What order should acne scar treatments be done in?
My advice is to address the deepest problems first and then focus on surface treatments. The contour of the acne scars should be corrected before they are resurfaced, since resurfacing cannot correct a scar that is tethered or deeply depressed and performing it first wastes a session. In practice this generally means subcision, then TCA CROSS or punch excision, then fractional laser.
Subcision comes first because a tethered scar is being held down. Until the fibrous bands beneath it have been divided nothing will lift it: not filler, which is working against the tether, and not laser, which treats only the surface. Resurfacing a tethered scar polishes the interior of a depression and the depression remains. Releasing the tether alters the shape of the problem, and every subsequent treatment works better.
TCA CROSS and punch excision address the scars that subcision does not, namely the narrow deep ones. TCA CROSS lifts the base of an ice pick or deep boxcar scar over several sessions, whereas punch excision removes a small number of very deep scars outright. Both can be performed at the same visit as subcision or shortly afterwards, and both leave marks of their own which heal over weeks. Resurfacing can help to blend in these marks and this is another reason for performing them before resurfacing.
Once the contour has been corrected what remains is surface irregularity, some of it created by the earlier procedures, and this is precisely what fractional resurfacing does well. Used at this point it evens everything out; used first it is treating the wrong problem.
It is therefore more useful to think in terms of a sequence of treatments. The commonest reason patients spend a great deal and see very little is that they purchased the last step first. My overview of acne scar treatment sets out how the plan is tailored to individual scar types.
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