Microsurgery for acne scars

1. What is the microsurgery or micropunch technique for the elevation or excision of acne scars?

It is a procedure, described by Dr. Didac Barco, that uses follicular unit extraction (FUE) micropunches to treat deep atrophic icepick and boxcar scars, difficult to improve with laser treatments. Titanium micropunches (circular scalpels) of different diameters are used to adjust their size to each of the scars.

2. What advantages does this technique have over previous ones?

Unlike CO₂ laser resurfacing or the CROSS technique with TCA, which can be ineffective on scars more than 1 mm deep, this technique allows correction by raising or removing the scar. In addition, the use of small-diameter micropunches allows a perfect adaptation to the shape and size of the scar.

3. What are the main indications of this technique?

It is indicated for patients with atrophic icepick and boxcar acne scars more than 1 mm deep and up to 2 mm in diameter, especially in cases where conventional treatments have not given good results.

4. So, can all acne scars be treated with microsurgery?

No. Only those with very defined edges, with a depth greater than 1 mm and a diameter of less than 2 mm. Interestingly, this type of scar is usually a therapeutic challenge and, to date, was very difficult to treat. Thanks to this technique, a therapeutic line of great interest for the patient has been opened.

The essence of this technique is to adapt the diameter of each scar to that of the punch, in order to be able to raise or remove it in its entirety.

5. What type of acne scars does this technique not have a role for?

For rolling scars; boxcar of more than 2mm in diameter or icepick/boxcar of less than 1 mm deep. These can benefit from subcision or the _CO2 laser technique on target.

6. What is the origin of this technique?

The treatment of boxcar or icepick scars with punch has been used for decades. Dr. Didac Barco has innovated it by using circular scalpels that are used in hair transplantation, making the chances of residual scarring much lower. The postoperative period, compared to older options, is also clearly better.

7. How is the procedure performed step by step?

Application of local anesthesia.
Selection of a micropunch with a suitable diameter.
Incision with the micropunch to the hypodermis.
Shape adjustment if the scar is not circular.
Control of hemostasis with gauze impregnated with tranexamic acid solution.
Lifting or excision of the skin with precision tweezers.
Fixation with Steri-Strips.
After 15 days, removal of the Steri-Strips and resurfacing with fractional CO₂ laser if necessary.

*Notice how, after the intervention, the floor of the scars is even with that of the surrounding skin.*

8. What are the diameters of the micropunches used?

Fully customized for each of the patient’s scars. Micropunches of 0.75 mm, 1 mm and 1.25 mm in diameter are usually used, selected according to the size of the scar to achieve an optimal fit.

9. Is it necessary to put stitches on the treated scars?

No. Another advantage of this technique is that it does not require stitches, as the holes are so extremely thin. It is necessary to cover them for two weeks with surgical bandages to reduce the risk of dehiscence.

10. What are the potential complications?

The main complications include infections, post-inflammatory hyperpigmentation and abnormal scarring. However, these can be minimized with correct surgical technique and adequate postoperative care. Compared to larger excisions or extensive classical CO2 laser resurfacing, the risks are very lower and the effectiveness greater if the scars to be treated are properly selected.

11. What results have been observed with this technique?

Better results have been obtained in the correction of deep icepick and boxcar scars compared to previous techniques. Elevation or excision of the scar, followed by laser resurfacing, provides a significant improvement in the texture and appearance of the skin. Similarly, the complication rate and postoperative period are drastically reduced.

*Response after a single microsurgery session together with CO2 laser with target technique.*

REFERENCES

· Barco D, López Sanz P, Mir-Bonafé JM. How We Do It: Follicular Unit Extraction Micropunch for Elevation and Excision of Deep Icepick and Boxcar Acne Scars. Dermatol Surg. 2025 Feb 26.

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