In the majority of cases I tell patients to expect at least a 70-80% improvement in acne scars. This is a ballpark approximation and not an absolute percentage. In some patients with much harder scars- examples include ethnic skin types (dark skin patients) with atrophic and rolling scars the improvement may only be 50-60%. In other patients with ice-pick scars or shallow box-car scars, I can deliver an 80-90% improvement.
So the question remain ‘can 100% be achieved?’ I think in the correct skin type, with a mixture of certain scar types, and if multiple treatments are performed, the answer is yes. Even if 99% of scars are gone, and one tiny scar has remained, I am confident that if additional procedures are performed, we can, at the end, achieve 100% correction. This is however the law of diminishing gains. Once we achieve, lets say 90-95% to obtain the last 5-10% of scar improvement, we may have to perform another 6-8 sessions to get close to, or at 100%.
Why is scar type so important? Because assessing scars will determine what is the best treatment for that particular scar. You will notice that when I examine acne, it only takes a glance to determine what type of acne you may have (examples include cystic acne- you can see that from 10 meters away), hormonal acne, (females with acne on the jawline/ chin areas, older patients), and blackhead acne (tiny rough bumps on the forehead, nose and cheeks). Acne per say is easy to diagnose and easier to treat.
Acne scars on the other hand takes time to examine and determine what type of scars one has, especially if they are mixed. Most patient will have a mixture of atrophic, rolling, tethered, box-car, hypertrophic, and ice pick scars on a background of open pores etc… Careful examination and planning needs to be achieved prior to scar revision techniques. Tethered scars can be seen with animation- smiling, puckering etc. These scars are treated surgically with subscion and not lasers.
If 100% of acne scars are to be removed, patients must have the correct subtype to begin with- predominantly box car scars, ice pick scars, and atrophic scars. Rolling scars are harder to treat, and tethered scars can be improved but 100% removal may not be possible.
The massive advancement in technology, as well as skill level plays an important part in scar removal, especially in acne scars. The quantum leap was the invention of the fractional laser, Fraxel was one of the very first on the market, followed by different wavelengths. Most frequently I will combine different fractional devices including radiofrequency (early acne scars), Fraxel (moderate scars, in darker skin types), but my choice is the fractional CO2 laser. Why? Because of the power to remodel collagen and remove scars. Most of my techniques are a fusion of methods to achieve the end goal-
- Ice pick scars I usually treat with TCA CROSS, or if very deep and isolated punch excision and sutures.
- Tethered scars are either treated with subscion, or if isolated in one area, excision followed a few months later with laser ablation.
- Rolling scars? Early scars respond well to eMatrix Radiofrequency whilst older scars respond to Fraxel (OK treatment) or CO2 Fractional (better treatment)
- Box car scars? If they are deep, I may perform a session of TCA CROSS to raise these scars up, then utilize fully ablative erbium or CO2 lasers, depending on the skin type. The reverse can be performed, ie- laser first to remove the superficial scars, then TCA to the ones that are left. (My preference is to TCA first, laser second)
- Atrophic scars were one of the hardest scars to treat, however I find them moderately easy to remove. Take a look at my before and after for fillers. Years ago dermal grafts were performed, but in the last 19 months newer fillers have taken over as they offer scar removal by ‘filling up’ empty spaces once occupied by collagen. Results are instant, and downtime minimal.
So, can 100% be achieved, yes- if you have the correct scar types to begin with and are willing to invest the time with multiple visits, I can deliver the end goal.
Remember - treat each scar as a particular scar type, as they each have an optimal treatment - lasers and fractional devices only play a small role in acne scar revision. It is the skill set of the Specialist (and your predominant scar type, and skin colour) that will determine that end result.
This patient had close to 98% improvement in her scars. I can see 3 scars remaining on her left cheek, these can be treated with TCA CROSS to give a 100% improvement, but she was happy with the end result. In her case I performed 2 TCA CROSS treatments before one fully ablative laser combined with CO2 CORE fractional laser session.
By Dr Davin Lim