Acne scar assessment:
what is graded at consultation

What is mapped first, and why zone by zone?

The first thing graded is a scar type map: each zone of the face is charted for ice-pick, boxcar, rolling and raised scars under angled light that throws a shadow into every depression. The map comes first because acne scar treatment matches a method to a scar type rather than a laser to a face: the three depressed shapes are formed differently and answer to different tools, and most faces carry more than one on the same cheek. The acne scar types page describes each shape and the four-question checker sorts the common patterns at home.

Zones matter because the same face is rarely uniform: temples and cheekbones often carry ice-pick and boxcar scars over bone, while the lower cheek and jaw more often carry rolling scars tethered into thicker tissue. Charting by zone lets the plan use subcision in one area, TCA CROSS in another and resurfacing across both.

What does the stretch test show, and what does the Goodman and Baron grade add?

The stretch test shows whether a scar is tethered. The skin beside each scar is stretched between two fingers: a scar that flattens or nearly disappears is held down by a fibrous band from below, whatever its shape, and that band has to be released before resurfacing, because a laser remodels skin in whatever position it finds it. A scar that stays as a sharp pit or a flat-floored dent on stretch is a surface and depth problem rather than a tethering one.

The Goodman and Baron qualitative grade, published in 2006, adds a shared language for how visible the scarring is: four grades based on appearance at a social distance and on whether the scarring flattens on stretch, from flat marks of colour at grade 1 to severe scarring that does not flatten at grade 4. It records severity for planning and later review; it does not choose the method, because two faces at the same grade can carry entirely different scar types.

“If someone offers you one treatment for your acne scars, they haven't looked closely enough.”

Dr Sin YongOn mixed acne scars

How do skin type and pigmentation risk change the plan?

Skin type sets the depth and the pacing of everything that follows. Fitzpatrick phototype is recorded, together with any history of marks darkening after a pimple, a cut or a previous procedure, because post-inflammatory hyperpigmentation after resurfacing is more likely in Fitzpatrick III to V skin and with sun exposure. In those skin types, fractional passes are set less densely, point-shot ablation is kept to the scar pits, TCA CROSS is applied with care, and the interval between steps is set by healing rather than by a calendar.

Flat brown or red marks are graded at the same time, because they are often the main complaint and are not textural scars: they are pigment and vessel questions, managed differently from depressions, and resurfacing can deepen pigment rather than clear it.

Why do active acne, isotretinoin and keloid history come before any scar plan?

Active acne defers scar work: new inflamed spots mean the skin is still being injured, and resurfacing or subcision is postponed until acne is controlled, which is assessed as its own problem. Isotretinoin, a prescription vitamin A derivative given for severe or scarring acne, is declared whether past or present: older teaching was to wait many months after stopping before resurfacing, recent reviews have found the evidence for a fixed delay limited, and the decision is made case by case by method, depth, skin type and healing history, as the isotretinoin and laser timing article explains. No one is asked to stop or change isotretinoin to suit a procedure date.

A tendency to keloid or raised scarring, including on the chest, shoulders or earlobes, is weighed before any procedure that injures the skin. Previous procedures, blood-thinning medicines, a bleeding tendency and known allergies are recorded, and expectations are discussed plainly: improvement in depth and texture is the honest endpoint, and no method returns skin to an unmarked state.

How does the grade decide the sequence in the Scar Repair Programme?

The map and the grade decide which stages a face needs and in what order. The Scar Repair Programme is the sequence Dr Sin Yong uses for depressed scars: release, resurface, support and maintain. Where the stretch test finds tethering, subcision is the first stage, so that the S3 Resurfacing Lift on fractional CO2 later works on a floor that can rise. Where narrow ice-pick tracts dominate, TCA CROSS joins the resurfacing stage; where shallow boxcar and rolling scars carry no tether, release is skipped. Raised scars take an injection-based path and are not resurfaced.

A higher grade usually means more stages and a layered plan rather than a stronger single treatment, and isolated scars too deep or wide for non-surgical methods are referred to a plastic surgery specialist for punch techniques. Each stage is spaced by review of healing, and the written quote that follows lists the stages, the areas and what is not included, as the how fees are quoted page describes; Singapore's rules prevent price advertising, so no figures appear here.

What photographs are taken, and why are they not published?

Standardised clinical photographs are taken at the first assessment and at each review: front and both three-quarter views, with the same camera position, light and expression, and with side lighting that makes depressions cast shadows. They exist for planning and for honest comparison at review, and they are part of the medical record.

They are not published. Singapore's guidelines for doctors restrict the use of patient images in advertising, and an image chosen for display is by definition a selected one; the site shows pre-treatment photographs with the post-treatment frame blurred, and the editorial policy sets out why. Your own photographs are reviewed with you at consultation.