Excision and Subcision
Ice-pick and box-car scars may also be removed by surgical excision. This technique may entail punch excision of a given small acne scar with a punch biopsy instrument of equal or slightly greater diameter. Then one or two 5.0 or 6.0 simple interrupted sutures are used to close the resulting defect, with the attendant transformation of a round, indented scar into a flat slit-like scar. Larger linear box-car scars can be excised by elliptical excision and repaired by bilayered closure. Sufficient eversion is necessary to avoid recurrence of an indented groove.
Alternatively, after punch excision of a small scar, the defect may be filled by a punch graft. Harvested from another area, commonly the postauricular sulcus, a punch graft is pressed into the created defect and either sutured or glued in place. Punch grafting creates a secondary defect and risks poor color and texture match between donor and recipient sites. However, by filling the deadspace at the excision site, punch grafting may reduce the likelihood that scar excision and closure will fail because of excessive tension in the closure.
Subcision treats rolling scars by separating the fibrous bands securing them to the deep dermis.7 A sharp device, often an 18-gauge Nokor® needle with a spear-like tip, is inserted at an angle into the dermis at a distance of 1-2cm from the scar. The needle tip is aimed upward, tenting but not puncturing the skin, and is advanced to a point under the scar. Backward and forward rasping of the underside of the dermis beneath the scar is used to sever fibrous bands while initiating a reactive fibrosis that gradually, over several weeks, propels the depressed scar upwards. Bruising following subcision can last 1-2 weeks, but the procedure is well-tolerated with local infiltration of anesthetic. A benefit of subcision is the absence of any epidermal injury, except for minute needle insertion points.
Skin Therapy Letter. 2006;11(9):7-9. © 2006 SkinCareGuide.com
Cite this: Treatment of Acne Scarring - Medscape - Nov 01, 2006.