David P. Rapaport is a board certified plastic surgeon in private practice in Manhattan, New York. Dr. Rapaport was Chief Resident at Harvard Medical School and later the Chief Resident at the Plastic Surgery Institute of Reconstructive Plastic Surgery at New York University Medical Center. Additionally he is a member of the American Board of Plastic Surgery, American Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, American Medical Association, American Society of Plastic and Reconstructive Surgeons, and the Plastic Surgery Research Council.
Q: When is scar revision / excision the best option for acne scarring?
A: Scar revision can be particularly rewarding when the acne scar is deep and sharply demarcated. Typically we call such scars ice-pick scars. Large depressed scars are also a good candidate for this procedure. Though depressed scars respond well to facial fillers.
Q: Won’t this leave the patient with another scar? Why is this a good option?
A: Great question. It is important to understand what makes some scars more noticeable then others. What people don’t immediately realize is that it is not the scar which is noticeable – it is the shadow of the scar. When the scar is protruding or indented or wide it is more noticeable. The goal with scar revision is to substitute those scars with scars that are a fine line – it is much less noticeable. Additionally, after scar excision if the patient elected for additional treatments such as laser the result is dramatic.
Q: But ice-picks are so small. Would the excision lead to a larger scar?
A: You don’t operate on ice-pick scars that are extraordinarily small. The typical ice-pick that we operate on is from 1 ½ mm – 4 mm. The problems with these scars are that they are so depressed that they cast a shadow and require very heavy make-up to cover. A fine line is easy to cover and, again, is less noticeable.
Q: What are the common types of acne scars that you treat?
A: The most common acne scarring in general is wide and superficial scarring which can cover a broad area of skin and these scars for obvious reason have no direct surgical treatment because the problem lies with a very large surface of skin.
Q: How do you treat those types of scars?
A: Those types of scars are generally treated with resurfacing techniques.
Which means we are not removing the tissue because there is too much of it to be removed, but instead we are trying to polish the surface so it will look smoother and more pleasing. Different technologies have tried to accomplish the same goals. These technologies include CO2 resurfacing, Erbium laser resurfacing, and various other modalities including most recently Fraxel.
Q: These lasers are ablative. What is the down-time with these procedures typically?
A: You are looking at about a week of serious down-time meaning raw potentially painful skin and several weeks of redness. What is unique about newer treatments such as Fraxel is that the down-time is less severe. The question is if the results are sufficient.
Q: With these ablative lasers how much improvement can be expected?
A: It really depends on the case. An experienced doctor can give you a realistic idea of how much you can expect to improve. Damaged and scarred skin can be improved but it can never be truly replaced with healthy unscarred skin. In general these treatments give the acne scarred face a much better appearance.
Q: What about Zplasty or Flap reconstruction?
A: One of the biggest issues that determine how noticeable a scar is on the face is the direction of the scar. When a scar follows the direction of normal skin creases it is much less noticeable then when it goes across the normal grooves and creases of the skin. Operations like Zplasty are designed essentially to alter the direction of the scar.