Acne scarring represents a physical change in the skin’s structure, involving damage to the underlying collagen and tissue. These textural changes often manifest as depressions or raised areas that reflect an alteration in the skin’s architecture. While many superficial treatments exist in general dermatology, plastic and reconstructive surgery typically addresses the more severe, deep, or structurally complex scars. This specialized intervention focuses on manually excising, releasing, or volume-restoring the affected tissue to achieve a smoother contour. The goal of surgical revision is to physically restructure the damaged area, which is necessary when scars are tethered to deeper layers or involve significant tissue loss.
Categorizing Acne Scars for Treatment
The success of scar revision depends heavily on an accurate classification of the scar type, as each presents a unique structural challenge. Atrophic, or depressed, scars are the most common type addressed by plastic surgery and are divided into three categories based on their depth and shape. Icepick scars are narrow, deep indentations that resemble large, open pores and extend into the dermis. Boxcar scars are wider with sharply defined vertical edges, creating a crater-like appearance, and are of medium depth.
Rolling scars are broad, shallow depressions that give the skin a wavy, undulating look due to fibrous bands pulling the skin’s surface downward. Some individuals also develop hypertrophic scars or keloids, which are raised, firm scars resulting from an overproduction of collagen. Surgical planning differs for each type, with excisional methods targeting deep, narrow scars and volume-based techniques addressing broader depressions.
Specific Surgical and Reconstructive Methods
Plastic surgeons employ several precise techniques that physically alter the scar tissue to improve skin contour.
Punch excision and punch grafting are targeted procedures used for small, deep scars, particularly icepick and narrow boxcar scars. Punch excision involves using a small, circular tool to remove the entire scar down to the subcutaneous fat. The resulting defect is then closed with fine sutures, converting a deep pit into a linear scar that is easier to treat later.
Punch grafting is a variation where a small plug of skin is harvested, often from behind the ear, and placed into the defect created by the excision. The graft is secured with sutures or glue, immediately filling the depressed area and aiming for a smoother surface. This technique can achieve a high degree of correction for discrete icepick scars.
Subcision is a minimally invasive surgical technique designed to treat rolling and depressed boxcar scars that are tethered by fibrous bands to the underlying tissue. A specialized needle or cannula is inserted beneath the scar and manipulated in a sweeping motion to physically break these deep, anchoring fibers. This release allows the skin to spring upward, reducing the depression. The resulting space fills with blood, which stimulates new collagen production as it heals.
Surgical dermabrasion is a resurfacing method that uses a rapidly rotating device to mechanically sand the skin’s outer layers. This procedure is much more aggressive than microdermabrasion and is highly effective for blending the edges of boxcar scars and smoothing skin texture after excisional procedures. The controlled surgical scraping levels the skin’s surface, promoting the growth of new, healthy skin.
Tissue augmentation is often used as a reconstructive step for deep atrophic scars and areas of generalized volume loss associated with rolling scars. Autologous fat transfer, or fat grafting, involves harvesting a patient’s own fat cells, typically from the abdomen or flanks. The processed fat is then injected into the depressed areas. This not only adds volume but also introduces regenerative cells that improve the quality of the overlying scarred skin.
Post-Procedure Healing and Recovery Timelines
The recovery period following surgical scar revision varies significantly depending on the invasiveness and extent of the chosen procedure.
Following punch excision or grafting, initial wound healing involves daily cleansing and dressing changes until sutures are removed, typically within five to eight days. Bruising and swelling are common in the first one to two weeks, and patients must protect the delicate healing skin from sun exposure.
Subcision causes immediate bruising and swelling due to the intentional creation of a hematoma beneath the scar. This immediate swelling helps elevate the depressed scar, but the bruising can take one to two weeks to fully resolve. Patients are usually able to return to work within a few days, though the visible discoloration requires time to fade.
Surgical dermabrasion has the longest and most intensive recovery period due to the extensive removal of the skin’s layers. The treated area will be raw, swollen, and red, requiring specific wound care, including frequent cleansing and application of ointments, for up to two weeks. Most individuals need one to two weeks off from work, and the skin remains pink or red for several weeks to months as it regenerates.
Realistic Outcomes and Long-Term Improvement
Plastic surgery aims for scar improvement and contour correction, not the total eradication of scar tissue. Surgical methods physically restructure the deep components of the scar, resulting in a smoother appearance and reduced shadowing. The treated area will still bear the mark of the revision, typically converting a deep indentation into a smaller, linear scar that is easier to conceal.
Achieving the final outcome usually involves a staged approach, combining several surgical techniques over time. For instance, deep scars may be excised first, followed by dermabrasion months later to blend the edges of the new scars. Full, long-term results are not immediately visible, as it takes several months for collagen remodeling and tissue integration to mature. Patients must maintain realistic expectations, understanding that while improvement in skin contour is possible, perfection is unattainable.