Acne has developed from a disease of puberty to a disease expanding from adolescence into adult ages. The most disfiguring element of acne is the development of permanent visible scars. Acne scarring is common but difficult to treat. A descriptive, universally acceptable classification system of atrophic acne scars includes three scar types: ice pick, boxcar, and rolling. Erythema and, less often, pigmentary changes may be associated.⁴

Ice pick and boxcar scars can be improved by several measures including chemical, mechanical, and laser peeling, fractional laser, subcision, dermal fillers, microneedling, excision, and a combination of procedures (Figures 1 and 2).⁵–¹⁰

Ablative lasers such as CO₂ and Erb:YAG are useful tools in the treatment of acne scars in fair-skinned patients only, as they have a higher risk of complications related to pigmentation. Prolonged post-treatment hyperemia is another unwanted side effect. Fractional lasers have less severe side effects but more moderate efficacy compared to ablative devices.

Fractional CO₂ laser with a laser fluence from 2.07–4.15 J/cm² has been shown to increase tissue repair both clinically and on cytokine levels.¹¹ Efficacy and safety of an erbium-doped 1,550-nm fractional laser in the treatment of facial acne scars in Fitzpatrick skin types IV to VI was studied in a prospective, single-blind, randomized trial in 15 patients with acne scars. Patients were divided into two groups; one was treated with 10 mJ and the other with 40 mJ. Five monthly laser sessions were performed. During treatment there was a significant improvement in the acne scarring and overall appearance with no significant difference between the 10 and 40 mJ groups. Patients were highly satisfied with their results. Significant postinflammatory hyperpigmentation was seen in patients. Pain was significantly higher in darker skin.¹²

More recently, nonablative laser systems have been introduced into acne scar treatment. The nonablative 1,550-nm erbium-doped fractional photothermolysis system has been effectively used for scar treatments in Asian skin, but it seems that several sessions of treatment must be delivered to achieve satisfactory improvement.¹³

Fourteen patients with atrophic acne scars were treated by a combination of subcision and permanent dermal filler injection (Artefill^®). Investigator ratings after eight months postprocedure indicated that 96% of the atrophic acne scars showed some degree of improvement. The majority of patients reported a moderate correction, correlating with a 51%–75% improvement in their acne scars at eight months. No adverse events or side effects were noted in this short study.¹⁴ Since permanent filler may produce adverse reactions after many years, the risk may not outweigh the benefits in younger adults. Nonpermanent filler such as hyaluronic acid (HA) may be considered, but repeated application will be necessary.

Boxcar scars are mostly treated by excision or ablative procedures. In a recent trial, 24 subjects with punched-out acne scars were treated monthly for two months with four passes of various square pulse Er:YAG laser resurfacing using a 7-mm spot size and a fluence of 0.4 J/cm². Subjects were divided into two groups and treated with two different pulse widths: 300 micros (short pulse) and 1,500 micros (extra-long pulse). In the short pulse group, skin smoothness improved significantly whereas in the extra-long pulse group, skin smoothness and scar volume improved significantly from baseline.¹⁵ For rolling scars, but not icepick scars, the 1,550 nm Erb:Glass fractional laser three times with a 6-week interval showed efficacy.¹⁶ Subcision is a reliable method for rolling scars. In a trial with 22 patients, subcision showed mild improvement in about 60% of patients and moderate improvement in about 40% of them.¹⁷ Other laser types used successfully to improve acne scars include Erb:YAG and CO₂ fractional lasers.

Microneedling is a relatively new and simple procedure for dermatology. In a study from Italy, 32 patients with acne rolling scars were enrolled. Each patient was treated in two sessions. Analysis of the patient photographs and of the degree of irregularity of the skin surface, supported by fast Fourier transformation, showed that after only two sessions, the severity grade of rolling scars in all patients was greatly reduced and there was an overall aesthetic improvement.¹⁸

The aim of acne scar treatment is to stimulate wound healing and collagen neogenesis. Skin relaxation is addressed by subcision and related methods. It seems that effects can be long-lasting. The usual outcome is an improvement of 25%–75%, with most procedures achieving around 50%. Complete resolution is still impossible.¹⁹

Chemical peeling can be used as an adjunct to acne treatment such as salicylic acid peels, but also for scar treatment. Chemical reconstruction of skin scars (CROSS) is a technique using high concentrations of trichloroacetic acid (TCA) focally on atrophic acne scars to induce inflammation followed by new collagen formation. This can lead to a reduction in the appearance of scars and cosmetic improvement. In an Indian pilot study, CROSS technique using 100% TCA was investigated for ice pick acne scars. Twelve patients were treated with the CROSS technique, using 100% TCA, applied with a wooden toothpick, at two weekly intervals for four treatments. More than 50% improvement was seen in all patients with eight out of ten patients achieving >70% improvement. Transient hypopigmentation and hyperpigmentation was an uncommon adverse effect. The CROSS technique with 100% TCA seems to be a safe, efficacious, cost-effective, and minimally invasive technique for the management of ice pick acne scars in Indian skin.²⁰

Possible adverse effects of scar treatment include hyperpigmentation, and less commonly, hypopigmentation, particularly in Asian skin. Temporary acneiform eruptions have been seen. Early effective acne therapy is the only way to avoid scarring.

Laxity of skin is related to biochemical chances within the connective tissue leading to a decrease of collagen and elastic fibres. Although the process becomes more visible in middle-aged subjects, weight loss and pregnancy may be associated with skin laxity also amongst younger patients.

Fine wrinkling around the eyes is often the first sign of facial aging. Whereas crow’s feet are caused by muscular activity, a major part of the wrinkling of lower eyelids is the development of skin laxity. Younger females in particular are looking for procedures that are noninvasive and don’t cause downtime. For skin tightening in this sensitive area, radiofrequency devices (monopolar or bipolar), laser, or ultra-pulsed light and infrared light devices have been used.²¹,²²

One of the therapeutic principles used is dermal remodelling by stimulation of collagen synthesis. This can be achieved by heating the dermal tissue or wounding as with fractioned CO₂ or Erb:YAG laser. Peak temperature, total time of exposure, and mechanical stress applied to the skin during the heating process affect the clinical results. Noninvasive radiofrequency and infrared devices seems to be more active on the looser and delicate skin such as eyelids (Figure 3).²¹

Most studies demonstrate an improvement measured by clinical scores, high-frequency ultrasound, or confocal laser microscopy in the range of 30%–50% during one treatment series (Table 1).

The major areas with facial wrinkles in the third decade of life are the forehead (frontalis muscle) and glabella (corrugator muscles). The most evidence-based data are available for the use of botulinum toxin type A. There are three approved products on the German market (from A to Z): Azzalure (Galderma, Paris, France/Medicis Aesthetics, Scottsdale, AZ), Bocouture (Merz, Frankfurt, Germany), and Vistabel (Allergan, Irvine, CA).

Both large multicenter trials and postmarketing surveillance clearly demonstrate that these drugs are safe and effective. There is no tachyphylaxis after repeated application. Adverse effects are mild and temporary as long as contraindications are not ignored. Injection pain and bruising may occur, others such as brow ptosis are mainly due to incorrect injection technique and are reduced by improved technique.²³–²⁵

The effects will last between five to six months with some interindividual variability. For advanced glabellar lines combining with a nonpermanent filler such as cross-linked HA gives longer lasting improvement. Recently, we described a new injection technique to correct the downturn of the corners of the mouth with botulinum toxin type A. We used a combination of platysma and depressor anguli oris modification by partial chemical denervation.²⁶

The use of dermal fillers has expanded over the last two decades. The major indication is volumizing and sculpturing (Figure 4). Fillers can be used in younger females although the indications and products preferred may differ from those in more mature females.

Small amounts of fillers may be useful in the correction of glabellar folds as mentioned earlier. Laterally placed filler in a fanning technique may be used to enhance the brows. Occasional minor irregularities may occur, but these can be smoothed out by massage or blended by further injection. Results lasting between six months and two years are reported depending on the type of filler. Some brow configurations that falsely project emotional states, such as anxiety, may also be corrected.²⁷

Liquid lift of the middle and lower face is realized by deep, periostal placement of higher crosslinked monophasic HA fillers in the cheekbone area. By this placement, the filler depot has a longer durability compared to nasolabial folds or cheeks because of the limited movements in this region. There is also a mild effect on upper lip position.²⁸ In nasolabial fold treatment, biodegradable microparticle injectables, including Radiance (BioForm, San Mateo, CA) or Radiesse (Merz) provide longer lasting results. Microscopically new collagen formation was observed around the microparticles consisting of calcium hydroxylapetite.²⁹–³¹

Lip contouring by filler injection is often requested. Short-term effects may be favorable when soft HA fillers are placed along the vermillion border to underline the upper lip. The Cupid’s bow should not be touched. In the case of lip contouring with smaller filler volumes, a cool pack may provide sufficient pain relief. Lip contouring effects may last for three to six months.

Volumizing the lip is a more painful procedure and local anesthetics are recommended. Overtreatment gives an unnatural look and increases the risk of adverse effects such as granuloma formation and others. It is important to investigate the fine motions of the lips before treatment. Filler placement should not result in a loss of such fine movements to avoid an artificial touch perceived by others. As skin laxity becomes more prominent, lip volumizing creates not only additional volume but also weight. This can lead to less satisfying results. The less the better as a rule.³¹

Indications of lip volumizing by fillers in young females may be genetically thin lips and posttraumatic irregularities. A tool for objective evaluation of the individual situation and the enhancement by filler is the lip index. Adding upper and lower lip indices resulted in the overall lip index, which was found to be approximately 50 in average females of Caucasian descent, about 100 in females of Asian descent, and nearly 200 in females of African descent.²⁸ It is noteworthy, that volumizing treatment of nasolabial folds and cheeks can result in an improvement in upper lip position.¹,²

Partial or whole face injection with uncrosslinked HA gels to provide a rapid but temporary improvement of skin smoothness and hydration is performed by syringes and other technical devices as part of mesotherapy. Long-term outcome has not been analyzed scientifically. Nevertheless, the combination of multiple punctures with HA injection leads to a mild oedema and may induce dermal wound healing responses but further studies are needed.³²