Treating Acne Scars with Punch Excision

Written by Quynh-Giao Sartor, MD, Board Certified Dermatologist on March 28, 2022 2 Comments

punch excision

After controlling their acne, many patients are left with deeply indented acne scars that can be noticeable even with cover-up. While there are many different treatment options for acne scarring including IPL and fillers, punch excision is an effective in-office procedure for more severe scarring. Various punch excision techniques can be used to reduce the appearance of wide and deep scars, converting them into linear scars that can be more readily concealed.  If considering treatment options for acne scarring, please read further for more information on punch excisions.

What is Punch Excision?

Punch excision is a minimally invasive in-office procedure that uses a round tool to transform indented scars into flat linear scars. The affected areas are first numbed with injection of a local anesthetic, commonly lidocaine. Then, a “punch” tool, which resembles a tiny cookie cutter, is used to remove the scar completely. The open area is then closed linearly with skin sutures, which ultimately results in a flat, linear scar.

Punch grafting is a modification to the punch excision. After the affected scar is removed with the punch tool, a graft of donor skin, typically taken from behind the ear or the earlobe, is placed over the excised area and held in place by skin sutures. This technique is reserved for extremely deep or wide acne scars that cannot be effectively closed in a linear manner with sutures.

Punch elevation is another modification to the punch excision that is also reserved for wider scars. Here,  a punch tool smaller than the original scar is used in order to raise the base of the scar and keep the edges of the original scar intact. Sutures are then placed to keep the base of the scar elevated.

How is Punch Excision Performed?

Prior to punch excision, the area to be treated is numbed with a local anesthetic such as lidocaine to minimize pain. Then, the surgeon uses a small, circular “punch” tool to puncture the top layer of skin and physically extract the scar. Punch tools come in different sizes, ranging from 1 to 12 millimeter, to best match the width of the scar. Remaining skin is then stitched together to close the hole left behind by the punch tool.

The flat scars resulting from punch excision are more likely to fade over time, particularly after skin resurfacing, and more easily covered with makeup.

What Results are Possible with Punch Excision?

Punch excision is a surgical procedure typically reserved for severe acne scars, specifically those resulting in skin indentation. These include ice pick scars, boxcar scars and rolling scars that are at least 1 millimeter wide.

Ice pick scars are deep, narrow scars that resemble the indentation made by an ice pick on wood. From a sideways cross-section, they appear triangular, with the edges of the scar pointing inward, forming a tip.

Boxcar scars appear as wide craters with sharply defined edges that run parallel to each other and perpendicular to the scar base. These scars can be rounded, oval, or polygonal in shape.

Rolling scars are craters with sloping edges. From a sideways cross-section, the edges curve into the base of the scar. The surrounding skin may further appear uneven or wavy. Punch excision is less effective for this type of scar due to its sloping edges and poor quality of surrounding skin.

While effective for ice pick, boxcar, and even some rolling scars, punch excision is not recommended for raised scars that are considered hypertrophic or keloidal.

Is Punch Excision Painful?

The most painful part of the procedure is the injection of the anesthetic in the beginning. Some report mild tenderness over the treated area after the anesthetic wears off, which starts several hours post-procedure. For a few days following treatment, the area may be sore or sensitive as wounds heal.

What is Punch Excision Recovery Like? 

Aside from mild discomfort, most patients resume normal activity after the procedure. A bandage is placed on the treated area and must be keep clean and dry for 24 hours following the procedure. Afterwards, the treated areas can be left un-bandaged. Direct sun exposure must be avoided for 1 week. Swelling and bruising is common through week 2. Complete wound healing generally takes 3 months.

What are the Side Effects of Punch Excision? 

Punch excision is a relatively low risk procedure requiring just local anesthetic. As with all surgical procedures, minor risk is involved, including bleeding, infection, skin hyperpigmentation, and new scarring. Detailed instructions are given after the procedure to minimize these complications.

Scarring: Punch excision will leave behind a scar, although this scar is usually more flat and preferable to the original. The resulting flatter scar can be minimized with skin resurfacing. In rare cases, the new scar after the punch excision can become more raised, requiring additional treatment to flatten.

Hyperpigmentation: With punch grafting, the grafted skin may not be an exact color match or may respond different to sun exposure as the surrounding skin. If undergoing a punch grafting, strict sun avoidance and protection will be key to preventing the grafted skin from becoming a different color than the skin surrounding the graft.

The following recovery tips are recommended to minimize risk of negative outcomes after procedure:

  • Minimize trauma to the treated areas
  • Keep the bandaged areas dry and clean for 24 hours
  • Apply the recommended healing ointments to the treated areas
  • Avoid sun exposure and wear broad-spectrum SPF daily

Are Multiple Treatments Required?

Punch excision is generally a one-time procedure. In many cases, scars will resolve on their own following the treatment. In some cases, patients may wish to further revise their punch excision scars with a skin resurfacing treatment such as any of the following:

Are Punch Excision Results Permanent?

Punch excision results are indeed permanent as the treatment completely removes the indented original scar tissue, resulting a flatter and more cosmetically favorable scar.

Quynh-Giao Sartor, MD

Quynh-Giao (QG) Sartor, MD is a Board Certified Dermatologist who obtained a Medical Doctorate and completed her internal medicine internship and dermatology residency at Baylor College of Medicine (BCM) in Houston. Dr. Sartor’s professional expertise includes medical dermatology as well as in-office cosmetic and surgical procedures. Dr. Sartor is passionate about connecting with patients, practicing open communication, and customizing a personalized plan for her patients.

2 Responses to “Treating Acne Scars with Punch Excision”

  1. Avatar Jean says:

    Question- Does punch excision leave behind a small white scar or just a smaller scar than before?

    ALso, can it be used for small white scars that are not responding to treatments?

    Thank you.

  2. WD Staff WD Staff says:

    Great question Jean, thanks for reading out post and submitting it! We passed it on to Dr. Sartor and here is her guidance on the matter:

    Punch excision would let to a flat scar that is smaller than the original scar being corrected. It is most used for atrophic scars (scars that divot into the skin) but it can be used to correct larger white scars.

    I hope that helps!

    WD Staff

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