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Punch excision
Punch excision
Punch excision may be used to remove deep pitted scars, such as ice pick scars, by excising scar tissue and resuturing; this leads to a subtle and ideally non atrophic scar.69 This approach may be followed by laser resurfacing or dermabrasion for optimal results. Punch grafts can also be taken from posterior auricular skin for deep scars, which may be a suitable choice for ice pick scars.55
Punch elevation is a combination of excision and grafting methods, in which a punch biopsy tool is used to remove the base of the scar, while leaving the walls intact. Punching the base of the scar makes the base parallel to the outer walls, elevating the scar base and reducing its depth.70 The elevated skin can then be positioned evenly via sutures or Steri-Strips. This technique is most suitable for deep boxcar scars with sharp borders and less than 3 mm of depression.71,72
Laser resurfacing can enhance the effect of punch excision combined with either grafting or elevation. Punch excision used together with CO2 laser resurfacing has been reported to result in significant improvement.55 Ablative laser treatment alone may lead to improvement rates ranging between 25% and 90% for atrophic scars. Disadvantages include a large time commitment and cost.73 Nonablative fractionated lasers have fewer side effects and a respectable success rate for atrophic scars.55