Ask ten people with acne scars what they want and nine will say "smooth skin." Ask a dermatologic surgeon what kind of scars they have and the answer is more specific, because "acne scar" is not one problem. It is at least three different shapes of damage, sitting at different depths, held down by different structures, and each one reacts differently to the tools most clinics offer. A tool that planes the edge of a shallow depression can do very little for a narrow puncture that runs deep into the dermis. A laser that remodels collagen well may leave a tethered, rolling scar looking much the same. Treating the wrong scar with the right tool is the commonest reason people say that "nothing worked."
This guide is organized around the scars, not the machines, and it covers every form of laser resurfacing only as far as it helps a particular shape. It describes how to tell what you have, what each approach physically does to that shape, why the order of treatments matters, what healing looks like for resurfacing, and where honest limits sit.
The anatomy of an acne scar: why shape matters more than severity
Acne scars are mostly atrophic, meaning they sink below the surrounding skin. During active inflammation, the body breaks down collagen and then rebuilds it unevenly. If it rebuilds too little, the result is a depression. If it anchors the skin to deeper tissue with fibrous bands, the result is a tethered depression that stays down no matter how the surface looks. A smaller share of scars are raised, either as hypertrophic scars or keloids, and these are a different category entirely.
Three atrophic shapes account for most of what patients present with.
Boxcar scars are round or oval depressions with sharp vertical edges, like a small crater with steep walls. They are broader than ice pick scars and often cluster on the temples and lower cheeks. Depth varies from shallow to quite deep.
Rolling scars are broad, shallow, wave-like undulations with gently sloping edges. They give the cheek a rippled look, particularly in raking light. Fibrous bands tether the skin beneath, which is why they can seem to appear and disappear as expression changes.
Ice pick scars are narrow, deep, V-shaped punctures, usually under two millimeters wide, that taper into the dermis and sometimes beyond it. They look like small open pores and are the hardest of the three to correct.
Many people have a mixture, and the proportion matters more than a severity grade. A face with mostly shallow boxcars is a very different project from a face with rolling scars and a scattering of ice picks.
Before choosing a tool: the checks that decide everything
Several things that have nothing to do with the scars themselves set the boundaries of treatment.
Active acne should be under control first. Resurfacing a face that still produces new inflamed lesions adds new scars to the old ones. This is not a small point; it is why a plan for scars often begins with the skin's current behavior.
Skin tone and tendency to pigment matter a great deal. Heat and inflammation can trigger lasting pigment changes in some skin types, and some resurfacing methods carry more of that risk than others. A careful practitioner asks about prior pigment problems, sun exposure, and how the skin has responded to previous procedures.
Medication history matters. Recent use of certain oral acne medications has traditionally prompted a waiting period before resurfacing, though the specific advice has been debated and varies between clinicians. The right answer for any person comes from their treating physician and not from a general article.
Finally, there is the question of what has been done already. A face that has had a series of mild treatments and plateaued needs a different conversation from one that has never been treated.
Dermabrasion: what it actually does, and where it fits
Dermabrasion is mechanical resurfacing. A rapidly rotating abrasive instrument removes the surface layers of skin to a controlled depth, and the skin heals from the deeper structures that remain, including the hair follicles and sweat glands. In the right hands it is among the oldest and most reliable ways to reduce the visible edges of scars.
Its particular strength is the sharp edge. A boxcar scar has a vertical wall; planing the surrounding skin down toward the floor of the scar blends the edge into its neighbors. Because the instrument is controlled by the surgeon's hand, it can be applied focally, concentrating on a cluster of scars on the temple while leaving the unaffected skin alone. The effect on the depth of the scar floor is more modest, which is why it works best when the scars are shallow to moderate and have defined shoulders.
Dermabrasion is a deeper intervention than most superficial treatments. It generally involves local anesthesia, sometimes with sedation, an open wound that heals over days to weeks, and a period of redness that can last for months. Because it is operator dependent, the skill and experience of the person using the instrument are not incidental. A dermabrasion consultation should include a frank discussion of depth, expected healing and what the procedure cannot do.
Where it struggles: narrow ice pick scars, which extend below the depth that can safely be abraded, and rolling scars, whose problem is tethering beneath the surface, not a sharp edge on top.
Fractional CO2 laser: remodeling collagen in columns
A fractional CO2 laser works differently. Instead of removing the whole surface, it creates thousands of microscopic columns of vaporized tissue, leaving bridges of intact skin between them. The body responds by repairing those channels and remodeling collagen over the following months. Because the intact skin between the columns speeds healing, recovery is generally shorter than with full-surface ablation.
For acne scars, this gives several advantages. The depth can be tuned. The treated area can be extended to the whole face or limited to specific regions. Texture, fine lines and some pigment can improve alongside the scars. And the collagen remodeling continues for months after the visit, so assessments made too early undersell the result.
The technique has limits. It is best suited to scars that are shallow to moderate, and multiple sessions are common. Deep scars may need several passes over time, and each pass has its own healing period. The method does not release tethering, so rolling scars often need other treatment. And like any heat-based treatment, it requires thought in people prone to pigment change. Settings are chosen around scar depth and skin tone, and the first two weeks of healing with fractional CO2 resurfacing are mostly redness, dryness and flaking that a good CO2 laser plan prepares you for in advance.
Radiofrequency microneedling: a gentler way to stimulate collagen
Microneedling creates tiny controlled channels in the skin with fine needles, triggering the wound healing cascade and new collagen. Adding radiofrequency energy at the needle tips delivers heat into the deeper dermis while sparing the surface, which lets the treatment reach layers a plain needle cannot.
For acne scars, radiofrequency microneedling is often chosen for patients who want less downtime than ablative lasers or dermabrasion, or who have skin types where surface heat is a concern. Because the epidermis is largely preserved, healing is quicker, and the redness typically settles within days. The tradeoff is that the change per session is gentler, so a series of treatments spaced weeks apart is the usual plan. Devices differ in how deeply they deliver energy and how the energy is shaped, so RF microneedling with a platform such as Potenza is chosen by needle depth and energy level for each region of the face.
This is a good fit for shallow scars, mild texture irregularity and pores, and as maintenance after more aggressive resurfacing. It is a weaker fit for deep boxcars and ice picks, where it can improve overall skin quality without changing the scars' depth much.
Adding PRP: does the biology of your own platelets help?
Platelet-rich plasma is made from a small blood sample, spun to concentrate the platelets that carry growth factors. Applied to the skin after microneedling or injected, it is thought to support healing and collagen production. Some practices combine it with microneedling, a pairing used in Morpheus8 sessions.
The evidence for PRP in acne scarring is encouraging but not conclusive, and results vary. It is reasonable to describe it as a possible adjunct that may support healing and add modest benefit, not as a standalone cure. Anyone considering PRP therapy should ask what outcome the treating team expects for their scar types and how they will judge whether it helped.
Subcision: releasing what holds a scar down
Rolling scars and many deep boxcars are tethered by fibrous bands beneath the skin. Surface treatments cannot release them, and attempting to resurface a tethered scar often produces a smoother-looking but still depressed one.
Subcision addresses the cause. A fine needle or blade is inserted through a tiny entry point and moved beneath the scar to cut the fibrous bands that pin it down, allowing the skin to rise. The space left behind fills with blood and then with new connective tissue, which helps hold the correction. Bruising and swelling follow, and the effect is judged over weeks, not days. Sometimes subcision is combined with a filler or a biostimulator in the released space to maintain lift while the new tissue forms.
Because subcision is a procedural step performed beneath the skin, it belongs in the hands of a clinician who understands facial anatomy, including the vessels and nerves of the cheek. It is the logical first step in a plan for rolling scars, with resurfacing following once the base has been released.
Ice pick scars: the narrow ones that resist everything
Ice pick scars are the stubborn ones. They are narrow, deep and shaped like a cone, and abrading or lasering the surface barely reaches the apex. Several approaches are used instead.
The scar can be excised: a tiny punch removes the scarred tissue and the small wound is closed with a fine suture or allowed to heal, converting a narrow deep scar into a fine linear mark that heals more shallowly. Smaller scars may be elevated or grafted with a small plug of the patient's own skin. Chemical reconstruction techniques use high concentration acid applied precisely into the scar to stimulate healing from the bottom. The right method depends on the scar's width and depth and on the clinician's experience with it. Resurfacing is then used afterward to blend the area.
It is worth being direct about expectations here: ice pick scars improve rather than disappear, and the improvement usually comes from combining methods.
Fillers and biostimulators for the scars that stay put
Even after releasing and resurfacing, some depressions remain. Soft tissue fillers can lift a scar floor temporarily, and some injectable materials that stimulate the body to build collagen can lift gradually. This is a way to fine tune individual scars, not a primary treatment. Using hyaluronic acid fillers in a scar has the advantage of reversibility with an enzyme, which many practitioners value in a delicate area. Longer lasting materials carry more commitment and require more caution.
Filler is also where the shape of the scar matters: it works best in broad, soft depressions and poorly in narrow deep ones.
Peels and topical programs: the supporting cast
Superficial and medium depth chemical peels can improve tone, brighten post-inflammatory pigment and soften the shallowest scarring, and they are useful between more intensive procedures or for patients who are not candidates for ablation. Medical grade topical care, including retinoids and sun protection, is the unglamorous foundation of every scar plan; a patient on a good skincare program tends to heal better and to keep gains longer. Sun protection deserves emphasis: new skin and treated skin are especially vulnerable to pigmentation from ultraviolet light.
Putting it in order: why sequence beats strength
A scar plan is a sequence. Done in the wrong order, treatments undo one another or waste effort.
Control acne and prepare the skin. Release tethered scars with subcision and let the area settle for several weeks. Treat narrow, deep scars with focal techniques, a category that overlaps with general scar revision. Resurface to blend: dermabrasion for a focal region with sharp shoulders, fractional laser for broader texture. Use microneedling and similar methods for ongoing collagen stimulation. Fine tune with filler or biostimulators. Maintain with sun protection and topical care.
The most important idea in that list is that tethering is addressed first. Resurfacing before release is a common reason a cheek looks smoother but not flatter.
A walk through three imagined faces
Examples illustrate the logic without implying outcomes.
Consider a man in his thirties with shallow boxcar scars concentrated on the temples and lower cheeks, sharp shoulders and no real rolling. A plan here might lean on focal dermabrasion for the clusters, followed by a broader fractional treatment later to even out texture. The question to answer is how deep the scar floors go, because dermabrasion does less for floors than for edges.
Consider a woman in her late twenties with rippling rolling scars across both cheeks that seem to change with expression. Her problem is below the surface. Subcision is the logical start. Once the tethering is released and the skin has settled, a series of radiofrequency microneedling sessions can build collagen across the area, and a gentle laser may be added later.
Consider a patient with a mixture: a handful of ice picks, moderate boxcars and some background pigmentation. The sequence is longer: focal treatment for the deep points, a staged plan for the boxcars, and careful pigment management throughout. The honest forecast is gradual improvement over a year, not a transformation in a month.
Raised scars are a different conversation
Most of this guide concerns depressions, but some acne scars rise above the skin. Hypertrophic scars stay within the boundary of the original lesion and tend to flatten slowly over time. Keloids grow beyond that boundary and can keep growing. They are most common on the chest, shoulders and jawline, and they are more frequent in some families and skin types.
Resurfacing is generally the wrong tool for these, because wounding the skin can provoke more of the same tissue. They are treated with different approaches, such as injections into the scar, pressure or silicone, and in selected cases surgical removal followed by measures to prevent recurrence. A scar that is itchy, tender, firm and growing deserves its own assessment before anyone suggests a laser. If you have both raised and sunken scars, the raised ones are usually dealt with first or separately.
The same scar through three different tools
A single shallow boxcar scar on the cheek, about the width of a pencil eraser, shows how the approaches differ.
Under dermabrasion, the surgeon planes the skin around the scar down toward its floor, so the sharp wall blends into a gentle slope. The scar is still slightly lower than its neighbors, but the shadow it casts has softened. The effect is immediate in the sense that the contour changes at once, though healing takes weeks to reveal the final shape.
Under a CO2 laser, the same scar receives a grid of microscopic columns, concentrated slightly more in the depression. Over the next several months, collagen remodeling gradually lifts the floor. The wall stays more defined than after dermabrasion, but the floor rises, and a second session adds to the effect.
Under radiofrequency microneedling, the scar is stimulated across a series of visits. No single session changes it visibly, but repeated sessions thicken the surrounding skin and slightly raise the floor.
None of these is a failure or a victory. They are different mechanisms with different timelines, which is why the choice is based on scar shape, how many scars there are, how much downtime a person can accept and how the skin tends to heal.
Scheduling around the calendar
Resurfacing is easier to recover from when the sun is easy to avoid. Many patients choose the cooler months, when they spend less time outdoors and have less exposure to ultraviolet light during the period when new skin is most vulnerable. That does not mean summer treatment is impossible, but it does mean more discipline: hats, shade and consistent broad spectrum protection.
Life events matter as much as seasons. Weddings, reunions and important meetings are poor reasons to rush. A procedure with a week of open healing and weeks of redness belongs in a schedule with room for it, ideally a couple of months before any occasion. Patients who plan staged treatments often find it helpful to put the heavier resurfacing at a time that allows for the longest quiet stretch afterward.
Beards, hairlines and the practical parts
Men with beards face a few extra considerations, a theme that runs through men's treatment generally. Acne scars often sit within the beard region, where hair follicles are a source of healing and also a source of bacterial load. Resurfacing may be done with the beard shaved or trimmed, and healing can temporarily affect shaving routines. Some men find that scars hidden by a beard become more visible after treatment because the skin around them improves.
Hair removal, shaving and exfoliation are generally paused around the time of treatment, and sunscreen or hats replace the usual routine. The practice's written instructions should settle the details, including when it is safe to return to shaving.
How scars are graded and photographed
Clinicians use grading systems to describe scar severity, but the numbers on a scale are less useful to a patient than the photographs. Consistent images taken under the same lighting, from the same angles, before treatment and at each review, make progress visible. Raking light, which comes from the side, shows depth best, and a few photographs under that light before treatment give a more honest baseline than frontal shots under flattering lighting.
If a practice does not take standardized photographs, ask for them. Without a baseline, improvement is hard to judge and easy to forget.
What the healing actually looks like
Recovery depends on depth. After dermabrasion or deeper laser resurfacing, expect an open, weeping surface for the first days, careful wound care, crusting and then new pink skin. Redness can persist for weeks to months, and the skin is extremely sensitive to sun in that period. Makeup is generally withheld until the surface has healed. Swelling can be significant in the first few days, especially around the eyes.
After fractional treatments and microneedling, healing is shorter: redness and a sandpaper texture for several days, then gradual normalization. Subcision brings bruising that may take one to two weeks to clear.
Patients are usually told to avoid picking or peeling, to keep the skin moisturized and protected, to avoid direct sun and to follow the practice's written instructions. Complications are uncommon but real: prolonged redness, infection, changes in pigment, new scarring and, with some herpes-prone patients, outbreaks that are prevented with preventive medication. Questions about these should be raised at consultation, and any sign of infection or unusual healing should be reported promptly.
Keeping the gains: maintenance after the main treatments
Scar treatment does not end at the last session. Collagen continues to turn over, the skin keeps aging and new sun exposure can undo some of what was achieved. A maintenance plan is usually modest: daily sunscreen, a retinoid or similar topical if the skin tolerates it, and an occasional microneedling or peel session if the skin quality starts to drift. Some patients return once a year for a review and a light touch up.
It also helps to keep acne from returning. A single new cluster of inflamed lesions can leave fresh marks, which is why scar treatment and acne control belong in one conversation. Picking at lesions is the most avoidable cause of new scarring. Patients who keep their routine consistent, and who treat breakouts early, generally keep the benefits of their resurfacing longer than those who do not.
Finally, remember that perfectly even skin is not the standard that people use when they look at one another. Most of the improvement that matters is the reduction of shadows and contour that draw attention. Reaching that point, and then stopping, is a reasonable and respectable end of treatment.
Pigment: the risk that surprises people
Post-inflammatory hyperpigmentation, darkening of the skin after inflammation, is a risk with many resurfacing treatments, particularly in medium to deep skin tones. It is usually temporary but can last months. Less often, treated skin lightens. Planning for pigment involves test areas where appropriate, pretreatment with brightening agents in some protocols, conservative settings, strict sun avoidance and quick treatment of any early darkening.
This is where experience shows. A practitioner who treats a range of skin types has a repertoire of adjustments, and a patient who raises the subject gets a more tailored plan.
The limits that deserve to be said aloud
No treatment erases acne scars. The realistic goal is improvement in the scar's visibility, and the amount of improvement varies by scar type, depth and the person's own healing. Studies and clinical experience generally report improvement for most patients, with residual scarring in many. A series of staged treatments over months to a year tends to produce more than any single intervention.
Scars also look different in different light. Under the bright, side-lit mirrors at home, even a good result can look imperfect, while in ordinary conversation distance it may be hard to see at all. Standardized photographs under consistent lighting help judge progress honestly.
Choosing where to be treated
Scars are a place where the clinician's range matters. A practice that offers only one device tends to recommend that device. One that offers dermabrasion, laser, microneedling, subcision, injectables and peels can match the tool to the scar. Look for a surgeon who examines your scars in raking light, names the types you have, explains the sequence, discusses pigment risk for your skin type and shows results on similar scars.
Dr. Doshi is a double board certified facial plastic surgeon whose practice includes both resurfacing and surgical options, which allows treatment to be matched to depth. For people outside the immediate area, a virtual consultation with photographs is a practical place to start.
Questions that tend to come up after the first appointment
Patients commonly ask whether the treatments hurt, how many sessions they will need, and when they can see the final result. Comfort depends on the treatment: numbing and local anesthesia manage most of it. Session counts depend on scar type and depth. And the final result is judged months after the last treatment, because collagen remodeling continues long after the visit. A good clinician sets those timelines at the start and reviews progress against photographs along the way.