The Complete guide to treating Acne Scars

Part II — Surgical Options for Scar Removal and How Subcision works?

The first thing, that comes to mind when we talk about treating acne scars — is laser. Laser treatment for acne scars has been around really long, but scar surgery has been around longer — but is much less known.

In this post, I will touch upon the most commonly performed scar revision procedures, that work great for acne scars. These scar revision surgical techniques may be used alone, or in combination with lasers or radiofrequency microneedling, but the choice is really that of the dermatosurgeon.

I choose the techniques, the sequencing and the follow through of treatments, depending on the type of the acne scar, age of the scar and the possibility of any long term pigmentation.

Subcision literally means, sub dermal incision. To understand this, we need to go a little in detail, into the architecture of the scar. Because of all the irregular inflammation that happens in an acne cyst, at the level of the dermis (the second layer of the skin from the top), and sometimes extending into the subcutaneous layer — the scar is also irregular.

We do follow a classification for the scars, but that’s the 2D part of it. The 3 dimensional image of an acne scar is much more complex.

In the deeper boxcar scars, the scarring is so severe, that the skin appears to be bound down or tethered to the deeper tissue. This binding down happens very irregularly, which explains the bizarre shapes of the acne scars.

Contrast this with chicken pox scars when tends to be a regular circle, even though they are depressed, just the same like acne scars.

So, one of the key goals in acne scar revision, is the release of all that binding down and tethering. Subcision is a surgical technique, that uses a small needle to go below the skin’s surface, and release all the tethers. This allows the depressed skin to rise up to the surface again. It may need several sessions, to achieve a good elevation of the scars, since as I mentioned above, the tethering would be very irregular, and in variable depths. I use a modification called thread subcision, which does a circumferential release of the scars. But even here, I may need to go over the same scar in multiple depth, to achieve a good scar release.

So is it all so complicated? Does it involve a lot of downtime? What are the risks of scar surgery?

Even though the explanation sounds very complex, it is actually a simple process. In fact, it is one of the most basic scar revision techniques, and among the first scar revision techniques taught to our residents. There would be a downtime of a week maximum, and the results are meant to be long lasting. The most common problem is the risk of temporary pigmentation, which can stay for quite a few days to weeks. Also, there is the possibility of persistent clots, and this usually improves with time, spontaneously. The trick is not to keep handling the treated area, or touching or picking to check the progress.

We discussed that a key goal in acne scar treatment, is elevation of the depressed skin. We also need to work on the margins — how much ever the scar gets lifted, as long as there is a sharp margin — the scar still tends to look visible and prominent. This is where combining a round of subcision with other scar removal treatments like a fractional laser or radiofrequency microneedling, makes a major difference. In fact, where the scars are more tough and leathery, the laser/ MRF procedures actually go ahead of the surgical procedures like subcision.

In all, it is important to understand that the choice of any procedure depends on a lot on what we want to address. And in about 90% of cases, at least in my practice, a combination of more than one technique works better than depending on one procedure alone. For example, I frequently combine subcision with MRF, and add on platelet rich plasma (PRP) for better scar remodeling. If there are some volume deficits, I would follow this through with a filler for correcting the bigger deficits.

Next, in this series, we will discuss the laser and microneedling treatments. These machine based treatments have revolutionized the process of scar revision, and have rendered some of the older acne scar removal treatments obsolete.

Do check out the previous article in this series, too — to get an idea of how to plan your acne scar treatment.