Dr. Rullan San Diego. You will have to do RF microneedling locally though.

1) Subcision + Filler (4of them)
2) Rf Microneedling 3 months apart fit in between subcision until filler runs out.
3) Dr Rullans acid peels or several tca peels. Another option is fully ablative erbium resurfacing.
4) V-beam for PIE
5) If that does not make enough of a difference High power low density CO2 on the pores.

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2) Rf Microneedling 3 months apart fit in between subcision until filler runs out.

Thanks for the quick response. What do you mean by "until filler runs out", isn't it supposed to last a year or so? I was reading Dr Lim and Dr Weiner's responses on another QA site and they both said that Infini + subcision + Fillers can be done on the same day?

I recall back in 2016 you didn't have a positive opinion of Infini RF, in that you were of the opinion that it caused fat loss and people should stick with Needling at home. Has your experience been different with Infini since then? My main concern is further fat loss in the cheek area.

@Meisteryou must be confusing me with someone else. Please show me where I said in the past that I didn't have a positive opinion of Infini. Since you Joined in January of 2018 and only have 3 posts...

I have said laser is a issue because of the side effects, but even that has it's place as a last ditch thing. Infini can be a issue with a poor operator if they go too deeply or too superficial. Must be experienced. IT's safer than laser as it's insulated. Lot's of doctors are set it and forget it types these days. You are fine with a experienced practitioner.

Just because a doctor can do it or says to do 3,4,and 5 treatments at once doesn't mean it's very smart to do. Emer does 5 and screws up peoples faces for life. Cha Ching $$$$, no follow up needed for that . IF you want a mega session travel to Dr. Lim. Your body takes 6 months to heal after a procedure and 3 months is the min recommended to do something. You also need time to see what works and what doesn't, doing it all at once can be rather confusing. What's healing and what's making things worse, ... no one will know. Subcision and Filler work together yes, and Infini works in a different way. They would infini you then subcise and fill you. But you don't get the stimulation of the filler creating collagen by doing it more spread out. In your case you could have Sculptra injected for you fat loss in the cheek , ... if you did this all at once it would not do the same thing.

People have to stick to lots of things they are not all the same. Different scars need different treatments. We have those who are broke doing DIY at home. Those who don't want energy devices. Those who want laser. Those who want the most bang for their buck. Those who nothing else works so it's time for the big guns. Those who are sensitive and heal poorly, and those who have ethnic skin. Microneedling and TCA peels is great for a DIYer but there will be a point of diminishing returns.

You already have fat loss in your cheek. Hence Sculptra and infini stimulating it. Sculptra was used for HIV patients with facial wasting. IF you wish you can start with HA and subcision, this will do a lot for you. Then decide on your next steps... All optional in the plan above.

No WAY Lim does filler and Infini on the same day- way too risky. Weiner might, Lim more conservative. Agree with BAs plan. Infini and subcsion can be safely done on the same day. Subcsion and filler, most would agree safe, but to do all 3 with preachment of the dermal layers with each shot of Infini with 49 holes in the proximity of filler... IMO only, risky, and shared by others. Infini is just a device, Weiner uses it exclusively, Lim uses Intensif and questions the solenoid and carbon build up of Infini. He uses it as a tool, and not his primary mode of scar revision. It is only as good as the operator. Many many bad things can arrises from incorrect use of this device. Your scars are very treatable, Rullan can easily manage - its manual over device in your case.....

@beautifulambitionProbably mixed you up with someone else who was quite active on this forum couple of years ago.

I contacted Dr. Rullan's office and they recommend two options. First being that I get a 2-day Phenol peel, however, it has two week downtime and then facial redness for 1-3 months. Second option being Subcision with TCA CROSS and Microneedling. Phenol peel results on his site are really impressive, but I can't afford that kind of downtime right now, so I guess I need to stick with subicision and fillers for now.

I thought TCA Cross was used mainly for ice pick scars. Looking at my pics, do you see the need for TCA? Is there some other lighter full face peel that I can get, that has a shorter recovery period (few days) and will result in texture improvement?

It's really hard to find a good Infini RF provider. I contacted two locally and both had differing opinions, one said that it has about a week downtime i.e. I'd be completely normal after that. The other said that Infini has a long downtime and he typically starts his patients on topical skin lighting couple of weeks before and uses strong sedation during the procedure and that I'd need someone to drive me home afterwards. This is in complete contrast to what Steve Weiner says in his videos. Do you know of any good providers in SF Bay area? I was thinking of going to Florida and getting it done by Dr. Weiner, however it appears, that even at his clinic he rarely performs the Infini treatment himself.

@Obi wanI came across Dr Lim and Dr. Weiner's answers on another site: https://www.realself.com/question/denver-long-after-fillers-infini-laser

Seems like they are both of the opinion that Inifini doesn't have much affect on fillers.

What did you mean by "solenoid and carbon build up of Infini"? I've never heard of that before.

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You already have fat loss in your cheek. Hence Sculptra and infini stimulating it. Sculptra was used for HIV patients with facial wasting. IF you wish you can start with HA and subcision, this will do a lot for you. Then decide on your next steps... All optional in the plan above.

@beautifulambitionI'm confused, so which filler is better for me? Does Infini work better with Sculptra?

I would not do the phenol peel. It does not make sense to me to do a whole face treatment when your scars are concentrated just on your cheeks mainly. Looking at your scars, I guarantee that fillers will make an immediate positive impact. The loss of volume in the middle of your cheek should be lifted with fillers. That in itself, will diminish the shadowing right away. Your skin color is also tan so that's enough reason to not do the phenol peel. Rullan is a good doctor from what I've seen, but I disagree with the phenol approach. Too aggressive for your issues. Your issue is volume loss and rolling scars, both of which subcision and fillers would address.

2 hours ago, dazzed said:

I would not do the phenol peel. It does not make sense to me to do a whole face treatment when your scars are concentrated just on your cheeks mainly. Looking at your scars, I guarantee that fillers will make an immediate positive impact. The loss of volume in the middle of your cheek should be lifted with fillers. That in itself, will diminish the shadowing right away. Your skin color is also tan so that's enough reason to not do the phenol peel. Rullan is a good doctor from what I've seen, but I disagree with the phenol approach. Too aggressive for your issues. Your issue is volume loss and rolling scars, both of which subcision and fillers would address.

I'm thinking the same, start with subcision, fillers and vbeam. Loss of volume in the middle of cheek is a huge concern for me, looks like Sculptra and Voluma both will work. Is one better than the other in my case?

I haven't tried those treatments before. Are they expensive?

Voluma is instantaneous, while Sculptra will take months to show up. They work by completely different mechanisms. Sculptra is not really a traditional filler but what the company has dubbed as "collagen stimulator". In truth, that "collagen" is really scar tissue that encapsultes the powderized suture material in Sculptra. Both will work, but Voluma is reversible while Sculptra is not reversible. Voluma is said to last up to 18 months while Sculptra can last 2-3 years, supposedly but it will vary based on the person.

Both of these are for volume so they must be injected deeply. For the superficial rolling scars, you should use Restylane or Belotero.

Depends on location or if you're going to a med spa or derm / plastic surgeon the price per syringe can be:
Voluma can be $500-$1000.
Restylane $300-$700

Sculptras Mechanism of Action

Poly-L-lactic acid (PLLA) is a member of the alpha-hydroxy acid family. It is biodegradable and biocompatible, and it has been useful in other forms for numerous medical applications such as absorbable sutures and mesh, plates, and screws for many years. Sculptra is composed of PLLA microparticles, sodium carboxymethylcellulose, and nonpyrogenic mannitol. Once injected, Sculptra is hydrolyzed into lactic acid monomers, which induce a localized tissue inflammatory response recruiting monocytes, macrophages, and fibroblasts. A capsule is formed around each individual microsphere as the lactic acid is metabolized, resulting in increased collagen deposition by host fibroblasts. The end result is dermal fibroplasia and subsequently-increased dermal thickness.

A technical version of what I basically wrote.

2 hours ago, Sirius Lee said:

The end result is dermal fibroplasia and subsequently-increased dermal thickness.

Dermal fibroplasia basically means scar tissue. Isn't scar tissue supposed to be permanent? Then why does Sculptra last 2-3 years?

There is conflicting advise on subcision, many doctors says they perform subcision and filler together. However, on this forum, people say to wait few days for filler. Last time I had subcision done, my face was quite smooth for a couple of months, I'm wondering if I wait a few days then how would the derm know which areas need filler, since my skin will be smooth?

Are Dr. Greg Morganroth, William Ting and Evan Ransom all good doctors to get subcision done? My first subcision was with Dr. Ting back in 2015, however, I felt as if he didn't move the needle in a fan like motion, he moved it like a plunger.

7 hours ago, Meister said:

Dermal fibroplasia basically means scar tissue. Isn't scar tissue supposed to be permanent? Then why does Sculptra last 2-3 years?

Well, that's how collagen is produced (or rather remodeled) via fibroblast.

Edit:Also it ain't so much about fibroplasia but neocollagenesis, the ability to continue to make collagen over the span of 2-3 years.

7 hours ago, Meister said:

There is conflicting advise on subcision, many doctors says they perform subcision and filler together. However, on this forum, people say to wait few days for filler. Last time I had subcision done, my face was quite smooth for a couple of months, I'm wondering if I wait a few days then how would the derm know which areas need filler, since my skin will be smooth?

How many scars and how deep? Severe scars require more aggressive subcision. Hence more bruising and swelling. Also, if you're using filler as a spacer to prevent scars from reattaching, then you can subcise and fill at the same time. But if the filler is used for cosmetic purpose, then it's better to wait until the swelling goes down, usually around a week or two.

Edit: BTW Sculptra, by its very nature, cannot be used as a spacer. I thought I should add that just in case.

@MeisterI will message you back channel. We were chatting a few days ago. Some conflicting info in this post. Please message me there concerning doctors above, questions, etc... I will get to it asap. Have 20 messages to also help today ;-P

It seems like there's a misunderstanding about Sculptra.

Sculptra does not make scars or scar tissues. It creates a chain of fibroblasts that, in turn, synthesize collagen. So it's like going through the wound healing process without the actual wound.

With regards to "reversing" the filler in case things go wrong. More than 90% of sculptra is water, which will get absorbed by the tissue within 24 hours followinginjection. Also Sculptra, unlike HA filler, is deeply injected into the dermis. There really is no need for "reversal".

Here's a brief snippet from a research article examining its effectiveness:

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Lemperle et al. (2003) examined the PLLA-injected human forearm tissue of one individual [92]. Histological examination revealed fine capsules surrounding the PLLA-based microspheres, as well as macrophages and lymphocytes three months after implantation. Six months after implantation, the porous surface of PLLA microspheres was surrounded by macrophages and giant cells and the degradation of PLLA was completed in month nine. A nasolabial tissue biopsy of a 55 year-old woman, taken 12 months after the last Sculptra treatment, revealed aggregation of giant cells, histiocytes and collagen fibres. Repeated biopsies after 30 months of implantation showed PLLA-free and collagen-enriched tissue [93]. These authors concluded a progressive dissolution of PLLA-microparticles and an association with a gradual ingrowth of type I collagen. Goldberg et al. (2013) analysed picro Sirius red-stained PLLA-treated tissue sections by digital microscopy and quantitatively assessed collagen I and III: compared to baseline, the mean level of type I collagen - and not type III collagen increased significantly [94].

Source:The biological basis for Sculptra-induced augmentation

Water or saline is just the delivery mechanism because it is a powderized form of the suture material. The water goes away like regular saline with in a day. The powder stays behind and is lodged in the tissues. The tiny beads of powderized suture material is encapsulated. As more and more collagen encapsulates the powder, more and more volume is generated. Bellafill works in a similar mechanism, but the KEY difference is that the beads in Bellafill are permanent. The suture material in Sculptra will eventually dissolve naturally.

Not all HA is injected superficially. Voluma for example is very thick and must be injected deeply in the same plane as Sculptra. You can't make a blanket statement about all HA fillers.

When I say reversed, I meanif TOO MUCH volume is generated and the face looks way too full (like a lot of celebrities) you cannot dissolve the volume like with hyaluronic acid fillers with an enzyme like hyaluronidase. You are literally stuck with an overinflated face for years until it dissipates on its own. If you read realself, there are many accounts of people who either had too much Sculptra injected or they had an extreme response to Sculptra. Sculptra works by inducing a immune, granulomatous response from the body, so some people have an overly aggressive reaction to it. They generate way too much volume and get lumps or develop way too much volume. In those situations they are stuck. So yes, there are cases where badly placed Sculptra needs to be reduced, but cannot be because it is not reversible.

HA Fillers = What you see is what you get, reversible
Sculptra = The volume is unpredictable depending on how your aggressively your body responds to it, not reversible.

9 hours ago, dazzed said:

When I say reversed, I meanif TOO MUCH volume is generated and the face looks way too full (like a lot of celebrities) you cannot dissolve the volume like with hyaluronic acid fillers with an enzyme like hyaluronidase. You are literally stuck with an overinflated face for years until it dissipates on its own. If you read realself, there are many accounts of people who either had too much Sculptra injected or they had an extreme response to Sculptra. Sculptra works by inducing a immune, granulomatous response from the body, so some people have an overly aggressive reaction to it. They generate way too much volume and get lumps or develop way too much volume. In those situations they are stuck. So yes, there are cases where badly placed Sculptra needs to be reduced, but cannot be because it is not reversible.

That might have been the case like 10 years ago due to bad prepping and general ignorance on the part of the injector. I believe most of that have been addressed.

What I said still stands. I merely offered facts. If someone's body has an aggressive response to Sculptra they will produce more volume than they may have wanted. And it is not reversible. No part of that statement can be refuted.

It's a fact that Sculptra can't be reversed if someone should hate it. We have already established that there are a lot of bad injectors. So wouldn't that mean that some people will get badly injected Sculptra? So wouldn't that mean some people will want to reversed the Sculptra but can't? I'm merely making a factual statement, so why must it be countered by a comment. When someone asks me for the pros and cons of various options, I'm going to present them relevant information. Then it's their job to make their decision.

Have you had any fillers? Because i sure have. Do you need to play one-upmanship? What's that constant need to "correct" me when I'm accurate in my statements?