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Surgical Treatment of Facial Acne Scars Based on
Morphologic Classification: A Brazilian Experience
B OGDANA V ICTORIA K ADUNC , P H D,
AND
A DA R EGINA T RINDADE
DE
A LMEIDA , MD
Dermatologic Clinic, Hospital do Servidor Publico, Municipal de Sa˜o Paulo, Brazil
BACKGROUND. Acne scar treatment remains a challenge in the
medical literature. It is very difficult to compare the efficacy of
different therapeutic approaches because of the lack of
consensus regarding acne scar description and classification.
OBJECTIVE. To establish a morphologic classification of acne
scars and to assess the efficacy of different therapeutic options
based on scar type.
METHODS. During an 8-year period, 228 patients were prospectively studied. Their acne scars were morphologically classified
and customized, staged rehabilitation programs were established
for each patient. The assessment of treatment efficacy was
conducted 18 months after the end of treatment and was based
on patients’ and physicians’ opinions ranked on a semiquantitative basis as percentage of improvement from baseline.
RESULTS. Among the 168 patients who finished the study, 26
completed three stages of the treatment plan, and 142 were
submitted to one or two therapeutic stages, depending on lesion
types. Eighty-six percent of the patients considered the results
excellent or good compared with 76% by the authors and 78%
by three independent dermatologic surgeons.
CONCLUSION. The classification and the staged therapeutic plan
for acne scarred patients facilitated treatment and improved
outcomes and may allow development of protocols by
comparing results among different authors.
B. V. KADUNC, PHD, AND A. R. TRINDADE DE ALMEIDA, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITH
COMMERCIAL SUPPORTERS.
ACNE IS an extremely common pilosebaceous disorder. In spite of the numerous therapeutic options,
undesirable sequels are frequent and interfere in
patients’ psychological profile.
Acne scars were traditionally and indiscriminately
treated by ablative techniques, such as chemical
peels1 and dermabrasion,2 but soon it was noticed
that some patients did not show any improvement,
even after aggressive procedures. The disappointment
led the surgeons to search for new options; various
surgical techniques, including laser resurfacing,3–5
have been used to treat acne scars. However, no
standardized method has ever been followed. As a
result, it is impossible to compare treatment approaches, mainly because of lack of consensus in the
literature, concerning acne scars nomenclature and
classification.
The objectives of this article are to propose a
morphologic acne scar classification and to assess the
efficacy of different therapeutic options based on acne
scar types.
Correspondence and reprint requests to: Bogdana Victoria Kadunc,
PhD, Rua Gaivota 91, apto 71, CEP 04522-030, Moema, Sa˜o Paulo, SP,
Brazil, or e-mail: bog@uol.com.br.
Methods
During an 8-year period (from January 1, 1993, to
January 30, 2001), 228 consecutive patients with mild
to severe facial acne scars referred to the Dermatologic
Clinic of Hospital do Servidor Publico Municipal, Sa˜o
Paulo, Brazil (86 patients), and to the private practice
of the authors (142 patients) were enrolled in this
prospective study. The exclusion criteria were recent
systemic therapy with isotretinoin or previous procedures to repair acne scars. Patients’ age ranged from
16 to 54 years; 137 were female subjects (60%), and
91 patients were male (40%). The Fitzpatrick phototypes varied from II to VI. An informed consent form
was signed by all patients before entering the study.
Previous, intermediate, and posttreatment photographs were taken using the same camera and lighting
settings, type of film, patient positioning, and developing process.
At the first visit, patients were examined with
oblique and superior light sources and had their acne
scars evaluated regarding the following aspects: location, number, shape (linear, round, star-like, punctiform), consistency (soft, hard, fibrotic), color,
distensibility, and relationship to the surrounding skin
(depressed or elevated).
Based on these characteristics and using terms
collected from the literature, acne scars were classified
r 2003 by the American Society for Dermatologic Surgery, Inc. Published by Blackwell Publishing, Inc.
ISSN: 1076-0512/03/$15.00/0 Dermatol Surg 2003;29:1200–1209
Dermatol Surg
29:12:December 2003
as (1) elevated, (2) dystrophic, and (3) depressed. Some
of them were further subdivided in order to facilitate
the indication of specific treatments, resulting in 11
distinct morphologic types.
Description of Acne Scars and Specific
Treatments Reported
1. Elevated scars. a. Hypertrophic lesions are raised
above the skin surface and are limited to the original
insult area. They are frequent in the mandibular,
malar, and glabellar regions (Figure 1) and can be reduced by steroid injections, direct or tangential excisions, or 585-nm flash-pumped pulsed dye laser sessions.6
b. Keloidal scars are found in patients with genetic
predisposition. Their dimensions exceed the initial
injury, and the scar grows to the side ‘‘in the shape of a
crab claw.’’7 They are common in the mandibular
arch, shoulders, and sternal region and are prone to
Figure 1. Hypertrophic scars: clinical and diagrammatic characterization.
Figure 2. Keloidal scars.
KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS
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recur. Keloidal scars are very difficult to deal with
because of their proliferating characteristics (Figure 2).
The therapeutic options are intralesional steroid or
bleomycin sulfate8 injections, subtotal excisions,9
cryotherapy,10 and X or b radiotherapy.
c. Papular are soft elevations, like anetodermas, that
are frequently observed on the trunk11 and mental area
(Figure 3). They can be treated by controlled CO2 laser
vaporization or light electrodesiccation of each papule.
d. Bridge is a fibrous string over healthy skin. This
kind of scars is common on the face and is treated by
tangential excision (Figure 4).
2. Dystrophic scars. These types of scars may have
irregular or star-like shapes with a white and atrophic
floor (Figure 5). They can also be represented by
fibrotic masses with multichanneled tracts that retain
sebaceous or pustular material. Direct excision5 under
primary elliptical or broken lines or even ‘‘M,’’ ‘‘Z,’’ or
‘‘W’’ plasties is required for their treatment.
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Dermatol Surg 29:12:December 2003
Figure 3. Papular scars.
Figure 4. Bridge.
Figure 5. Dystrophic scar.
3. Depressed scars. They are contour or volume de-
fects that can be (a) distensible and (b) nondistensible.
3.a.1 Distensible retractions After skin distension,
they remain attached only by the central
portion (Figure 6) through myofascial attachments that have to be released by undermining
or subcision.12 If necessary, a filling agent is
the next step of treatment.
3.a.2 Distensible undulations (valleys) They disappear completely after skin distension (Figure 7)
and are the best indication for dermal or
subdermal filling techniques, performed in one
or more sessions.
3.b Nondistensible depressions These do not disappear after skin distension and are characterized as
surface defects. These types of scars accumulate
make-up and sunscreen lotion, and the projection
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Figure 6. Distensible retractile scars.
Figure 7. Distensible undulated scars.
Figure 8. Nondistensible superficial scars.
of their margins casts a dark shadow on the
bottom. They can be subdivided into the following: (3.b.1) Superficial (dish-like) are shallow
defects (Figure 8) in which the only useful
therapeutic approach is isolated use of ablative
methods, including phenol chemical peeling,1
dermabrasion,2–13 chemabrasion,14 and CO23–15
or pulsed Erbium YAG4–16 laser abrasion. (3.b.2)
Medium (crater-like) has a scar base that is
relatively smooth and has normal color and
texture and wide diameter (Figure 9) and can be
treated by either of two ways: (1) the base is
surrounded and cut by biopsy punches17 or mini
blades, followed by elevation with forceps until
the clot formation, to keep it in the new position
or (2) the shoulders can be sculpted and beveled
to the peripheral skin by razabrasion18 (using the
razor blade as abrader), electrodesiccation19 or
CO2 laser vaporization. (3.b.3) Deep (ice-pick or
pitted scar) are narrow and fibrotic scars, with
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Dermatol Surg 29:12:December 2003
Figure 9. Nondistensible medium scars.
Figure 10. Nondistensible deep scars.
Figure 11. Tunnel.
sharp shoulders perpendicular to the skin. They
are epithelial invaginations that can reach the
subcutaneous layer (Figure 10). They have to be
excised by cylindrical punches, which have to be
large enough to involve the entire lesion. They
can be left to second intention healing or be
replaced by full-thickness grafts from the postauricular area, which are 25% to 50% larger
than the defect (punch graft technique).20–23
Direct closure of these small holes very frequently
leads to enlarged and unpleasant scars, unless
they are submitted to deep intradermal sutures.
(3.b.4) Tunnels are constituted of two or more ice
picks connected by an epithelized tract (Figure
11). They have to be excised but can also be
repaired by punch grafting.22
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29:12:December 2003
Study Design
After the morphologic classification, all studied
patients were submitted to skin conditioning with
sunscreens, a-hydroxy acids, and/or tretinoin agents
and then enrolled in a three-staged rehabilitation
program (Table 1).
Stage I: complementary techniques. In this stage,
patients were submitted to one or more of the
following procedures: intralesional steroid injections
addressing erythematous hypertrophic or keloidal
scars; focal light electrodesiccation to treat the papular
ones; tangential excisions to eliminate bridges and
nonerythematous hypertrophic lesions; direct (elliptical, broken lines, or W-plasty) excisions to improve
dystrophic areas; subcision to release distensible
retractions; punch elevation to raise medium nondistensible depressions; and punch grafting to correct
deep nondistensible scars and tunnels.
These techniques were performed in one to three
sessions (30 days apart) at least 6 to 8 weeks before
stage II intervention.
Stage II: ablative techniques. They were indicated to
treat patients whose scars presented nondistensible
superficial depressed pattern or to complement stage I
techniques. The methods used were as follows:
1. Chemabrasion: A full-face 35% TCA chemical
peeling was followed by regional motor-driven
dermabrasion on the most scarred cosmetic units.
This combined procedure facilitated mechanical
exfoliation and was useful to blend dermabraded
and nondermabraded regions, reducing demarcation lines, mainly on the eyelids and neck area.
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2. Full-face resurfacing: We performed two or three
passes using high-energy pulsed CO2 laser
(Coherent Laser Corporation, Palo Alto, CA)
equipped with computer pattern generator handpiece (CPG) in the Ultrapulse mode at 300 mJs,
60 W, with a density of 4 to 6. This method was
indicated mainly to flaccid skin patients.
Punch elevations or excisions frequently completed the
ablative processes, aiming at achieving the best
leveling grade. Antiviral and antibiotic systemic
therapy and semiocclusive dressings employing sterilized veil fabric and petrolatum jelly were used in the
preoperative and postoperative periods.24
In spite of the use of complementary techniques,
some severely scarred patients had to be submitted to
two ablative processes, with a 6-month interval
between them. In general, these patients had a large
number of dystrophic scars, ice picks, and tunnels.
Stage III: filling techniques. To correct distensible
undulated scars, we chose to use hyaluronic acid25
injections (Perlane and Restylane; Q-Medical, Inc.,
Uppsala, Sweden) to treat superficial (dermal) tissue
loss or microlipoinjections to treat deep (subcutaneous) tissue loss. This stage of treatment took from
one to several sessions or served as a sequential step
after the other previous ones.
Evaluation
As a follow-up procedure, all patients were examined
and photographed at 2-month intervals. The final
evaluation for assessment of treatment efficacy took
place 18 months after the beginning of the procedures
Table 1. Morphologic Classification of Acne Scars and Specific Procedures Employed in the Three-Staged Treatment Plan in
228 Patients
Scar Types
1. Elevated
a. Hypertrophic
b. Keloidal
c. Papular
d. Bridges
2. Dystrophic
3. Depressed
3.a.1 Distensible retractions
3.a.2 Distensible undulations
3.b.1 Nondistensible superficial
3.b.2 Nondistensible medium
3.b.3 Nondistensible deep (ice picks)
3.b.4 Tunnels
Specific Procedures
Intralesional steroid injections/tangential excisions (stage I)
Intralesional steroid injections (stage I)
Focal light electrodesiccation (stage I)
Tangential excision (stage I)
Elliptical, broken lines, or W-plasty excisions (stage I)
Subcision (stage I)
Hyaluronic acid/fat injections (stage III)
Ablative techniques (stage II)
Punch elevation (stage I)
Punch grafting (stage I)
Punch grafting (stage I)
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KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS
Figure 12. Dark-skinned patient with nondistensible medium scars.
Figure 14. Final results after punch elevation and dermabrasion.
Table 2. Evaluation of Acne Scar Improvement
Excellent: when improvement of 75% or more was observed in all
four analyzed variables
Good: when improvement between 50% and 75% was observed in
all four analyzed variables
Unchanged: when improvement below 50% was observed in all
four analyzed variables
Poor: worsening of the characteristics of the four variables
analyzed variables: (1) a reduction in number of scars,
(2) a reduction in deepness of scars, (3) an improvement of color uniformity, and (4) a reduction in
retention of sebaceous material. The authors and the
independent dermatologic surgeons assessed improvement similarly, except for item four. The authors based
their judgement of improvement on clinical data and
photographic evaluation, whereas the surgeons not
involved in the study based their opinions on blind
analysis of pretreatment and posttreatment photographs.
The final results were rated as excellent, good,
unchanged, or poor, as a percentage of improvement
from baseline, based on a semiquantitative scale (Table
2). Chi-square statistical analysis was used to compare
the three treatment efficacy evaluations.
Figure 13. Postinflammatory hyperpigmentation after dermabrasion.
Results
(Figures 12–14) and collected the opinions of patients,
the authors, and three dermatologic surgeons not
directly involved in the study.
Patient self-assessment consisted of their subjective
impression of the percentage of improvement of four
Out of 228 patients initially enrolled in the series, 168
(74%) completed the study. Forty patients (24%) were
classified as phototype II, 58 (34%) as group III, and
70 (42%) as groups IV, V, and VI. The majority of the
patients presented morphologically heterogeneous
acne scars, but type 3 (the depressed scars) was
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KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS
predominant in this population. The elevated and
dystrophic types were less frequently seen.
Table 3 shows the number of patients in each
treatment stage. Out of the 168 patients who finished
the study, 46 (27%) were treated with complementary
techniques, and 40 (24%) were submitted to resurfacing or chemabrasion only, whereas 21 (13%) received
soft-tissue augmentation. Thus, 107 (64%) patients
covered only one step of the treatment plan. Thirtyfive (21%) patients were treated using two of the
therapeutic stages, and 26 (15%) completed the three
stages. Of 89 (53%) patients that needed ablative
methods, including the 12 (7%) most severely scarred
subjects, who required two sessions, 25 were classified
as phototype II, 30 as type III, and 34 were included in
IV, V, and VI Fitzpatrick groups.
The results analyzed by the overall impressions of
patients, the authors and the dermatologic surgeons
are presented in Table 4. In their self-evaluation, 144
patients (86%) considered the results excellent or good
compared with 128 (76%) by the authors and 131
(78%) by the panel of dermatologic surgeons.
Based on chi-square analysis, there were no
statistically significant differences (P 5 0.3113) among
the evaluations of the three groups.
Common adverse events assessed on the 2nd month
were observed in 54 (32%) patients and included
herpes simplex flares (5 patients), milia formation (11
Table 3. Number of Patients Submitted to Each Treatment
Stage
Stage I
Stage II
Stage III
Stages I1II
Stages I1III
Stages II1III
Stages I1II1III
Stages I1II1II1III
46 patients 5 27%
40 patients 5 24%
21 patients 5 13%
16 patients 5 10%
12 patients 5 7%
7 patients 5 4%
14 patients 5 8%
12 patients 5 7%
Table 4. Impressions of 168 Patients, Authors, and Three
Dermatologic Surgeons Not Directly Involved in the Study
on Efficacy of Acne Scar Treatment Based on Morphologic
Classification
Excellent
Good
Unchanged
Poor
Patients
Authors
Independent
Dermatologic
Surgeons
45 (27%)
99 (59%)
17 (10%)
7 (4%)
33 (20%)
95 (56%)
25 (15%)
15 (9%)
41 (24%)
90 (54%)
25 (15%)
12 (7%)
1207
patients), and transient postinflammatory hyperpigmentation. The later was observed in 38 (42%) of the
89 patients submitted to ablative methods. Among
them,8 patients were classified as phototype III and 30
as IV, V, and VI Fitzpatrick types. Stage II procedures
were more frequently associated with adverse effects.
True complications assessed on the 18th month
were observed in 14 (8%) patients and included
postexcision widening of scars (10 patients), demarcation lines (3 patients), and residual hypopigmentation
(1 patient).
Discussion
Treating acne scars, according to Fulton, ‘‘is perhaps
the most difficult cosmetic surgery procedure that
exists.’’26 It is really challenging to achieve total
correction of tissue destruction caused by severe
inflammatory acne, which can destroy the epidermis,
dermis, and the underlying fat. The main treatment
goal is to obtain as much improvement as possible
rather than perfection.
After studying acne scars in different articles, we
noticed that authors have been using their own acne
scar denominations. There is no reproducible method
that encompasses the majority of acne scar types and
correlates the lesions and the specific techniques used
to repair them.
Ellis and Mitchell27 suggested the use of the words
ice picks, craters, undulations, tunnels, shallow-type
and hypertrophic scars, whereas Koranda7 referred to
craters or pits, ice picks, keloidal and hypertrophic
scars. Goodman,28 based on pathophysiologic findings, suggested that atrophic postacne scarring could
be divided into superficial macular, deep dermal,
perifollicular scars, and fat atrophy. Langdon,29 in
turn, described three types: I, small diameter shallow
scars; II, ice picks; and III, distensible scars. Jacob et
al.30 referred to other three different subtypes: ice pick,
rolling, and boxcar.
The most frequently described lesions are the
depressed ones, indiscriminately referred as pitted or
atrophic acne scars,3–20 with few references to other
morphologic patterns.
Historically, acne sequels have been treated by
ablative techniques such as deep chemical peels,1–19
dermabrasion,2–5 and more recently, resurfacing procedures with CO23,15,31,32 and Er:YAG4–16 lasers or
their combination.33 However, according to the
literature, the results of isolated ablative techniques
are extremely variable, presenting outcomes that range
from 25%,34 40%4 to 81.4%.3
In 1941, Eller and Wolff,19 after performing phenol
peelings to treat acne scars, noticed this fact and
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KADUNC AND TRINDADE DE ALMEIDA: ACNE SCARS
recommended beveling the ‘‘cuplike scars’’ edges by
electrodesiccation or shaving. Nowadays, the consensus is that acne scars cannot be effectively corrected by
one single treatment modality because of the wide
variety. Multiple other methods have been added to
ablative techniques, including injections of collagen,35
silicone,36 or fat,37 excision with primary closure,5
facelifts,27,28 punch elevation,5–17 and punch excision
with full-thickness graft replacement.20–23
Different authors have also tried to facilitate acne
scar treatment by suggesting schematic diagrams that
correlate scars morphology and treatment,21,30–38
whereas others have used sequential therapeutic plans
in treating theses scars. Whang and Lee32 suggested
three stages: 1, 50% TCA focal chemical peeling in
pitted areas; 2, CO2 laser vaporization 1 to 3 months
later, and 3, full-face dermabrasion 6 to 8 weeks later.
Conversely, Jacob et al.30 did not suggest definite
stages, as they considered that by performing punch
excision, punch elevation, subcision, and laser skin
resurfacing would be enough to reach good results in
any type of acne scars.
Fulton and Silverton37 preferred multiple approaches such as subcision, small-volume fat transfer,
laser resurfacing, dermabrasion, excision, and grafting—all of them performed at the same surgical time.
In this study, we proposed a more comprehensive
classification, encompassing most of the different types
of acne scars and unifying the literature terminology.
In our three-staged treatment plan, we used at least
eight different therapeutic modalities to reach appropriate improvement of acne-scarred patients. In our
opinion, it is safer to perform the procedures at
different times, which allows better understanding of
patients’ psychological profile and guarantees their
compliance and confidence.
Another difficult issue is the evaluation of the results.
Reviewing the literature, we found that Jordan et al.39
tried to assess the effectiveness of laser resurfacing
treatment for facial acne scars. They concluded that
there is a need of ‘‘good quality randomized controlled
trials with standardized scarring scales’’ in order to
compare treatment results among different articles.
Objective methods such as comparative counting
and measuring of lesions in specific areas13 and
analysis of textural skin changes applying optical
profilometric programs3 were recently introduced in
the medical literature. Nevertheless, we noticed that
most of the studies published on acne scars treatment,
ranked the improvement in scales that translated
opinions of authors and independent physicians.4,16,31
This is a result of the difficulty to count the
innumerous lesions that can be present in acne scarred
faces. For this reason, in our study, which was initiated
8 years before, we chose the same criteria.
Considering the 168 (74%) patients that completed
the staged treatment plan and returned for the final
evaluation, it was observed that acne scar improvement caused a very positive psychologic impact on
these frequently stigmatized people, building their selfesteem.
Seventy-nine (47%) patients with predominant
distensible lesions, craters, or ice picks were treated
by filling or focal techniques and did not undergo
ablation. This possibility enhanced treatment compliance because patients did not have to be away from
their professional or social activities, and no pigmentary alterations occurred, even in dark-skinned individuals.
Conversely, the most commonly observed adverse
event (transient postinflammatory hyperpigmentation)
was observed in 42% of the 89 patients submitted to
chemabrasion or laser resurfacing. The problem was
always detected by the 3rd week after the ablative
procedure and occurred in 27% of the patients
classified as phototype III and in 88% of patients
who were phototypes IV, V, and VI. These values may
be explained by the high percentage of mixed ethnicity
and dark-complexion people in the Brazilian population; the problem was easily solved within 30 days
with tretinoin-hydroquinone combined creams. No studied patient presented long-lasting hyperpigmentation.
Although the three independent treatment efficacy
evaluations classified the outcomes as excellent or
good improvement in more than 76% of the patients,
our results cannot be compared with the literature
because of lack of standardized and worldwide
accepted acne scars classification.
We believe that the systematic application of the
staged treatment program in 228 patients, followed by
long interval evaluations, provided good experience
and improved the authors’ clinical and surgical
accuracy. The unified classification of scar types
facilitated the correct selection of the best therapeutic
option for each specific scar.
Conclusion
The classification based on morphologic patterns and
the staged therapeutic plan for acne-scarred patients
facilitated the treatment, improved the final outcomes,
and may allow development of protocols comparing
results among various therapeutic approaches and
different authors.
Acknowledgment The authors thank Maria Helena Kiss, MD,
PhD, for her suggestions and Luciana Gadelha, MD, for the
drawings.
Dermatol Surg
29:12:December 2003
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