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Tonitrus09

Looking for Acne Scar Advice for rolling / boxcar scars on cheeks

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I tried to take pictures in different lighting so that the deep scars are easier to see...

I have done about 10 rounds of Fraxel 1550 laser (spread out over 9 years), then unfortunately I got some new scarring due to a big breakout - thankfully acne is under control now. Honestly I don't think the Fraxel did much of anything for my rolling scars. 

Recently I have done 4 rounds of subcision with microneedling. I am now doing RF microneedling as well. Then I will do TCA cross. After that, I think it would be wise for me to do CO2 / fully ablative laser. My goal is to raise up / fill in the depressed scars as much as possible. 

Honestly, looking at how deep some of the depressions are I think I need filler. I would probably go with temporary filler - I think the permanent ones are risky. 

Any tips / recommendations are appreciated for scar treatment. Also I'm in New England / the Boston area if anyone knows someone local who's a great scar specialist. I may be able to travel to NYC and/or FL to see some of the preferred providers there but I'm not sure when that will be.

Thoughts?? Am I going about this the wrong way? 

Thank you!!!

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51 minutes ago, Tonitrus09 said:

I tried to take pictures in different lighting so that the deep scars are easier to see...

If you don't mind, can you take another set of pics, this time with the following instruction in mind?

More shadows, the better. Angled lighting is an approach used to create a heavy shadow that will accentuate the scar for better evaluation as shown below. This is done by pointing a bright light perpendicular (90-degree) to the angle of the camera lens. See below.

Also don't shoot so close that it only shows the cheek. Try to include other parts of the face (eg. nose, mouth and/or ear). This will give better perspective of the scar size.

 

image.png.ceef7ca2fcb2f56e3f1d18f76085e5c4.png

 

55 minutes ago, Tonitrus09 said:

I have done about 10 rounds of Fraxel 1550 laser (spread out over 9 years)

Fraxel is a "non-ablative" laser geared more towards fine wrinkles and super shallow scars. I'm surprised the doctor even recommended this treatment, let alone for 9 years.

 

56 minutes ago, Tonitrus09 said:

Recently I have done 4 rounds of subcision with microneedling. I am now doing RF microneedling as well. Then I will do TCA cross. After that, I think it would be wise for me to do CO2 / fully ablative laser. My goal is to raise up / fill in the depressed scars as much as possible. 

That's quite a lot of subcision. How much improvement do you see after 4 rounds of sub? If you haven't already seen any improvement, I wouldn't continue with subcision.

RF micro is effective for nominally shallow scars, especially if combined with Sculptra. It basically gives an extra boost by zapping the filler molecules in Sculptra. This is especially effective if you have large atrophy like widespread rolling scars.

HOWEVER, DO NOT GET FILLER WHEN THERE STILL IS A SIGN OF VISIBLE SCAR BORDERS.

That is, if you have boxcars with prominent scar edges, you'll need to take care of that first. This can be done by utilizing TCA Cross or fully ablative laser. 

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52 minutes ago, Sirius Lee said:

That's quite a lot of subcision. How much improvement do you see after 4 rounds of sub? If you haven't already seen any improvement, I wouldn't continue with subcision.

RF micro is effective for nominally shallow scars, especially if combined with Sculptra. It basically gives an extra boost by zapping the filler molecules in Sculptra. This is especially effective if you have large atrophy like widespread rolling scars.

HOWEVER, DO NOT GET FILLER WHEN THERE STILL IS A SIGN OF VISIBLE SCAR BORDERS.

That is, if you have boxcars with prominent scar edges, you'll need to take care of that first. This can be done by utilizing TCA Cross or fully ablative laser. 

Here's some more info about the subcision...I don't think it was the traditional field subcision that folks talk about for their acne scars...the doctor used a dual bevel 1.00mm angled Sideport Knife to untether individual scars on my face. It was a tiny knife that barely went into the skin. I had topical numbing. I think traditional field subcision you would use a canula or nokor needle and it would be a much larger treatment area than one individual scar at a time...so what I got was NOT that. Not sure if I need to get "traditional" field subcision instead or...? Honestly I can't tell if it yielded any improvement. 

I do plan on doing TCA cross before getting fillers. 

Edited by Tonitrus09
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Fully ablative would be ineffective for your skin.

For it to be worth the down time you would need to have practically smooth skin already.

What you see with a lot of fully ablative before and afters is the BBQ effect on steroids. BBQ effect (shrinking effect) is "a short term effect...the immediate contraction of collagen fibers and protein denaturation induced by heat...this reaction generates a perceptible skin toning and a quite visible facial lift-up." The BBQ effect has mostly released and gone by 6 months. However it is this short term effect along with microswelling that can give people a very good temporary effect.

Also, I can't quite tell but are you a red head? Redheads are genetically predisposed (similar to some higher Fitzpatrick skintypes) to form hypertrophic/keloid scarring from invasive procedures. Redheads along with darker skintypes are in a higher risk category for keloids from fully ablative. 

 

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22 hours ago, Amanda Hall said:

Who's the doctor who encouraged you to do 10 rounds of Fraxel???  Did you see improvement after a few sessions?

Dr. Thomas Rohrer of Skincare Physicians. He is clearly not an acne scar specialist either as he insisted that the Fraxel he was giving me is the "best treatment out there" for acne scars...*eye roll* but I was not educated back then about the topic and didn't know better.

Not really...I did it once a year and my scars were always GONE right after the procedure but that was just swelling. Then the swelling would go away and they'd be back. the laser did get rid of any PIE / hyperpigmentation and it probably smoothed out the edges of my scars but of course did nothing to lift / fill the depressions. 

I was a teenager when I started seeing him and myself and my parents didn't know any better, sadly. I wish I knew then what I know now so I could have pursued other treatments instead 

 

16 hours ago, TheOraclesDream said:

Fully ablative would be ineffective for your skin.

For it to be worth the down time you would need to have practically smooth skin already.

What you see with a lot of fully ablative before and afters is the BBQ effect on steroids. BBQ effect (shrinking effect) is "a short term effect...the immediate contraction of collagen fibers and protein denaturation induced by heat...this reaction generates a perceptible skin toning and a quite visible facial lift-up." The BBQ effect has mostly released and gone by 6 months. However it is this short term effect along with microswelling that can give people a very good temporary effect.

Also, I can't quite tell but are you a red head? Redheads are genetically predisposed (similar to some higher Fitzpatrick skintypes) to form hypertrophic/keloid scarring from invasive procedures. Redheads along with darker skintypes are in a higher risk category for keloids from fully ablative. 

 

any suggestion for which treatments I should try, if not fully ablative laser? 

and yes - I am a pale, freckled redhead. Thank you for the warning. 

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9 hours ago, Tonitrus09 said:

Dr. Thomas Rohrer of Skincare Physicians. He is clearly not an acne scar specialist either as he insisted that the Fraxel he was giving me is the "best treatment out there" for acne scars...*eye roll* but I was not educated back then about the topic and didn't know better.

Not really...I did it once a year and my scars were always GONE right after the procedure but that was just swelling. Then the swelling would go away and they'd be back. the laser did get rid of any PIE / hyperpigmentation and it probably smoothed out the edges of my scars but of course did nothing to lift / fill the depressions. 

I was a teenager when I started seeing him and myself and my parents didn't know any better, sadly. I wish I knew then what I know now so I could have pursued other treatments instead 

 

any suggestion for which treatments I should try, if not fully ablative laser? 

and yes - I am a pale, freckled redhead. Thank you for the warning. 

First of all, every doctor will say he/she is an expert at lasers or whatever procedure. It's sad but you never know who the experts are unless you do your own research or you know someone who's gotten treatment done by that doctor. I would say the majority of dermatologists and plastic surgeons don't know how to use lasers to the fullest extent. This is just my opinion. I've gotten lasered (ablative and non-ablative) by five doctors. The same applies to other procedures..... subcision..... TCA Cross.... etc. I'm not putting you down because you didn't know - just like I was clueless for the first few years I tackled acne scarring. 

I got aggressive fractional CO2 done several years ago and after several weeks, my scars looked about 60-70% better. Then the swelling went away..... still saw improvement but it wasn't as much as when there was swelling.

The crappy thing about treatments is that it's not easy to single out what works or not because of variables. You need to think about whether it's the procedure or the doctor that's the issue. Fractional CO2 can be aggressive or mild, and there are a variety of lasers. I just had a mild one done a month ago and I peeled in about 3 days with barely any redness. No results - I'm not even going to assume that there's going to be collagen remodeling (results in 3-6 months) or that BS after a light treatment. With my aggressive CO2 treatment several years ago, I saw smoothing out of several crater and boxcar scars. I suffered from PIH (went away though). I saw results because of the experienced doctor and type of laser procedure.

Based on your pictures, I'd think that subcision would be appropriate but you said you already got it done multiple times. But you said it wasn't traditional. Maybe see someone else for subcision. Stop going to the same doctor. Get a consultation from another doctor. I'd look into Cross as well but you'd need a series of treatments and lots of patience. 

In the future, if you're considering laser treatments, go somewhere else and don't stick with the doctor who's done 10 Fraxel treatments on you. SMH.

 

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On 2/27/2021 at 2:21 AM, Amanda Hall said:

First of all, every doctor will say he/she is an expert at lasers or whatever procedure. It's sad but you never know who the experts are unless you do your own research or you know someone who's gotten treatment done by that doctor. I would say the majority of dermatologists and plastic surgeons don't know how to use lasers to the fullest extent. This is just my opinion. I've gotten lasered (ablative and non-ablative) by five doctors. The same applies to other procedures..... subcision..... TCA Cross.... etc. I'm not putting you down because you didn't know - just like I was clueless for the first few years I tackled acne scarring. 

I got aggressive fractional CO2 done several years ago and after several weeks, my scars looked about 60-70% better. Then the swelling went away..... still saw improvement but it wasn't as much as when there was swelling.

The crappy thing about treatments is that it's not easy to single out what works or not because of variables. You need to think about whether it's the procedure or the doctor that's the issue. Fractional CO2 can be aggressive or mild, and there are a variety of lasers. I just had a mild one done a month ago and I peeled in about 3 days with barely any redness. No results - I'm not even going to assume that there's going to be collagen remodeling (results in 3-6 months) or that BS after a light treatment. With my aggressive CO2 treatment several years ago, I saw smoothing out of several crater and boxcar scars. I suffered from PIH (went away though). I saw results because of the experienced doctor and type of laser procedure.

Based on your pictures, I'd think that subcision would be appropriate but you said you already got it done multiple times. But you said it wasn't traditional. Maybe see someone else for subcision. Stop going to the same doctor. Get a consultation from another doctor. I'd look into Cross as well but you'd need a series of treatments and lots of patience. 

In the future, if you're considering laser treatments, go somewhere else and don't stick with the doctor who's done 10 Fraxel treatments on you. SMH.

 

thank you for the reply and the great info!

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