Best treatment for 10+ year-old traumatic forehead and cheek scars: laser, subcision, or surgical scar revision?

Question

I am 33 years old and looking for advice on improving two mature facial scars from an accident more than 10 years ago. My main concerns are the linear scar on my forehead and the scar/indentation on my left cheek. The darker mark on my right cheek is unrelated—it is post-inflammatory hyperpigmentation from acne and has been gradually fading. Over the years, I have tried several nonsurgical treatments in hopes of improving the traumatic scars, including radiofrequency microneedling, Pico Genesis, chemical peels, and silicone scar sheets. I have seen some improvement, but the scars are still noticeable to me, particularly because of the contour/indentation and the way they catch light. I have seen patients with older traumatic facial scars achieve meaningful improvement with treatments such as fractional CO2 or Er:YAG laser resurfacing, other fractional lasers, subcision, surgical scar revision, or combination treatments, but I am unsure which approach would be most appropriate for my scars. At this point, I am highly motivated to pursue further improvement and am open to both nonsurgical and surgical options if the potential benefit justifies the procedure and recovery time. Note: The scars are flat/normal, and my skin heals normally after an injury or surgery.

Anna Chacon, MD, FAAD · Answer

With scars that are more than 10 years old, the age of the scar itself doesn't necessarily prevent improvement. The important question is what type of scar we're treating—whether the main issue is a change in color, surface texture, or a deeper depression/tethering that creates a shadow when light hits the skin.

Based on your description, the contour/indentation of the left cheek scar sounds particularly important. If the scar is tethered to deeper tissue, resurfacing alone may improve the surface but won't fully release the indentation. In that situation, subcision can be useful because it releases the fibrous bands pulling the skin downward. Depending on the amount of volume loss, it can sometimes be combined with a carefully selected filler or other volume-restoring treatment.

For the linear forehead scar, the best approach depends more on its width, texture, and how sharply it contrasts with the surrounding skin. Fractional laser resurfacing, including fractional CO₂ or Er:YAG, can soften the texture and make the transition between the scar and surrounding skin less noticeable. Several treatments may be necessary, and the improvement is generally gradual.

Surgical scar revision is another option, particularly for a well-defined linear scar where the scar itself can be removed and the area meticulously re-closed. However, surgery creates a new scar, so it isn't automatically better than laser treatment. It tends to make the most sense when the scar has an unfavorable shape, widening, significant contour abnormality, or another structural issue that resurfacing cannot adequately address.

In many cases, the most effective strategy is combination treatment rather than choosing only one procedure. For example, a depressed cheek scar may benefit from subcision to address the tethering followed by fractional resurfacing to improve texture. A linear forehead scar may be approached primarily with fractional resurfacing or, depending on its characteristics, surgical revision.

Since you've already tried radiofrequency microneedling, Pico Genesis, chemical peels, and silicone sheets with some improvement, that history is useful—it suggests you've already addressed some of the surface component, while the remaining light-catching indentation may require treatment at a deeper level.

One important caveat with fractional CO₂ and other aggressive resurfacing treatments is that the risk of prolonged redness or post-inflammatory hyperpigmentation varies with skin type. Treatment settings need to be individualized rather than simply choosing the strongest laser.

Overall, I would think of your scars in terms of structure first, texture second, and pigmentation third. Correcting the underlying depression or tethering, when present, can make a bigger visual difference than continuing to treat the surface alone.

Laser Skin Solutions · Answer

When evaluating mature, traumatic scars that are over a decade old, patients often wonder if they are permanent fixtures. Working with mature tissue requires a nuanced approach because old scar tissue is often fibrous and tightly tethered. In my clinic, I find that a combination approach almost always outperforms a single modality. For deep, tethered tissue, subcision is essential to release the fibrous bands pulling the skin down, whereas advanced fractional resurfacing lasers work wonders to remodel the surrounding collagen and smooth out surface texture. When clients come to me looking for meaningful improvement on long-standing forehead or cheek scars, I typically recommend pairing targeted subcision with a series of microneedling RF treatments to stimulate deep dermal healing without excessive downtime

Best treatment for 10+ year-old traumatic forehead and cheek scars: laser, subcision, or surgical scar revision?

Answers (2)

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