TCA Cross or Punch Excision for deep cheek scar? (photo)

What would you do? 3 PS, 3 different answers. 2 of 3 said an excision will fail but the other one says it's a piece of cake. Not sure what to do. TCA seems risky but so does excision. Help!

Doctor Answers 4

How to Treat Deep Acne Scars On Cheeks

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I know others have said not to excise these types of scars, but I have great success in using 2 mm punch biopsies and closing them.  Then waiting 2-4 weeks and performing fractionated co2 resurfacing. TCA cross (based on your photos) likely wont work well on these scars because they appear to be more broad rolling scars and not thin, ice-picked types.  I would suggest either trying co2 or erbium resurfacing or fraxel 1550nm or microneedling without surgery if you are conservative.  But the fraxel will take many treatments, if it works at all.  If I had my choice I would likely punch excise a few of the spots, then follow 2 weeks later with fractional co2 laser on the entire cheek.  I am not a big fan of spot treating scars, I think the area needs to be blended.  There is no perfect answer for this situation, go to someone with advanced training in lasers, subcision, fillers into acne scars, and surgery on the face.  I am one of few doctors who uses Silikon for treatment of these types of scars when all else fails.  I wish you the best of luck, Dr. Emer.

Los Angeles Dermatologic Surgeon
4.8 out of 5 stars 203 reviews

Subcision & Fractional Medical Microneedle Therapy Work Well Together For Raising & Blending Depressed Scars

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When scars are fully matured, i.e. have been present for at least a year, as appears to be the case here, there are a variety of approaches that can be considered. For over twenty years, subcision has proven an easy and effective method for permanently elevating depressed scars of various types, including traumatic scars and acne scars.

Subcision is a procedure in which a sterilized needle is inserted, following the administration of local anesthesia, directly beneath a depressed scar (regardless of whether from acne, infection, trauma, or surgery) and used to break up the thick bands of fibrous scar tissue that bind down the surface and create the depression. 

Breaking up the abnormal bands of thickened, scar collagen accomplishes two things. First, it allows the surface of the scar to float to the surface. In addition, the tissue fluid that immediately fills the space following treatment contains growth factors and other wound healing substances that promote neocollagenesis, native collagen production, that allows for improvement and elevation of the scars. Between two to four treatments, spaced at six week intervals, are generally required to promote sufficient new collagen to achieve a satisfactory improvement. Since, the collagen produced is one's own, the results of subcision are typically permanent. A small amount of collagen-stimulating volumizer, such as Radiesse, may be instilled right after treatment to further promote neocollagenesis (new, native collagen formation). 

Fractional microneedle therapy aka medical microneedling (or dermarolling) works by creating numerous areas of controlled microwounding that set off in turn a cascade of events that result in new, native collagen synthesis, which translates into healthier, thicker skin that improves the appearance of the underlying scars. It is particularly useful for improving the surface tone and texture of skin to enhance blending with the surrounding normal skin. In this case, it would be helpful for improving what appears to be a background of acne scarring.

Unfortunately, to date I have not been impressed with laser success rates nor the actual degree of overall aesthetic improvement with their use. When it comes to lasers, there is an abundance of media hype and a dearth of rigorous scientific support. I would be reluctant use CROSS therapy in this case, as the scar appears to broad and may actually become wider following such therapy. Scarabrasion, in which the scar is first removed (by punch excision) and then followed up by manually dermasanding the area about eight to twelve weeks later, is certainly a possibility. However, subcision is much simpler, requires no stitches or surface healing and would seem to me to be the treatment of first choice in this case. 

Consultation with a board certified aesthetic core physician with extensive experience in all forms of scar treatment is essential.

Facial Scar Revision

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I feel this scar would best be treated with fractionated CO2 laser resurfacing.  I would not perform excision on such a visible portion of the face for this mild type of scar.

Anthony Corrado, DO
Philadelphia Facial Plastic Surgeon
4.9 out of 5 stars 41 reviews

Treatment of Deep Cheek Scar

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I would do a combination of TCA CROSS method alternating with Pixel Erbium (fractionated Erbium laser for collagen stimulation) every 2 weeks for about 6 to 8 treatments. Would not recommend excision in the central cheek - you risk exchanging a scar for a scar.

Tatiana Khrom, MD
New York Dermatologic Surgeon

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.