Best treatment options for long-standing acne scars after microneedling, TCA CROSS and subcision? (Photos)

Question

I’ve attached photos showing my acne scarring on the temples, forehead and cheeks. I had severe acne when I was younger and have been left with long-standing atrophic scarring. Previous treatments: • Multiple microneedling sessions (several years ago) • 2 sessions of TCA CROSS • 1 subcision session I don’t believe the subcision was performed using a Taylor Liberator — it appeared to be done with a smaller needle — and the overall improvement has been limited. Based on the photos, I would appreciate professional opinions on: • What type(s) of acne scars are present (rolling, boxcar, ice-pick, tethered scars, etc.) • Whether further subcision (including Taylor Liberator) would be appropriate • Whether combination treatments (e.g. subcision with RF microneedling, laser resurfacing, fillers, or additional TCA CROSS) would likely give better results • What level of improvement is realistically achievable and approximately how many sessions may be required • Expected downtime, risks, and long-term maintenance My goal is to improve skin texture and reduce scar depth in a safe and effective way. Thank you for your advice.

Raffy Karamanoukian, MD, FACS · Answer

Our office has many different treatments for scars depending on the depth of atrophy or hypertrophy. Scars require a combination approach using our HI DEF protocol which uses a combination of lasers, topical scar modulation, and RF treatments to pixelate scars, improve contour, reduce hyperpigmentation, and improve the visibility of the scars so that they are no longer visible in ambient light. Everyone has a unique pattern of scarring and we employ our HIDEF technique to improve texture, color, contour, and topography. We often use a combination of treatments that begin with a careful examination to examine the micro texturing of the acne scars. Atrophic scars and indented scars can benefit from injectable fillers such as Radiesse, Sculptra, and Restylane with or without subcision to remove tethered scars and atrophic depression. Hyper-redness in scars can be improved with V beam laser, Excel V, BBL, IPL, and Venus RF to improve the redness and reduce the visibility of deep scars. Fractional Thulium laser and clear & brilliant can also reduce the inflammation and redness of the scar when combined with topical therapy. Fractional lasers such as Fraxel, erbium, and CO2 laser can be combined with radio frequency and also fractional RF to improve textual issues and microtopography. Subcision and TCA cross are also used for deep ice pick scars and narrow valley scars in order to improve the micro texture. Above all, our combination approach with our clinical nurses and board-certified plastic surgeons can improve the quality of your skin by using at home Melarase creams combined with PRP treatments in our office to improve your skin quality and tone. I recommend getting a formal evaluation with an experienced team of experts in order to reduce your scarring.

Finally, hyperpigmentation of scars can be improved with at-home Melarase AM, Melarase PM, and Melapads to help reduce active PIH and melanin deposition.

Best,
Dr. Karamanoukian
Realself100 Surgeon

Finally, hyperpigmentation of scars can be improved with at-home Melarase AM, Melarase PM, and Melapads to help reduce active PIH and melanin deposition.

Best, 
Dr. Karamanoukian
Realself100 Surgeon

Nelson Lee Novick, MD · Answer

I can certainly understand your frustration and disappointment with seemingly having gone through the treatment mill for acne scarring with little to show for it. 
In the course of my career I have seen many expensive "bells and whistles," light and energy-based gizmos with alluring names come and go--here-today-gone-tomorrow. So, I am not surprised by any disappointment with these devices.
Some treatments, on the other hand have stood the test of time. These include Field Subcision for treating large areas of scarring, such as that cheeks or the temples; simple individual subcisions for elevating and smoothing boxcar and rolling scars; and TCA CROSS for addressing ice pick scars and dilated pores, and manual dermarolling microneedling, as a final finishing step for improving overall skin tone and texture, once the prior treatments have been performed.  (At least from the photos provided all of the foregoing types of acne scarring and issues appear present.
What is crucially important for every patient suffering from acne scarring to be armed with are realistic expectations for success and how many treatments might be necessary to achieve those expectations. 
In general, for both individual subcisions, TCA CROSS, and microneedling (although they are all different procedures), one can realistically expect somewhere between a 60-80% overall improvement. What is equally important is that to achieve that degree of improvement typically requires between two to six treatment sessions, on average three to four sessions. 
When it comes to the the light and energy-based gizmo treatments, it is also important to be aware that unfortunately the hard science to back up their use lags woefully behind the heavy marketing hype and social media buzz to promote them. So, "buyer beware" is appropriate when considering or undergoing treatment with these. And, I have also treated quite a few patients who have come to me following treatment elsewhere from scarring and fibrotic complications of the Liberator procedure, which is an aggressive form of the Field Subcision. 
Hope this helps and best of luck

Anna Chacon, MD, FAAD · Answer

Thank you for sharing your photos and detailed history. Based on what I see and your prior treatments, here’s my assessment:

1. Scar Types:

Rolling scars: Predominant on the temples and cheeks. These are broad, shallow depressions with tethering.

Boxcar scars: Some shallow boxcar-type depressions are visible on the forehead and cheeks.

Ice-pick scars: Fine, deep scars are present, mostly on the temples.

2. Subcision:

Given your prior subcision was likely done with a small needle, it may not have fully released the tethered scars. Using a Taylor Liberator can more effectively free deeper rolling scars and may give more noticeable improvement.

3. Combination Treatments:
For optimal results in long-standing atrophic scars, a multi-modal approach often works best:

Subcision (with Taylor Liberator for deeper scars)

Fractional RF microneedling or laser resurfacing (to stimulate collagen and improve skin texture)

TCA CROSS (for residual ice-pick scars)

Dermal fillers (for rolling scars that remain depressed even after subcision)

4. Expected Improvement & Sessions:

Realistic improvement: 50–70% in texture and scar depth with combination therapy.

Rolling scars usually require 2–3 subcision sessions plus 2–4 sessions of RF microneedling or laser.

Ice-pick scars may need 2–3 TCA CROSS sessions.

Fillers may require 1–2 sessions for remaining depressed scars.

5. Downtime & Risks:

Subcision: 5–7 days of bruising and swelling.

RF microneedling/laser: 3–7 days redness and mild peeling.

TCA CROSS: 3–5 days of pinpoint scabbing.

Risks: temporary redness, bruising, hyperpigmentation (especially in darker skin), infection (rare).

6. Maintenance:

Periodic treatments every 6–12 months may help maintain results.

Sun protection and gentle skin care are essential to prevent worsening or pigmentation.

Summary:
A tailored combination approach—subcision with a Taylor Liberator, RF microneedling or laser resurfacing, targeted TCA CROSS, and optional fillers—offers the most effective and safe way to significantly improve long-standing atrophic scars. While perfection is unlikely, meaningful improvement in texture and scar depth is achievable with proper sequencing and patience.

Best treatment options for long-standing acne scars after microneedling, TCA CROSS and subcision? (Photos)

Answers (3)

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