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What type of scars do I have and the best treatments for my case? [PICS]

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Hello. Long time reader, but my first post. I've been treating with one doc for about three years now, what we've done so far, in the order I did it:

  • Voluderm (4 sessions) - I'm from Brazil, so not sure if you guys have this one, it is like a RF dermaroller
  • Dermaroller (4 sessions) - about a month apart
  • Radiesse with subscision (1 session) - the only one I feel some improvement, especially when stretching the skin, this Radiesse is a filler I think
  • Voluderm (4 sessions)
  • Juvederm (1 session) - Filler for hydration with Hyaluronic acid.

I saw some videos of Dr. Davin Lim and he says to treat each scar separately, to examine each one with directional light, etc. Well, my doc never done that, he's trying to improve everything slowly. Also, he's trying to do erbium laser, which I didn't accepted for now since from what I read lasers are just to do some finishing touches, and I'm really far from being satisfied. Apart from that, I don't think he have anything new to offer me, I ask about TCA and he don't want to do it (do I need it?).

The path we have now is to do 3~4 dermarollers, then another subscision (it will be 1 year apart from the other one).

My doubts are, what scar type do I have? And what treatments/creams do you recommend?

Also, any recommended doc in Brazil? I couldn't find any acne scar specialist.





Edited by UnusedNylon

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@UnusedNylon Hi there box cars and rolling scars on the temples and cheeks. ""Radiesse with subscision (1 session) - the only one I feel some improvement, especially when stretching the skin, this Radiesse is a filler I think." You need multiple sessions of this not just 1 (probably 4), spaced 3 months apart. While Radiesse can be used, I would for your case put a vial or 2 of over dilute saline sculptra with a cannular throughout the cheek to stimulate collagen. The dermaroller - rf - Voluderm should not have been done in that order. At this time I would do profractional erbium or 3-7%co2 laser with the highest energy setting. You could have underlying Fibrosis which would need a deep strong co2 laser like ultrapulse, ... it depends on the feel of the skin. 

You need multiple tca peels for texture once you raise things. 

Use tretinorin/retin-a/or differin every night with a kojic licorice cream to prevent hyperpigmentation and make cell turnover. 

I would not bother with normal microneedling. 

Yes you need subcisions and for it to be done more aggressively.  

Regarding the Dr call around and ask plastic surgeons if they can do cannula subcision and how many a month they do and call a dermatology teaching school and ask.

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Hey thanks a lot @beautifulambition, its good to have a plan again, I was feeling pretty low without a course of action.

I'll buy the kojic and differin and start using today. And spend the next year doing 3~4 cannular subcisions, I'll check if I can find sculptra, if not probably using Radiesse again.


You could have underlying Fibrosis which would need a deep strong co2 laser like ultrapulse, ... it depends on the feel of the skin. 

Ya, in that Radiesse/cannular subcision I've done in the past, there was a lot of "cracking" in the skin. Should I do the laser before or after the 4 subcisions?

Edited by UnusedNylon

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Only if they cannot move the cannula though the skin then get ultrapulse done, otherwise you can just do it after. In cases like this the skin is so tethered down subcision is hard without laser, 


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So I had a consult with my dermatologist today and we agreed on cannula subcision, which I'll be doing in May since he wants at least a year apart from my last one. He gave me two options:

  1. Same as the last one, cannula subcision with Radiesse.
  2. Or divide the Sculptra in two and do two cannula subcisions with half vial of the Sculptra in each with one month apart.

His reason to divide the Sculptra is because, by his explanation, Radiesse works for a year with one treatment, but Sculptra needs 3~4 monthly sessions to get the same results. Since I'm paying for the vial, this option would be 3~4 times more expensive, but as I said I want to do as many subcisions as possible, he can divide one vial for two sessions. So, both options would cost me more or less the same.

Of course I want to do as many subcisions as possible so I'm inclined to pick the second option. And I'm definitely don't want to wait a year between treatments, so maybe I can repeat the Sculptra 3~4 months after the second treatment. Would like some opinions?

PS> I've been using differin and kojic licorice cream and its definitely helping the skin, especialy the redness.



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@beautifulambition I'll be doing subcision with Sculptra next month so I want to talk with my derm about this "over dilute (saline) thing". First, I'll try to convince him to use the full Sculptra vial and repeat the procedure every three months (now he wants to do it monthly with half vial).


About this over dilute saline, is it somewhat common for dermatologists to use it? The Sculptra vial recommends to reconstitute with 5ml of sterile water, from what I understand the saline should be added after this reconstitution right? How much saline should be added to the mix?


Maybe I'm just wrong and the Sculptra should be reconstituted with saline directly (no sterile water added), then how much saline?


Not sure if the doc will want to do that by my recommendation if it isn't that common to begin with. So I want to know a little more to discuss this with him.


Thanks again for the support @beautifulambition I'll add some pictures in 20 days or so before the procedure.

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@UnusedNylon Ok great. 

Over dilute means Saline or sterile water same thing, one just has preservative. The Dr know's the dilution ratio, I cannot tell you this for your case as I am not injecting you. The vial is prepared 72 hrs ahead of time in the office if they know what their doing. Over dilute means more water than normal. So that it's not too strongly injected under all the scars. We are not using this for volume but as a layer under the scars, make since. Volume is done by HA filler in latter subs on to individual pits.

Wait are you doing this yourself, ... 5ml sounds like your trying this on yourself (I don't know any Dr who uses that small of amount - asking for problems), this is nuts. Any Dr knows this is a bad dilution amount you gave me.

The questions your asking me sounds like a non certified Dr is injecting this on yourself, these are basics. If they do not know them they should not be doing this on you can cause serious problems. 

Ask for more saline than normal, that is all, it's very simple. 

Most Dr's are arrogant and will not follow anything I say, as such it's up to you to negotiate with them and make sure they do what you wish, ... if he won't dilute it it's your choice. 

Please make sure this Dr knows how to inject Sculptra, ask how many times they do it per month, ... if they are just injecting it ... it could be terrible. Difficult substance to inject.

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One day before sculptra. @beautifulambition







Ok so I did the subcision with sculptra today and talked to my doc, here's what I discovered that didn't make me happy:

  1. I thought cannula subcision is what I have done because it sounds the same to me, but the doc says what we did is a "type" of subcision. What we actually did has the name of "dermal tunneling", @beautifulambition do you know that? It looks like this is modern form of subcision but I'm afraid it isn't agressive enough for my scarring. If this new type isn't enough for me I'll be changing treatment or doctor if he don't do it.
  2. I asked how he diluted the sculptra and he did with distilled water. I talk to him about saline and he says he knows it but the maker of sculptra doesn't allow/recommend that, the usage of saline in his opinion is so it hurts less.


I'll put the picture of just one hour after the procedure. Looking forward for your help again @beautifulambition, thanks.






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Type of Scubsiion don't even know what that means, using vague language. He could be doing anything. Or just injecting Sculptra which is not subcision. It's not a modern form of subcision, what? Dermal tunneling is injecting filler, this is not modern. I don't know that your Dr can do subcision if he thinks, what you said above. Find someone who can, remember you can treat with Sculptra, and then do scubsion elsewhere. What... distilled water, this is verrrrrry dangerous. This is not medical to use "distilled water." I don't even know if you had Sculptra, sounds like he just injected you with distilled water. Did you see a vial with white liquid in it and the SCulptra label? Perhaps we have a language difference, ... they sure don't recommend "distilled water" which is not sterile to anyone. No Saline is used because that is what is supposed to be used with all injections, or they can use sterile water for injection called various things world wide, not "distilled water." The results look good but this is swelling for the water. Remember, this will go away, and then slowly if Sculptra was really used collagen will build over 3 months and after for years.

I would find someone better for subcision


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It was "sterile water", sorry about that, it was my mistake.


We did subcision, but the term he used was "dermal tunneling" and not "cannula subcicion", still he used a cannula and had to put a lot of strength to go through the skin, for every hole he draw like 5~10 lines and did the subcision on those lines. It was pretty satisfying hearing the sounds of the skin "breaking up". And he injected a little diluted Sculptra in every one of those lines.


Yes I did saw the sculptra vial. It is a good clinic and I know the people there pretty well. My confusion was if there was any difference between "dermal tunneling" and "cannula subcision", I think it is just different terms for the same thing then since you found the pictures to be good, etc..


About the saline thing unfortunately he said he can't used because it isn't approved by the maker of sculptra.


Anyway, I'll be doing this procedure again with the other half of the Sculptra vial in 25~30 days. I'll put some pictures before and after that.


Thanks again @beautifulambition, you're awesome helping everyone

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@UnusedNylon IT's exactly what I thought, semantics or the wrong terms used. You had cannula subcision (he is calling it tunneling, ... call it whatever they wish) and he used sterile water, that is fine. It's his preference on that one. So yes everything was done as it should be, now for the healing and the results. 

Pictures in 30 days won't mean anything as you will still be under swelling which can last for 3 months after injection, hence the healing period. We will know best after that time. I know he is doing the 2-3 total Sculptra standard treatment close together, but this is not how we do scubcision for acne scars (this is fine though now for Sculptra), ... after that wait the months between treatment when you do your 8 total subcisions. Just a fyi ;-)

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Posted (edited)

Hey @beautifulambition how're you doing?


So I talked with my derm and he said my skin is firm and almost don't have more tethers (but definitely have some still) so he recommended erbium 2940 (ablative) so we can start working on the top layer of the skin (mainly the rolling scars).


Just to remember you I've done 3 subcision total, 2 with sculptra (half vial each) and long before that 1 with radiesse. I also have done multiple dermarolling and voluderm sessions.


What do you think about this laser? Should I do some more subcision and then consider it again maybe?


Let me know if you need some pictures. Thank you again.

Edited by UnusedNylon

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@UnusedNylon Very busy, ... thanks for asking ;-)

Hmm without pictures I don't know what he means by start working on the rolling scars, filler and subcision should have lifted them a lot. The laser would just be for texture. 

Ok on the treatments... did you do rf needling and co2 laser, or we are just doing Erbium ?

Without pics I cannot say on ... if more sub is needed, but you know if your scars are lifted enough to your liking, Some need 3-8 sessions of sub.

Don't laser unless were only dealing with slight texture. should be a final step before peels. 

Yes some pics would be helpful

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@acnescars2000 @beautifulambition


Sorry for the delay. I think the skin definitely feel better to touch since I started (its not too loose anymore) but not sure if I can see huge improvements visually, maybe a little but nowhere close to where I expect, but again I'm not in a hurry and any improvement is better than nothing.


I did voluderm, not sure if this is considered rf needling, but I think it probably is. I never did laser before and the derm wants to do this erbium 2940 ablative, he also have co2 there but didn't recommended it for me.


I think I probably need more subcision anyway, but the derm said we could continue doing it after the laser so to get a improvement on the overall texture first (especially the rolling scars in the cheeks). I'm thinking about getting more 2 subcision with sculptra and then doing the laser, but not sure what do you think?


Here is the requested pictures taken yesterday









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@UnusedNylon Hi there thanks for including the pictures.


You have atrophy or fat loss, rolling scars, box cars, icepicks.

You will need lots of subcision and in your case I would consider Suclptra post cannula subcision or dilute Radiesse. Your biggest improvement is going to come here, then you can treat your surface texture. 

Regarding a Dr in Brazil, I don't think I have anyone. Check the FAQ pinned to the main scar treatments sub, goto the bottom of that for hints how to find someone in Brazil. I would look for someone who can do cannula subcision or nokor subcision and someone to inject sculptra. Plastic Surgery is very popular in Brazil so do some consults with some of those Drs. 

  • Voluderm (4 sessions) - I'm from Brazil, so not sure if you guys have this one, it is like a RF dermaroller

- this is out of order, ... I would not have done it before adressing our atrophy. Also that device isn't that great. 

  • Dermaroller (4 sessions) - about a month apart

- Again we don't dermaroller anymore, we dermastamp, and you must address your atrophy and pitting first.Then do this at home between Dr's sessions every 3 months to the borders of your scar walls, alternate with glycolic peels or peels from a nearby med spa.

  • Radiesse with subscision (1 session) - the only one I feel some improvement, especially when stretching the skin, this Radiesse is a filler I think

- Once sessions is nothing you will need 8+ sessions you have severe scarring, and in your case, I would have used Sculptra over Radiesse, but I don't know if that's popular in Brazil. 

  • Voluderm (4 sessions)Juvederm (1 session) - Filler for hydration with Hyaluronic acid.

- Why are we doing filler without aggressive subcision, makes no sense. 

You sound like you had terrible Dr(s) who did not treat your property or have the skills to do so. Some travel for treatment. This is why your treatments partially have failed and out of order treatments not addressing the issue.

You will need a deep peel or fully ablative laser resurfacing at the end but ONLY once you raise your atrophy. 



Never start with laser treat the deeeeepest problem and move to surface resurfacing.

* I would do 3-8 sessions of cannula subsision to your scars, this will help you most, ... they can do a bit of filler after or you can do Chinese Cupping (Amazon) for a whole month (with cupping yes you bruise, so be prepared if you take this route, you can vary the suction strength, wear a concealer over the area like dermablend). A buffer keeps things from re-tethering.

* TCA Cross for icepicks can be done at the same time as subcision

* I would do rf needling to your scars, ... this helps rolling / boxcars (4 sessions or more)

* CO2 laser if you need a boost in low density and high power setting.

* For texture we lastly do Sciton fully ablative laser resurfacing, notice I said ablative, non-ablative with do nothing for your scars. Jplasma, or a Deep Chemical Peel is good.  OR several TCA peels, or a deep peel on the scar areas only. You have sensitive skin discuss this aspect with the Dr you goto, talk about steriod shot to the hip, doing a test area, and aftercare. This works once you raise your pits, but there is down time.

* buy a dermastamp or derminator (google it) and stamp them monthly. You will be treating with the Dr every 3 months - the above things, regardless of what they tell you, the body is incredibly slow to heal and they want $$$$ quickly, observe your progress of what works). Once a month your dermastamping and you can alternate with do glycolic peels at home. Treatment for many takes 3 years, everything is optional. Treat as you have time and money (for some that's only 2 things a year), it's a slow process again with most of it related to how you heal and what works best for you, do more of that.  

* For redness we do pulse dye laser, or something like picosure, picoway. Laser resurfacing (Above) and Q switch is used if the pigmentation is not responding after several treatments. Alternatively you can try first peels for discoloration or hyperpigmetnation.

* Nightly before and after treatments until the issue is taken care of:

Use nightly: Retin-a or tretinorin(prescription), or Differin (Target/Walmart), The Ordinary Granactive Retinoid (if you can't get the above) or Avene or Osmosis (I am not a big fan of their other products) "Retinaldehyde" product (for sensitive skin). Cureology(USA) & Yoderm(USA) provide monthly - online prescriptions with customized skin care creams for your concerns, those in UK Dermatica provides the same thing. Apply a moisturizer when your face is dripping wet. Wait 5 minutes for it to dry, and then apply the tretinoin. This cuts down on irritation, you can also skip days of application (or do one or two days a week) if it's irritating and you need to build up %. This provides skin turnover - new collagen. To prevent (reds & browns from all Dr-treatments to ethnic skin or to work on current skin discoloration), try PCA hydroquione free gel for Hyperpigmentaion (Amazon) or Cureology/Yoderm/Dermatica includes this in their products if ordered. Using this prevents hyperpigmentation from treatments. Hydroquinone has side effects for some people, natural options  are better with ingredients like: kojic acid/Konjac, Alpha Arbutin, Niacinamide by The Ordinary is great for large pores, discoloration, and inflammation. The Ordinary, Cerave, Eucerin (QV Skincare in AUS), Dr Sam Bunting Flawless Cleanser, Avene, La Roche-Posay (sensitive), and Acne.org's products are all great options for moisturizers and cleaners without fragrance / dyes / allergens. The Three most important things one can use are: Vitamin A skin turnover (retinol, retinaldehyde, retinoid), Vitamin C Serum which makes collagen, and a sunscreen (zinc oxide physical for sensitive skin - DRMTLGY Active Sunscreen, Elta MD Physical, La Roche).

Checkout the main scar treatments sub, find the FAQ pinned on top there, goto the bottom, there are Dr's or call around and ask who does cannula subcision or nokor subcision (needle type) to dermatologists and or plastic surgeons, consult a few before you decide who you like, even if you have to pay as treatment is expensive, better like them. Ask how many subcisions they do a month and if they treat your skin type. If they just do laser run they will just blast you and not solve your issue. Please Note I do ongoing support by PM for complex cases / questions, daily - you can message me there. Please be patient as I can get over 100+ of the worst acne scar cases to help.

Disclaimer: Information and support is not meant to diagnosis, treatment, or cure any health or mental condition and is not a substitute for professional face to face medical care  (consult with a few Dr's and pick your favorite one). Posts are for informational purposes only, please consult your personal health care practitioner before engaging in anything discussed.

Please note, I offer more "customized" and ongoing consulting through Private Messaging.


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