What's the best treatment for my acne scars? (Photo)

I had cystic acne 8 years ago and took accutane for half a year and that left me a full face of scars. Besides the atrophic scars, I also have hard scar tissues that are slightly above the surface but not noticeable. However, I can feel them when I touch them with my fingers and they help to form creases when I smile or laugh (plz see the last two pics. They are slightly above the corners of my mouth). I am looking for best treatments to diminish the overall scar appearance. No fillers. Thanks!

Doctor Answers 9

A combination of laser resurfacing and subcision using tumescent anesthesia works best for your type of scars.

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I recommend a combination of treatments that include tumescent anesthesia, submission of rolling scars, laser resurfacing, Fraxel Repair or Fotona Fractional Erbium Laser to acne scar areas and punch excision and suture of pitted acne scars.  With this combination of treatment, it is possible to obtain an average of 72% percentage improvement in a single treatment session with about one week of down time.


Salt Lake City Dermatologic Surgeon
4.2 out of 5 stars 18 reviews

A Combination Of Techniques, Rather Than "A One Size Fits All" Approach Is Best For Treating Acne Scars

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As is usually case, your photo demonstrates a mix of scars, including pit (ice pick) scars, rolling scars, boxcar scars and possibly elevated hypertrophic scars. There is also some suggestion of generalized cheek volume loss, which may be contributing to the elevations you are seeing near your mouth. If indeed there is volume loss, I would first begin by volumizing the area beneath it with a volumizing filler, which by itself can help to elevate and stretch the overlying scars, and may even reduce the elevations you are seeing with smiling. For this purpose,  in my Upper East Side Manhattan office, I would opt for Voluma XC, while in my Israel satellite facility, where a far greater number of regulatory agency approved volumizers are commercially available, I would opt for Stylage XXL. If hypertrophic scars indeed are present, these may be flattened with the injection of an antiinflammatory agent, such as triamcinolone acetonide suspension. Atrophic (indented scars), i.e. the rolling and boxcar types, can be treated with subcision to raise them up with or without the addition of a lifting filler, both for its immediate lifting and for its biostimulatory effect (to promote new, native collagen and elastic fiber synthesis). My choice would be Restylane Lyft (NY) and Hyaluronica 2 (Israel). Pits and very dilated pores may be treated with The TCA CROSS Technique, using either full strength TCA or phenol; rolling and boxcar scars may be improved with subcision followed by microneedling. Tiny droplets of Botox may be placed in a grid fashion throughout the pitted area to achieve additional improvement. I have not been impressed with expensive fraxels, radiofrequency or ultrasound devices, which are proving themselves to be backed far more by device manufacturer supported marketing hype than hard science. For more information on any of the above, you may check out the archives of RealSelf.com and be certain to consult wtih a board certified aesthetic physician with experience and expertise in treating acne scars. Be particularly cautious about places interested in hawking some relatively expensive one-size-fits-all,  "next best thing" device to come along. Hope this helps. Good luck.

Different treatments for acne scars are applicable to depth, and types of scars - there are substitutes for fillers available

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Thank you for the question. You submitted 2 photos, and state 8 years prior you had severe cystic acne. You took Accutane for 6 months and you state you are now left with multiple pitted scars, as well as some hard scar tissue below the skin. You are looking for some guidance on improving your appearance, but you are not interested in fillers.

I can certainly give you some guidance on how I approach patients like yourself and acne scar situations in general in my practice. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I’ve been in practice in Manhattan and Long Island for over 20 years. I have a full series of options available to my patients to treat acne scars, which are ultimately customized to each individual’s needs.

You made one specific statement about not wanting fillers. If we take fillers off the table, you are restricting some opportunities that use traditional fillers. Often, people come to us with the same request for a variety of reasons:  they think fillers are expensive, or they don’t have time for filler treatment.

To begin with understanding the different types of acne scars helps guide any doctor in how to optimize the results of treatment. Let’s start with where fillers actually fit, and what we use as a filler substitute. The types of acne scar called rolling scars and atrophic scars are best managed with fillers. These are the scars that appear to improve when you pull the skin and stretch, which then soften up, meaning there is room to work with underneath. When someone has that type of situation, and they understand that although they don’t want fillers, but they want volume, the options include fat grafting. Fat grafting means harvesting fat from one place, and placing them under the skin of the face and within the skin. We also use platelet-rich plasma (PRP), or platelet-rich fibrin matrix (PRFM). Very often, because of logistics, people choose platelet-rich plasma (PRP) or platelet-rich fibrin matrix (PRFM) as the first line treatment because fat grafting is a surgical procedure that requires a certain amount of operating room time.

What we do with platelet-rich plasma (PRP) and platelet-rich fibrin matrix (PRFM) is concentrate the growth factors and the healing factors that naturally stimulates collagen procedure as part of the healing process. Just to give you a brief explanation, PRP is derived from your own blood, so for people who want something all natural, it doesn’t get more natural than coming from yourself, and from your own blood. This benefits scar tissue, and improving vascularity, while the blood vessels also benefit. We’ve used platelet-rich plasma (PRP) for acne scars, as well as to soften scar tissue. Platelet-rich fibrin matrix (PRFM) is a little different, but it’s still PRP, but is activated so it’s made into a gel, which acts like a time release capsule so it allows growth factors and other things to be released in a specific way, so you get both the correction short-term from the gel, and you get some correction from the replacement of that gel with your body’s own tissue. It is not the same as getting hyaluronic acid fillers, but is certainly more palatable for people who don’t want fillers.

We can also help release any scar tissue with a procedure called subcision where scar tissue underneath the skin is released, allowing the skin to elevate to provide room for platelet-rich plasma (PRP), platelet-rich fibrin matrix (PRFM).

There is also a type of ablative laser strategy often beneficial particularly for boxcar scars. These are scars with very sharp defining edges. Generally, when using a laser, we try to soften the edges of these scars, then blend the skin so the skin heals smoothly for improvement.

There is also acne surgery where scars are excised, sutured, then closed, then the healed area can be laser resurfaced.  This strategy takes several months to actually execute, so you don’t necessarily do everything at once.

Especially with the field of regenerative medicine, you treat, you observe and then you strategize, so it’s very important you identify a doctor you are comfortable with, and you are willing to work with, and who is willing to work with you with these stipulations of not wanting injectable fillers. Once you find a doctor, you will get an understanding of the level of expected improvement. For yourself and the doctor, define what is success. For me, I try to help patients define success simply by one word - improvement. If there is improvement, that is success and we work together to try to maximize that improvement. If you want to have something that is unrealistic, which I doubt, then you will end up disappointed. But if you want to see improvement, and you want to see the particular scars really bothering you improve, bring that to the attention to the doctor, and move forward from that point on.I hope that was helpful, I wish you the best of luck, and thank you for your question.

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Identify scar type, then target acne scar treatments.

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See the video link below for a full explanation. Bottom line, you have multiple scar types and will benefit from several sessions of subscision, Infini RF with PRP, fillers etc... Expect a 50% improvement after 5-8 months . Realistic expectations must be met. All the best. (Oh, if you don't want fillers, consider fat grafting to atrophic scars, which maybe visible on angled lighting). 

Dr Davin Lim.

Brisbane.Australia. 

​Cystic acne scars with elevated scars rolling scars and atrophic tissue loss from the acne scarring process.

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Cystic acne scars with elevated scars rolling scars and atrophic tissue loss from the acne scarring process. For elevated scars some of those scars need to be reduced through ablation with a laser. What that means is that we would destroy part of that elevation with the use of lasers. For the rest of your tissues you can treat it from the surface of the skin. You have to treat the deeper layers in order to get the best result. We have a 5-7 step process that treats all types of acne scars in one treatment in about 2 hours.

Philip Young, MD
Bellevue Facial Plastic Surgeon

Deep Acne Scars

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The best combination for your acne scars would be a combination of EMatrix lasers and fillers such as Restylane and Juvederm. Please consult an expert. Best, Dr. Green

Acne scars in Baltimore

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I would see Dr. Kontis in Baltimore and get treated with the Infini. It is a great treatment for acne scars. You might need filler as well to get the best results. Dr. Kontis will take care of you. 

Steven F. Weiner, MD
Panama City Facial Plastic Surgeon
4.8 out of 5 stars 52 reviews

Acne Scarring -- Lasers (Fraxel, Co2/Erbium, VIVA, Intensif); Microneedling/PRP, Fillers (Bellafill); Subcision; Punch Excision

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Acne scarring needs a series of combination treatments and you will need long term maintenance.  Please see an expert in lasers, microneedling/PRP, fillers and subcision. Best, Dr. Emer.

Jason Emer, MD
Los Angeles Dermatologic Surgeon
4.8 out of 5 stars 202 reviews

Fraxel

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Fraxel is a laser skin rejuvenation treatment that resurfaces your outer skin, erasing imperfections. It also encourages the production of collagen, a protein found in connective tissue.The result is clearly visible lines, folds and wrinkles. Fraxel laser skin rejuvenation is a non-invasive technique that affects only about 20 percent of the facial skin exposed to it. The most common side effects of Fraxel laser treatment are swelling and skin redness, which should subside within a couple of days. Other temporary side effects may include minor itching, dry skin, peeling or flaking, and a bronzed skin appearance. The risk of infection or scarring is very limited. You should stay out of the sun 2-4 weeks.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.