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Because there are different types of acne scars, the surgical revision will depend on the type of scar that you have. Simply put, there are hypertropic (raised) scars or atropic (depressed) scars. Atropic scars are the most common and will be covered here. These atropic scars can range from having the appearance of an ice pick to a wide saucer.

Ice pick scars are deep-pitted scars that make the skin look like it had been jabbed with an ice-pick. With this type of scar the physician will do what is called a “punch excision” and cut out the core of scar tissue with a biopsy punch needle and carefully stitch up the hole. The technique is sort of like using a cookie cutter. Many of these types of scars can be treated in one session. With this punch excision some physicians may choose to do a punch grafting technique at the same time. During this procedure the scar tissue is removed with the same biopsy punch needle. Then with this same needle a small graft of normal skin usually taken from behind the ear is then transferred to the wound, filling in the cavity and then taped in place.

Another type of acne scar is called the “boxcar” acne scar, which is a saucer-like, type scar. For this type of scar, physicians use a technique called "punch elevation”, sometimes called a “punch float”. This is a surgical technique where the scar tissue is elevated from the surrounding fat to level it with the surrounding tissue and held in place with a special tape or stitch.

Some people have groups of very small acne scars. In this situation the doctor can use a needle to cut the fibrous collagen bands that attach the scars. This “subcision” technique will allow the skin to pop back up. After any of these procedures are done, you will probably need some type of resurfacing at a later date to level everything out such as a Laser or Dermabrasion.

Soft tissue augmentation with an injectable filler is another option for some of the shallower acne scars. Injectable fillers range from temporary to permanent. Temporary fillers are products that usually last anywhere from a few weeks to 9 months; possibly longer depending on the individual, product and injector. However, there are newer products that may last up to 2 to 6 years after injection. They come from animal sources, donated human sources (yours or someone else's), or are completely synthetic.

Today our FDA approved temporary injectable fillers include Zyderm® and Zyplast® bovine collagen, CosmoDerm™ and CosmoPlast™ human collagen, Fascian, an injectable AlloDerm®, called Cymetra®, and hyaluronic acid products such as  Restylane and Hylaform.  Restylane and Hylaform are made from hyaluronic acid, a sugar-based gel, which is naturally present in the skin and joints of all living organisms. In some people the results can last a few months longer than collagen; in others the results are about the same as collagen. Since this substance is naturally occurring a skin test is not required. It used to be that bovine collagen injections were the only option that people had to enhance their lips. There are some people who are allergic to bovine collagen, therefore if you decide to use bovine collagen, it’s very important to get two skin tests one month apart to make sure that you are not allergic to it. On the down side, these injectables are not permanent, so you will probably need touch-ups. However, if you don’t like the look, you only have up to a few months to wait it out.

Radiance is a long-lasting soft tissue filler that lasts up to 3 to 5 years and is currently FDA approved to treat human vocal cord paralysis only and is in the investigational stages for cosmetic use in the US. Radiance consists of calcium hydroxiapatite (CaHA), a primary component of teeth and bones. This injectable does not require skin testing.

There are probably 25 different types of permanent injectable fillers. These injectable fillers work by stimulating collagen around the filler,  which acts to plump up the area that is injected. This may sound like a wonderful idea, however there are permanent risks involved. Lumpiness, firmness, inflammation and even migration of the material may occur. The most common permanent injectable fillers today are Artecoll and silicone. FDA approval is pending for Artecoll and silicone is not FDA approved for cosmetic purposes but some physicians are using it off-label for cosmetic soft tissue augmentation.

Fat grafting also known as fat injections involves suctioning small amounts of fat, usually from the abdomen or thighs, processing it in a centrifuge to separate the fat from other substances, and then injecting the fat into the scars. There is no chance of an allergy with fat since it comes from your own body and there is the observation that a series of fat injections over a period of time may bring a more permanent improvement.

Finding a cosmetic surgeon that you feel comfortable with and is committed to working with you over a period of time to correct the problem is the first step. In most cases, a dermatologist will be the type of physician who will be doing this type of surgery. You will want to go to someone who has had a lot of experience in acne scar revision. The reason for this is that you will probably need different procedures to deal with the different stages of correction. Don’t be discouraged! Most cosmetic surgeons will probably tell you that there isn’t much that can be done. They may tell you that you should learn to live with your scars and that they really aren’t that bad. Or they may just offer you a resurfacing technique. It is possible that resurfacing is all you will need. However in most cases your treatment will need to be individualized and you will need multiple level revisions. Be persistent. Do your research. There are physicians out there who specialize in acne scar revision. You need to find someone who will take the time and effort to work on each individual scar. As with any surgical procedure there are complications, so don’t forget to discuss these with your physician.

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