Atrophic Acne Scars: Types and Rebuilding Protocols

The Three Basic Types

• Ice pick: <2 mm narrow channels reaching deep dermis — the most stubborn.
• Rolling: 2-4 mm undulating depressions from dermal-subcutaneous tethering; subcision works well.
• Boxcar: sharp-edged, flat-based depressions with larger surface area.

Most faces are mixed — which is why no single device “fixes scars”.

The Staged Rebuild

1. Foundation: fractional CO2 or RF microneedling as the full-face workhorse (CO2 fractional for moderate-severe with downtime tolerance; gold RF microneedling for darker skin or downtime-sensitive patients).
2. Structure: subcision for rolling tethering; TCA CROSS or excision for ice pick.
3. Volume: residual depressions corrected with HA or collagen-stimulating fillers.
4. Surface: pigmentation and texture finished with energy-based work.

Why Multiple Courses

Dermal rebuilding depends on wound healing and collagen deposition; each intervention covers part of the depth and area. Expect 3-5 main sessions at 6-8 week intervals and a timeline measured in months — expectation management is half of satisfaction.

FAQ

Can scars become perfectly normal skin?

Significant improvement is realistic; invisibility is not — residuals remain visible under raking light. Align expectations with standardized photos first.

Subcision or fractional first?

With obvious rolling tethering, subcise first for efficiency. Most clinics order individually: assess → subcise/CROSS → fractional/microneedle → fill.

Related Terms

• Fractional Photothermolysis
• RF Microneedling
• CO2 Fractional Laser