Scars can come in different shapes and forms , in this section we will discuss the most common type of scars.

The main distinction made between scars is the differentiation between Hypertrophic and Atrophic Scars. A Hypertrophic scar is raised (protruding), whereas an Atrophic scar is a visibly depressed part of the skin. A Hypertrophic scar is left after a deep skin injury (i.e. deep wounds inflicted during surgery, superficial wound followed by an protracted infection) and in case of Atrophic Scars, these are usually left after Acne, Chickenpox or other types of skin inflammation.  Burn scars are not discussed here and they are referred to as contractures to learn more about this type of scars please click here.

Figure 1. The two main types of scars "Atrophic" or "Depressed scars" and "Hypertrophic" or "Protruding scars".

In  Figure 1 we can see the main two types of scars which can develop after an injury or traumatic event to the skin, Atrophic (depressed scars) or Hypertrophic (raised scars).

It is important to emphasise the difference between Keloids and Hypertrophic scars, because they are often mistaken for one another.

Figure 2. Example of Keloidal formations not to be confused with normal Hypertrophic scars.

Keloids and Hypertrophic scars are fundamentally different. To learn more about the difference between Hypetrophic scars and Keloids, please Click Here.

Atrophic scars are those depressed areas (or missing part) of the skin left after a certain skin traumatic event, typically dermal inflammations. The likelihood of developing an Atrophic scar depends on how deeply the inflammation has developed and the healing process. In some cases an Atrophic Scar can also develop after a skin injury.

Atrophic scars are usually classed into three categories: "Ice Pick Scar", "Box Scar" and "Roll/ing Scar".

Figure 3. Depending on the type of skin inflammation the scar which can develop can have different characteristics. In case of atrophic scars this can be classed into: "Ice pick", "Box Scars", "Roll/ing Scars". In certain other cases, especially when an infection persists for a long time or a deep wound has been inflicted a Hypertrophic scar can develop.

The are are several types of skin inflammation which can lead to Atrophic Scar formation. The most common cause of Atrophic Scars are severe acne and chickenpox.  However, other types of injuries can cause atrophic scars as well. More generally atrophic scars are produced by skin conditions that cause an endured inflammation of the dermis. The most common atrophic scar formation process typically begins as a mild form of acne, called comedone. This comedone is formed when oil secreted from the sebaceous glands combines with the dirt or skin cells in the hair follicles. This combination creates a plug that blocks the hair follicle. After the comedone forms, bacteria begin to multiply inside the blocked hair follicle. The white cells of the body rush to the site of the infection in order to destroy the bacteria. With the build-up of white blood cells, pus is formed.

In a few cases, the bacteria, white blood cells and sebum can burst into the surrounding skin and cause further skin inflammation. With the aggravation of inflammation, pressure is created and this pushes the inflammation deeper into the skin. This in turn causes severe damage and can lead to the formation of nodules or cysts. The inflammation on the skin damages the skin tissues and disrupts the structure of the collagen. When the resultant scar tissue is formed after the severe inflammation, it sinks into the skin and appears as an atrophic scar. Depending on the extent and depth of damage to the dermis the type of atrophic scar can develop into, Ice pick, Box or Rolling Scar. The deeper the damage caused to the dermis the higher the likelihood of the formation of "Ice Pick Scars" . In case the damage is not involving the hypo-dermis then "Box Scars" can develop. If the damage to the dermis is superficial then the atrophic scar can evolve into a "Rolling Scar".

Figure 4. The main difference between the three types of scars is not merely in the depth of the missing skin. It is mostly the with of the scar itself and the shape of the scar edges.

Small depressed atrophic scars of a diameter less than 2mm are usually referred to as "Ice Pick Scars". If the edges of the scar are sharp, then they are classed as a "Box Scar" (usually the diameter of Box Scars are between 2 to 4 mm). When the edges are not very well defined then the atrophic scar is usually referred to as "Rolling Scar". Rolling scars are normally over 5 mm in diameter.

Figure 5. Distinction between the main types of scars at a glance.

The difference in classification of atrophic scars is not always very well marked, whereas the difference between Atrophic and Hypertrophic Scars are very well defined and recognisable. In case of Atrophic Scars the difference between "Ice Pick Scars" and "Rox/Rolling Scars" is quite marked. On the other hand the difference between "Box Scars" and "Rolling Scars" can blur sometimes. This is because the edges of "Box Scars" tend to have a different degree of sharpness.

In Figure 6 below, you can see an example of "Ice Pick Scars" on the face caused by severe Acne. These type of scars are clearly indented, typical of "Ice Pick Scars". The missing part of the skin can be reconstructed using minor skin grafting.

Figure 6. "Ice Pick Scars" or indented scars are generally caused by severe acne, where the inflammation has affected the hypo-dermis.  "Ice Pick Scars" are deep, small and narrow. The scar appear as if it has been injured by a sharp instrument such as an ice pick. Some people may have deep holes or large open pores. Often, "Ice Pick Scar" treatments can involve minor skin grafting to reconstruct the missing part of the skin.

"Ice Pick Scars" appear on the face and other parts of the body, after a severe episode of skin inflammation and are sometimes difficult to cover up. As the name itself suggests, this type of scar looks as if your skin has been pierced by an ice pick or a sharp instrument because they are deep and very narrow. Not all acne, chickenpox or skin inflammation develop into "Ice Pick Scars". This type of atrophic scars appear only if the inflammation has affected the deeper parts of the dermis (Hypo-dermis).  Usually the deeper the inflammation the more the likelihood of forming an "Ice Pick Scar".  Very often, "Ice Pick Scars" appear after the formation of an infected cyst, which destroys the innermost parts of the dermis.

Figure 7. Typical example of "Box Scars". Their edges are very sharp and well defined. Normally they are 3 to 4 mm in diameter.

"Box Scars" occur when an inflamed acne lesion destroys the skin tissue, leaving a sunken area on the skin. They have an oval shape and look like depressions in the skin. Unlike Ice Pick Scars, "Box Scars" do not taper to a point. Depending on how severe acne was, the depth of the "Box Scars" varies. This kind of scar is most frequently seen on temples and cheeks.

Normally on young skin when the scar have recently formed the edges of the Box Scar are very sharp and very well defined. This is what characterises "Box Scars" when they are recently formed.

The difference between "Box Scars" and "Rolling Scars" can be blurred at times as seen in the figure below when the edges become less defined over time.

Figure 8. Over time or after collagen regeneration treatments (i.e. cosmetic peels, laser resurfacing, plasma resurfacing etc) the edges of the box scars become less defined. Therefore over time, the line between box scars and rolling scars becomes less and less defined as shown in the atrophic scars displayed in this picture. .

Almost all Box Scars over time will transition to "Rolling Scars". This is due to the natural collagen regeneration process which occurs over time. This process can be speeded up by using collagen regeneration treatments like cosmetic peels, plasma skin resurfacing, laser resurfacing, micro-needling etc.

Figure 9. Rolling Scars grouped close together. Over time or after a few skin resurfacing treatments the edge of the scars start to smooth progressively.

Normally all aesthetic treatments for atrophic scar attenuation which does not involve minor skin grafting  or subcision, focus on accomplishing this first transition, from "Box Scars" to "Rolling Scars" by using collagen regeneration techniques (which smooth the edges of the scar become less defined).

Figure 10. Typical example of "Rolling Scars". Where the depressed areas have become blurred  over time.

"Rolling Scars" are much larger in diameter than Box Scars, and because  their edges are not as sharp and defined as those of the Ice Pick or Box Scars they are much easier fade using most skin resurfacing techniques.

So to recap Atrophic Scars are usually distinguished into three categories:

1. Ice Pick Scars
2. Box Scars
3. Rolling Scars

The differentiation between Box Scars and Rolling Scars fades over time due to the slow smoothing of the scars edges.

Figure 11. Box Scar 1, Ice Pick Scar 2, Various types of rolling scars 3, Small Hypertrophic scar 4, Small Atrophic scar 5. In the net sessions we will explore the most effective aesthetic treatments used to remove the scar types 1, 2 and 3. Scars Types 4 and 5 are usually attenuated by using skin resurfacing treatments. Electrical arcing can be very easily used to remove small scar types 4 and other minor Hypertrophic skin imperfections.

Atrophic scars are not as easily removed as Hypertrophic scars, however there are a number of effective treatments available for atrophic scar removal and atrophic scar attenuation. Atrophic scar removal generally is more complex than normal Hypertrophic scar removal. In the case of Hypertrophic scar removal, the ablative process focuses on removing the raised part of the scars using various methods, Laser, Electrical arcing (Plasma), Excision etc. Also occlusion is another effective method for Hypertrophic scar attenuation over time, this is used as a home treatment solution which is scientifically proven to lead to good results.

First of all, it is important to make a clear distinction between atrophic scar removal and atrophic scar attenuation. The two main techniques are fundamentally different. Atrophic Scar removal focuses on finding ways to "fill" or removing the skin depression which causes the atrophic scar, as we will see this can be done effectively in various ways. The best and cost effective method depends on the type of each atrophic scars and where it is positioned. Some atrophic scar removal techniques are surgical while some others are straight forward non surgical procedures. Atrophic scar attenuation are generally aesthetic non surgical treatments and focus on finding ways to gradually improve the appearance of atrophic scars.

Atrophic, sometimes, can be challenging to remove completely because the aesthetic procedure has to focus on finding the best way to reinstate the the missing part of the skin. Depending on a number of factors, this cannot be always straight forward. Sometimes, atrophic scar removal can involve some degree of minor skin re-constructive technique in order to achieve the best possible results in the least number of treatments.

The strict requirement for reconstructing the depressed part of the skin is not always necessary because in certain cases a satisfactory result can be accomplished by using simple skin resurfacing methods or other very simple aesthetic treatments. As we will see, this is specifically the case for superficial rolling scars treatment.

Generally in case of box scars the natural skin regeneration process (which occurs over time or induced by using skin resurfacing techniques) leads to a progressive smoothing of the sharp edges of the atrophic scar and therefore Box Scars normally progress into Rolling Scars over time. In case of superficial rolling scars, a number of skin resurfacing treatments generally lead to further smoothing of the "Rolling Scars" until satisfactory results.

Figure 12. Typical atrophic scars left after severe acne. In this picture the depressed area of the skin typical of atrophic scars is evident. The best first line of treatment is these type of atrophic scar removal procedures maybe surgical. The type of removal treatment for each scar maybe different depending on each type of atrophic formation. The choice of the best type of treatment for each type of scar is left to the practitioner. The second line of treatment is the use of skin resurfacing techniques, localised skin tightening or collagen regeneration treatments in general. These are used to fine tune the results of the main scar removal treatments.

1. Atrophic scar removal treatments. The use of minor surgical procedures and atrophic scar removal procedures are usually the first line of treatment. These procedures focus on reconstructing the missing part of the skin caused by the acne or injury that produced the atrophic scars in the first place. As we will see, not one type of removal treatment suits all types of atrophic scars.  For example in case of very deep relatively large box scars, the best technique can be minor skin grafting where the a small section of the skin is "implanted" into the depressed part of the scar. In case of deep Ice Pick Scars instead the use of targeted potent cosmetic peels is usually effective in the removal of this type of atrophic scar.
2. Atrophic scar attenuation treatments. These are all aesthetic non surgical treatments. These aesthetic procedures focus on the use of collagen stimulation techniques or skin regeneration principles (skin resurfacing) and sometimes localised skin tightening. This is done using laser and voltaic plasma skin resurfacing, micro-needling, cosmetic peels etc. These are usually the second line of treatment after the main atrophic scar removal treatment. They are used as to perfect the results accomplished by the removal treatments. Also scar attenuation treatments are used as first line of treatment in cases of superficial rolling scars (like the one seen in Figure 10).  In this case simple skin resurfacing procedures can lead to satisfactory results without the need for using minor surgical procedures.

Figure 13. Use of TCA for "Ice Pick Scar" Removal. The use of suitable potent cosmetic peels inside the scars is the preferred option for Ice Pick Scars removal. This method is referred to as "Bridging" the ice pick scars. Although this is considered the best practice for Ice pick Scar removal, this is an easy non surgical technique.

In case of very deep indented Scars (Ice Pick Scars), the smoothing effects of skin resurfacing procedures will be effective in improving the appearance of this type of Atrophic Scars, however the  missing part of the skin cannot be  reconstructed by using  traditional skin resurfacing methods. Traditional skin resurfacing treatments using lasers, micro-needling, repeated cosmetic peels or skin tightening using electrical arcing at the borders of the ice pick scar usually lead to a degree of improvement in the appearance of this type of atrophic scar, however the this type of aesthetic treatments on their own seldom lead to satisfactory results in the treatment of very deep "Ice Pick Scars". Additionally these methods on their own are classed as "Ice Pick Scar Attenuation", instead of "Ice Pick Scar Removal". This is because on their own, traditional skin resurfacing techniques cannot remove deep "Ice Pick Scars". In fact traditional skin resurfacing treatments, on their own, do not lead to the reconstruction of the deep missing part of the skin in deep "Ice Pick Scars".

A very effective method used to reconstruct the missing part of the skin in deep and narrow "Ice Pick Scars" is a technique called "Bridging". Throughout the years this method has been used the world over with great success for "Ice Pick Scars" removal. It is referred to as "Bridging" because this technique takes advantage of the fact that the internal walls of "Ice Pick Scars" are very close together. Because of this, when a superficial ex-foliation is carried out inside the "Ice Pick Scar" during the healing period the internal walls of the scar tend to join together as extra collagen is produced to "Bridge" the small "gap" of this type of atrophic scar. In other words, the highly concentrated cosmetic peel delivered inside the narrow scar, causes a very superficial small "wound" inside the narrow walls of the  "Ice Pick Scar". As the internal walls of atrophic scar heal, the effect is as if the scar starts to "fill up" with new skin tissue which is formed between the walls of the scar (Bridging Effect). Therefore the depth of the scar decreases visibly due to the new collagen formed inside the scar.

The preferred product used for this application, in many  aesthetic clinics with very good and repeatable result is  TCA. Highly concentrated Trichloroacetic Acid solutions (over 80% in concentration) are delivered in small droplets  inside the ice pick scar. Immediately after the TCA solution has been delivered the atrophic scar turns white. This "whitening" will last in the region of 3 hours. It will then be followed by redness around the "Ice Pick Scar". A couple of days after the treatment the scars treated will start turning black, a sign that the scabbing process (and bridging ) is taking place.  The scars usually recover completely within one week. Please note that other specialised cosmetic peels  other than TCA can be used instead, leading to similar results in "Ice Pick Scar" removal.

Over several years, tooth picks impregnated with the potent cosmetic peel have been used to deliver the cosmetic substance inside the "Ice Pick Scar". Some aesthetic practitioners prefer the use of small conventional mesotherapy-type of syringes to deliver the small droplets of potent peel inside the "Ice Pick Scars". Please note that the Cosmetic peel is NOT injected but simply purred in droplets inside the "Ice Pick Scar".  The use of the Syringe allows a faster and more effective delivery of the the cosmetic peel.

In the video below you can appreciate how this easy method is applied on a real case.

During the healing process, the part has to be kept free of infections and disinfected twice a day. Sun screen must be worn for at least 3 months after the last treatment and exposure to sun light or UV sources deliberately avoided for at least that period.

This type treatment has to be repeated a number of times in order to achieve good results. On average two sessions are normally sufficient. This treatment is usually followed by the skin resurfacing treatments, using Lasers, Electrical arcing, or cosmetic peels. These techniques are used to fine tune the results and correct minor skin imperfections.

If using one of our AC Electrical arcing devices to fine tune the results after the "Bridging" treatment for Ice Pick Scar removal, set the device at minimum power level and apply the spot mode on the edge of each scar and between the scars. Do not apply the spots inside the depressed part of the scars themselves.

In the following video you can see a voltaic arcing treatment for acne scar attenuation. As you can see the arc is applied between each scar and never inside the scar itself. Please note that in this case no Bridging treatment was used before this voltaic arcing treatment.

The use of a topical numbing product is always recommended for the comfort of the client. Remind the client of the recommended after care after this type of treatment.

Laser, micro-needling and other aesthetic treatments can also be used instead of Voltaic Arcing.

Before you perform any "Box Scar" removal treatment, make sure the area is vascularised (properly reached by blood vessels). This is especially important in recently formed scars, as some of them may not be ready for scar removal treatments (scar tissue hard to the touch).  Appreciating whether the scar tissue is properly vascularised is done simply by touching the scar tissue, if it is soft to the touch and not stiff then this is a sign that the scar is adequately vascularised. If the area is stiff then a number of skin resurfacing treatments are recommended before performing any of the following procedures. The preferred option to vascularise stiff scars is the use of micro-needling. Other options involve laser resurfacing, voltaic arcing resurfacing, cosmetic peels.  If the skin is soft  to the touch and you can pinch it with your fingers without encountering any stiffness, then you can go ahead and perform any of the box scar removal procedures described here.

Figure 14. Different size and shapes of "Box Scars". Some can resemble Ice Pick scars while others can resemble Rolling scars.

We have seen how the preferred method for Ice Pick Scar removal is the use of suitable highly concentrated peels to accomplish the "Bridging" effects between the internal walls of the Ice Pick scars. This is possible due to the proximity of the internal walls of the Ice Pick Scars.

In case of "Box Scars", because the walls of the scar are further apart, than Ice Pick Scars the technique of "Bridging" may not be the most suitable to accomplish the best results because the internal walls of Box Scars are too far apart to join after the use of highly concentrated TCA or other suitable cosmetic peels.

Currently, the most popular treatments available for box scar removal are:

• Minor Skin Grafting or Punch grafting (floating), when the Box Scar is particularly deep and placed on an area of the skin not particularly subject to stretching, like the forehead, temples or chin area.
• Punch excision, discard and close. It is done by making a little punch excision of the scar. This is the same technique used when performing skin excision to send the sample for histological examination to verify a lesion is benign. After the excision is performed, the area is stitched up and heals by primary intention.
• Subcision, is used when the "Box Scar" is quite swallow, or it is placed on an area of the face particularly subject to stretching or wrinkling. This technique focuses on making a wound inside the scar itself in order to trigger a Hypertrophic scarring formation which would elevate the depresses part of the scar.

Fillers. Also some aesthetic practitioners use fillers to try and elevate the depressed part of the "Box Scar". Although effective, this technique is not explored here as it is not a permanent solution and it requires ongoing treatments due to the fact that fillers will naturally be reabsorbed over time (within 12 to 24 months after the treatment). Therefore every time the filler is absorbed, the treatment has to be repeated. Because the use of fillers is not a permanent solution and there are effective permanent Box Scar removal solutions available, we prefer to explain and explore those instead.

Generally, there is no right or wrong removal treatment choice for Box Scars. This is because Box Scars come in different part of the face, in different shapes and depths. Sometimes they resemble Rolling Scars if they are large, sometimes they  can resemble more Ice Pick Scars. Therefore it is the choice of the aesthetic practitioner to use the technique that it is deemed best suited for the particular Box Scar based on its shape, position on the face and depth of the depressed area.

Skin grafting is used in many areas of skin reconstruction and it is particularly useful and effective in reconstructing the missing skin in a "Box" type of scar.  Punch Grafting is a simple minor surgical technique used to "fill" the missing part of the skin inside the atrophic scar. Another part of the skin is implanted into the missing part of the atrophic scar.

Figure 15. Typical Box and Ice Pick Scars on the face. Based on the individual type of scar the treatment can be different.  This is a classical example of the various types of scars that a single individual can present. In this case we have many Box Types of scars and some other Box Scars can resemble Ice pick scars. So the practitioner has to choose the type of scar removal treatment for each individual scar based on their experience and specific type of scar. There is never a right or wrong type of scar removal treatment for each scar.

This technique is generally used when  subsicion would be quite difficult to carry out especially in case of particularly deep Box Scars. However, if the Box Scar is deep and located on an area of the face prone to stretching or wrinkling (i.e. periorbital area, cheeks etc) then this technique should be avoided as the new skin may not implant properly in place of the missing part of the skin. In this case the "punch excision, discard and close" technique should be used instead.

Minor Skin Grafting or Punch grafting (floating) provides the most optimal results in less mobile areas of the face such as the forehead and temples. Punch floating is the treatment of choice for most deep "Box Scars" and usually heals in 3 to 4 weeks without a trace of the circular incision used to make the punch.

In this video we can see how skin grafting is used to regenerate the missing skin of the depressed area of an atrophic scar.

The surgeon deliberately inflicts a wound into the "Box Scar". Once the wound is made, the small skin graft (punch graft) is implanted on to the fresh wound and stitched up. Stitches are used in case of large "Box Scars".  The stitches are removed within 15 days. In case of small Box Scar, given that the sutures would be impractical, skin glue is the preferred option used instead of stitching.

Once the part has healed usually further skin resurfacing treatments are used in order to correct minor imperfections left after this minor surgery. The main treatments used are laser resurfacing to smooth out the skin in general. In case of protruding imperfections voltaic arcing and laser ablations can be used to level off these imperfections. Also a course of home peeling treatments can be performed by the client at home.

This is another easy and effective technique used with great success in the removal of Box Scars. It is carried out by excising the scar itself and closing it with stitches. The part is then left to heal by primary intention. The stitches are removed 7 days after the procedure. This technique is used when Minor Skin Grafting or Punch grafting (floating) is not the most suitable option for Box Scar removal (i.e. the scar is too large, or the practitioner would deem the grafting could be unsuccessful).  One downside with this procedure is that this technique will usually lead some other form of scar-tissue due to the stitching. Fortunately, if the procedure is carried out correctly,  the new scar tissue is normally slightly Hypertrophic and hence very easily removed like any minor skin imperfection. This then allows simple skin resurfacing treatments (scar attenuation) to blend in the new small scar with the surrounding skin area.

In the following video you can see a demonstration of this simple technique.

In case Voltaic Arcing (Plasma), is used after this procedure to smooth the area, then the arc is used on top of the new hypertrophic scar in order to level it off with the surrounding skin area. Please note that not all scars left by the sutures maybe hypertrophic and the beauty practitioner has to choose the best technique for the specific skin imperfection left after the area has healed.

Other skin resurfacing method can be used too, including micro-needling, localised and overall laser resurfacing, cosmetic peels etc. As usual, these are secondary treatments aimed at fine tuning the results and help the new scar to blend in and achieve a smoother skin after the "Box Scar" removal treatment. If some minor protruding or hypertrophic imperfections are left after healing these can be easily removed by using voltaic arcing (Plasma) or Lasers.

The main challenge in improving the appearance of atrophic scars in general, is finding the best way to regenerate the missing part of the skin which creates the "hole' in the skin. As we have seen there are sometimes very simple and effective techniques (Bridging) used for removing deep "Ice Pick" scars.  However if the Box Scar is particularly superficial then the Punch, Discard and close  or Minor Skin Grafting or Punch grafting (floating)  techniques would be unnecessary (because too invasive) since there is a more simple, less invasive  and effective permanent removal treatments for this type of shallow scars.  This is done by achieving a minor elevation of the depressed part of the scar using a technique referred to as subcision. This is a technique where a conventional scalpel is carefully used to cause a deliberate wound inside the depressed part of the scar itself.

Figure 16. Typical acne scars, some Rolling and Box Scars. The practitioner may decide to perform subsicions to raise the depressed areas of the individual atrophic scars. The procedure is quite time consuming but simple.

Subcision is a technique used in order to raise the depressed area of the individual atrophic scar in general. This is done intentionally inducing another process of scarification. Essentially, the atrophic scar is carefully cut at its bottom and a wound is purposely formed which is left to heal. The natural scar generation process will produce extra collagen which in turn will raise the previously depressed area of the atrophic scar.

Scabs will form three to four days after the procedure. The scabs should fall off by themselves within 5 to 7 days and the results are typically very good and permanent.  After this type of simple surgery the improvement is normally visible however further aesthetic treatments are usually recommended to correct the minor imperfections left after the surgery. In other words, surgical subsicion is used to coarsely improve the appearance of shallow atrophic scars and other aesthetic treatments (scar attenuation treatments) normally follow to fine tune the results.

Normally a number of skin resurfacing sessions are carried out once the area has recovered fully. This will allow to smooth the skin imperfections left after the subcision treatment. The skin resurfacing can be carried out by using cosmetic leasers, voltaic arcing, or a number of treatment of cosmetic peels.

This technique (subcision) is preferred when the atrophic scars (typically Box Scar and sometimes  Rolling Scars) are are relatively shallow. Usually the the depth chosen to opt subcision is between 1 and 2 mm.  However, in case of particularly deep scars, this technique maybe impractical and do not lead to very good results and "punch grafting and closing"  or "minor skin grafting" may be preferable instead.

The best treatments to better the results after subcision, are laser resurfacing, cosmetic peels or micro-needling.

Bear in mind that atrophic scars are generally difficult to remove completely, therefore a certain degree of improvement in their appearance is considered to be the most appropriate expectation for this type of aesthetic treatments. No treatment both surgical or non surgical can always guarantee complete disappearance of the atrophic scars (or Acne Scars) even if carried out correctly.

Above we have discussed the types of treatments that are notoriously effective in the removal of atrophic scar of various shapes and depths. These techniques have been used around the world for several years with great success. However  there is not right of wrong treatment choice for any given type of atrophic scar. The aesthetic practitioner is called every time to evaluate the type of scar individually and choose the type of treatment which he or she deems best suitable for each individual type of scar.

Often these treatments are followed by some atrophic scar attenuation treatments to fine tune the results and get rid of minor skin imperfections.

Above, we have discussed the first line of atrophic scar removal treatments. They are effective and usually lead to very good results. These treatments aim at finding the most effective way to either "Bridge" the small  gap in the narrow scar (Ice Pick Scars), reconstructing the missing part of the skin (Large and Deep Box Scars), stitching up the missing part of the skin (Small and Deep Box Scars), trying to elevate the depressed part of the skin by using Subcision (Shallow Box Scars).

However, although effective, these techniques may leave some residual imperfections, hence in order to accomplish the best possible results other follow up treatments may be required. This is because almost any scar removal treatment can leave some degree of imperfections both atrophic or hypertrophic. Sometimes the imperfections could present themselves as minor hypertrophic formations, other times as atrophic formations most commonly resembling shallow rolling scars formations. The type of imperfection left depends on the type of scar removal treatment performed, the after-care and the reaction to the removal treatment itself.

Figure 17. Example of mixture of box and superficial rolling scars. The superficial Rolling scar can be treated using the atrophic scar attenuation techniques described here. While the deeper "Box Scars" should undergo scar removal procedures before carrying out any scar attenuation treatment. Please bear in mind that in cases like this 4 to 6 treatments may be required in order to attenuate the deeper atrophic scars, unless a scar removal treatment is carried out for the deeper scars before hand.

These imperfections can be smoothed off using various techniques. If the imperfections are hypetrophic the best post treatments are either Voltaic Arcing or Laser Removal of the protruding imperfections. If the imperfections are atrophic or depressed there are several options for Atrophic scar attenuation treatments. Atrophic scar attenuation is performed as a second line of treatment after main removal procedures with the techniques described above. Typically, atrophic scar attenuation treatments focus on collagen regeneration and sometimes also localised skin tightening.

This is done in various ways:

• Using laser resurfacing techniques. Suitable to remove minor hypetrophic imperfections and smooth atrophic areas.
• Voltaic Arcing also referred to as Plasma. Suitable to remove minor hypetrophic imperfections and smooth atrophic areas.
• Micro-needling. Suitable to stimulate collagen regeneration, therefore smoothing shallow rolling scars.
• Cosmetic peels. Suitable to stimulate collagen regeneration, therefore smoothing shallow rolling scars.

The aesthetic techniques presented below, although they should be used as second line of treatment, namely to attenuate the appearance of atrophic scars, they are very often used as the first and only line of treatment. This is because in several aesthetic clinics the minor skin grafting technique, punch and close or bridging are not used, very often due to to the personnel unfamiliarity with these removal treatments or lack of qualifications to carry them out. However even if these scar attenuation techniques are used as first and only line of treatment they often lead to  very good results on their own after several treatments.

Figure 18. Typical example of superficial rolling scars which can be treated within one to two session with a good atrophic scar professional attenuation treatment.

Even thought in the video examples below the atrophic scars attenuation techniques are presented as the first and only line of treatment, whenever possible it is recommended to use them as the second line of treatment after the major atrophic scar removal treatments. Experience shows that coupling the scar removal treatments with the atrophic scar attenuation presented below accomplish the best results using the least least exposure to aesthetic treatments.

The fact that atrophic scar attenuation procedures are advertised, in several aesthetic clinics, as "all in one" effective scar removal treatments, shows that they are effective because their repeated use eventually satisfactorily fade the atrophic scars. However, in several cases, given that there are more effective techniques to achieve the desired results in less treatments and sometimes in a more cost effective way it is advisable to use the techniques presented below as second line of treatment and market them as atrophic scar attenuation procedures. If using both the scar removal techniques presented above in conjunction with the appropriate scar attenuation procedures, satisfactory results are usually achieved minimising the number of treatments and therefore minimising the costs to the client.

Below we explore the use of  Voltaic Arcing (Electrical Plasma) treatments in special detail. Voltaic Plasma like Lasers present the triple benefit of being used for:

1. Removing minor hypertrophic imperfections left after the scar removal treatments.
2. Collagen regeneration stimulation.
3. Localised skin tightening.

Lasers (normally CO2 and Fraxel) are often used for atrophic scar attenuation. These treatments are often advertised as scar removal treatments. Laser treatments stimulate collagen regeneration by causing a controlled burn into the skin. This burn has a natural collagen regeneration and skin tightening effect. Depending on the laser wavelength, the burn (or heat transferred into the skin) can be more or less superficial. The higher the laser's beam wavelength, the deeper the heat penetrates into the skin. Conversely the shorter the wavelength the more superficial the heating effects. In the video below you can see a CO2 laser treatment for superficial rolling scar attenuation.

A number of treatments may be required to accomplished the best possible results. Mostly 4 to 5 treatments are usually in order to achieve the desired results in case of deep scars. Please note that although they are often promoted as surgical treatments in aesthetic clinics (to increase their perceived value) they are clearly non invasive, non surgical treatments.

Voltaic Arcing (Plasma).

The use of electrical arcing for atrophic scar attenuation is for:

• Removing the small imperfections left by the minor surgical procedures (i.e. minor skin graft and/or punch/close). If used for removing minor hypertrophic imperfections (i.e. the minor hypertrophic scars naturally left after the use of minor skin grafting, or punch and close), the common spraying technique can be used to ablate the minor hypertrophic formation with the view of levelling it off with the surrounding skin. This is the same technique used for Moles Removal.
• Like Lasers, it is also used for its skin tightening and collagen regeneration properties to smooth the shallow rolling scars or the shallow atrophic imperfections left after atrophic scar removal treatment.  Therefore voltaic arcing treatments are very good for atrophic scar attenuation in general.

Attenuate shallow atrophic scars.

When using Plasma (Voltaic Arcing), use the typical spot technique on the borders of the scars and never inside the scars themselves. What we are trying to accomplish is "pulling" the surrounding skin area so that after a few treatments the scar will be less noticeable. Please note that for treatment of very deep scars, using AC electrical arcing, can improve the appearance of this aesthetic condition by making the deep scar look more shallow, in most cases however, the complete disappearance of the scar is unlikely.

If the atrophic scars are isolated (or far apart from each other), apply the spots around each scar. Never apply the arc on the depressed part of the scar as doing so could eventually worsen the appearance of the scars instead of improving it.

In the video below you can see how the typical spot technique is applied for a relatively large  isolates atrophic rolling scar. The scar is over 15 years old and therefore it has not preserved its original Box type characteristics (the typical sharp edges) and it has evolved into a relatively large rolling scar. In this case the atrophic scar was caused by a childhood wound and not acne or a cyst.

In this short video the voltaic spots are applied very tightly together and the device is set at minimum power level.

In the following video we can appreciate the treatment of another isolated rolling scar using skin tightening resurfacing techniques. As seen in the video the technique used was a slight spray operation with the device set at the minimum power level. Although the preferred technique is the spot mode, some experienced users move to spray operation for skin tightening and skin resurfacing purposes.

The following video presents another case of minor atrophic scar attenuated using AC Electrical Arcing. As we can see in the video the arc is applied in the spot mode at the borders of the scar itself to cause the desired "pulling" effects.

In case of superficial box Scars or superficial rolling scars cluttered close together the spot technique can be used between the scars as shown in this video below.

As seen in the above examples the basic techniques using voltaic arcing for atrophic scar attenuation of any kind is very simple.This is a safe aesthetic treatment which does not involve surgery. Remember that for relatively deep scars it is always recommended, whenever possible, to use these attenuation techniques after the main atrophic scar removal treatments. This aesthetic procedure is also highly recommended for localised skin tightening and skin resurfacing after main scar removal procedure of deep and ice pick scars.

How to perform the treatment:

1. Apply topical numbing cream before starting this treatment to achieve maximum comfort to the client during this type of aesthetic procedure.
2. Use the intensity treatment you consider appropriate. Usually the the fist time you use voltaic arcing for this application it is advisable to set the power level of our device to minimum, use an instantaneous spot duration and distance between spots varying between 2 to 3 mm apart. The treatment usually lasts between 10 to 15 minutes depending on the area to be covered.
3. Downtime ranges between 5 to 6 days, however it can last longer depending on the intensity of the treatment and how the after-care is carried out.  In case, Voltaic Arcing for atrophic scar attenuation, we define as "downtime" the time period during which the area looks as if is getting worse rather than better. This is the time period required for scabbing to form during which the use of cover up make-up of any type is strictly forbidden.
4. Allow a minimum 4 weeks' interval between treatments. A slight improvement after each session is generally noticeable after the scabs have fallen off.
5. In case voltaic plasma is used as a first line of treatment without prior scar removal procedure, this type of treatment has to be repeated 5 to 6 times in order to achieve reasonable good  scar attenuation results. Remember that the use of plasma is recommended as a second line treatment for smoothing off imperfections of both atrophic and hypertrophic nature left after the main scar removal treatments. If Plasma is used as second line treatment, usually one or two sessions suffice in order to achieve the desired results.
6. Apply make-up only after he scabs have fallen off and never before 2 weeks after the treatment. Apply total sun protection after any scabs have fallen off for at least two to three months after the last treatment. Avoid direct sun exposure for at least 2 months. Generally instruct your client to follow the normal after-care instructions.

Treatment of deep Atrophic Scars. In case of very deep scars, slight improvement in their appearance will be possible by using electrical arcing, however their complete disappearance or best results would be unlikely with this technique alone. Also this applies to any other skin resurfacing technique for atrophic scar attenuation. This technique is primarily used to improve the appearance of atrophic scars in general and flatten swallow rolling scars by using the skin tightening and skin resurfacing properties of voltaic plasma. In case of medium deep or particularly deep scars, the best option to accomplish dramatic results is the combination the atrophic scar removal treatments  (subsicion and/or localised skin grafting etc) followed by the plasma skin resurfacing discussed here. In this case skin resurfacing (using electrical arcing, lasers, micro-needling or cosmetic peels) is done after the area has recovered from the scar removal procedure.

Micro needling

Micro-needing is extensively used to stimulate collagen regrowth. This has good applications in acne scar attenuation. This is a non surgical non invasive technique. Depending on the depth of the needles penetration into the skin and the level of vascularisation of the skin a certain degree of bleeding can occur during the treatment.

In the video below we can see a micro needling device used for collagen stimulation.

Cosmetic peels.

Collagen regeneration is at the basis of most scar attenuation treatments. As it is well known collagen regeneration can be triggered easily using simple cosmetic peels. In the video below we can see a course of chemical peel treatment for acne scar attenuation. Please note that most cosmetic peels suitable for this application are all allowed in the CosIng cosmetic European Portal can be freely used for this type of treatment.

Figure 19. Representative dramatic results of combined minor cosmetic surgery and skin resurfacing/tightening.

There are different approaches in treating atrophic scars and in general there is no right and wrong answer. Treating atrophic scars and improving their appearance can be a long process and you can combine a number of different types of treatments to improve their appearance.

The method proposed is treating the deeper scars and ice pick scars to make them shallower first and then perfect the results by using easier aesthetic treatments.

The initial treatments should be tailored to try and improve the appearance of the deeper scars. Identify the deepest and "pick scars" and apply the relevant aesthetic treatments to flatten them as much as possible. You can use subcision or punch discard and close to improve deep "Box Scars".  For "Ice Pick Scars" the most popular is the "bridging method" using TCA, This is the most popular because it is "non surgical" and TCA is widely available.  However you can also use punch discard and close to improve the appearance of Ice pick scars. If your clinic has a surgeon or medical practitioner then the "punch discard and close" method can be used; minor skin grafting is also another option.

Once the deepest scars have been flattened and they resemble shallower box scars you can perfect the results by repeating the following aesthetic treatments:

• Voltaic Arcing Atrophic Scar Attenuation Treatment (plasma)
• Micro Needling Atrophic Scar Attenuation Treatment
• RF Micronnedling
• Cosmetic Peels Atrophic Scar Attenuation Treatment.