Whenever someone talks about acne-scar solutions — I'm talking real acne scars, not the post-inflammatory marks left behind — the inevitable answer is almost always lasers. Well, here's something I wish I'd known before spending thousands of dollars on lasers, trying to eradicate the biggest of the acne scars that marred my face after getting hit with a pimple firestorm at age 28: No laser was going to erase those ego-deflating craters that followed a round of Accutane, no matter how much grief they caused me. In the frustrating, unfair world of acne, some people don't scar — their bodies produce enough collagen to reverse the fat loss and subsequent divots that are caused by a particularly aggressive pimple — while others are left with a cornucopia of scar variations. And — ready for this? — two of the most common acne-scar types won’t see any discernible improvement with lasers. “If you have a significant boxcar or rolling scar, you have to fill what’s missing — volume — and there is not a single laser, radio frequency, or ultrasound device that will bring that back,” says Suzan Obagi, MD, medical director of the Pittsburgh-based UPMC Cosmetic Surgery and Skin Health Center, as well as associate professor of dermatology and plastic surgery at the University of Pittsburgh. In case you’re wondering what acne-scar type you have, here’s a quick primer: Boxcar scars have a well-defined border and indent that are visible in any light. Rolling scars are not as apparent in dim light, but when you are sitting in any scenario with bright overhead lights or side-lighting (i.e. lights that create defined shadows on your face), they become very apparent. I had mostly rolling scars (with a few boxcar scars) on my cheeks, forehead, left temple, and chin. After countless visits to different derms and multiple laser treatments with Fraxel, Yag, and VBeam to no avail, I was getting desperate. And a conventional non-fractional CO2 laser, which has been shown to be one of the better options for scarring, was off-limits due to my olive skin tone — there is a significant risk of hypo- or hyperpigmentation for olive and darker complexions. Which is what led me to a far less gadgety — yet infinitely more effective — option that’s actually been around for decades: acne-scar subcision. Here’s how it works: With your face numbed by either cream or a local anesthetic, a hypodermic needle is inserted underneath the skin, below the scar tissue, and run from side to side, beneath the surface of the skin. This breaks the connective tissue holding the scar to the undamaged skin below, encouraging the skin to regenerate, and eventually promote new collagen growth, which lifts that depression in the skin causing the scar. For me, there was never a sweeter sound than the “Pop! Pop! Pop!” that accompanied the inserted needle breaking up the fibrous bands, which had been pulling down my skin and creating the scars I longed to erase.
Subcision works best with rolling scars, but there are also other factors, like age, that come into play. “With subcision, I don't find the age of the scar is as important as the age of the patient,” says Adam Mamelak, MD, a board-certified dermatologist in Austin, Texas. “Older patients do not have the same ability to regenerate collagen as younger patients.” In my case, I was 34 when I began a series of acne-scar subcisions — spaced six weeks apart, at roughly $500 a treatment. After several months — almost half a dozen treatments — my pitted cheeks filled in. (While there’s no hard-and-fast data, dermatologists typically report improvements anywhere from 40 to 90%, based on patient feedback.) It’s not to say my skin was perfect afterward. Subcision will not work on other scars — those of the icepick and atrophic variety — but in those cases, lasers can actually have some benefit. But even with those few scars lingering, having done away with the majority of those self-esteem-destroying depressions in my skin, I am one giddy acne survivor. And I no longer fear the light.