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

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.

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

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.