Punch Excision for Acne Scars: What It Changes and What Studies Show
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Short answer (Limited evidence): Punch excision for acne scars is a surgical option that a clinician performs on selected discrete, deep scars. The original scar is removed and the wound is closed, so you end up with a new surgical scar rather than scar-free skin. It is different from punch elevation and from subcision. The only direct outcome series we retrieved combined excision with laser resurfacing in 21 people, so its results can't be credited to excision alone.[^1]
How we sourced this: we used 10 PubMed records. Nine have abstracts and one is title-only. Accessible full text was reviewed for some records (noted below); others remain abstract- or title-only because Europe PMC failed or no PMC record was indexed. Outcomes below stay within what those accessible sources support.
What is punch excision for acne scars?
"Excision" means cutting tissue out. In punch excision, a clinician removes one selected scar and closes the resulting wound. The goal is to swap a deep, shadowed scar for a flatter surgical scar that may be less noticeable.
That swap is the central tradeoff. The new scar is real, and how it looks depends on healing and on choosing a suitable scar. This is not something to try at home. This article does not cover tool sizes, technique, anesthesia, closure or aftercare. Those decisions belong with the treating clinician.
Which acne scars may lead to a punch excision discussion?
Evidence: Expert opinion (review-based selection, not a predictive rule).
One classification review sorts atrophic acne scars into three types[^2]:
- Icepick: narrow, deep pits.
- Rolling: broad depressions with soft edges.
- Boxcar: depressions with sharper edges.
The review pairs these scar types with a treatment algorithm that includes punch excision, punch elevation, subcision and laser resurfacing. Its authors list affiliations with a private dermatology practice and Beth Israel Deaconess Medical Center. The PubMed record states no funding and no conflict-of-interest information. That means not stated, not "none."
A narrative review focused on skin of color found that deep grade 4 scars improve poorly with resurfacing alone, and says punch excision and punch elevation "can be tried" for them.[^3] Its authors are from an Indian private clinic and academic dermatology departments. The record states there are no conflicts. No funding is indexed.
A clinical review adds that treatment choice depends on the type and number of scars, Fitzpatrick skin type (a six-point scale of how skin responds to sun) and how much downtime the patient can accept.[^4] Its authors are from Cooper University Hospital. Conflicts are reported as "None disclosed." No funding is indexed.
Broad icepick scar diagnosis is planned for a separate icepick scars guide. Tethered rolling scars are more relevant to subcision.
Is punch excision the same as punch elevation or grafting?
No. The names sound alike, but the methods do different things, and the evidence for each is separate.
| Technique | Intended concept | What the retrieved evidence covers | Evidence label |
|---|---|---|---|
| Punch excision | Removes the scar and closes the wound | One excision-plus-laser series[^1]; one title-only report[^5] | Very limited |
| Punch elevation | Raises the existing scar base toward the skin surface | One randomized split-face trial with laser[^6]; review support as an add-on[^7] | Limited |
| Punch grafting | Replaces scar tissue with grafted tissue | Two case reports that used many methods together[^8] | Very limited |
| Subcision | Releases fibrous attachments beneath a depression | Part of a review algorithm[^2] | Expert opinion |
A 2026 review of punch-based techniques says punch elevation "may improve outcomes in selected atrophic acne scars." It also says most evidence across all its indications comes from small observational studies.[^7] Its authors are from a plastic surgery department in China and report no conflicts. The full text states funding from the Jilin Scientific and Technological Development Program and the Jilin Provincial Special Program for Health Research Talents.
What direct punch excision evidence is available?
Evidence: Very limited.
The main direct source is an uncontrolled series of 21 people with Fitzpatrick skin types I–III.[^1] Everyone had punch excision and laser resurfacing in the same session, and there was no excision-only or untreated comparison group. A blinded dermatologist and a laser nurse rated photographs. The ratings were given as ranges:
- Assessor ratings: 25–50% improvement for skin type I and 50–75% for types II and III.
- Patient self-ratings: 25–50% for type I, 50–75% for type II and 75–100% for type III.
These are categories of rated improvement. They are not a single average, and they are not a percentage of scars eliminated.
Five people developed postoperative hyperpigmentation (darkening after the procedure). The authors saw no hypopigmentation, wound separation, infection or hypertrophic scarring. In a series this small, that shows those problems weren't seen here, not that they can't happen. The abstract does not say how long follow-up lasted.
The authors are from the Dermatology Laser Center at Harvard Medical School and Massachusetts General Hospital. Funding and conflicts are not stated in the PubMed record, and full text was not checked.
A second, more recent report describes modified punch excision combined with other methods.[^5] It has no indexed abstract, so we could not verify its sample, outcomes or complications. Bibliographic identity: Savant SS Jr., Indian J Dermatol Venereol Leprol 2025;91(1):139-141 (doi:10.25259/IJDVL_914_2023), private clinic in Mumbai. Funding and conflicts are not stated.
Does the punch elevation laser trial prove punch excision works?
Evidence: Limited (adjacent technique).
No. The randomized split-face trial enrolled 42 people with Fitzpatrick skin types III–IV and moderate to severe atrophic scars.[^6] "Split-face" means each person's two cheeks got different treatments: one side had fractional CO2 laser alone, and the other had punch elevation plus the laser.
- At one month: blinded dermatologists found no difference between the sides (P=.56).
- At four months: they favored the combination side (P=.02).
- Side effects: both sides had crusting and itching, which fits the fact that both sides had laser.
This tells us about an elevation add-on under one protocol. It doesn't show that excision works on its own, guarantee results, or show that the combination is safe for all skin types. The authors are from several Iranian universities. PubMed COI is "Nil." Accessible full text lists source of support as the Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences.
Two case reports, from one Hispanic patient and one African-American patient, describe peels, punch grafting, punch elevation, subcision, dermal grafting and dermabrasion used together. Both patients had "satisfactory" outcomes.[^8] Two cases can't establish success or safety rates. They come from a Colorado private practice, and funding and conflicts are not stated.
Is punch excision for acne scars better than TCA CROSS?
Evidence: Expert opinion / review context (not ranked).
None of the 10 selected records directly compared excision with TCA CROSS, so we treat "beats TCA" as unproven. The table below is context, not a ranking.
| Option | Scars discussed in reviews | Intended action | Evidence label |
|---|---|---|---|
| Punch excision | Selected deep, discrete scars; grade 4 scars[^3] | Remove the scar and close the wound | Very limited |
| TCA CROSS | Icepick scars[^3] | Chemical reconstruction of the scar | Limited (review summary) |
| Subcision | Rolling, tethered scars[^2] | Release attachments beneath the scar | Expert opinion |
| Resurfacing (lasers, RF microneedling) | Mild to moderate scars[^3] | Remodel surface texture | Limited (strongest of these in one review) |
For TCA CROSS evidence, see our TCA chemical peel guide. For device data, see RF microneedling. Neither page shows that those treatments are interchangeable with punch excision.
A classification-based review found few high-quality studies. Those studies used different scar scores and often didn't define scar type, which makes comparisons difficult.[^9] Its authors are from the University of Illinois at Chicago and Northwestern. Funding and conflicts are not stated.
Does punch excision for acne scars leave a new scar?
Evidence: Very limited for downtime and complication probabilities.
Yes. Removing a scar creates a wound, and the wound becomes a new scar. Improvement may be partial. In the combination studies, resurfacing appears alongside excision, but that doesn't establish a recommended sequence.[^1]
The complications reported in the retrieved records are:
- Pigment change. The 5 of 21 hyperpigmentation figure comes from a combined procedure in skin types I–III. It is not the risk of excision alone, and it can't be used as an estimate for darker skin.[^1]
- Dyspigmentation in darker skin. The case-report authors describe it as an added risk after surgery or resurfacing in darker skin.[^8]
- Evidence gaps for darker skin. The skin-of-color review notes there are no guidelines and little high-quality data.[^3] The elevation trial's skin types III–IV don't establish safety for types V–VI.[^6]
Downtime is a factor in choosing a treatment,[^4] but these records don't support a set number of days off work, a fixed timeline for the scar to fade, or claims like "no pigment change" or "safe for all skin tones." Take questions about recovery, pigment or medications to the treating clinician.
What long-term evidence is missing?
Evidence: Limited.
The reviews point to inconsistent outcome measures, combined treatments, results that depend on the operator, and small observational series.[^7][^9]
A Cochrane review searched through November 2015 and included 24 randomized trials with 789 adults across many acne scar treatments. These were not punch trials. Nine trials gave no usable data, and most findings were low or very low certainty.[^10] The review concluded there was no support for using any intervention first-line. That reflects weak methods in the field at the time. It doesn't prove that nothing works, and it doesn't mean newer trials are absent.
On disclosures, the review's authors are affiliated with Cairo University. One author helped run three of the included studies and was not involved in assessing them. Another reported ties to Galderma, GlaxoSmithKline, MEDA, LeoPharma, Pfizer, Novartis and L'Oréal. A third reported Novartis honoraria. An editor noted that NIHR HTA funded part of the work. This review should not be labeled conflict-free.
In the excision reports we selected, durability, repeat procedures and how patients weigh one scar against another remain unresolved.
Who paid for the punch excision evidence?
PubMed GrantList entries are empty for these records, but that is not the same as no funding. Accessible full texts identify institutional or program support for some papers (noted with those studies). Several records also state no conflicts in some form ("Nil," "no conflicts," "None disclosed")[^3][^4][^6][^7].
Five records give no funding or conflict statement at all.[^1][^2][^5][^8][^9] A missing statement isn't the same as having no funding. Academic or clinic affiliations also don't rule out commercial relationships.
The Cochrane review discloses industry ties and partial public funding.[^10] An empty conflict statement or the absence of a branded product does not establish that a paper has no industry ties.
Where the evidence stops
- None of the selected records gives an outcome estimate for excision on its own.
- None of the selected records directly compares excision with TCA CROSS, subcision or resurfacing.
- Combined procedures make it impossible to say which method produced the improvements or the pigment changes.
- There is no reliable pigment-change rate for specific skin types and no exact recovery time.
- Older reports don't fully state their follow-up.
- One directly relevant report has no abstract.
- All of the above applies to the 10 records selected, not to all published literature.
FAQ
What is punch excision for acne scars?
It is a surgical option that a clinician performs for selected discrete, deep acne scars. The scar is removed and the wound is closed. Reviews describe it as one option among several. The only direct outcome series retrieved for this article combined excision with laser resurfacing, so the evidence for excision on its own is very limited.
Does punch excision leave a new scar?
Yes. Removing a scar creates a wound, and the wound heals as a new surgical scar. The aim is a scar that looks less noticeable than the original, but the records reviewed here do not promise an invisible result, and how it looks depends on healing and on which scar was chosen.
Is punch excision the same as punch elevation or grafting?
No. Excision removes the scar and closes the wound. Elevation raises the existing scar base. Grafting replaces scar tissue. The randomized split-face trial retrieved here tested punch elevation plus fractional CO2 laser, so it is not a punch excision trial.
Which scar types are discussed in the evidence?
Classification reviews discuss icepick, rolling and boxcar scars, and they link punch techniques to selected deep, sharply defined scars. A skin-of-color review says deep grade 4 scars respond poorly to resurfacing alone and that punch excision or elevation can be tried. This is clinical selection, not a trial-proven eligibility rule.
Is punch excision proven better than TCA CROSS?
Not in the records reviewed. None of the 10 selected PubMed records directly compared punch excision with TCA CROSS. One review reports TCA CROSS efficacy in icepick scars and lists punch techniques for deep grade 4 scars, but that is context, not a head-to-head result.
Does the punch elevation laser trial prove excision works?
No. The 42-person split-face trial tested punch elevation added to fractional CO2 laser, and both sides received laser. The combination was favored at four months but not at one month. That tells us about an elevation add-on under one protocol, not about excision on its own.
What downtime and pigment risks are known?
Only limited, mixed-procedure data were found. In a 21-person series of excision plus laser resurfacing, five people had postoperative hyperpigmentation. That figure cannot be read as the risk of excision alone or applied to darker skin tones. No fixed recovery time is established in these records, so ask the treating clinician.
Can punch techniques remove every acne scar permanently?
That is not established. Reviews describe small observational studies, mixed scar types, inconsistent scoring and limited long-term controlled data. Durability and the need for repeat or combined treatment have not been resolved in the records reviewed.
References
[^1]: Concurrent use of laser skin resurfacing and punch excision in the treatment of facial acne scarring. PubMed PMID 9598006. Abstract reviewed; full text not checked. Funding/COI: grant information not indexed; conflicts not stated in PubMed record; affiliation Dermatology Laser Center, Harvard Medical School, Massachusetts General Hospital.
[^2]: Acne scarring: a classification system and review of treatment options. PubMed PMID 11423843. Abstract reviewed; full text not checked. Funding/COI: grant information not indexed; conflicts not stated; affiliations private dermatology practice and Beth Israel Deaconess Medical Center.
[^3]: Evidence-based Surgical Management of Post-acne Scarring in Skin of Color. PubMed PMID 32792773. PubMed abstract, metadata and accessible full text (PMC7394107) reviewed. Funding/COI: full text reports nil financial support and no conflicts of interest; affiliations Indian private clinic and academic dermatology departments.
[^4]: Procedural and surgical treatment modalities for acne scarring: Part II. PubMed PMID 35469981. Abstract reviewed; full text not checked. Funding/COI: grant information not indexed; conflicts "None disclosed"; affiliation Cooper University Hospital/Cooper Medical School of Rowan University.
[^5]: Savant SS Jr. Modified acne scar revision - Punch excision, punch-in-subcision with shoulder dermabrasion followed by dermal grafting. Indian J Dermatol Venereol Leprol. 2025;91(1):139-141. doi:10.25259/IJDVL_914_2023. PubMed PMID 39152862. Title and metadata only; no indexed abstract; sample and outcomes unverified. Funding/COI: grant information not indexed; conflicts not stated; affiliation Humanitarian Clinic, Mumbai, India.
[^6]: Efficacy of Punch Elevation Combined with Fractional Carbon Dioxide Laser Resurfacing in Facial Atrophic Acne Scarring: A Randomized Split-face Clinical Study. PubMed PMID 26538695. Abstract, metadata and accessible full text (PMC4601415) reviewed. Funding/COI: source of support Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences; Conflict of Interest Nil.
[^7]: Clinical Applications of Punch-Based Techniques in Dermatologic Surgery. PubMed PMID 41988096. Abstract, metadata and accessible full text (PMC13077225) reviewed. Funding/COI: funded by Jilin Scientific and Technological Development Program (20250601014RC) and Jilin Provincial Special Program for Health Research Talents (2024SCZ55); authors report no conflicts.
[^8]: Case reports: surgical therapy of acne scars in pigmented skin. PubMed PMID 17373164. Abstract reviewed; full text not checked. Funding/COI: grant information not indexed; conflicts not stated; affiliation Colorado Dermatology Center.
[^9]: A Review and Update of Treatment Options Using the Acne Scar Classification System. PubMed PMID 30856634. Abstract reviewed; full text not checked. Funding/COI: grant information not indexed; conflicts not stated; affiliations University of Illinois at Chicago and Northwestern Feinberg School of Medicine.
[^10]: Interventions for acne scars (Cochrane review). PubMed PMID 27038134. Abstract reviewed; Europe PMC full-text request returned an error, full text not verified. Funding/COI: grant information not indexed; PubMed COI reports one author's involvement in included studies (recused from their assessment), author ties to Novartis, Galderma, GlaxoSmithKline, MEDA, LeoPharma, Pfizer and L'Oréal, and an editor statement that NIHR HTA funded part of the work.