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About Face

Chapter Four Acne Scarring Types of Scars Scar Treatments Dermabrasion Injections Dermal Punch Grafting Excision Face-lift

Excision

Excision, the fourth method of treating acne scarring, involves excising or cutting out a series of old acne scars and replacing them with a single linear scar. Sometimes the old scars have produced tunneling, where two or more pits have joined beneath the skin. The most dramatic case of tunneling I’ve seen was when we started examining a patient’s acne-scarred nose and the pits extended from the top of the nose down its length to a spot just above the nasal tip. It looked like a honeycomb when we lifted off the skin to reveal the tunneling.

No matter what the cause of such scarring, it does not respond as well to grafting as it does to excision. We simply go in there and cut out the scar and then sew it up, just like an ordinary wound. Unlike with most other acne scarring techniques, Histoacryl glue is not enough to hold the would together, so slowly absorbing sutures placed under the skin are used instead. These are stitches that will eventually disappear in the body so they don’t have to be removed. We sew on two levels: a deep dermal stitch anchors the wound together from below; surface sutures keep it as level as possible.

The cosmetic trick behind excision is to hide the new scar in an existing wrinkle or at the junction of two regional aesthetic units like the lip and the cheek. Near the beginning of this chapter, I mentioned that plastic surgery applied to acne scarring is the art of trompe-l’oeil, or tricking the eye. Acne scarring is nonlinear scarring, which is why it’s so noticeable on the face. With excision, we replace it with linear scarring and fold it into the existing lines of the face. The eye is fooled - though there are still scars, they are difference and less obvious.

Any patient who undergoes excision should try to remember the “six and six” rule: at six weeks, the new scars will look their worst; at six months, the scars start to mature. As six weeks, the body is working furiously to lay down natural collagen and pump blood to the scars so that they will heal. As a result, this is when scars are bright red. Slowly, over the next couple of months, the scars will turn lighter and lighter shades of pink. Then, six months after the operation (I’ve seen it happen nearly to the day), the scars begin to whiten. A mature scar is a white scar. If properly concealed, it will be barely noticeable.

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