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Acne Scars
Acne Scar Treatment


Acne Scar Treatment in Santa Monica with Kare Plastic Surgery using eMatrix laser and Fraxel laser

Acne scars can vary from individual to individual.  There are three basic types of acne scars, with variations in between each category. Some scars are atrophic, which means that there is a definitive loss of collagen in the dermis that has caused the skin to indent.  Other acne scars are either red (hypervascular) or brown (hyperpigmented).  In addition to the acne scars, Dr. Karamanoukian also emphasizes the need to treat the active acne.  New research has shown the benefits of a low glycemic load diet and abstinence of dairy products in the short and long term maintenance of acne breakouts.


Acne scars are difficult to treat and can be varied in terms of their presentation.  Acne scars can be red, brown, and discolored or they can present with contour changes such as a hollowness or shallow pit.  Historically, acne scars were associated with names, such as ice-pick scars or box-car scars, but Dr. Raffy Karamanoukian prefers to discuss acne scars in terms of their depth to width ratio that he developed to eliminate the confusion in discussing these scars.  The following is a partial list of different types of acne scars and we have included chicken pox scars as they are treated in a similar fashion. 


  1. Ice-Pick Acne Scars
  2. Box-Car Acne Scars
  3. Chicken-Pox Scars
  4. Keloids from Acne Scars
  5. Depressed Acne Scars
  6. Hypertrophic Acne Scars

A question that is often asked is 'What causes acne scars?' Well, to answer the question, you have to understand what happens during an acne breakout.  When a pimple erupts, a tiny pore becomes so enlarged and bacteria laden, that it forms a small pustule or cyst under the skin. If the cyst is located within the dermis (midportion) of the skin and pops, you are often left with a giant crater as a result of the entire process.  These craters are known as acne scars.  In practice, we see lots of patients with acne scars in our Los Angeles plastic surgery office and we can provide you with options to treat and resurface the scars.  If there is a lot of volume loss in the dermis, some patients will not only need recontouring of the skin, but a means of rebuilding the collagen that was lost in the dermis.  Other patients with acne scars will only need topical creams or minor laser acne scar treatments to balance out the color and thickness of an acne scar.  The options can all be explained to you in simple terms during your consultation with Dr. Karamanoukian or one of our skin care specialists. Schedule a consultation today by calling (310) 998-5533.

Acne is prevalent among healthy teenagers and adolescents. The long-term physical implications of acne include permanent facial scarring. Severe inflammatory acne can lead to scars on the face that may require treatment with lasers, skin resurfacing, and acne surgery.  Acne scars are caused by damage to the epidermis and dermis during the active healing phase of an inflammatory pustule.  There are two categories of acne scars, including atrophic and hypertrophic scars.  The majority of acne scars are atrophic. Atrophic scars are characterized by a loss of dermal integrity during the inflammatory phase of acne healing.


Atrophic scars are further characterized as ice pick, rolling, or boxcar scars.  Ice pick and boxcar scars account for the majority of permanent facial scarring resulting from inflammatory acne.  An ice pick scar has a high depth to width ratio, characterized by deep scars with a narrow diameter.  The opening of the scar is typically narrow as compared to the depth of the scar resulting in a V shaped skin deformity that is punctate in nature.  Rolling scars have a more gradual transition from the normal skin to the depth of the acne scar.  They are associated with tethering of the dermis to the subcuticular tissue as a result of fibrous scar attachments.  Usually they are wider than 3 mm to 4 mm and can be associated with contour irregularities of the skin.  Unlike rolling scars, boxcar scars have a more precipitous vertical edge on the periphery, which leads to more noticeability of the scars. Box car scars and rolling scars have a lower depth to width ratio and can cause permanent skin irregularities.


Hypertrophic and keloid scars are caused by an exaggerated collagen response during the acute phase of acne healing.  They are associated with collagen deposition and decreased collagenase activity.  In the early stage they may be red and firm but may gradually soften with time.  The more aggressive form of a hypertrophic scar is known as a keloid acne scar in which the scar extends beyond the plane of the skin.  Keloid scars on the neck and chin can cause physical deformity and contour irregularity.




  1. Remove discoloration of the skin associated with acne (red and brown spots).
  2. Resurface acne scarring and reduce contour deformities.
  3. Treat active acne. 
  4. Reduce future acne breakouts. 


  1. Laser Acne Scar Resurfacing: Fractional CO2 laser
  2. Ematrix Fractional RF - less downtime and skin damage
  3. Clear + Brilliant Laser: Mini Fraxel
  4. Microdermabrasion: DiamondTome Microderm
  5. Subcision: Release of tissue tethering and deep scar tissue
  6. Chemical Peels: ViPeel, Cosmelan, TCA, Melasma, Obagi Peel
  7. Facial Fillers: Juvederm, Perlane, Radiesse, Restylane, Belotero
  8. Vascular Pulse Dye Laser: VBeam, Candela Gentle Yag (Nd:Yag)
  9. TCA Cross technique for fine ice pick scars
  10. SmartXide DOT
  11. KareSkin Brightening Regimen


Dr. Raffy Karamanoukian performs a very meticulous procedure for acne scars that is known as subcision. Subcision is a surgical technique that is used to release tethering and fibrous scarring underneath an acne scar, traumatic scar, or surgical scar.  In some patients, scarring may lead to an overgrowth of fibrous collagen that acts to tether scars down, causing tiny contour defects that show on the surface of the skin.  In some cases, there is absence of dermal collagen that also accentuates the amount of contour deficit in the scar.  For both of these conditions, Dr. Karamanoukian performs subcision of acne scars in which he surgically releases the fibrous band of collagen with a very small beveled blade.  There are no resulting scars left by the procedure and the acne scars or dermal scars are improved. 

Subcision of scars is performed as an outpatient procedure by Dr. Raffy Karamanoukian under local anesthesia. During your consultation, Dr. Karamanoukian will discuss options for laser resurfacing, punch excision of scars, subcision, TCA cross technique, TAC injections, IIT, or pulse dye laser of your acne scars.  Most likely, Dr. Karamanoukian will recommend a combination treatment plan that incorporates several of these treatment modalities for improved results with your acne scars. We look forward to seeing you in our office. 

  1. What is subcision used for in terms of acne scars? Subcision is a meticulous surgical technique that is used to undermine scar tissue that tethers down and depresses acne scars.  It is ideal for fibrous scars that cause dynamic problems during facial expression, but can also provide outstanding results for boxcar and depressed valley scars on the face and neck.  Our office offers expertise in subcision for acne scars and can provide even the most severe cases an option for treatment.  During the procedure, a specialized needle is used to release scar tissue underneath an acne scar, thereby creating new collagen and decreasing collagen tethering.
  2. How important is VBeam laser acne scar treatment with VBeam laser? VBeam remains an important acne scar treatment for those patients with reddish or red acne scars on their back or face. Multiple laser treatments are required for full effect. 
  3. How many subcisions are needed for acne scars? The number of treatment sessions needed for subcision of acne scars depends on the severity of the problem.  Most patients will benefit from one treatment, but multiple treatments can provide additional improvement in depressed acne scars.  Patients may experience a recovery phase with collagen accumulation in the initial phase of acne scar recovery after subcision. 
  4. Can subcision be used for ice pick scars? Subcision is not ideal for ice pick scars.  However, Dr. Karamanoukian performs other treatments for isolated ice pick scars that can address this very difficult problem without prolonged recovery.  One of the most touted procedures for ice pick scars is a therapy known as TCA Cross method, which incorporates TCA therapy during the treatment. 
  5. How does Fractional CO2, Smart Xide DOT, and CO2 laser compare to subcision therapy? All of these techniques can be used in unison to improve an acne scar.  Dr. Karamanoukian incorporates all of these treatments in order to maximize your improvement without relying on single modality acne scar therapy.
  6. Can microdermabrasion improve acne scars? Acne scars are usually caused by atrophy of the dermis during the inflammatory cycle of pimple formation.  These scars can lead to contour irregularities and contour depressions that can cause pits in the skin that can either be narrow based or wide based.  Microdermabrasion is a cosmetic skin technique in which a mechanical abrasion device is used to gently exfoliate the skin and epidermis.  Although microdermabrasion will help improve pigmentation and the overall texture of the skin, it will do very little in terms of improving atrophic and pitted acne scars.  However, Dr. Raffy Karamanoukian, a board certified plastic surgeon and specialist in acne scar recommends microdermabrasion and hydrafacial treatment for improvement of the skin prior to acne scar treatment.  He performs acne scar revision with lasers including a CO2 fractional laser and the pulsed dye laser.  Both of these laser types target different aspects of an acne scar and improve the overall texture and color of your skin.  In combination with these acne scar treatments, Dr. Karamanoukian also performs acne scar surgery including subcision and acne scar release.  These procedures, in concert are beneficial for patients who have acne scars.  Dr. Karamanoukian recommends the hydrafacial treatment and the microdermabrasion treatment for those patients who have resistant acne and recurrent acne, even as an adult.  If you have questions about acne scar surgery or microdermabrasion treatments in Los Angeles with Dr. Karamanoukian, please call our Los Angeles plastic surgery patient care coordinator at 310-998-5533
  7. Can acne scars cause keloids on the face? Acne scars and active acne cause an inflammatory reaction on the jawline and face which may lead to permanent keloid scars.  The inflammation from the cystic acne and cumulative acne scar formation can contribute to the development of thickened keloid scars.  The areas that are particularly forms keloid scars are the cheeks and the jawline.  Once the acne is uncontrolled, the development of keloid scars may progress to a point where they may limit normal movement of the jaws and neck.  Thickened keloid scars on the jawline and chin areas are frequently associated with keloids and can cause severe and permanent scarring.  Dr. Raffy Karamanoukian is an expert in keloid management in the Los Angeles area and performs keloid treatment in his Los Angeles plastic surgery office.  Please call our plastic surgery patient care coordinator to discuss options for keloid surgery or acne treatment related to keloid scars.  Consultations are available by calling 310-998-5533.
  8. What are the most common types of acne scars? There are indented and raised acne scars. The most common types include ice pick scars, box car scars, rolling or valley scars, and hypertrophic scars. Some patients will also get keloid scars from acne on the chest or back. 


CO2 laser resurfacing

Our office performs the Fractional CO2 laser resurfacing system SmartXide for acne scars and traumatic scars of the face, chest, and back.  This innovative laser has been featured on NBC, Fox TV and Vogue Magazine. The laser resurfaces the skin and improves acne scars and skin depressions caused by traumatic scars or surgical scars. The treatment does require pretreatment with topical creams and works by ablating surface irregularities, thereby smoothing scars.

  1. Is there a role for Fractional CO2 laser peel treatment for acne scars? There are many different reasons why acne scars are currently being treated with Fractional CO2.  The laser peel works well to resurface and tighten skin inundated with acne scars.  The laser works well to improve skin texture, improve collagen production, resurface skin, address atrophic scar tissue, and reduce pigmentary changes associated with acne scars.  Our office uses the Fractional CO2 laser in cases of mild acne scar irregularities, rolling scars, boxcar scars, valley scars, and even hypertrophic and shiny scars with surface changes. 
  2. Can Fractional CO2 be used in darker skin complexions? Dr. Raffy Karamanoukian is internationally known for his expertise in dark skin complexions and pigmentary skin issues.  He has lectured to international and national audiences about skin pigmentation and discoloration.  An appropriate treatment with Fractional CO2 may include a pre and post-therapeutic regimen with a Skin Brightener protocol. He utilizes his expert protocol for skin pigmentation during his consultation and treatments with the Fractional CO2. In our Los Angeles plastic surgery office, we employ and pre and post treatment skin protocol to address  melanocyte activity prior to your Fractional CO2.  If you are considering acne scar treatment, your consultation will address the appropriateness of laser therapy within the context of your skin color. 
  3. What are some of the best treatments for acne scars? A study from the Department of Dermatology from the University of Zagreb Croatia discussed the newer approaches to acne scar treatment and found that the best treatments included chemical peels, lasers, light therapy, and cryotherapy, among other available treatments.  The authors note that none of the currently available options may achieve complete resolution of the scar.  At Kare Plastic Surgery, we offer laser, light based, chemical peel, and laser resurfacing acne scar treatments in addition to subcision, acne scar surgery, and surgical excision and punch grafting of acne scars.  Some patients also benefit from TCA cross techniques for deep scars. 



Microdermabrasion is an outstanding dermatologic treatment for the improvement of skin tone, skin complexion, and clogged pores.  The utility of microdermabrasion has been expanded to include treatment of some acne scars and epidermal melasma.  The severity of acne scars will dictate the utility of microdermabrasion in improving the appearance of the scars.  Deep dermal acne scars cannot be improved with microdermabrasion because microdermabrasion does not penetrate into the papillary dermis and thus cannot effectuate a deep improvement in skin contour.  However, microdermabrasion is useful for more superficial acne scarring as a result of hyperpigmentation, closed comedones, and active acneic cysts.  One of the most important aspects of acne scar improvement includes treatment of any active acne. 




One of the most innovative advancements in acne scar treatment has been the introduction of the eMatrix Fractional treatment by Kare Plastic Surgery. Using the advanced eMatrix RF treatment, sublative energy is used to build collagen deep within the dermis and epidermis to improve atrophic acne scars and contour problems of the skin. Useful for acne scars on the facial skin that have caused contour irregularities. 


Ematrix uses fractional RF to successfully treat acne scars and large pores on the face. Ematrix is the top acne scar treatment in Los Angeles


The benefits of sublative eMatrix treatments are many.  The most benefical to patients is that eMatrix delivers powerful sublative energy to the skin without the downtime seen with traditional fractional lasers such as Fraxel or Fractional CO2.  Ematrix is the top fractional treatment available for atrophic acne scars such as valley scars, ice-pick scars, box car scars, and rolling acne scars. Fractional RF can target the deeper layers of skin, inducing collagen formation to help level-out the skin and smoothe superficial irregularities in contour. 


Q: Is the Ematrix useful for acne scars?

A: Ematrix is among several different non-laser treatments available for acne scars. In our Santa Monica office, we offer chemical peels, topical treatments, Ematrix fractional RF, subcision, and acne surgery to help improve atrophic acne scars on the skin.  



A method known as TCA cross is a technique that has been refined for the treatment of ice pick acne scars.  For those of you who have acne scars and are unsure of the type of acne scar you have, ice pick acne scars are defined as very small but deeply pitted contour scars on the surface of the skin.  They usually represent an old inflamed pore that has become atrophic and sunken in. 


Most ice pick scars are not associated with hyperpigmentation, but there may be overlying valley scar and box scar acne scars in the vicinity.  The major problem with ice pick scars are their high depth to width ratio and their presence on the central part of the face.  Most commonly, common acne scar treatment such as subcision, microdermabrasion, dermabrasion, and laser peels are minimally effective on ice pick scars. 


A technique known as TCA cross can be used to treat ice pick acne scars effectively within a couple of sessions.  This technique employs a highly concentrated form of TCA chemical peel which is directly placed on to the deep acne scar.  The technique must be meticulously performed with magnifying loops in order to prevent spillage of the highly concentrated medicine on to the surrounding tissue.  Although beneficial for ice pick scars, TCA cross must be performed in association with other scar revision techniques in order to refine and enhance the overall appearance of the scar.  If you have questions about acne scar treatment in our Los Angeles Plastic Surgery office, subcision, TCA cross method for acne scars, or acne surgery, please call our plastic surgery office at 310-998-5533.


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