Correction of Acne Scarring NYC New York NY

Acne scars are not all the same.  Some are large, gently depressed areas while others have a pinpoint “ice-pick” appearance.  Some scars are deep while others are more shallow.  Occasionally acne scars can be thick and elevated.  Most often several different kinds of scars are present simultaneously.  It should thus come as no surprise that there is no single treatment that is “best” for all types of acne scarring.  A combined approach using surgery, laser treatment, and injections often produces the best overall outcomes.

Surgical treatment is needed to achieve best outcomes for most patients with facial acne scarring.  Only in the most mild cases does laser treatment alone provide sufficient improvement in acne scars to meet the patient’s Aesthetic needs.  Surgical treatment of acne scars can be divided into 3 categories:  subcision, excision, and dermal grafting.  These procedures are all performed in the office under local anesthesia (numbing injections as might be provided by a dentist or dermatologist).  General anesthesia or intravenous sedation is not necessary although some patients choose to take oral sedatives prior to surgical treatment of acne scars.  Most procedures take 30 minutes or less.

Subcision is a procedure reserved for acne scars which are depressed or indented due to scar tissue bands pulling downwards on the skin.  This procedure involves using a special needle to work underneath the scars from all sides, thus releasing the skin and allowing scar to appear less deep.  To enhance subcision results when treating deeper scars, an injectable filler such as Restylane may be placed in the pocket that is created.  Alternatively, for a more permanent solution a piece of skin may be harvested from behind the ear or another inconspicuous area and placed in the subcision pocket.  Borrowing skin from one area to place beneath the skin’s surface elsewhere is referred to as dermal grafting.  The advantage of dermal grafting is the permanent nature of the outcome while the disadvantages are the fact that scarring (no matter how discrete or inconspicuous) will occur at the donor site and that irregularity or undesirable contour changes at the subcision site may be difficult to correct.

Excision of acne scars, sometimes referred to as punch excision, is a treatment reserved for ice-pick type scars.  When performing excision of ice-pick scars a tiny “cookie cutter” type instrument is used to remove the deep scar.  The surrounding tissues are freed up from deep scar tissue and  and stitches are used to close the wound.  The stitches are left in place for approximately 1 week.  While it may seem that trading one scar for another would not make much sense, it is the deep depression of the ice-pick scars that makes them so noticeable.  A smoother, less-depressed scar is much more aesthetically acceptable than is a deep pock mark.  Laser resurfacing is typically performed 3-4 weeks after subcision and excision of scars to improve the appearance of these wounds further.  In my experience, there is no treatment other than excision for ice-pick acne or chicken pox scars that yields satisfactory results.

Laser skin resurfacing also plays a pivotal role in the treatment of acne scars today.  Numerous types of laser resurfacing procedures have been used to treat acne scars:  traditional laser resurfacing (CO2 laser), Er;YAG skin resurfacing, noninvasive laser treatment (CoolTouch, Smoothbeam), first generation fractional laser resurfacing (Fraxel, Affirm), and now second generation laser resurfacing (Pearl Fractional [2790 nm YSGG], Deep FX [CO2], Fraxel [CO2]).  Choosing the best laser to treat a given patient requires consideration of the extent of scarring, downtime or recovery time the patient is willing to endure, and relative safety profile.  In most cases today I feel that ablative (second generation) fractional resurfacing is the best option for patients with acne scars.  I typically advise patients that more than 1 resurfacing treatment will be needed to achieve the desired outcome.  Ablative fractional resurfacing treatments are usually separated by no less than 3-4 weeks.

The key to success in treatment of acne scars is setting realistic expectations.  It is appropriate to anticipate 30-50% improvement in the depth of scars but it is not appropriate to expect that there will be no residual evidence of scarring.  Patients with mild scarring can of course anticipate less evidence of residual scars than those with more severe scars.  As long as improvement and not perfection is the anticipated outcome, patients treated for acne scarring are generally very happy with the treatment results. Recovery after subcision and/or excision of acne scars usually involves mild to moderate bruising and swelling.  The majority of bruising and swelling is usually resolved within 1 week but some patients may have visible bruising for much longer.  There are no special limitations or restrictions after surgical treatment of acne scars but I do recommend that patients avoid entering a lake or swimming pool for at least 1 week.  Discomfort is usually minimal with the vast majority of my patients finding that Tylenol or other nonprescription pain relievers are more than sufficient to keep them comfortable.

Recovery after traditional CO2 laser skin resurfacing laser requires 10 to 14 days followed by several months during which the treated skin is pink.  Following ablative fractional resurfacing, the procedure I recommend for most patients with acne scarring, recovery is typically 5-7 days followed by only slight discoloration of the skin for an additional 2-3 weeks.  The risks of ablative fractional resurfacing are significantly lower than those associated with traditional resurfacing while the results are very good.