Published 8 September 2026 · Reviewed by Dr Sin Yong
Most people talk about their acne scars as a single problem — "my scarring". Look closely at almost any scarred cheek and you will find three or four distinct scar types sitting side by side, and they do not respond to the same treatment. That observation decides the whole plan.
The classification most clinicians use — described by Jacob and colleagues in 2001 — divides atrophic acne scars into three morphologies, and each one is a different structural problem.
Icepick scars are narrow pits, usually under 2 mm across at the surface, tapering into a V-shaped tract that can reach deep into the dermis. They look small and they are the hardest to reach, because most resurfacing energy never gets to the bottom of the tract.
Boxcar scars are broader depressions with sharply demarcated walls — a U-shaped cross-section, as though a small volume of skin were punched out. Their depth varies, and depth is what determines how they are approached.
Rolling scars are wider still, typically beyond 4–5 mm, with soft shoulders and an undulating look. Their cause is not at the surface at all: fibrous bands beneath the skin pull the dermis downward, the way an upholstery button dimples a cushion.
And running through all three is the question of tethering — whether a scar is anchored to deeper tissue by a fibrous band. A tethered scar deepens when you smile or animate, and it will shrug off surface treatment for as long as the anchor remains. I have written about this separately in the guide to tethered scars and subcision, because it is the single most common reason scar treatment disappoints.
If a clinic examines your cheek and offers a single machine for everything on it, the assessment has stopped too early.
The reason is mechanical. An icepick scar is a deep, narrow tract — surface resurfacing planes down its shoulders but cannot follow it to the base. A rolling scar is held down from below — no amount of surface work releases a band that sits in the subcutaneous plane. A shallow boxcar, meanwhile, may respond well to exactly the fractional resurfacing that does little for the other two. Same cheek, three mechanisms, three answers.
There is also a direction-of-error problem specific to Singapore. Most of the skin I treat is Fitzpatrick III to V, where inflammation reliably produces post-inflammatory hyperpigmentation. Treating every scar with the aggressive settings the worst scar seems to demand risks trading texture for pigment — swapping one visible problem for another. Energy is chosen for the skin type as much as for the scar.
None of this means any single device is poor. It means a device is an instrument, and instruments follow diagnosis.
“If someone offers you one treatment for your acne scars, they haven't looked closely enough.”
Dr Sin YongOn single-device scar plans
In my acne scar assessments, the useful work happens before any treatment is named: the cheek is examined under directed lighting, at rest and in animation, with the skin stretched between two fingers. Stretching matters because it separates the scars that flatten — surface problems — from the ones that stay pinned down, which are tethered.
What comes out of that examination is a map rather than a verdict. This region is predominantly rolling and tethered; these clusters are icepick; this scatter of boxcars is shallow enough for resurfacing alone. Each entry on the map carries its own method: release for the tethered scars, focal techniques for the deep narrow tracts, fractional resurfacing for the surface change, support where volume has been lost beneath.
The map also sets the order. Releasing tethers before resurfacing means the surface work is done on skin that is free to remodel flat, rather than skin still pinned to its anchor. Sequence is not a detail — done backwards, each step undermines the next.
This is also why I am wary of scar consultations conducted from photographs. A photograph flattens exactly the information — depth, tethering, behaviour on animation — that the plan depends on.
Because a scarred cheek is several problems at once, the honest plan is almost always a combination — and combinations are staged, not stacked into a single heroic visit.
My 4D Scar Reconstruction protocol is built on exactly this logic: it addresses the scar in four dimensions — the tether below, the volume deficit, the scar walls, and the surface texture — matching a method to each rather than hoping one energy source covers all of them. Which components apply, and in what order, comes out of the map, not out of a menu.
Staging is deliberate for another reason: skin needs time between insults. Collagen remodelling after each step continues quietly for months, and the skin's response to the first stage genuinely informs the second. Response varies between individuals and between scars on the same face, which is why the plan is reviewed as it proceeds rather than fixed at the outset.
What I will not do is promise a number of visits or a percentage of improvement. Anyone who quotes either before examining your skin in person is estimating, not assessing.
Acne scarring is one of the areas where people most want to see photographic proof, so the absence deserves a direct explanation.
Under Singapore's Healthcare Services Act, before-and-after imagery in advertising for licensable healthcare services is prohibited. No consent form or disclaimer creates an exemption, and after-only images fall under the same rule. This applies identically to every licensed clinic in Singapore — a site displaying such images is not demonstrating better results, only weaker compliance.
What can happen instead is an examination of your own scars, in person, where depth and tethering can actually be felt rather than guessed at from a screen.
Prices for licensable healthcare services cannot be advertised in Singapore, including as ranges or "from" figures. What can be set out honestly is what the cost depends on.
The factors are the area involved, what the assessment finds — how many scar types are present, how many are tethered, how deep the tracts run — whether a single method or a combined protocol is indicated, and how the plan is staged over time. A scatter of shallow boxcars on one cheek and a decade of mixed, tethered scarring across both are not comparable pieces of work.
Fees are set out in full at consultation, once there is something specific to cost. If you want the mapping done thoroughly before committing to anything, that is precisely what a private aesthetics analysis is for.
Acne scarring is not one condition. It is icepick tracts, boxcar depressions, rolling tethered valleys and sometimes raised scars, sharing one cheek and requiring different answers — which is why the examination matters more than the machine, and why single-device plans so often stall.
Dr Sin Yong — MBBS (NUS), MRCS (Edinburgh), MSc Aesthetic Medicine (London), MSc Practical Dermatology (Cardiff) — maps scars personally at Orchard Road, and will tell you plainly which of yours need release, which need resurfacing, and which are better left alone.
Atrophic acne scars are commonly classified into three types: icepick scars, which are narrow pits under about 2 mm wide with a deep V-shaped tract; boxcar scars, which are broader depressions with sharply demarcated walls; and rolling scars, wider undulating depressions caused by fibrous bands pulling the skin down from below. Raised hypertrophic scars are a separate category — an excess of collagen rather than a deficit. Most scarred cheeks carry a mixture of several types at once.
A rough guide at home: stretch the skin gently between two fingers. Scars that flatten with stretch are predominantly surface problems; scars that stay pinned down are tethered to deeper tissue. Narrow deep pits suggest icepick scars, sharp-walled depressions suggest boxcar scars, and soft wide undulations suggest rolling scars. A proper classification needs examination under directed lighting, at rest and in animation — which is why in-person assessment comes before any treatment decision.
No single device addresses every scar type well, because the types are structurally different problems. Fractional resurfacing works on surface texture and shallower boxcar scars, but cannot reach the base of a deep icepick tract and cannot release the fibrous band holding down a tethered rolling scar. Realistic plans combine methods — release, focal techniques and resurfacing — matched scar by scar, and staged over time.
Deep icepick scars and tethered scars are generally the most stubborn, for different reasons. Icepick tracts are narrow and deep, so surface energy rarely reaches their base. Tethered scars are anchored to deeper tissue by fibrous bands, so they persist through any amount of resurfacing until the anchor is released. Neither responds to the treatments that suit shallow surface scarring, which is why identification comes first. Response varies and is assessed individually.
Scar treatment is performed routinely in Fitzpatrick III to V skin, which covers most patients in Singapore, but settings cannot simply be copied from protocols designed for lighter skin. Inflammation from over-aggressive treatment can produce post-inflammatory hyperpigmentation — trading a textural problem for a pigment one. Energy, density and the staging of the plan are chosen for the skin type as much as for the scars.
True atrophic scars — icepick, boxcar and rolling — are structural changes in the dermis and do not resolve on their own, although their appearance can soften as post-inflammatory redness and pigment fade over months. That fading is often mistaken for the scar itself improving. Red or brown marks without a change in skin texture are usually post-inflammatory pigmentation rather than scarring, and they behave very differently.
A tethered scar is a depression anchored to deeper tissue by a fibrous band, so the surface cannot sit level regardless of what is done to it from above. The tell-tale sign is behaviour on movement: a tethered scar deepens when the face animates, and it stays pinned down when the surrounding skin is stretched. Tethered scars are typically released by subcision before any resurfacing is considered.
Yes. Active acne means ongoing inflammation, and inflammation is what creates new scars and pigment — so resurfacing over active breakouts means treating a moving target while the condition continues to add to it. Getting the acne controlled first is the sequence, not a delay. Once the skin is quiet, scar treatment can be planned on a stable surface.
Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification system and review of treatment options. Journal of the American Academy of Dermatology 2001;45(1):109–117. source
Consultations by appointment at Orchard Road, Singapore.
WhatsApp +65 8023 7170 →