الفهرس 
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Abstract
Acne is the most common skin disease affecting the vast majority of adolescents and young adults. It is one of the commonest dermatological problems encountered in the out-patient clinics of dermatology.
Severe scarring is a serious complication of acne which associated with considerable psychological distress, poor self-esteem, depression, anxiety, body image alterations, embarrassment, anger, low academic performance, and even unemployment.
Most treatment modalities can be grouped into the broad categories of lifting procedures and resurfacing procedures Lifting procedures raise the base of the scar closer to the normal skin surface level. Resurfacing procedures cause an injury to the epidermis and superficial dermis with resulting neocollagenesis and epidermal repair
The punch elevation method is better for improving deep acne scars than depth resurfacing and it can be combined with depth resurfacing depending on the type of acne scar. Therefore, punch elevation techniques have increased the efficacy of treatment of atrophic acne scars.
For the CO2 laser, the absorption of its wavelength (10,600 nm) in water is high. However, because the chromosphere
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of CO2 laser is water that exists uniformally in soft tissues it stimulates new collagen formation and cause tightening of the skin resulting in the scar being raised to the surface.
This study aimed to evaluate the safety and efficacy of combination of punch elevation technique and fractional CO2 laser compared to fractional CO2 laser alone.
This study was carried out on 20 patients complaining of atrophic post acne scars. They were selected from out-patient clinic of dermatology and venereology department of Ain Shams University Hospital.
All the patients were subjected to complete history taking, general examination and dermatological examination. Evaluation of acne scars, their types (icepicks, boxcar or rolling) and their grades (mild, moderate or severe) were identified.
Clinical evaluation of treatment response before start of treatment ,before each fractional CO2 laser session and 4 weeks after the last laser session was done using Goodman and Baron quantitative classification, patients photographs and patients satisfaction (VAS a rating from 0-10).
Furthermore, assessment of the treatment complication as pain, erythema and post inflammatory hyperpigmentation were recorded.
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On the other hand, histopathological examination of skin biopsies taken from a specific scar area from both sides of the face for 5 patients before treatment and 4 weeks after the last fractional CO2 laser session was done using H&E, Mallory trichome, sliver stain and immunehistochemical VEGF.
Our results showed that combined treatment with fractional CO2 laser and punch elevation was more effective in improving post acne scars than fractional CO2 laser resurfacing alone.
Furthermore, histopathological examination carried out before treatment with combined fractional CO2 laser and punch elevation technique or fractional CO2 laser alone and one month after the last fractional CO2 laser treatment session showed high significance increase in epidermal thickness (using H&E), increase in collagen fiber type III (using Mallory trichrome stain), decrease in collagen fiber type I (using sliver stain) and increase in fibroblast activity (using VEGF).
In conclusion, both punch elevation technique and fractional CO2 laser resurfacing show promising efficacy and safety in treatment of atrophic post acne scars, they complement each other to improve skin texture and appearance that give excellent cosmetic results