Introduction

The face is especially susceptible to injuries, as the most visible portion of the body. Wounds to the skin, teeth and sensitive face tissues trigger pain in the face area. As a maxillofacial surgeon we are more conscious about the skeleton components and dentitions rather than soft tissue, but it leaves facial scar and it will give psychological trauma to patient (Levine, Degutis, Pruzinsky, Shin, & Persing, 2005). The facial scar may have significant psycho-social implications. Patients have extreme emotional stress, especially where they arise in noticeable regions of the face, due to maxillofacial painful injuries, surgical operations, and serious acne. Aesthetically speaking, the standard of the life of patients may be impaired and in men and women, while traumas and elective processes also trigger minimal scarring, substantial distress and self-awareness is reported (Fernandes, 2005; Harris, Naidoo, & Murrell, 2015).

Maxillofacial accidents that cause scar tissue growth are fairly normal and contribute to aesthetic or functional enhancement care for patients.Maxillofacial surgeons must understand that increased scar functional efficiency may be mirrored in the enhancement of patients' psychological well-being and behaviour (Levine et al., 2005).

Revising facial cells provides the maxillofacial surgeons with a significant diagnosis and technological task. Facial cavities are also more painful than wounds on certain parts of the body, as they are not easy to hide. Suitable preparation and technological expertise are important if the outcome is to be both clinically and cosmetically useful for the user. The wound healing cycle ends in development of scars affected by various factors accompanying maxillofacial trauma including basic repair (Moetaz, Manal, & Sherif, 2015). Many scar attenuation procedures available in secondary maxillofacial dermatology include scar revision surgery, chemical peeling, laser treatment, fractionated laser, pulsed dye and laser, Percutaneous Collagen Induction (PCI) with dermaroller and selective derma-abrasion with dermapen (Fernandes, 2005).

Dermarollers have recently become common as a easy way to treat scars, primarily acne scars. The specialist or dermatologist with limited training will comfortably use it. Combined use of micro-needling platelet rich plasma (PRP) infusion method is well known as the latest approach for managing post-wound and acne rash (Chawla, 2014).

Rich plasma platelets (PRP) include several active growth factors that release neurotransmitters from nearby areas that promote development inducing enhanced immune responses (Asif, Kanodia, & Singh, 2016). PRP includes many triggered growth factors. This research project intends to carry out a PCIcombined with PRP for management of post-traumatic scars.

Research Objectives

This study intends to study dermaroller alone and in combination with Platelet Rich Plasma (PRP) for management of post-traumatic facial scar. This research seeks to assess the successful utilization of combination of microneedling as well as PRP in post-traumatic scartreatments.

Literature Review

Fernandes (Fernandes, 2005) outlines concepts, rules, contraindications, procedures including post-operative surface mark treatment utilizing derma-roller in his distinguished paper. PCI is a easy process that will effectively that rapidly perforate every skin with the proper device. While the smoothing observed in laser remodelling might not come from a single operation, the cornea is relatively natural. Treatment could be replicated if the outcome is not enough. The method is appropriate in places not ideal for scratching or resurfacing with lasers.

Percutaneous injection of collagen with dermaroller was carried out with Liebel (Aust, Fernandes, Kolokythas, Kaplan, & Vogt, 2008) using multiple 1.5 mm needles to treat atrophic acne marks. Dermaroller was found to be efficient and healthy in the care of the atrophic acne scars for PIC. Majid (Liebl & Kloth, 2012) and Asifet al. (Majid, 2009) performed related experiments. Both observed that micro-needling treatment is a safe and convenient way of coping with atrophic face bruises from various etiologies.

Throughout the context of an acne scar procedure, Fabbrocini (Fabbrocini, 2011) made an evaluation of the feasibility of simultaneous usage of micro-needling including PRP. The study revealed that somehow the degree of severness of scars across all patients had been reduced significantly across the face, however, at hand, both micro needling and PRP were more effective for improved performance. The cumulative use of needle and PRP has been shown to be more successful than needle skin in the treatment of acne cavities. The research of transdermal PRP, 100% focus TCA as well as combination skin needling and even with topical PRP in the therapy of atrophic acne scars, was performed by Nofal (Nofal, Helmy, Nofal, Alakad, & Nasr, 2014).

Statistically the extent of acne marks after diagnosis was greatly reduced across the 3 cohorts. It was the first research used for the diagnosis of atrophic acne lesions using intra-dermal PRP application alone. The 3 methods have demonstrated an outstanding efficacy and protection in atrophic acne scar therapy.

The paper published by Singh and Yadav (Singh & Microneedling, 2016) in the summary of Micro-Needeling discussing progress and expanding perspectives, suggested that micro-needle is a very simple and effective clinical method which is efficient and minimally invasive. It was first implemented as skin rejuvenation, but has now been included in a broad spectrum of signs such as hypertrophic scars, acne, post-traumatic / burning scars, male pattern baldness, skin peels, drug supply, seborrheic dermatitis, stretchmarks, etc. Microneedling by the derma roller tool for the treatment of atrophic acne scars was found to be efficient yet secure for activation of percutaneous collagen.

Materials and Methods

This research was carried out after approval by the Ethics Committee in the Ministry of Oral and Maxillofacial Surgery, Dental Science School; KIMSDU, Karad. A total of 20 patients were involved in this research (including males and females both). All patients were randomly divided into two groups;

Group A: PCI with dermaroller alone and

Group B: PCI with dermaroller and in combination with PRP.

Inclusion Criteria

• Patients with post traumatic scar (> 21 days)

• Patients willing to participate in the study and for the follow-up visits.

• Patients in the age group of 20 -50 years.

Exclusion Criteria

• Patients having history of keloid scarring or keloidal tendency

• Patients with uncontrolled diabetes mellitus

• Patients with bleeding disorder

• Patients on long term oral steroid therapy

• Patients on anti-coagulant therapy

• Patients with active skin infections, like herpes infection and bacterial infection.

Preoperative Evaluation

Assessment of all the cases was done pre-operatively on the basis of the following factors

• Case history

• Clinical examination

• Laboratory investigations

A thorough history and clinical evaluation was performed and recorded based on the case history proforma. The method, its risks as well as the observation time included in the research process were clarified to the patients. Those patients willing tounder go the procedure and the follow-up visits were enrolled in the study and an informed written permission was taken. A. Tourniquet, B. Syringes (10 ml), C. Flashback blood collection needle, D. Vcacutainer without Anti-coagulant, E. Vacutainer with C.P.D.A. Anti-coagulant, F. 10 % CaCl2, G. 12 ml borosilicate glass tube, H. Clean sterile stainless steel bowl.

PRP Preparation

Tourniquet was placed on the arm and the patient was instructed to clench the fist so as to make the vein prominent. Tapping over the vein with finger was also performed if required to make the vein more prominent. Under aseptic techniques, 10 ml of blood was drawn intravenously from the anti-cubital region of patients. Vacutainer tube was placed and counter balanced in centrifuge machine. The blood vacutainer was centrifuged for 10 minutes at 2400 rpm. The effect is a breakdown of the entire blood into the bottom of Red Blood Cell (RBC). This plasma contains platelets which is collected and centrifuged to yield platelet rich plasma (PRP). PRP has been placed into sterile stainless-steel tubes, then PRP has been applied to 0.5–1ml of 10% calcium chloride to develop PRP gel (Figure 2).

Dermaroller Technique

Before the treatment, the scar area of patients were digitally photographed and filled in a database. The area over the skin to be treated was cleaned with medical spirit followed by painting of the respective area by 10% betadine solution. Steriledrape was applied to the face to expose only the treatment area.Topical anaestheticcream(prilocaine25mgandlidocaine25mg) was applied for 60minutes. Using a dermaroller tool,(Figure 3; Figure 1) the micro-needling was achieved. The microneedles were carried out consecutively in the regions affected for a minimum of 10-14 runs in four directions: vertically, horizontally, diagonally right-hand as well as diagonally left-handed.

Results and Discussion

Number of total males and females enrolled for the study were 15(60%) and 5(40%) respectively. The total male and female among group A and B was 8(80%), 2(20%) and 6(60%), 4(40%) respectively (Table 1). Etiology of facial trauma in the study included Road Traffic Accident (RTA) 14(70%), assaults in 4(20%), and sports related injury in 2(20%) of patients (Table 2).

Figure 5; Figure 4 represent before and after treatment images. In group A and group B, RTA 7(70%), assaults in 2(20%), and sports related injury in 1(10%) of patients respectively (Table 3). Site of distribution of post traumatic facial scar in the study was; forehead 4(20%), angle of mandible 1(5%), fronto-zygomatic region 6(30%), chin 4(20%), and cheek 1(5%) patients (Table 4).

In group A frequency of distribution of area involved was forehead 2(20%), angle of mandible 1(10%), fronto-zygomatic region 3(30%), chin 2(20%), and midface 2(20%). In group B frequency of distribution of area involve was forehead 2(20%), fronto-zygomatic region 3(30%), chin 2(20%), and midface 2(20%) and cheek 1(10%) (Figure 6).

The Frequency of distribution of shape of scar among the study was linear in 10(50%), oval in 6(30%), and irregular in 4(20%) patients (Table 5). The Frequency of distribution of shape of scar in both the group A and group B was linear in 5(50%), oval in 3(30%), and irregular in 2(20%) patients respectively (Table 6).

Conclusions

PCI was introduced by Fernandez in South Africa for first time Since then it became a popular method for skin tightening, acne scar revision and skin wrinkle removal but in the field of maxillofacial dermatology and for post traumatic facial scar attenuation this method is new and better in comparison to other available options in recent days. This study was carried out with an aim of comparing and evaluating precautious collagen induction with dermaroller device alone and in combination with PRP for post traumatic facial scar attenuation. Total 20 patients were enrolled in this assessment which were arbitrarilyseparated into 2 groups (Group A and group B) The parameters evaluated were pain, bleeding and inflammation on immediate post-operative day and1 week follow-up,and modified standard six point aesthetic scale was used to determine a side-by-side assessment of the accepted standards for clinical progression photographs and which were compared by Chi-square test, and independent t-test.

Acknowledgements

Authors would like to thank Dept. of Dermatology,Krishna Institute of Medical Sciences, Karad, and Maharashtra, India for the necessary financial support.

Funding Support

NIL.

Conflict of Interest

I hereby declare that there is no conflict of interest related to this manuscript.