Thank you for your question. You submitted a photo of your cheek area and ask for an opinion on fractional CO2 laser versus a Baker-Gordon peel to treat acne scars. I can give some perspective on this, and it’s probably different from what you hear from a lot of colleagues.I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic reconstructive surgeon practicing in Manhattan and Long Island for over 20 years, so my opinion is based on doing this for so long, and observations of what happens to skin over time.The photo you submitted shows you are younger, and multiple typical acne cheek scars. One that thing I can tell you from seeing patients over the years is when you had acne, you lost volume of skin, so there are small depressions. These are not just depressions, but also scar tissue underneath. One acne scar procedure is called subcision where a special type of blade is placed under the acne scar, and release it because it’s not inflammation that causes scarring. It is the depression or loss of volume in the dermis, and there’s a band of scar tissue underneath. The purpose of lasers or peels is taking the adjacent skin and making it more even with the deeper skin in terms of the relative depth of the acne scar. In other words, we are trying to create less contrast between healthy normal skin and acne skin. It’s my observation that patients who had peels and lasers in the past, especially when done multiple, aggressive procedures were done, not fractionated limited procedures, their skin got thinner. They effectively sacrificed good skin to match the depth and continuity of scarred skin. In my practice, for someone like yourself, I explain that perfectly smooth skin is not realistic after this type of acne scarring. However, we can take attention away from the scarred areas.In my practice, we use platelet-rich plasma in combination or with the hyaluronic acid filler to try to build up the skin under the scar, and to soften that transition, but instead of an ablative method we add volume. This is a new concept of regenerative medicine. Fillers have always been around to help people with acne scars, but I found that many patients with this chronic problem bounce from doctor to doctor for lasers, and fillers, but are often so frustrated they just keeping looking for one new solution after another. I always explain that if we are going to do something, we need a strategic plan for long-term results.I use PRP or platelet-rich plasma derived from your own blood to soften the scars, improve the quality of skin, and with hyaluronic acid fillers to help plump up the skin. There are clinical studies for wound healing showing the synergistic and long-term improvement based on more permanent fibro-vascular ingrowth, which means new tissue grows in places where the hyaluronic acid filler disappears. We treat everyone on a case-by-case basis. Generally, I advise against aggressive deep peeling at a younger age, and focus on regenerating and rejuvenating the quality of the skin. Again, you can’t completely eliminate the scars, but you can improve the skin quality. Over a period of time with the right treatments, you can reach a better place without going through the trauma and long-term loss of very young skin. It’s different as you get older as things change in terms of facial volume.I suggest you explore the idea of regenerative methods using platelet-rich plasma, hyaluronic acid fillers, subcision, and some ablation. We sometimes combine this with limited fractional CO2 laser. Personally, I try to maximize skin quality before doing something ablative. So I hope that was helpful, I wish you the best of luck. Thank you for your question.
