Morphology · Depth · CityLink Mall
Acne scarring is not one condition. Five distinct entities sit underneath the word scar, and two of them are not scars at all — which is the usual reason one laser applied across a whole face improves part of it and leaves the rest unchanged.
An acne scar is the outcome of dermal wound healing, not a mark sitting on the surface of the skin. Inflammation destroys collagen in the dermis, and the repair that follows either under-produces collagen, over-produces it, or binds the healed skin down to the tissue beneath. The shape you can see is a direct readout of which of those three happened.
Two of the five things patients bring in under the word scar are not architectural scars at all. Post-inflammatory erythema is residual dilatation of small vessels left behind by the inflammation, and post-inflammatory hyperpigmentation is melanin deposited in response to it. Both are flat, both fade on their own timetable, and both are routinely over-treated with resurfacing that was never required.
The atrophic scars — the ones that are genuinely missing tissue — are separated by their depth-to-width ratio. An icepick tract may reach three millimetres into the dermis through an opening under a millimetre wide. A fractional laser vaporising columns to a depth of one and a half millimetres is well matched to the wall of a boxcar scar and poorly matched to the base of that icepick tract, which is why a full-face resurfacing pass flattens some scars and barely touches others.
In Fitzpatrick III to V skin there is a second constraint. Every instrument capable of remodelling a scar also produces controlled injury, and controlled injury in melanin-competent skin carries its own hyperpigmentation risk. The correct plan is usually the shallowest settings that still reach the depth of the lesion, repeated over several sessions, rather than one heavy pass with a long and unpredictable recovery.
Classification
Before any device is selected, scarring is sorted into three groups that behave in fundamentally different ways. The distinction matters because the treatment appropriate to one group is at best useless and at worst harmful applied to another.
Most disappointing acne scar results come from treating five different lesions with a single instrument.
Sequencing
Active acne is controlled first. Resurfacing skin that is still producing inflammatory lesions creates new scars while treating old ones, and no sequence that ignores this produces a durable result. Where disease is still active, the plan begins with acne treatment and the scar work is scheduled afterwards.
Once the skin is quiet, tethering is released before resurfacing. Subcision of rolling scars lifts the floor of the depression so that a subsequent fractional pass is working on a surface that can actually respond. Icepick tracts are addressed focally with TCA CROSS in the same period, because a field treatment will never reach their base. Only then does full-field resurfacing earn its place.
A realistic course runs over months, not weeks. Collagen remodelling after fractional injury continues for three to six months, so assessing the result of a session at three weeks tells you very little. Expect several sessions, expect the plan to be adjusted between them as different scar types resolve at different rates, and expect that a proportion of deep scarring improves substantially without disappearing.
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