Am I a good candidate for subcision and TCA Cross? (photos)

Question

I have really severe acne scarring. These are the worst pictures I could find. I wanted to do subcision/TCA Cross in hopes of improving these scars but every dermatologist I've been to tells me that I'm not a candidate for these cause the scars look too "mild" and disregard the pictures I show them. I have done dermapen but wasn't happy with the results so I figured subcision/tca cross would be better. I wouldn't want to get lasers though cause I had bad experience in the past with them.

Raffy Karamanoukian, MD, FACS · Answer

Acne scars are usually characterized within the subtypes of atrophic, hypertrophic, pigmented, or inflammatory. These subtypes of acne scars can be visually discerning in ambient light and can cause significant cosmetic concerns. Indented and atrophic scars require a combination approach to stimulate collagen and elastin, thereby smoothing contour and uneven skin. These are usually combined with lasers and depigmentation protocols to reduce inflammatory hyperpigmentation (Melarase AM and Melarase PM). Our Hidef protocols for acne scars include fillers such as Sculptra, Juvederm, Radiesse, and Restylane to improve deep acne scars; Vascular lasers to reduce inflammation and post-inflammatory redness and erythema; Fractional lasers to smooth contour and collagen; and Fractional RF to stimulate production of collagen within atrophic scars. Textural improvement and superficial scarring can be improved with Cosmelan peels, TCA Cross for ice-pick scars, deep chemical peels, and fractional CO2. We offer a personalized approach to your combination of scars and a formal evaluation with consultation is recommended to help you achieve your final results. Our plastic surgery office offers subcision and combination TCA Cross to help reduce deeply pitted scars. In terms of pigmentation and skin resonance, we recommend daily use of Melarase AM and Melarase PM coupled with Retinoid creams to achieve brilliant skin.

Best,
Dr. Raffy Karamanoukian
Realself100 Surgeon

Best, 
Dr. Raffy Karamanoukian
Realself100 Surgeon

Nelson Lee Novick, MD · Answer

First let me say that I am hardly surprised by your lack of desire to repeat the laser therapy. Anyone who reads my Q&As regularly is aware that I have been expressing my disappointment in fraxels (as well as the current radiofrequency and ultrasound devices) for the past several years, having personally found them to be far more backed by device manufacturer supported marketing hype than hard science. I am also not surprised by your lack of success with the Dermapen microneedling treatments. While microneedling (along with subcision) was touted at the most recent meeting of the American Society of Dermatologic Surgery as one of the latest hot therapies, it has actually been around for years (I have personally been using it for over fifteen years and have been writing about it for years, as well). However, microneedling whether manually performed with Dermarollers or automatically with Dermapen is best reserved for treating residual surface color and texture irregularities, rather than a first-line treatment for deeper scars. Microneedling would not be my choice as a stand alone treatment for deeper scars. From the photos, it appears to me that a number of your atrophic (indented) acne scars would very likely benefit from the use of subcision lifting accompanied by a filler to elevate them more in order to diminish the shadowing (craters on the moon effect) that is making them more visible.  Likewise, TCA CROSS may be helpful for any pit (ice pick) scars. Since there appears to be some overall acne related volume loss in the cheeks, injected a volumizing filler throughout the cheeks might help to significantly smooth the deflated cheek regions and would actually be what I would consider performing first before either subcision, TCA CROSS  or microneelding. Make sure you seek consultation and treatment by a board certified aesthetic physician with experience and expertise in all forms of acne scar treatments. Best of luck to you.

Jason Emer, MD · Answer

This type of contouring requires a series of treatments including subcision, fillers, lasers and microneedling/PRP.  I suggest you see an expert for treatment options.  This will take a long term series of treatments to get best results.  Dr. Emer.

E. Victor Ross, MD · Answer

these are somewhat tough scars- would recommend a combination of traditional erbium YAG laser, fractional lasers, and possibly down the line some fillers- TCA cross could be applied to some smaller isolated scars

Michele S. Green, MD · Answer

Thank you for posting photos of your acne.  You would require a combination of injections to volumize the area and treat the individual scars and eMatrix.  It would take several treatments with the eMatrix to help with surface irregularities. I would first proceed with fillers as the scars need to be injected first to give you the best cosmetic results. Please consult an expert at cosmetic injections and lasers.  Best, Dr. Green

Steven F. Weiner, MD · Answer

I don't think that subcision with TCA cross is the treatment for you. I would use Infini for these scars. Also, you have significant volume loss and need filler as well. Dermapen gives very mild results and needs 8 at least to be effective. TCA is for ice pick scars and subcision is mainly for tethered scars.