Will subcision with filler like Sculptra or Restylane improve these acne scars? (Photo)

Question

How many treatments will I need? Also which treatment do you recommend after? I have already done multiple laser treatments like co2, halo, ematrix, infini, microneedling with PRP, TCA cross, etc. but I have never done subcision with filler. Thank you!

Raffy Karamanoukian, MD, FACS · Answer

Our treatments use combination therapy to improve the epidermis and dermis for most deep scars. The options available for acne scars depend on the character of your scars, in terms of topography and contour. We see atrophic and hypertrophic acne scars, as well as scars that have hypo and hyperpigmentation. We begin each scar evaluation with an assessment of scar quality and subtype. Our main concern is rebuilding collagen and that is why we use a HIDEF protocol that includes combination therapy. Morpheus 8, scar subcision, fibrous release, fractional laser, CO2 laser, Thulium laser, PDL Vbeam laser, and fractional resurfacing can be used in addition to TCA Cross and chemical peels to further improve skin. Patients should start Melarase AM and Melarase PM for active hyperpigmentation. Always begin with a consultation to decide whether early subcision should be started.

Best,
Dr. Karamanoukian
Realself100 Surgeon

Best, 
Dr. Karamanoukian 
Realself100 Surgeon

Jason Emer, MD · Answer

these type of scars are ice pick and need TCA cross, peels and rollers at home, and in office lasers like halo/co2/fraxel/profractional.  subcision will not help nor will filler, but you do need filler for cheek/mid face voulme and facial contouring.

at home peels like cosmelan, enlighten and aerify along with dermarolling (MTS roller with anteage MD ampules weekly) should be started now

if you have post inflammatory hyperpigmentation/melasma/discoloration that needs cosmelan or enlighten peels at home which we can do virtually and send to your home along with aerify peels regularly, vivatia foam, restorsea 10x, faith essence serum, and cosmelan 2 cream.

Acne scar treatment needs a combination approach for improvement.  For the best results, one should target the acne scar type.  As everyone has a unique pattern of acne scarring, the best solution is a tailored one.  Typically you need fillers like bellafill and sculptra for atrophic indented type scars with or without subcision.  Subcision for depressed tethered scars.  Vascular lasers like yellow laser, aerolase, excel V or IPL for redness or thick scars. And lasers such as fraxel, erbium, co2 or fractional radiofrequency like venus viva, skinfinity, intensif or fractora microneedling RF for textural issues and superficial scarring.  Deep ice pick scars and narrow box car scars are best treated with TCA CROSS and punch excision.  All lasers are combined with microneedling and PRP to get even better results and improve healing times.   The majority of patients will have a collection of different scar types, and hence a tailored treatment plan is needed by an expert physician.  It is never about the laser or product that gives the results, its about the expert behind the equipment that gets you the outcome.  Scars cannot be cured and will need life-long treatments to maintain and build on the results.  For those at high risk for hyperpigmentation (darker skin types or asian or hispanic or mixed ethnicities) we already pre-treat the skin with cosmelan or enlighten lightening peels to prevent complications from energy-based or chemical-based treatments.  Best, Dr. Emer.

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 (your dermatologist will choose based on location/depth of scar/age etc), 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

Most of my modalities for scar revision is manual, this case is not one of them. From the photos seen, the scars seem superficial. Possibly the use of energy devices such as lasers maybe indicated in this situation.

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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