Subcision with Cross or CO2? (Photo)

Question

Hello, I've spoken to 2 skin professionals who recommended 2 different things. 1 recommend 2-3 sessions of Subcision with Cross and microneedling. The other thought that that option was not a good idea and suggested I'd do 2-3 sessions of CO2 with filler instead. Pictures are attached. Please guide me in the right direction. Thank you in advance, docs!

Nelson Lee Novick, MD · Answer

I have been performing subcisions since 1994 for treating all kinds of indented (depressed, atrophic, sunken) scars from all causes, whether post-surgery, post-trauma, or boxcar and rolling scars post-acne. Subcision is a simple, inexpensive and tried and true technique for elevating and smoothing wider-based sunken scars, such as chickenpox scars and the boxcar and rolling scars that follow acne, as in your case. The results of subcision are long-lasting to permanent. Ice pick scars and dilated pores are best treated by TCA CROSS, a technique that I have been employing for the past twenty-two years. Here, too, the results tend to be long-term or lifelong. And finally, for also about twenty-two years, I have been employing professional microneedling to better blend the color and texture of the above-treated areas  with the surrounding normal skin. Your photos suggest some generalized facial atrophy and slight sinking, so a Field Subcision should be discussed with your physician. (Just fyi: There is no hard science to prove that radiofrequency microneedling is any more effective than standard, simple microneedling-although it certainly more expensive and often more uncomfortable to undergo).  All of the foregoing procedures can be performed during the same treatment session if deemed necessary if logistics dictate. So no worries there. Be cautious when evaluating claims for this or that bells and whistles laser or energy-based devices as the purported benefits of these tend to be backed far more by device manufacturer supported marketing hype than hard science. Make sure that you are consulting with a board certified aesthetic physician with extensive acne scar treatment experience before agreeing to proceed, and for more information on any of the above, check out the archives or RealSelf.com. Best of luck.

Raffy Karamanoukian, MD, FACS · Answer

Our office has many different treatments for acne scars depending on the depth of atrophy or hypertrophy. Acne scars require a combination approach using our HIDEF 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 acne 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 acne scars and indented acne 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 been 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 laser 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.

Subcision works well alone and in combination with other laser and RF platforms, including fillers and air subcision. TCA Cross can be combined with subcision. I recommend getting a formal evaluation with an experienced team of experts in order to reduce your acne 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

Subcision works well alone and in combination with other laser and RF platforms, including fillers and air subcision. TCA Cross can be combined with subcision. I recommend getting a formal evaluation with an experienced team of experts in order to reduce your acne 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

Jason Emer, MD · Answer

Fraxel and/or CO2 are best for resurfacing, but Erbium is a good alternative. I always combine lasers with microneedling/PRP for more robust outcomes. For skin tightening, I recommend a combination of Ultherapy with RF treatments and Sculptra for skin tightening. I recommend getting a formal evaluation with a cosmetic dermatologist. Best, Dr. Emer

Jeff Rapaport, MD · Answer

In  my opinion, you have tethered saucer-shaped scars, box cars and pits. Both treatment plans recognize the need to lift the scars. I prefer subcision and PRP, microneedle radio frequency and TCA cross. If needed, this can be followed by  ablative low density laser and fillers.Jeff Rapaport MD FAADRealself Verified All-star

Steven F. Weiner, MD · Answer

I see mostly rolling scars and boxcar scars. I would treat with TCA Cross and subcision. I'd also add RFM, the Genius, at the same time. I don't think filler is needed initially but may be needed down the road if you can't get the elevation needed with these treatments. CO2 I would also hold off on  because your skin is at risk for PIH. Consider 3-4 treatments initially.

Davin Lim, MBBS, FACD - Account Suspended · Answer

I agree with the comments, MANUAL subcision over any devices in your case. CO2 etc. can be used as adjunctive and NOT primary treatment. 
The ideal treatment for acne scars will depend on the morphology of individual scars. For example, rolling scars are best treated with subcision, atrophic scars with fillers, pick-ice pick scars with TCA or Phenol CROSS/ Paint, box-scar scars with fractional laser/ modified TCA/ phenol chemical peels, hypertrophic scars with steroid injections/modulated fractional delivery. 
Energy devices such as lasers, microneedling RF and bipolar radiofrequency are other methods to treat ‘general’ scar types. For example devices can improve rolling-tethered scars as well as ‘deep - superficial scars’ such as broad ice-pick scars and broad box-car scars. Devices should be viewed as a method of scar revision, and rarely as a sole modality. Exceptions do apply- for example in patients with predominantly shallow/broad box-car scars and or superficial pits. 
Another factor that will determine the ideal combination of treatment is the skin type of patients. Skin typing used to determine the ‘skin colour’ of patients. Darker skin patients will require modifications to treatment parameters. This includes a lower percentage of chemical peels, conservative protocols for lasers and energy devices and in some cases pre and post treatment of skin to reduce but not eliminate the chances of PIH- post inflammatory hyperpigmentation- skin darkening. 
The very first step in scar revision is to accurately determine the subset of scars you have. This is best done with a real time examination. Factors such as animation (rather than static photographs) are frequently used to determine the amount of ‘deep scarring’ /anchored scars or tethering. Palpation or touch is also extremely important to determine the presence of dermal and subdermal fibrosis. Scars that have altered ‘texture’ either hard or soft (atrophy) are more challenging to treat compared to scars with ‘normal’ texture. In some cases the use of angled lighting can be employed to accurately map scar types. 
My answers given in the context of this question is a general plan given the limited information. For an accurate guide, one has to take into consideration factors such as animation, touch, feel, real time examination and most importantly subjective measures, namely patient expectations. A real time consult with a procedural dermatologist or plastic surgeon is required for the best accuracy- diagnosis. 
All the best, Dr Davin S. Lim, Dermatologist. Brisbane. Australia.

Subcision with Cross or CO2? (Photo)

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