Acne scarring treatment - Is subcision really needed in my case? (Photos)

Our office has many different treatments for acne scars depending on the depth of atrophy or hypertrophy. Acne scars require a combination approach using our HIDEF protocol which uses a combination of lasers, topical scar modulation, and RF treatments to pixelate scars, improve contour, reduce hyperpigmentation, and improve the visibility of the scars so that they are no longer visible in ambient light. Everyone has a unique pattern of acne scarring and we employ our HIDEF technique to improve texture, color, contour, and topography. We often use a combination of treatments that begin with a careful examination to examine the micro texturing of the acne scars. Atrophic acne scars and indented acne scars can benefit from injectable fillers such as Radiesse, Sculptra, and Restylane with or without subcision to remove tethered scars and atrophic depression. Hyper-redness in scars can be been improved with V beam laser, Excel V, BBL, IPL, and Venus RF to improve the redness and reduce the visibility of deep scars. Fractional Thulium laser and clear & brilliant can also reduce the inflammation and redness of the scar when combined with topical therapy. Fractional laser such as Fraxel, erbium, and CO2 laser can be combined with radio frequency and also fractional RF to improve textual issues and microtopography. Subcision and TCA cross are also used for deep ice pick scars and narrow valley scars in order to improve the micro texture. Above all, our combination approach with our clinical nurses and board-certified plastic surgeons can improve the quality of your skin by using at home Melarase creams combined with PRP treatments in our office to improve your skin quality and tone.

Subcision works well alone and in combination with other laser and RF platforms, including fillers and air subcision. TCA Cross can be combined with subcision. I recommend getting a formal evaluation with an experienced team of experts in order to reduce your acne scarring.

Finally, hyperpigmentation of scars can be improved with at-home Melarase AM, Melarase PM, and Melapads to help reduce active PIH and melanin deposition.

Best,
Dr. Karamanoukian

"Acne scars need a combination approach for long-term improvement. Everyone has a unique pattern of acne scarring, and most people have various types of scars, so we create a tailored treatment plan for each patient. Generally speaking, we often use:

- Injectable fillers like Bellafill and Sculptra (with or without subcision) for atrophic, indented scars.
- Subcision for depressed, tethered scars.
- Vascular lasers like Yellow laser, Aerolase, excel V, BBL or IPL for redness or thick acne scars.
- Lasers such as Fraxel, Erbium, CO2, Halo or fractional radiofrequency (Venus Viva, PiXel8, Morpheus, Skinfinity, Fractora, Intensif microneedling RF) for textural issues and superficial scarring.
- TCA CROSS and punch excision for deep ice pick scars and narrow box car scars.
- All lasers are combined with microneedling/PRP to improve the results and accelerate your healing time.

For darker skin types, it is important to avoid strong lasers such as CO2/Erbium and Fraxel as they can cause hyperpigmentation. Instead, scars in darker skin types can be improved with a combination of microneedling RF (Fractora, Intensif, Infini), Aerolase or Laser Genesis, microneedling with PRP, skin lightening, peels like Cosmelan, enlighten and aerify along with dermarolling (EmerageSkin roller with anteage AERIFY MD ampules weekly, and a proper skin care protocol (hydroquinone, vitamin c, kojic acid, azelaic acid, retinol)​. Sun protection is essential. I recommend getting a formal evaluation with a board-certified cosmetic dermatologist and acne scarring expert. Best, Dr. Emer​"

I would do subcision and 3-4 profractional or radiofrequency microneedle treatments and wait a year for result,

The pattern in your case is very superficial (ie. deep 'superficial' scars). Simple TCA- Phenol etc.. with low density lasers can make a good difference *you do have active acne L side, jawline. This should be controlled.

Subcision can help, but simple procedures will yield good gains.


The ideal treatment for acne scars will depend on YOUR pattern of scarring. Do not approach scar revision with method in mind, but rather the opposite.

Treatment methods are employed to best address your scar pattern. 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.

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 consultation with a procedural dermatologist or plastic surgeon is required for the best accuracy- diagnosis.

All the best,
Dr Davin S. Lim
Dermatologist. Brisbane
Australia.