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Treatment
Punch excision
The deepest ice pick scars are removed outright. Each scar is matched to a punch of the same diameter, lifted out, and the skin heals flat in its place. One procedure rather than a course.
What it is
Punch excision uses a fine, circular blade to remove a scar in a single movement. The punch is chosen to match the width of the scar, so only the scar is taken and the skin around it is left alone.
Where TCA CROSS rebuilds a scar gradually over several sessions, a punch removes it on the day. The small opening left behind heals over the following week into a flat, fine mark that is far less visible than the pit it replaced.
What brings you here?
Ice pick scars
Ice pick scars are narrow tracts that run deep into the dermis, sometimes down to fat. They are the hardest scars to lift with lasers or acid, because the base sits too deep to reach.
A punch removes the whole tract. Each scar is measured and matched to a punch of the same width, so an 0.8 mm scar gets an 0.8 mm punch. Openings of 1.5 mm or less heal on their own, without stitches.
What it will not do: treat rolling or wide, shallow scars, or the texture between scars. Those need subcision, fillers or resurfacing.
Enlarged pores
I treat individual, deep enlarged pores that you can point to, the ones that look like small pits or hold a permanent dark plug. A fine FUE punch removes each one, and the skin closes over flat.
General pore size across the face is driven by oil production and skin thickness. That is treated with topicals and lasers, not a punch.
What it will not do: shrink every pore on the face, or reduce oiliness.
Understanding scar types
Why a punch suits only some of themEach scar type has a different shape under the skin, and each shape needs a different tool.
A punch works best on ice pick scars: narrow and deep, with a small opening at the surface. Boxcar scars are wider with a flat floor, rolling scars are broad dips pulled down by bands underneath, and hypertrophic scars are raised. Those need resurfacing, subcision, fillers or injections instead.
Punch excision
Most people carry several of these at once, so good scar revision nearly always needs several methods used in the right order. Read the full guide to matching treatment to your scar signature.
The punches I use
Matched to the exact size of each scarA punch only gives a good result if it is the same size as the scar. Too small leaves scar behind; too large leaves a bigger mark than necessary.
Standard biopsy punches come in few sizes and blunt quickly. I use specialised 1.0, 1.2 and 1.5 mm punches alongside FUE punches borrowed from hair transplant surgery, which run from 0.5 to 1.5 mm in 0.1 mm steps and stay sharp across many excisions.
TCA CROSS vs punch excision
Two ways to treat deep, narrow scarsBoth treat the scar itself rather than the whole face. TCA rebuilds a scar gradually; a punch removes it at once.
| TCA CROSS | Punch excision | |
|---|---|---|
| How it works | Acid placed into the scar base rebuilds it from below | The scar is removed with a matched punch and heals flat |
| Sessions | Usually 3–6, six to eight weeks apart | Usually one |
| Healing time | 4–7 days of small crusts, each session | 3–6 days, once |
| Anaesthetic | Usually none | Local anaesthetic |
| Best for | Ice pick, small boxcar and polymorphic scars; many scars at once | The deepest, well-defined ice pick scars; individual pores |
| Result | Gradual; each session gives part of the result | Scar gone on the day; mark fades over weeks |
| Limits | Slow on the very deepest scars | Only suits certain scars, and punches cannot sit too close together |
| Cost | $890–$1,990 per session | $1,890–$2,990, Medicare rebate applies |
- Pro: no needles or cutting, very little discomfort.
- Pro: treats many scar shapes, including boxcars.
- Con: several sessions, each with a week of crusts.
- Con: the deepest pits may only partly lift.
- Pro: one procedure, and the scar is gone.
- Pro: the most reliable option for very deep ice picks.
- Con: needs local anaesthetic.
- Con: leaves a fine flat mark, and suits only select scars.
These are not rivals. On the same face, I often punch the deepest ice picks and use TCA for the shallower pits and small boxcars, then resurface once everything has healed.
Everything below applies to the above conditions
The technique is the same whichever concern brought you here. Only the scars chosen and the punch sizes change.
What happens on the day
- Preparation, weeks before
Pigment-preparing topicals for olive and darker skin. Active acne must be under control first.
- Mapping and sizing
Photographs, then each scar to be treated is marked and matched to a punch size.
- Numbing
Local anaesthetic with adrenaline is placed under the area with a fine, blunt cannula. It numbs the skin and reduces bleeding.
- Excision
After about ten minutes, each marked scar is removed with its matched punch.
- Afterwards
Ointment, sunscreen and written aftercare. Openings of 1.5 mm or less heal on their own.
Recovery, at a glance
Allow three to six days of small crusts. Most people return to work within a day or two with makeup once the crusts have lifted.
Risks
| Effect | Frequency | Notes |
|---|---|---|
| Minor bleeding, crusting | Expected | The first few days. This is healing, not a complication. |
| Pinkness | Expected | A few weeks at each treated site, fading steadily. |
| Temporary darkening | Common | Very common in darker and Asian skin, usually settling within 8 weeks. See darker skin types. |
| Small visible mark | Expected | A fine, flat mark replaces the deeper scar. It can be refined later with resurfacing. |
| Infection | Rare | Treated promptly. |
| Raised scarring | Rare | None seen in our published series. People who form keloids are not treated. |
Punch excision in darker skin
Including Asian and other ethnic skin typesIn darker and Asian skin, temporary darkening after treatment is very common. It is an expected part of healing, not a sign that something has gone wrong.
This darkening is usually short-lived, settling within eight weeks. To help it fade sooner, I prescribe skin-lightening topicals, and in some cases add pico laser to even out the colour.
Who is and isn't a candidate
Suited to all skin types, in people with deep, well-defined ice pick scars or individual enlarged pores.
Your acne must be in remission. Treating scars while new ones are still forming wastes the procedure.
Tell me beforehand if you are pregnant, take blood thinners, have a tan, or have a history of keloid scarring. People who form keloids are not treated with this method.
To effectively revise acne scarring, all skill sets are required
Acne scar revision is not about a device or even claiming to master a technique. It’s about having all the skill sets required to treat scar types such as ice pick, boxcar, rolling and polymorphic scars, in all different skin types and facial shapes.
Once this is mastered, patients can expect to have truly effective, life-changing results.
Published research · Dr Lim
Repurposing follicular unit extraction punches for excision of ice pick acne scars
Lim D, Hang X. Clinical and Experimental Dermatology 2026;51:198–199.
Standard punch biopsy tools come in few sizes and blunt quickly. FUE punches, borrowed from hair transplant surgery, are finer, run from 0.5 to 1.5 mm in 0.1 mm steps, and stay sharp across multiple excisions. Each ice pick scar can be matched to the exact punch size.
Scars are mapped and sized, the area is numbed, and each scar is removed with its matched punch. Openings of 1.5 mm or less heal on their own, without stitches. Across 34 procedures, no scar worsened and none became raised.
Clin Exp Dermatol · p. 198
Published research · co-authored by Dr Lim
Trichloroacetic acid paint for boxcar and polymorphic acne scars
Sun C, Lim D. Dermatologic Surgery 2022;48(2):214–218.
The companion to punch excision. This study showed that 90% TCA painted on with a fine brush treats boxcar and mixed scars, not just ice picks. Forty-one patients had three sessions; all had good to excellent outcomes.
Dermatologic Surgery · p. 214
Opinion · Dr Lim
Are we too reliant on energy-based devices for the treatment of acne scarring?
Lim D. Opinion and Progress in Cosmetic Dermatology 2022;2(3):72–74.
Lasers keep improving, but some scar patterns respond better to manual methods: punch excision, focal TCA, subcision and filler. This paper sets out which scars those are, and why the best results come from combining methods rather than relying on one device.
Common questions
How much does it cost?
How many sessions will I need?
How much downtime is there?
Will it leave a scar?
Do I need stitches?
Should I have TCA CROSS or a punch?
Does it hurt?
Why I use FUE punches
Dr Davin Lim · Dermatologist · The Skin Hospital, Sydney — Laser, Procedural and Anaesthetic Division
Ice pick scars vary by fractions of a millimetre. A standard biopsy punch set jumps in half-millimetre steps and dulls after a handful of cuts. FUE punches let me match each scar to within 0.1 mm and stay sharp across a full session, so every excision is as clean as the first.
Where it sits in a scarring plan
Early. The deepest ice picks are your rate-limiting scars, the ones still visible after everything else is done. Removing them first means TCA, subcision and resurfacing later work on a much shallower problem.
— Dr Davin Lim, Consultant Dermatologist
Conditions this treats
Related treatments
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