Would I benefit from subcision + filler treatment? (Photo)

Question

In the past I did few times of ablative CO2 laser but my scar does not really improve. My scars are mainly in cheek + temple area. Thank you.

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

Benjamin Barankin, MD, FRCPC · Answer

I have treated many hundreds of patients with atrophic/depressed boxcar scars with nice results. Typically multiple treatments are required, and multiple modalities. Treatment options depend on many factors including age, skin type, previous treatment experiences, budget, downtime, extent and location of scarring, pain tolerance, etc; It most certainly is not 1-size fits all and requires a proper in-person assessment by a scar expert such as a dermatologist. It is also key that your acne is under good control and/or in remission. I believe that subcision, often with fillers, is a great way to start, followed by subcision alone (usually every 6-8 weeks). Laser resurfacing such as ErYag (Profractional) or CO2 fractionated lasers is also an excellent option, again several sessions (usually every 4-6 weeks). Medical grade & deeper chemical peels can also be helpful, whereas microdermabrasion isn't so helpful. I also very much like microneedling (medical-grade, deeper, although home devices can help a bit too), especially when boosted with PRP (platelet-rich plasma) or RF (radio frequency). For stubborn scars not sufficiently responsive to aforementioned treatments, we do punch excisions. For thicker/keloid/hypertrophic scars, we do cortisone or cortisone-mix injections. Best to chat with your local dermatologist who has the most experience and training in treating both acne and acne scars.

Davin Lim, MBBS, FACD - Account Suspended · Answer

I do think that subcision would be in your best interest, all other modalities can be secondary. If you are in SG, consult with the dermatologists at Mandalay Bay Laser Center or the NSC.
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.

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Would I benefit from subcision + filler treatment? (Photo)

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