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Severe forehead scarring / textural damage how best to proceed?

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Hi everyone. 28 yo male. Long-time forum scanner and acne sufferer. Took accutane last year finally and been clear since — now to try tackle the damage. Worst damage was done to the forehead area — combination of frown lines, wrinkles & acne scars is not a good look!! I'm aware forehead is the hardest areato treat due to lack of underlying tissue to work with :( 

Some photos below to try give a good idea of current skin situation — sorry if the quality isn't great on the last 1. Hopefully you can get an idea. 

What bothers me most is that there are kind of "scar lines" - almost like the forehead expressions coupled with acne produced these linear irregular scars, not just the usual pits (although these are there too)
Should be visible in first photo - i've tried to highlight with red circle in the 3rd but quality is poorer there.

Money isn't much of a factor & i'm ready to throw the kitchen sink at this — both temporary & permanent solutions welcome. 

I'm currenlty considering:

Laser resurfacing: Total or Deep FX — might get overall textural improvements, even though they seem not to do much for acne scarring specifically. But may improve the "general mess" that is my forehead
Dermal filler (temporary)— particularly for one scar located above the nose which is quite deep (highlighted 3rd photo). Don't believe they would use filler on forehead as skin too thin.

Any opinions on these, or suggestions otherwise??

Many thanks :) 




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@kman101 This is a very tough area to treat. The forehead has lots of muscles, little fat, and is highly vascular (veins and arteries). 

""What bothers me most is that there are kind of "scar lines" "" -- This typically is a job for botox, as everyone get's lines on their forehead. Botox will soften this up. 

That being said you can do botox as you don't want your forhead or area between your nose to move. Few Drs will put filler in your forehead as it's potentially  dangerous to do so.

You can try subcision with a normal needle, no filler, ... prp or saline can be used.

RF microneedling is great for these types of scars 3-4 treatments are needed. You do these 3 months apart between your subcision sessions.

You can use a dermastamp to smash the scars at home as well.

I would do erbium resurfacing and or tca peels for the texture once you work on the scars a bit. 

Treat when you have time and money. 


Dr Treacy is good in Ireland. 
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@beautifulambition thanks for the above.

By "scar lines" I'm referring to what seem to be linear depressed scars. It's hard to tell my forehead is such a mess!
I actually went and got botox 2 weeks ago for the hell of it as much as anything else... liked the results, but in many ways it highlighted my scars even more because with the forehead lines gone they stood out more! But i guess that was to be expected.

As it turns out I went to Dr Treacy a few months back. His recommendation was laser Active FX.. which from my research is quite shallow and unlikely to do much.. or micro-needling which he described as equivalent to about 1 tenth of a laser treatment... He subcised a couple on my temple but generally didn't think my scars were deep enough to be subcised allover. His website lists TCA cross but when I suggested this to him he said he didn't like doing it much anymore noting he was dealing with a couple of patients who were badly damaged from it (not by him I gathered)

Few qs if you don't mind please: 

There is a laser clinic, ran by "skilled nurses, doctors and aesthetic therapists" in Dublin that do Deep FX which is much deeper than Active FX. Would it make more sense to plunge for this? Or would multiple Active FX with an expert like Treacy be just as good? Is it important I ask them at what depth & energy they use the machine?

Also in terms of home treatments, I have also numerous scarring on the temples. I would like to treat these along with the foreheads at home—you mention dermastamp above, should I just plunge for Derminator 2 if price isn't an issue? I can adjust the needle length whcih might be an advantage as it will be my first time micro needling and i may have to ease my skin into it..

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I am sorry @kman101 It seems Treacy has stopped doing some treatments and using lasers in other ways. He is more of a laser dermatologist, ... but with the advent of plastic surgery perhaps that is more lucrative for him.

Botox ... Great. Yes they probably look worse but should soften a bit with a little time. You also need treatment. I would do a combo of Subcision with saline. I do not know who to recommend you to in Ie. I am sure there is someone make sure they have done hundreds if not thousands of subcisions. Try plastic surgeons and derms.
I do not think laser alone is the solution here. Weather co2 or rf microneedling which is commonly used.

Even if they do standard needle subcision to the scars this could help a bit (no fillers). 

I also think you need other procedures. Like paint on or spot peel with acid inside the linear scars (also can be called tca cross).

See if you can find a plastic or derm who does erbium resurfacing (no grids), this is not active FX, which is grids. You want to resurface the forhead but we cannot do this before doing some work first on the scars to raise them as much as possible. 

You might have to goto multiple drs. Goto Chu in London if you cannot find anyone for subcision and his standard treatment. See how you go with a few of these. Then consider resurfacing with laser.

I don't think Active FX alone is good here. CO2 may be good but as a alternative to rf needling. They would angle the laser around the border of your scars. 3-7% density and the highest power. I don't see standard active fx giving huge improvements. 

If no one else will do anything, ... see if a plastic surgeon will do a deep peel here, ... call around.

The derminator 2 could be great for you, single needle the border walls of the scars at home monthly and do a few peels. Sure this could be great to try,... then goto Chu or something. Really stamp those scars individually, ... not the whole forehead.



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Thanks @beautifulambition . I have inquired to meet a Plastic in Dublin who is v familiar with subcision. I'll see what she says when she sees me. 
I like the idea of using laser at the end as an overall smoother. One thing you might be able to clarify is the ablative v. non-ablative treatment. I see online that ablative is what is required for any considerable acne scarring and that non-ablative will not do much if anything. Is this generally true? I recall reading somewhere that multiple non-ablatives laser treatments can equate to an ablative laser treatments, i just can't find the source. Would there be any truth in this i.e any science behind it? Or is it just a ploy to get multiple fees out of a patient? and instead is ablative the only way to go to see significant improvements?

Thanks again

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@kman101 Common errors understanding lasers.

Fully ablative means it's not fractional and to ablate means it vaporizes the tissue. This can be similar to a acid peel if it's deep enough where layers of the skin area treated.
Fractional ablation means instead of a peel, fractions (grids) are vaporized.
Non-ablative means something like V-beam or other laser treatments where no tissue is vaporized and the laser does not make visible channels. The epidermis stays intact.

RF microneedling is fractional and a good alternative to low density co2 3-7% with the the highest power. 

So multiple non-ablative treatments are not equal to a deep peel or fully ablative treatment.

Your biggest improvement will come from botox to the scars with a few untis of product. Separate  vertically subcise with saline to the spot. A soft HA filler injected superficially to the scars (this area is extremely vascular / dangerous - so some providers will refuse). Co2 low density 3-7% or rf needling/infini can be done as well to break up some of the scars... The peel or peels weather acid or laser would be the last part of the treatment. 

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I've got similar scars on my forehead. I've tried numerous dermaroller sessions, deep FX, subcision, fillers and picosure. No significant improvements were made. It's really extremely hard to treat. I don't have the courage to do a fully ablative.

I am using a super cheap blur cream when I have an important meeting. It is a lot more cost effective than those treatments.

Edited by KeithV
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