Does the combination of subcision and HA fillers give a permanent improvement in atrophic/rolling acne scars?

Question

I am reading a bunch of different reviews, articles and opinions. I have a mix of rolling and atrophic scars and I have gotten mixed answers. I have read that HA fillers and prp act as buffers that allow the scar to heal properly after a series of subcision treatments. Is this true, and if so, does this mean that the results of this combination are permanent? I am considering scar treatment but I don't want to do a treatment that is not going to give good improvement.

Jeff Rapaport, MD · Answer

Subcision is an excellent treatment to break up shallow or atrophic scars that are tethered. In my opinion, the combination of subcision with PRP is superior to that of subcision with hyaluronic acid.. PRP has the ability establish a fibrin matrix that can act as a form for the collagen deposition. Hyaluronic acid is a space filler, and can temporarily keep the shape, however it may not encourge as much new collagen formation and wound healing. Find an acne scar expert. Ask to see photos.

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

Best, 
Dr. Raffy Karamanoukian
Realself100 Surgeon

Michael A. Zadeh, MD, FACS · Answer

Acne scars are treated most effectively with a combination of treatments including lasers, microneedling, fillers, chemical peels, subcision, punch excision, at home skin care, etc. Usually multiple treatment sessions are needed. It is an ongoing process and commitment is key. The goal should be improvement and not total elimination. Make sure you find an experienced provider to minimize complications. Best wishes.

Jason Emer, MD · Answer

Yes, acne scars need a combination of subcision and fillers combined with lasers, microneedling/prp, and Cosmelan to get the most improvement. It will take a series of treatments and will need some treatments to maintain. I recommend getting a formal evaluation with an acne scarring expert. Best, Dr. Emer

Payman Kosari, MD, FAAD · Answer

The primary role of subcision is to disrupt the tethers binding down rolling acne scars.  It secondarily creates a space that blood will occupy supporting neocollagenosis as your skin heals.  Subcision is working towards long term improvement of your scars.  PRP promotes healing.  Hyaluronic acid fillers used for acne scars are biodegradable and therefore provide short term improvement.  Hope that helps

Michele Zormeier, MD · Answer

Thank you for your question. 
Multi modality treatment may be your best option. Microneedling is a good choice but may require 3-4 treatments. We combine Radiofrequency microneedling with platelet rich plasma (PRP) to obtain the best results. Deep FX laser resurfacing softens acne scarring nicely; however, downtime is needed with this procedure, and more than one treatment may be required. Sublative RF treatments also stimulate collagen production to improve acne scarring but multiple treatments are needed. 
Subcision May be a good choice for Ice pick scarring along with HA fillers but much depends on the type, location, and depth of your acne scarring  
Bellafill contains PMMA microspheres which provide a scaffold that supports your own natural collagen production as it develops over time.  Bellafill replaces lost volume in the skin below the acne scar, and is best used for distensible, rolling acne scars. More than one treatment may be needed, but results are excellent and long lasting. It is a great choice for acne scarring on the cheeks. 
Please consult a local board certified facial plastic surgeon for more information and a comprehensive consultation

Ingrid Trenkle, MD · Answer

The only FDA approved filler for acne scarring is Bellafill. It is FDA approved for 5 years, but they have come out with 10 year studies showing it does last longer. It does take a series of treatments usually using 1-2 syringes each time. To have Bellafill you need to have a skin test done 30 days prior to treatment to ensure you are not allergic to the collagen. HA fillers may last anywhere from 6-24 months. Pico Resolve laser is also FDA approved for the treatment of acne scars and works beautifully with Bellafill.

Jessica H. Kim, MD, FAAD · Answer

A combination approach is best to address acne scars - punch excisions, subcisions, fillers, lasers, microneedling, skin care, and peels.  When combined, you can get longer lasting results but I would not say "permanent" since you are continuing to age and losing collagen.  As always, consult with an experienced cosmetic dermatologist.

Davin Lim, MBBS, FACD - Account Suspended · Answer

Yes, many articles, good Italian study showing continued improvement with HA fillers after 5 years, just completing my 4 year study on Volbella. Bottom line is that it depends on your immune system. I use fillers and subcsion as a passive way of improving scars- namely to break the bonds the buffer the attachments. This gives good instant results (with realistic expectations). The second aspect of scar revision is active collagen remodelling- with both RF and CO2 a few months after this procedure. Now, if your immune system has fibroblast that can manufacture collagen, results are permanent. Filler itself, as you would have read does stimulate collagen (however for massive atrophic scars this is not sufficient). So to answer your question, treatments with subcsion and filler in the context of tethered and atrophic scars WILL give you improvement. Longevity is dependent on your immune system. I know work is currently underway regarding stems and FB (fibroblast transfer), so within 10-15 year we will have reliable fibroblast and stems. Acne scar revision comprises of specialised procedures. For the best results, one should target the acne scar type with ideal treatments METHODS. Using one device is not optimal. As everyone has a unique pattern of acne scarring, the best solution is a tailored one.  The web reference below will take you to a resource to help you understand acne scar revision at a specialist level. I embedded all the videos in one page to help. 
  
 
  
As an example deep ice pick scars, and narrow box car scars are best treated with TCA CROSS. Deep narrow scars respond better to this treatment than even the most expensive lasers. On the flip side, rolling, and atrophic acne scars can improve with fractional devices such as Fraxel, fractional lasers, ProFractional erbium lasers, Infiini –Intensif –Intracel radiofrequency microneedling. Atrophic scars (depressions) can be treated with either fat grafts, PRP or dermal fillers. Tethered and anchored scars are best treated with surgical techniques such as subcision. Other surgical techniques that I use include punch elevation, surgical elevation, punch excision and traditional excision for focal scars. Early and very mild acne scars respond well to eMatrix and non-energy microneedling, as well as vascular lasers. Skin colour changes such as PIH or dark marks respond best to sun protection, creams, and Q switch lasers in the nano and pico pulse durations. 
  
 
  
The majority of patients will have a collection of different scar types, and hence a tailored treatment METHOD will be best. Careful examination, especially under angled lighting with scar mapping will give you an understanding of what are the best options for your scars. Additionally tactile examination namely touch will give me an understanding of the amount of subdermal fibrosis, as special equipment is needed for this sub-set of acne scars.  In the majority of patients its finding the correct combination that give you best results, and everyone is unique! It is never about the device, its about the specialist behind the equipment that will deliver the best outcomes. All the best, Dr Davin Lim. Acne scar dermatologist specialist. Brisbane, Australia.

Does the combination of subcision and HA fillers give a permanent improvement in atrophic/rolling acne scars?

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