Scars from past cystic acne can diminish self-confidence. It is often a very frustrating problem for people because a single treatment does not create the results they want. It’s important for you to understand that acne scars can be treated to achieve the best possible results for you by customizing different treatment options. You need to feel comfortable with your understanding of the types of scars you have and what you can expect with treatment.
Acne scars are due to loss of skin and soft tissue from past cystic acne. Tissue loss can range from the loss of surface skin (epidermis) in mild scarring, to deeper loss of the backbone of the skin (dermis) and the tissue under the skin (fat). Enlarged pores can also contribute to the depth and extensiveness of acne scarring. Active acne treatment can dry the skin of oil and moisture, and affect the integrity of skin which can also contribute to the severity of scarring and general loss of skin health.
Acne scar treatment is generally not a single procedure. There is no single definitive method that works for all people. The first step of acne scar treatment is proper diagnosis. Dr. Prasad will take special photos using a method called “back lighting” to show you the levels of the scars and he will educate you about the types of scars you have. After you are informed about the types of scars you have, Dr. Prasad will develop a customized acne scars treatment plan. It’s not unusual for people suffering from acne scars to want immediate results. Unfortunately, this is not realistic and over aggressive treatment can actually lead to damaging your skin further. We’ve observed that frustration from acne scar treatment often leads people to change doctors or even go to a practitioner with limited knowledge and experience who then uses a device such as a laser in a way that is ineffective or worse, damaging.
The basic strategy of acne scar treatment is to treat, wait to allow for healing and recovery, assess the results, and then treat based on the results. This is clinical medicine and is why Dr. Prasad continues to make assessments to guide you toward an optimal result.
Acne scar treatment is not a “one size fits all” treatment that works the same on everyone. Factors that contribute to determining the right individual treatment plan include: skin color (amount of pigment), skin type, depth of scars, age of scars, age of the patient, current skin quality and skin thickness, patient age, gender, and past treatments used.
What is the best treatment for acne scars?
Acne scar management requires proper evaluation and clear communication about expected outcomes
and long term strategy it’s very important to understand that one
strategy for acne scars doesn’t apply to everybody and it’s not usually a single
one off process where we do one thing and then you’re done when you seek
opinions from doctors regarding acne scar treatment keep in mind that you
will get different opinions because there is more than one way to approach
these issues practitioners make recommendations based on a perspective
of experience and often whatever is the latest branded device they’re currently
leasing I’ll discuss the steps I take in evaluating a patient with acne scars and
how I make my recommendations and set expectations
I’m Dr. Amiya Prasad I’m a Board-certified cosmetic surgeon and
Fellowship-trained oculofacial plastic and reconstructive surgeon I’ve been in
practice in Manhattan and Long Island for over 20 years I perform a wide range
of procedures for patients with acne scars including lasers use of
radiofrequency technology skin boosting regenerative medicine technology such as
PRP or platelet-rich plasma and a cellular matrix as well as acne surgery
such as subcision scar removal and skin grafting when I look at a patient with
acne scarring I take high-resolution digital photos
and I also take photos with the method called backlighting to look at the
shadows which provide me with information about the depth and extent
of the scars acne scars are typically classified as rolling scars Boxcar scars
and ice pick scars there are different levels of all these
scarring and a strategies developed based on these specific classifications
when you’re dealing with acne scars you are dealing with one common issue tissue
loss the underlying strategy is to maximize the volume where tissue is
deficient and to blend the interface between the normal skin and the adjacent
area of tissue loss unfortunately many people with acne scars literally jump
from one laser to another based on aggressive marketing resulting in
frustration and disappointment a very important limitation is the generally
accepted standard amongst ethical professionals as to the maximum level of
change that can occur with acne scars generally speaking improvement of about
20 percent followed by maintenance procedures is a realistic expectation of
course the term twenty percent can be up for subjective interpretation for my
patients I find that defining success as an improvement avoids unrealistic
expectations my approach to acne scars is comparable to my approach with facial
aging I create a customized strategy to work from the inside outward for example
if the cheek volume can be enhanced I will place a long-lasting filler such as
Juvederm Ultra Plus or Juvederm Voluma at the bone level the improvement in
projection can have a significant effect on softening the appearance of acne
scars this becomes particularly relevant with the natural progression of facial
aging I also see how improvement in volume and facial balance can shift
focus away from the acne scars at the skin level although it is commonly
accepted that various lasers can help depress cars by controlled injury which
then stimulates a healing response by cells
in the skin called fibroblasts to produce collagen the question is how
much of a difference can be achieved when the tissue is scarred in addition
how much collagen generation can occur when the patient has had one or more
previous laser radiofrequency or micro needling procedures
I find myself consistently integrating the use of PRP or
platelet-rich plasma to induce collagen production without causing any
significant injury as a first-line before or in conjunction with non
ablative laser treatment PRP or platelet-rich plasma not only stimulates
collagen production but also improves blood supply and softens the scar tissue
in particular for patients with Boxcar scars I find this strategy useful I
routinely combine PRP with hyaluronic acid filler which is delivered to the
dermis using a procedure called skin boosting rolling scars and scars
associated with the lack of underlying fat are often managed through a
combination approach procedures such as subcision injectable fillers are placed
on the bone level below the skin and in the dermis that combination can be very
effective there is also a type of ablative laser technology often
beneficial particularly for Boxcar scars these are scars with very sharp defined
edges generally when using a laser we try to soften the edges of these scars
and then blend the skin so that the skin heals smoothly for improvement
another approach which is more convenient and beneficial particularly
for shallow scars is water-based microdermabrasion or a procedure that
has called HydraFacial there is no downtime and the improvement in the skin
can be appreciated immediately afterwards I recommend that any
therapeutic strategy for acne scar involve regular follow-up examinations
and some maintenance procedures which are customized to the individual in a
time where devices get aggressively marketed and unrealistic expectations
are promoted it’s more important than ever for you to find a physician who you
trust to have your best interest at heart all
too often new devices come on the scene and many doctors buy or lease these
devices and then think only about the profit from the transaction and have no
interest in a long-term management plan I recommend you meet with experienced
doctors and make sure you feel that you are being well informed and you have
confidence in the doctors treatment plan for you and what the short-term and
long-term outlook will be
I hope you found this information helpful thank you for your question
Acne scar treatments range from:
Depending on the individual, a combination of some to all of these treatments may be needed in various amounts and aggressiveness.
Subcision is the process of releasing acne scar tissue from the dermis. This involves using a special blunt cannula-type tool, or a special needle to go underneath the skin to release scar tissue directly underneath the scar. Subcision is used for deep pitted, rolling acne scars where the surface of the scar is tethered to deeper scar tissue at the dermis. Once the surface scar is released from the deeper scar tissue at the dermis, the depth of the scar is reduced. However, because of the previous loss of tissue, volume augmentation is generally needed to fill the area where tissue was lost causing the depressed scar.
With subcision release of the scar, there is still a volume deficit from previous tissue loss. Volume augmentation is needed to support the skin and fill the depth left from lost facial tissue from acne scars. Injectable cosmetic fillers such as Restylane or Juvederm are applied in specific amounts in the dermal and subdermal layer to improve scar depth.
Subcision can actually be performed simultaneously as a filler application. In this situation, the needle of the filler syringe is used as a subcision tool to release the scar tissue, followed by the filler placed in the pitted area.
Fillers can treat specific acne scars such as atrophic scars (sunken or deep pitted scars due to collagen destruction) and tethered scars (attached to deeper dermis and requires subcision). Lasers can improve skin quality and tautness, but generating collagen with lasers will not do much for very deep scars compared to fillers.
One of the best advantages of using fillers for acne scars is the fact they can improve the appearance of scars immediately, and with virtually no downtime. Fillers cannot treat every type of scar. Fillers are often used in combination with other treatments, such as lasers, PRP, and TCA peels. There may be differing recovery times based on the type of treatment. Fat grafting can also be used in areas with thicker skin such as the cheeks. Fat grafting requires harvesting of fat with liposuction and placement with some recovery time. One significant challenge with fat is predictability of result. 30-70% of fat can be absorbed and it is typical to need more than one procedure for maximal benefit.
Platelet rich plasma also referred to as “PRP” is a concentration of healing factors from your own blood to stimulate your body to produce collagen, increased blood supply as well as improvement and increase in the fat cells seen with healthy skin. Platelet-rich plasma (PRP) can be used in combination with other acne scar treatments. For example, microneedling with a device such as a Dermapen, tiny channels are created through the skin, PRP can be applied on the skin surface to allow it to pass through to the deeper layers. PRP can also be injected directly beneath the skin. PRP can also be used in conjunction with cosmetic fillers to improve skin quality, and provide volume for deep scars.
PRP is also used as a topical healing agent after laser skin resurfacing for acne treatment. When injected directly to specific areas, PRP helps improve the volume blood supply and healing proteins such collagen. PRP helps tissue healing as well as pigmentation caused by scarring or trauma.
Laser resurfacing is frequently used for acne scar treatment when the scars are relatively the same depth, such as shallower scars or boxcar scars. Lasers are used to level scars through partial or full ablation of the top layers of skin to allow for a fresh, smooth layer of skin to come in.
The heat of the laser also stimulates an injury response within the deeper layer of skin (dermis) to produce collagen. It is the loss or destruction of collagen in the dermis that results in the scars. Producing new collagen in the injury response to heat treat improves the overall quality of the skin within and around the scar.
Laser treatments can be widely used in lighter skin types,. In darker skin however, these types of laser may cause hyperpigmentation (skin darkening) or hypopigmentation (loss of skin pigment) so application of these lasers must be done cautiously or not at all.
Lasers are often used for acne scars which are shallow to medium depth where the depths of the scars are at about the same level, such as is often seen in boxcar scars. Deeper scars don’t respond in the same way to laser resurfacing because it is too unsafe to resurface the skin to the depth of deep scars. Deep scars are best treated with subcision, acne scar surgery, or TCA cross (in the case of icepick scars).
Most lasers can be used safely for lighter skin types, but it is important that the right laser or combination of lasers be used to get the most optimal result. For lighter skin types, we use fractional erbium and CO2 laser as well as ND:Yag, and Q Switch lasers.
For darker skin types from Mediterranean, olive skin, to Asian skin types, we use ND:Yag, Erbium, and Q Switch lasers, as well as radiofrequency devices such as Pelleve for more gentle heating.
For even darker skin types such as African or Arabian skin, we approach these on a case-to-case basis. Some darker skinned people may react to laser treatment with hyperpigmentation of the skin, as well as scarring, so in some cases no laser or thermal energy treatments can be used. In such cases, we treat acne scars with options such as chemical peels to resurface the skin, platelet-rich plasma (PRP) for skin improvement, and cosmetic fillers.
Some acne scarring does not involve deep pitted or depressed scars, but rather skin discolorations such as red or brown spots. These spots can be treated with less aggressive laser protocols like the 1064 YAG or the Q switch QX Max with minimal downtime. Platelet-rich plasma can also be used to treat dark spots by helping heal the scarred area and increasing collagen and blood circulation into the localized spot.
Fully ablative CO2 and Erbium lasers were the standard for acne scar laser treatment before the introduction of fractional lasers. Full ablation is an aggressive technique that completely removes, or ablates, the top layer of skin (epidermis and dermis) so a new layer can grow in, and triggers a collagen response in the backbone of the skin (dermis) as a response to the injury. The fully exposed dermis leaves the skin with a very raw appearance, which can appear anywhere from dark pink, red, or even light brown. This red and raw appearance is the biggest drawback of fully ablative laser treatment as downtime can be extensive – patients have to avoid being outside for the first week because of potential side effects from sun exposure to the raw skin. The raw appearance can last for over a week, making fully ablative laser resurfacing less popular for busy, working people.
The advantages of fully ablative laser resurfacing are the level of results and long term benefit. There is no need for a series of treatment sessions. The fully ablative procedure only requires one treatment session, followed by longer downtime when compared to a non-ablative or partially ablative procedure that has little to no downtime, but requires multiple treatment sessions. It can be argued that the results of a fully ablative procedure are better and more thorough, but multiple non-ablative procedures can achieve comparable results.
Why are skin treatments not improving my acne scars?
Unfortunately it’s very common for people with acne scars to be frustrated with their acne scar treatments
I see patients who’ve been treated with multiple devices ranging from different lasers as well as
radio frequency and micro needling devices
patients also report having undergone chemical peels or platelet-rich plasma or PRP injections
and just not seeing the results that they were expecting I’ll share some of my experience helping
my patients who have acne scars I’m Dr. Amiya Prasad I’m a Board-certified cosmetic surgeon
and Fellowship-trained oculofacial plastic and reconstructive surgeon been practicing in New York
City and Long Island for over 25 years I routinely help people with acne scars using specific
lasers and radiofrequency devices I perform acne scar surgery such as subcision for tethered scars
I also have a lot of experience with PRP to improve skin quality texture and hyperpigmentation
these treatments mentioned can improve the appearance of acne scars because
they improve skin quality the skin texture and can even tighten and resurface the skin however
there is a major aspect of acne scars that these treatments cannot address especially the deeper
acne scars where there is deeper tissue loss acne scars are primarily the result of inflammation
inflammation can leave the skin architecture to be fragmented disorganized and leading to tissue
loss at the skin level and deeper the treatment of deeper acne scars may involve some form of
restructuring and restoration for example i perform a procedure to release the tethering
of the skin with the underlying tissue and the procedure is called subcision during subcision
different instruments are placed under the skin to release scar tissue that’s responsible for
pulling the skin inward subcision also stimulates collagen production as part of the body’s natural
healing response after the procedure subcision is generally performed for rolling type scars
after subcision for a rolling scar a hyaluronic acid filler can be placed
underneath the skin to support the skin for a smoother appearance
boxcar scars are more limited to the skin level and have defined edges they are also generally not
as wide as rolling scars I often use combination treatments to help people with boxcar scars
and for example I’ll perform a non-ablative laser for dermal tissue remodeling and use
hyaluronic acid with PRP to optimize volume and collagen production within the skin speaking
of hyaluronic acid an area that is frequently overlooked is volume deficiency below the skin
this volume deficiency can be due to bone projection fat volume or a combination of the two
I’ve had a lot of patients who for all intents and purposes came in to see me after they underwent as
much skin focused treatments as could ever be performed I recognized that for many of
these patients volume support below the skin can create projection and smoothening of this
acne scars fairly effectively so as opposed to placing the filler just below the acne scars
I often place the filler at the bone level with a specific technique called structural volumizing
now this technique allows more stable support of the skin from the bone level many of these
patients have been delighted by the results which they can appreciate immediately afterwards
aggressive marketing of devices in my opinion is why many people are frustrated after not seeing
benefit after one treatment this frustration causes many people to go from one practitioner to
another all of whom who claim to have the latest and greatest device unfortunately these patients
often end up damaging their skin even further recognizing that there are different types of
acne scars skin color and skin types so that there is no one best treatment that applies to everyone
with several modalities and techniques available to use for treating acne scars I generally take
a fairly conservative approach what I frequently do is to treat observe the results and customize
future treatments accordingly in my opinion rather than being manipulated by aggressive marketing
focused on financial transaction it’s better for you to identify a physician who can provide you
with the treatment plan and realistic expectation of results I hope this information from my
experience helped you
If you are interested in recommendations for your individual situation
you may contact us through our websites or call our offices to schedule a consultation thank you
Trichloroacetic acid (TCA) is a non-toxic chemical that is related to vinegar. TCA peels have long been the standard of skin resurfacing before the advent of laser technology and laser resurfacing. A TCA peel can be used for renewing the outer surface of the skin (epidermis) with the same principles of fully ablative to partially ablative treatment as lasers. The treatment depth of a TCA peel depends on the concentration of TCA, which can range from 15% to 50%. Also, manipulating the TCA solution by the extent of rubbing or placement on the skin can also affect the depth of the treatment.
The TCA cross is a unique way of treating deep acne scars. A tiny amount of high concentration TCA is placed directly onto medium depth acne scars. The TCA cross leaves a white spot on the treated area for about 3 hours, while redness of the skin lasts about 5-7 days. This process raises the depth of acne scars, making it an effective option for deeper acne scars, but it still needs additional cosmetic filler to support the raised scar.
TCA can be used, but in different treatment techniques, from more uniform acne scarring at shallower depths with a TCA peel, to deeper scars with a TCA cross.
Linear acne scars, or longer acne scars, tend to be a more severe form of acne scarring due to being longer and larger. The treatment of larger scars include a combination of the previously mentioned acne scar treatments, but also involve surgical closure of the scar. When dealing with bigger linear scars, it is important to choose a doctor based on surgical skill and the prevention of forming bigger scars. Cosmetic surgeons are chosen for acne scar surgery because of their extensive experience in surgical closure to maximize the cosmetic results.
Contact us today for an evaluation of your acne scarring by Dr. Prasad. He will develop a customized treatment plan for you.
Fill out the contact form below, and we will get back to you shortly, or call contact form below, or by call (212) 265-8877 for our Manhattan, New York City location, or (516) 742-4636 at Garden City, Long Island.