Follow-up question: Would subcision work on scars that are worse from TCA cross? (Photo)

Question

Where do I go from here? It has been 7 weeks since my TCA cross treatment and I have 3-4 craters/trench that have definitely been created by my dermatologist who applied 100% TCA to what was previously small ice pick scars (she also spilled some and did not neutralize in time). These scars took the shape of her instrument - a blunt wooden end of a Q-tip What treatments can fix these giant craters in my skin now? Would subcision work? And do I now need fillers every year because of the damage done? Thanks so much.

Jeff Rapaport, MD · Answer

In my opinion, one or two of the pits can be retreated with TCA cross. It appears that the other lesions have elevated and  low density ablative laser can be utilized. Finally, a filler can be used to touch up had a later time.
Jeff Rapaport MD FAAD
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Steven F. Weiner, MD · Answer

I don't think subcision is helpful in this case. I see some PIH but not deep scarring. I would treat with hydroquinone and retin a and maybe 1927 laser. There are some ice pick scarring that would respond to TCA Cross from a skilled provider. Subcision is mainly used for tethered atrophic scarring.

Davin Lim, MBBS, FACD - Account Suspended · Answer

I agree with Dr Rapaport- TCA to further raise the scars, add low density lasers. Wait a few months to fade pigment, then resurfacing with possibly erbium. Not a hard job, just have to be patient. 
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.

Follow-up question: Would subcision work on scars that are worse from TCA cross? (Photo)

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Follow-up question: Would subcision work on scars that are worse from TCA cross? (Photo)

Answers (3)

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Everything you need to know about Subcision

Our mission is to create a world where every investment in modern beauty is Worth It.