Age 50, female, best treatment for acne scars? (photos)

Question

I'm a 50 year old female. I'm wondering what would be the best approach to help my acne scars. I'm considering subscision with filler (not sure what kind or maybe fat graft?). Or maybe C02? Or both? Thank you for any thoughts or advice.

Nelson Lee Novick, MD · Answer

Subcision, which I have been performing since 1995 has a several decades' long track record for safety and efficacy for elevating and smoothing acne scars in all skin types. Field Subcision, which refers to performing subcision under a large area, such as the cheeks or temples, can be performed prior to performing individual subcisions for individual scars to provide a healthier foundation to these acne-scar-damaged areas. Be cautious when consider expensive gizmo treatments, like CO2 laser therapies, as these carry significant posttreatment downtimes and run the risk of dyspigmentation and scarring. And be cautious about the use of permanent fillers as these can translate into persistent, long-lasting and difficult-to-treat complications, since they are not easily reversible (unlike HA fillers). You would be wise to consult a board certified cosmetic dermatologist and best of luck.

Anna Chacon, MD, FAAD · Answer

At 50, you can absolutely still get meaningful improvement in acne scarring. The important thing is that there usually isn't one procedure that treats every type of scar equally well. The best results typically come from matching the treatment to the specific scar type—rolling, boxcar, or ice-pick scars—and sometimes combining treatments. The American Academy of Dermatology also emphasizes that acne-scar treatment should be individualized based on the type and severity of scarring.

If your scars are primarily depressed or rolling scars, your idea of subcision is very reasonable. Subcision releases the fibrous bands that tether the scar downward, allowing the depressed area to elevate. It is particularly useful for rolling scars.

Subcision + filler

For selected rolling or deeper depressed scars, I often think of subcision followed by a conservative hyaluronic acid (HA) filler as a very logical approach. The subcision addresses the tethering, while filler provides additional support underneath the scar.

There is evidence that combining subcision with HA filler can produce better improvement than subcision alone.

I would generally favor HA filler before jumping to fat grafting, particularly when treating individual scars. HA is temporary and can be adjusted or dissolved if necessary. Fat grafting is another option and can be useful when there is more widespread volume loss, but fat survival can be variable and some patients require additional treatments.

What about CO₂ laser?

Fractional CO₂ laser is another well-established option for atrophic acne scars. It works by creating controlled microscopic injuries that stimulate collagen remodeling and improve overall skin texture.

However, I wouldn't necessarily choose CO₂ alone if you have deeply tethered rolling scars. A laser can improve the surface texture, but it doesn't release the fibrous bands underneath the scar the way subcision does.

That's why a combination approach can make sense: release the deeper tethering first and then use resurfacing to improve the remaining textural irregularity. Studies have found meaningful improvement when subcision is combined with either fractional CO₂ or HA filler.

At age 50, I would also consider your skin's healing and pigmentation

This is important. CO₂ is an ablative treatment and can involve significant downtime, and the risk of post-inflammatory hyperpigmentation needs to be considered, particularly in pigment-prone skin. A 2026 meta-analysis found that fractional CO₂ and needling treatments have comparable overall effectiveness, while CO₂ carried a higher risk of post-inflammatory hyperpigmentation.

So I wouldn't automatically say “CO₂ is better because it is stronger.” A less aggressive treatment with the right scar-specific approach can sometimes produce a better overall result with less risk.

How I would think about the options
Rolling/tethered scars: Subcision is often the key treatment.
Deep, broad depressions: Subcision + conservative HA filler can be very effective.
Boxcar scars and overall texture: Fractional CO₂ or another resurfacing treatment may be useful.
Ice-pick scars: These often need a more targeted treatment such as TCA CROSS or punch techniques rather than simply CO₂.
Generalized facial volume loss: Fat grafting may be worth considering when volume restoration is also a goal.

So, if your photographs show predominantly rolling and depressed scars, I would be more inclined toward subcision with selective HA filler, followed by fractional resurfacing if needed, rather than doing CO₂ alone. You don't necessarily need to do everything at once—the treatment can be staged so you can see how much improvement you obtain from each step.

And I would set expectations realistically: the goal is usually significant softening of the scars rather than completely erasing them. At 50, collagen remodeling and healing can be slower than in younger skin, but age alone does not prevent a good response to appropriately selected scar treatments.

Raffy Karamanoukian, MD, FACS · Answer

Our office has many different treatments for scars depending on the depth of atrophy or hypertrophy. Scars require a combination approach using our HI DEF protocol which uses a combination of lasers, topical scar modulation, and RF treatments to pixelate scars, improve contour, reduce hyperpigmentation, and improve the visibility of the scars so that they are no longer visible in ambient light. Everyone has a unique pattern of scarring and we employ our HIDEF technique to improve texture, color, contour, and topography. We often use a combination of treatments that begin with a careful examination to examine the micro texturing of the acne scars. Atrophic scars and indented  scars can benefit from injectable fillers such as Radiesse, Sculptra, and Restylane with or without subcision to remove tethered scars and atrophic depression. Hyper-redness in scars can be improved with V beam laser, Excel V, BBL, IPL, and Venus RF to improve  the redness and reduce the visibility of deep scars. Fractional Thulium laser and clear & brilliant can also reduce the inflammation and redness of the scar when combined with topical therapy. Fractional lasers such as Fraxel, erbium, and CO2 laser can be combined with radio frequency and also fractional RF to improve textual issues and microtopography. Subcision and TCA cross are also used for deep ice pick scars and narrow valley scars in order to improve the micro texture.  Above all, our combination approach with our clinical nurses and board-certified plastic surgeons can improve the quality of your skin by using at home Melarase creams combined with PRP treatments in our office to improve your skin quality and tone. I recommend getting a formal evaluation with an experienced team of experts in order to reduce your scarring.
 
Finally, hyperpigmentation of scars can be improved with at-home Melarase AM, Melarase PM, and Melapads to help reduce active PIH and melanin deposition.

Best, 
Dr. Karamanoukian
Realself100 Surgeon

Age 50, female, best treatment for acne scars? (photos)

Answers (3)

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