Do I need subcision for my acne scars? Do you always need a filler with subcision? (Photo)

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

Although there is no substitute for an-person examination that allows for manipulation and palpation of the scars, the photos do suggest that subcision would be of value. Most forms of depressed (indented, sunken, atrophic) scars from any cause, are at least tethered down by fibrous tissue to some degree. The degree to which the sunken scar is held down, whether it is a rolling scar or a more crater-like boxcar scar, can be determined by simply stretching the surrounding skin to see just how smooth it can be made. Subcision,whether performed by needles, trochars or cannulas, works by breaking these tethers and creating a blood bruise under the skin, which in turn, via the wound healing factors and growth factors contained in the blood, promote new collagen and elastic synthesis. Although a filler is often added to further help fibroblast production of collagen and elastin, this is not absolutely necessary and would be less advisable in the forehead region. I have been performing subcision for twenty-five years when treating all kinds of depressed scars from all causes, including acne, surgery, trauma and infection (e.g. chickenpox) with gratifying results. Be very cautious in evaluating claims for this or that fraxel, ultrasound or radiofrequency treatments, as these relatively expensive approaches are far more backed by device manufacturer supported marketing hype than hard science.  Hope this helps. Best of luck

In  my opinion, the gold standard for treating tethered scars is subcision with PRP. Recent studies have  shown a 25% Improvement in results when adding PRP to subcision. Filler can be utilized at a later time. Find a scar expert.Jeff Rapaport MD FAADRealself Verified All-star

I would be very careful with fillers to your forehead as this is a known danger zone. Conservative subcision without fillers might be an option. I usually prefer to do blunt subcision using a cannula which is less invasive than sharp subcision. See an expert in the treatment of scars. You need to be evaluated in person. Regards,Dr. Ort

I agree with the panel that manual therapy is the Gold standard. Forehead area - should use saline over any filler. Temples, subcision with or without adjunctive devices would give a good outcome. Any remaining atrophy can be addressed with filler. \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.