Skin and Beauty

Types and Techniques of Acne Scar Revision Surgery

Written by Dr. Suvash Sahu and medically reviewed by iCliniq medical review team.

Image: Types and Techniques of Acne Scar Revision Surgery

Acne scars and wrinkles have always a challenge for treatment. Surgery in acne is indicated usually either for acne scars or post-inflammatory hyperpigmentation. Pitted facial scars, although commonly caused by acne, also result from a variety of conditions such as chicken pox, herpes zoster, etc. They are deep with well-defined margins, which cast a shadow, thus making them cosmetically more conspicuous. These deep pitted scars are either crateriform or ice pick shaped with depressed fibrotic base and with firm, indurate, rolling or slopping edges.

Types of Acne Scars:

Acne scars are of three types:

  1. Ice pick scars.
  2. Rolling scars.
  3. Boxcar scars.

Ice pick scars are narrow, less than 2 mm deep, sharply marginated with vertical extents to the deeper layers of skin.

Rolling scars occur when scars are adherent to dermis with relatively normal looking skin. They are wider than 4 mm to 5 mm. The abnormal adherence of scars to dermis leads to superficial shadowing and rolling or undulating appearance of the overlying skin. In this type of scars, subcision is essential for successful treatment.

Boxcar scars are round or oval depressions with sharply demarcated vertical edges. They may be shallow or deep and are commonly up to 0.5 mm or deep, more than 0.5 mm and most often 1.5 mm to 4 mm in diameter. These types of scars respond well to punch excision or punch elevation treatment.

Various Techniques to Treat Acne Scars:

  • Subcision - A technique of uplifting the scars by cutting the underlying fibrous band with the help of hypodermic needles.
  • Punch excision and closure - A kind of circular blade is attached to a pencil like handle. In this method, the scar tissue will get cut and sutured back.
  • Punch incision and elevation - In this method, the scar tissue will just get incised with punch and uplifted to the level of surrounding skin by elevation techniques. This procedure is useful for deep boxcar scars.
  • Punch excision and graft replacement - In this type, pitted scars of up to 4 mm diameter are first excised with the help of punch and immediately replaced with a skin graft taken from other parts of the body.

Factors That Decide Which Technique Has to Be Followed:

1) Number of Scars:

If plenty of closely placed scars are present, then subcision should be a preferred method. If scars are less in number, then other techniques can be done subsequent to subcision for a better result.

2) Orientation Along RSTL:

Scar lying along or parallel to RSTL (relaxed skin tension line) should be punch excised and closed primarily for best results.

3) Scar Surface:

When few scars are present, not along the RSTL, then two alternatives are available. Punch incision and elevation is performed for scars with normal surface texture and punch excision with graft replacement for those with atrophic surface and irregular skin texture.

4) Size of Scar:

The excision with grafting should be avoided for scars more than 4 mm to prevent poor esthetic results. In these types of scars, elliptical excision and suturing can be done.

5) Shape of Scar:

Linear scars are best excised and closed primarily. Circular scars probably require punch float.


The complications of scar revision surgery are hematoma, infection, wound dehiscence, graft rejection, allergic reaction to dressing and scarring.

Are you worried about acne scars? Consult an acne scar removal specialist online -->

Last reviewed at: 07.Sep.2018



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