|Why do some acne scars persist as a little cup on the skin, and why do they never flatten by themselves?
To answer this we have to think back to the way these scars form.Deep cystic acne describes the situation in which there is an inflamed, pus-filled sphere several millimetres under the skin surface. Whether it ruptures or not, this deep pus-filled sphere eventually heals but leaves behind some deep strands of scar tissue that attach to the skin surface but also attach to deeper tissues. As this scar matures it contracts, and thus pulls the skin down like an upside-down tent. Whilstever this scar tissue remains in place, the skin surface will be pulled down by the scar, and will appear as a pit on the skin.
The answer in many cases is to cut these deep strands of scar tissue. Local anaesthetic is administered to the scar, then we use another needle to approach the undersurface of the acne scar and divide the strands underneath. This allows the middle of the deep scar to rise and lie flatter with the surrounding skin.
Some bruising invariably occurs as a side effect, but is well worth it as the bruises last only briefly whilst the improvement persists forever.
Having said that, it would be nice if subcision cured all depressed acne scars, but it does not. Some scars are so deep, and have been there so long, that subcision alone does not give the best result. The result with rolling, bowl-shaped scars is improved if we inject some filler under the centre of the scar. Our favourite for this purpose is Radiesse.
Some scars have walls that are so thick and angled that even subcision followed by filling does not give the best result. These are often described as “ice-pick” and “boxcar” scars. They look as they sound.
You actually get a better result with icepick and boxcar scars if you carefully excise them entirely and suture the wound edges together. This, of course, creates a smooth flat linear scar on the skin surface, but in these cases such a result is still better than the original acne scar.
Of course, the “subcision” approach can be applied to scars other than acne scars. The case study above relates to an appendicectomy scar, with a terrific result (that photographs very well). Depressed surgical scars, such as this was, are commonly caused by tethering of the skin to deeper structures and some subcision with a Toledo cannula (named after/by famous Brazilian plastic surgeon Dr Luis Toledo) can clearly bring about a vast improvement.
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