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Facial scarring is a common complaint among patients seen by cosmetic dermatologic surgeons. Several etiologies, including inflammatory acne, trauma, previous surgical procedures, and viral infections such as varicella or herpes simplex, can lead to permanent scarring. Treatment of scarring remains an evolving subject among dermatologic surgeons. In order to better understand the optimal treatments for facial scarring, we first explore the different morphologies of facial scars. This is followed by a review of treatments grouped according to each distinct type of scar. We conclude with a discussion of combination treatments and how to apply these modalities to the patient with acne scarring to achieve the maximum results.


There are two broad classifications of facial scarring: atrophic and hypertrophic. This review focuses on atrophic facial scarring. We expand upon the classification previously proposed by Jacob et al.1 by dividing atrophic facial scarring into four main types: ice pick, boxcar, shallow/atrophic, and valley/rolling scars (Fig. 26-1). Ice pick scars are typically small (1–2 mm) and have a wide aperture with steep edges that taper to a single point at the base, as if the skin has been pierced by an ice pick. An epithelial tract forms along the sides of the opening within the scar. These scars may be shallow or deep, and may extend as far as the dermal–subcutaneous junction. Boxcar scars are round to oval in shape with well-defined vertical edges and a flat base, as if the scar has been punched out of the skin. They typically range from 0.1 to 0.5 mm in depth and are usually widely spaced out on the skin surface, occurring as solitary scars. Unlike ice pick scars, this type of scar does not converge to a single point. Shallow/atrophic scars present as a cluster of miniaturized boxcar scars. They usually emerge in groups of four or more and occur mainly on the cheeks. Valley scars (“rolling” scars) are deeper and have an undulating appearance that is best appreciated in indirect lighting (Fig. 26-2). Valley-shaped scars arise from a variable loss of dermis and/or subcutaneous tissue. Because acne and varicella scars are dermal defects, they require a treatment modality that reaches the dermis in order to achieve clinical improvement.


Schematic illustrating the different types of acne scars.


Valley scars viewed in direct light (left) and indirect light (right).

Pretreatment Considerations

Open communication and good rapport with the patient cannot be emphasized enough. Patients paying for cosmetic procedures tend to have high expectations of the results; therefore, realistic outcomes of the various treatment modalities must be discussed in detail with the patient prior to the procedure. Potential side effects and adverse ...

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