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Jack817

What should be the recommended coverage for Fraxel Repair

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Hi All,

I would like to know what should be the recommended coverage for Fraxel Repair for acne scars?

My derm has told me that he always uses 30% for Asian skin type and 35% for skin type I or II. While I read from the realself that some doctor suggest coverage 40%-50% for acne scars, but my derm does't recommend me to increase the coverage over 35% since the risk of PIH/PIE and scarring will increase exponentially when the coverage is increased. 

Also I've read from Dr. Lim that he uses high energy and low density to treat acne scars with CO2 lasers, but he didn't mention the exact number. 

Therefore, I would like to know your experience and suggestions as well.  

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5 hours ago, Jack817 said:

Hi All,

I would like to know what should be the recommended coverage for Fraxel Repair for acne scars?

My derm has told me that he always uses 30% for Asian skin type and 35% for skin type I or II. While I read from the realself that some doctor suggest coverage 40%-50% for acne scars, but my derm does't recommend me to increase the coverage over 35% since the risk of PIH/PIE and scarring will increase exponentially when the coverage is increased. 

Also I've read from Dr. Lim that he uses high energy and low density to treat acne scars with CO2 lasers, but he didn't mention the exact number. 

Therefore, I would like to know your experience and suggestions as well.  

From what I have read high energy and low density, meaning small % covered skin treated each time is the way to go with lasers and energy devices. The higher the intensity the more effective the treatment is as the high energy can penetrate to and change the base of the scar, raising it, remodelling it, improving it. 

And you would want low density because healing and regeneration happens from the surrounding healthy tissue not affected by the laser. You will heal quicker and ideally without complications. So it's probably not a bad thing that your doctor wants to be on the safe side with the settings on your first treatment. 

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9 hours ago, Sisi90 said:

From what I have read high energy and low density, meaning small % covered skin treated each time is the way to go with lasers and energy devices. The higher the intensity the more effective the treatment is as the high energy can penetrate to and change the base of the scar, raising it, remodelling it, improving it. 

And you would want low density because healing and regeneration happens from the surrounding healthy tissue not affected by the laser. You will heal quicker and ideally without complications. So it's probably not a bad thing that your doctor wants to be on the safe side with the settings on your first treatment. 

Thanks for your response @Sisi90. I've had 5 Restore treatments before and see about 40% improvement and my derm told me that I only need 1-2 Fraxel Repair to wrap up. But what I'm thinking is that even after 2 treatments at 35% coverage, my whole area is not fully covered yet. Does it mean I need at least 3 treatments? The Fraxel repair is not some cheap laser TBH :(

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1 hour ago, Jack817 said:

Does it mean I need at least 3 treatments? 

Although I do want to learn and understand how the laser treatments work, truth is, my guess is just as good as yours because I am not the derm performing the laser :) I would say even the dermatologists cannot answer you this question because everybody is different. Somebody would get the biggest improvement after the 1st time and little after the 2nd, another would get it after the 2nd, or the 3rd. Some scars will respond better than others. 

As for the fractional vs full ablation, it's up to you really. I personally think that full ablation is too much of a risk with no proven benefit, but if you are aware of all the risks and you are willing to give it a go, it's up to you, really. 

But 40% improvement from the Restore is amazing! That's the non ablative laser by Fraxel, isn't it? You must really respond well to lasers or have a good doctor or both :) Fraxel Repair could really wrap things up then. Who is your doctor and what kind of scars improved most if I may ask? 

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@Sisi90You're right and I do realize the high risk in regards to the fully ablative lasers and I will just go with the safer settings this time and see how my skin will react. 

And I need to be clear with my treatment history: I've received 5 Restores, 3 subcision, 2 syringes of HA fillers and 1 TCA cross. The 40-50% improvement is given by my derm and my friends, but from my perspective, the improvement might be around 30%-40%. (May be I am more critical to myself lol). I have bad scarring and have a combinations of all scar types, 50% icepicks, and 50% of rolling and boxcars. The improvements mainly come from rolling, shallow boxcars, and the skin texture. I barely see any improvements for icepicks. And when I talk about improvements, I don't mean they are gone. Instead, either the border of the scar wall is not that noticeable, or the depth of the scars is shallower, however, they are still noticeable under harsh lightening.

After suffering acne scars for about a decade, I've realized and accepted the fact that I won't have glass-smooth skin anymore and my scars can only be improved to some extend. I only hope the Fraxel repair can fix more on my boxcars and rollings so that they are barely visible under harsh lightening and I can just live with my icepicks for the rest of my life.

My derm has told me that he only sees up-to 20% improvements on icepicks even after multiple ablative laser and TCA cross treatments. Therefore, that's why I've given up on those scar as well lol. 

 

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30 minutes ago, Jack817 said:

 The improvements mainly come from rolling, shallow boxcars, and the skin texture. 

 

That is what I have heard from other people too. Those scars respond best to subcision and lasers. Would you say the filler helped much, or was is just the subcision + laser? 

That's a very sober opinion I think. Unless the scarring is only minimal, it can never be eradicated 100%. The fact that we scarred in the first place doesn't speak in favour of this. But the scars can be improved to a level where they are not as harsh and jarring and we feel more comfortable with them.

OK. Why didn't you get more TCA cross treatments? Just 1? Usually 3 up to 4 are recommended for good results. I always thought that ice picks and small 3-4mm boxcars like I have would be the easiest to improve. You've got TCA or phenol cross and as a 2nd line you've got punch excision as options. You just have to make sure your derm is good at the cross technique so that you don't waste money or worse get more scars.  

I also have 2 large crater like rolling or boxcar scars I don't know exactly and they make my scarring severe because I think they have dermal and subdermal atrophy. So I think I wouldn't be able to go without lasers and fillers at some point. 

Also have a look at what Dr Peter Pullan is doing: he subcises even the ice pick scars because he thinks some might be tethered. He achieves very good results for most of his patients, and most of them seem satisfied with the treatments. Maybe he is onto something there. You can also politely ask your derm to try to subcise the most stubborn ice picks next time and see if it will be of any use. Just a thought. 

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3 hours ago, Sisi90 said:

That is what I have heard from other people too. Those scars respond best to subcision and lasers. Would you say the filler helped much, or was is just the subcision + laser? 

I think the fillers help to bump the rolling and boxcars and the subcision + laser helps to change the scar shape and blur the scars. 

3 hours ago, Sisi90 said:

OK. Why didn't you get more TCA cross treatments? Just 1? Usually 3 up to 4 are recommended for good results. I always thought that ice picks and small 3-4mm boxcars like I have would be the easiest to improve. You've got TCA or phenol cross and as a 2nd line you've got punch excision as options. You just have to make sure your derm is good at the cross technique so that you don't waste money or worse get more scars.  

My first post on this forum is to ask for help in regards to scar widening from TCA cross. I have had several side effects from that TCA treatment including PIE, PIH, and scar widening. I actually don't know what has caused all these side effects (My skin type, after care, bad techniques, etc...) Therefore, I've decided to stop after the first one. 

From my opinion, icepicks are hard to fix since you have to remodel the scar to either boxcar and rolling, and then use other modalities to fix the rest of the issue. 

3 hours ago, Sisi90 said:

I also have 2 large crater like rolling or boxcar scars I don't know exactly and they make my scarring severe because I think they have dermal and subdermal atrophy. So I think I wouldn't be able to go without lasers and fillers at some point. 

I have had some large deep scars as well and the subcision + filler has improved them a lot. Even my wife can tell the differences lol. Usually she doesn't care about my scars at all...

3 hours ago, Sisi90 said:

Also have a look at what Dr Peter Pullan is doing: he subcises even the ice pick scars because he thinks some might be tethered. He achieves very good results for most of his patients, and most of them seem satisfied with the treatments. Maybe he is onto something there. You can also politely ask your derm to try to subcise the most stubborn ice picks next time and see if it will be of any use. Just a thought. 

This is interesting to know since my doctor doesn't think subcision will help on icepicks and this is also what I've read from the publications. I will definitely let him try subcising the icepick next time to see if it helps :) 

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17 hours ago, Jack817 said:

I think the fillers help to bump the rolling and boxcars and the subcision + laser helps to change the scar shape and blur the scars. 

 

I understand. My dilemma right now is whether it is better to have a couple of rounds of subcision for the craters and TCA cross for the ice picks / boxcars like Dr Rullan suggests, and do the Chinese cupping method at home, or to get the subcision with filler? It will save me some money and the headache whether I will get any side effects of the filler at some later point or not :)

 

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15 hours ago, Jack817 said:

I think the fillers help to bump the rolling and boxcars and the subcision + laser helps to change the scar shape and blur the scars. 

My first post on this forum is to ask for help in regards to scar widening from TCA cross. I have had several side effects from that TCA treatment including PIE, PIH, and scar widening. I actually don't know what has caused all these side effects (My skin type, after care, bad techniques, etc...) Therefore, I've decided to stop after the first one. 

 

I see where you are coming from, however you might want to give TCA cross a second thought. Or you could do phenol cross, where both these risks of widening and pigmentation are lower. These are good treatments. Just a suggestion. Maybe with another more experiened doctor.

As for the PIH, I have researched extensively how it can be prevented and treated as I am prone to it due to my skin type. It takes a lot of dilligence and daily even hourly skin care to prevent it in my skin type. Little negligence here and there and you already got PIH after procedures. I saw recently that even Dr Lim magaged to get post-laser hyperpigmentation somehow. His face was dotted with PIH in the last video. 

I have my own "How to prevent PIH" list of advice, compiled watching the videos of Dr Lim, Dr Dray and also other sources. There is really a lot you can do from maybe the most important thing wearing a sunscreen and strict sun avoidance to certain topicals before the procedure. If you are interested I can send it to you. I gather you are a darker skin type, too? 

About subcision of ice picks, yeah, I hadn't heard about that either. But it comes from no other than Rullan, a guy with 30+ years of experience with scars and impeccable reputation. I thought it is maybe worth it to give his experience and opinion about ice picks treatments a thought or a try.

 

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13 hours ago, Sisi90 said:

I understand. My dilemma right now is whether it is better to have a couple of rounds of subcision for the craters and TCA cross for the ice picks / boxcars like Dr Rullan suggests, and do the Chinese cupping method at home, or to get the subcision with filler? It will save me some money and the headache whether I will get any side effects of the filler at some later point or not :)

 

I think you can start with temporary filler, which from my opinion is the safest procedure among all acne scar treatments. Nowadays, even the temp fillers can last between 15 - 18 months. 

I might give TCA Cross a 2nd thought, but it might be the last treatment I would like to pursue because of the previous damage lol. I have Skin type III, and from what I've learned that in order to prevent PIH from ablative lasers, I need to use hydroquinone creams 2 weeks before and after the procedure. Also avoid the sun exposure as mush as possible. 

But it would be great if you can also send me the information in regards to the PIH prevention :) 

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