Is fat grafting the best next step for acne scar revision? (Photos)

Question

Hi, I have made many posts on here about a big scar i had on my nose. I have tried various modalities (non-ablative laser, juvederm, and dermabrasion). Dermabrasion has by far been the most effective procedure, I have had it done four times and the photos attached show the progress. Although the surrounding skin has a little bit of texture still, it’s significiantly better than before. At this point, I am the most concerned about the central indented pore/scar and how I can get this large pore to go away. I am currently scheduled to start fat grafting treatments in september, but the procedure will be quite expensive, my plastic surgeon has mentioned the possiblilty of having to do it several times, and i’m not sure if fat grafting will even help improve the central pit, which is definitely the area I am seeking improvement in still. Wondering if professionals think fat grafting will actually improve the central indented pit? Or if not what other treatments I should try? I would love to just get a punch excision on the area, but i have been unable to find someone in my area that actually performs this procedure :( I feel lile that would be the best way for me to get good results

Anna Chacon, MD, FAAD · Answer

You’ve actually made very significant progress, especially considering how many treatments you’ve already undergone. The fact that dermabrasion has produced the most noticeable improvement is useful information because it suggests that the overall texture and surface component of the scar respond well to resurfacing.

For the small, central indented pore/pit, however, I would be more cautious about assuming that fat grafting will be the best solution. Fat grafting is generally better suited to restoring broader areas of volume loss or depressed scarring. A very small, sharply defined central depression may not respond as predictably because the issue is more localized to the scar itself rather than a general lack of volume.

Fat could potentially soften the depression, but it may not make that individual pore disappear, and some of the grafted fat can be reabsorbed over time. That is one reason your surgeon is discussing the possibility of multiple treatments. Given the expense, I think it is reasonable to make sure the treatment is addressing the specific problem you are trying to correct.

Your thought about a punch excision is understandable. For a very focal, deep, well-defined scar, removing the scarred tissue and replacing it with a small linear or circular scar can sometimes give a more predictable result than trying to fill the depression from underneath. The trade-off is that you are essentially exchanging one type of scar for another, so the final cosmetic result depends heavily on the location, size, depth, and how your skin heals.

Other scar-directed options can include subcision, focal resurfacing, fractional laser, microneedling, or carefully performed surgical scar revision, depending on whether the depression is tethered to deeper tissue or primarily represents a surface defect. Since you have already had four dermabrasion treatments with good improvement, additional aggressive resurfacing should be approached carefully because repeated procedures can also cause unwanted texture changes or scarring.

If this were my treatment-planning question, I would first focus on identifying exactly what is creating that central depression: a true ice-pick-type scar, tethering underneath the skin, loss of tissue volume, or a pore/follicular structure that has been altered by the previous procedures. That distinction matters because each problem is treated differently.

So, in short, fat grafting may improve the overall contour, but I would not consider it a guaranteed way to eliminate a small, sharply defined central pit. For a very focal defect, a targeted scar revision such as punch excision may potentially be more precise, provided the scar is appropriate for that technique. I would also be cautious about committing to several expensive fat-grafting sessions before knowing that the central defect is actually a good target for volume replacement.

Nelson Lee Novick, MD · Answer

Any kind of excision on the nose (an area under a good deal of static tension), including punch excisions runs the risk of a stretch scar and even stitch tracks.  Likewise, I would be concerned that fat grafting will simply result in a bump without addressing well the central indentation.
 TCA CROSS, which I have personally been performing for over a quarter of century, is, however, indicated for the treatment of ice pick scars and dilated pores. If necessary, following this, mechanically performed Dermastamp Microneedling (no need for the added expense or risks of RF microneedling) can be used to better blend in both color and texture the treated area with the surrounding normal skin. 
You would be wise to consult with an experienced, board certified cosmetic dermatologist scar treatment specialist. Hope this helps and best of luck.

Is fat grafting the best next step for acne scar revision? (Photos)

Answers (2)

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