mottled pigmentation of the skin post-injection. As a final reminder, when Bellafill is injected on label into the dermis for the treatment of depressed acne scars, there is not typically larger (>0.5mm) vessels present.

Combination Therapy for Acne Scars Patients may require a multimodal approach for treating their scars; for example, the use of a vascular laser for red scars, fillers for depressed, distensible scars, punch excision of icepick, scars and ablative and nonablative fractional lasers for boxcar scars. Dermal fillers can often work even with scars with discrete edges and should be considered a first-line approach for atrophied and/or rolling scars. Reinflation of the underlying tissue may put the skin more “on stretch,” allowing for better treatment of superficial scars and possibly enhancing results. Staging combination therapy must be customized to meet the patient’s individual needs, such as budget, timeline, risk tolerance, and psychological impact. If there is significant atrophy, fillers may be the first approach followed by an energy-based therapy. For patients without significant atrophy, energy therapy might be performed first, with fillers following. Acne scars located on the temple often require filler for appropriate treatment. Many factors should be considered when staging combination therapy including the type(s) of scars, the patient’s age, type of skin, the patient’s tolerance for risk and discomfort, and treatment goals. When selecting the types and order of therapies, the following clinical outcomes must be considered: correction of color, tone, texture, tightness, and volume. While treating acne scars can be challenging for any skin type, darker skin may be at elevated risk for postinflammatory hyperpigmentation.24 Fitzpatrick skin types IV to VI compose an increasingly large proportion of American dermatology patients, but there are relatively few

studies of acne scar treatments in these specific populations. Moreover, acne is prevalent in Asian patients, and these patients (Fitzpatrick skin types III to V) are known to be at increased risk for hypertrophic and keloid scarring.25 In many cases for all skin types, dermal filler plus resurfacing will provide better results than dermal filler or resurfacing alone. Patients should be educated that the loss of volume makes the scar appear more prominent, thus volume restoration is essential to complete treatment success in almost all cases.

Incorporating Dermal Fillers to Treat Acne Scars into a Dermatology Practice The typical dermatology practice sees many acne patients and has the opportunity to help patients with acne scars. Acne scars tend to become more visible over time and may be detrimental to the patient’s self-esteem and quality of life. Since most dermatology patients prefer to stay at a single practice rather than travel to see a variety of specialists, acne scar treatment has the potential to become an important offering for virtually all dermatology practices. The learning curve for adding nonconsumable dermal filler to a dermatology practice is relatively short (even for dermatologists with minimal injection experience), and the procedure is straightforward, simple, and will likely produce high success rates. Costs for this type of injection can be kept reasonable and it is not difficult to educate patients about the role, risks, and benefits of these innovative dermal fillers as part of their acne scar treatment. Dermatologists wishing to train using a nonconsumable dermal filler should seek out hands-on training with an experienced colleague. The authors recommend the following multiphase training regimen: • Online video to get an overview of technique and to use for subsequent review • A series of observational cases with a physiciantrainer • In-clinic cases with physician-trainer observing and exposure to advanced techniques • Peer-group forum or conferences, possibly industry supported, in which experts can discuss their experiences, insights, and optimized techniques. Some patients with troublesome acne scars are unaware that their scars can be minimized. For that reason, an advertising or social media campaign may be helpful to inform patients about acne scar treatment options. For example, a patient-advocate willing to talk about their acne scars and subsequent treatment might help encourage more individuals to seek treatment. In today’s increasingly cost-conscious healthcare market, the costs of dermal filler might pose a substantial obstacle. For reimbursement-based practices, even asking

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for payment can be a difficult patient discussion. Patients who learn about acne scar treatments may expect them to be covered by their insurance and will express disappointment and frustration when they learn they are not. Even when patients are prepared to pay out-of-pocket for dermal filler treatment of acne scars, they may think the cost of dermal filler is prohibitively high. With misplaced concern, some dermatologists may be overly sympathetic to their patients’ financial reluctance and reduce prices for acne scar treatments in order to accommodate their patients’ pricing sensitivities. Instead, an alternate approach is to re-affirm the value in this kind of treatment. Nonconsumable dermal fillers offer durability and longevity that can be amortized over the long term. This is not a treatment that will be consumed over time and need to be repeated. For instance, the dermatologist may position a nonconsumable dermal filler as a treatment you “buy” outright rather than “rent.” The goal is to encourage patients to see nonconsumable dermal fillers as a permanent solution to a difficult problem for them, rather than as just one more expense.

Conclusion Dermatologists today can find great professional satisfaction in being able to effectively treat acne scars that were previously considered untreatable. Most patients are extremely grateful for successful treatment and may even report marked improvements in their mood, outlook, and quality of life. Many treatment options exist, including the innovative new nonconsumable dermal filler Bellafill. This is important, as many patients will require combination therapy to achieve optimal results.

References 1. Johnson M, Roberts J. Skin conditions and related need for medical care among persons 1 to 74 years, United States, 1971–1974. Vital Health Stat. 1978;11(312):1–72. 2. Fife D. Practical evaluation and management of atrophic acne scars: tips for the general dermatologist. J Clin Aesthet Dermatol. Aug 2011;4(8):50–57. 3. Cooper JS, Lee BT. Treatment of facial scarring: lasers, filler, and nonoperative techniques. Facial Plast Surg. 2009;25(5):311–315. 4. Jacob C, Dover J, Kaminer M. Acne scarring: a classification system and review of treatment options. J Am Acad Dermatol. 2001;45(1):109–117. 5. Goodman G, Baron J. The management of postacne scarring. Dermatol Surg. 2007;33(10):1176–1188. 6. Goodman G, Baron J. Postacne scarring: a qualitiative global scarring grading system. Dermatol Surg. 2006;32(12): 1458–1466. 7. Chandrashekar BS, Varsha DV, Vasanth V, et al. Safety of performing invasive acne scar treatment and laser hair S8

removal in patients on oral isotretinoin: a retrospective study of 110 patients. Int J Dermatol. 2014;53(10):1281–1285. 8. Yoon JH, Park EJ, Kwon IH, et al. Concomitant use of an infrared fractional laser with low-dose isotretinoin for the treatment of acne and acne scars. J Dermatolog Treat. 2014;25(2):142–146. 9. Shamban A, Narurkar V. Multimodal treatment of acne, acne scars and pigmentation. Dermatol Clin. 2009;27(4):459–471. 10. Alexiades-Armenakas MR, Dover JS, Arndt KA. Fractional laser skin resurfacing. J Drugs Dermatol. 2012;11(11): 1274–1287. 11. Gotkin RH, Sarnoff DS. A preliminary study on the safety and efficacy of a novel fractional CO2 laser with synchronous radiofrequency delivery. J Drugs Dermatol. 2014;13(3): 299–304. 12. Gold MH, Biron JA. Treatment of acne scars by fractional bipolar radiofrequency energy. J Cosmet Laser Ther. 2012;14(4):172–178. 13. Qian H, Lu Z, Ding H, et al. Treatment of acne scarring with fractional CO2 laser. J Cosmet Laser Ther. 2012;14(4):162–165. 14. Brauer JA, Kazlouskaya V, Alabdulrazzaq H, et al. Use of a picosecond pulse duration laser with specialized optic for treatment of facial acne scarring. JAMA Dermatol. 2015;151(3):278–284. 15. Orentreich D, Orentreich N. Subcuteaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg. 1995;21:543–549. 16. Agarwal N, Gupta LK, Khare AK, et al. Therapeutic response of 70% trichloroacetic acid CROSS in atrophic acne scars. Dermatol Surg. 2015;41(5):597–604. 17. Agarwal N, Mittal A, Kuldeep C. Chemical reconstruction of skin scars therapy using 100% trichloroacetic acid in the treatment of atrophic facial post varicella scars: a pilot study. J Cutan Aesthet Surg. 2013;6(3):144–147. 18. Halachmi S, Ben Amitai D, Lapidoth M. Treatment of acne scars with hyaluronic acid: an improved approach. J Drugs Dermatol. 2013;12(7):e121–e123. 19. Bellafill for acne scars. The medical letter on drugs and therapeutics. 2015;57(1471):93–94. 20. Epstein RE, Spencer JM. Correction of atrophic scars with artefill: an open-label pilot study. J Drugs Dermatol. 2010;9(9):1062–1064. 21. Karnik J, Baumann L, Bruce S, et al. A double-blind, randomized, multicenter, controlled trial of suspended polymethylmethacrylate microspheres for the correction of atrophic facial acne scars. J Am Acad Dermatol. 2014;71(1):77–83. 22. Cox SE. Clinical experience with filler complications. Dermatol Surg. 2009;35(Suppl 2):1661–1666. 23 Cohen J. Understanding, avoiding, and managing dermal filler complications. Dermatol Surg. 2008;34(Suppl 1):S92–S99. 24. Semchyshyn N, Prodanovic E, Varade R. Treating acne scars in patients with Fitzpatrick skin types IV to VI using the 1450nm diode laser. Cutis. 2013;92(1):49–53. 25. Ho SG, Chan HH. The Asian dermatologic patient: review of common pigmentary disorders and cutaneous diseases. Am J Clin Dermatol. 2009;10(3):153–168.

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