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  1. I have Fitzpatrick Skin Type V and had Erbium YAG laser resurfacing done 15 years ago on my cheeks, which didn’t do much for my scars and my cheeks ended up a shade lighter than my forehead/cheeks/under eye area. I did a zillion fractional laser treatments with no improvement at all and most dermatologists are scared to treat me due to my skin color. I spent years slathering my face with hydroquinone and gave up as I saw no change in the skin color, I regret not getting my whole face done but then again it did nothing for my acne scars either, so was a waste of money, time and made things worse with the discoloration - I should just never have had it done. Additionally, I am sick of wearing makeup all the time to camouflage the scars and the discoloration. When I first had the laser resurfacing done and was using makeup up, it clogged up my pores and made me breakout. Luckily there are now better brands in my skin color and I haven’t had acne in over 10 years after taking out dairy and starch from my diet. I live in Europe and Dr Lim recommended I see Chu or Henningsen. He mentioned I might need subcision and/or filler with light fractional co2 or RF Needling. This seems alright. I am not sure what the sequence is? You get subcision/filler done, then wait 3 months and get laser done and then 3 more months for next round of subcision/laser? Or is it done in one go? And does he treat you at the first visit? I can’t stomach the idea of PRP and after reading posts on here on Dr Chu’s procedure, I felt queasy enough to never want to attempt it. I think I will go to Dr Henningsen as he seems to be able to do fillers and laser as well.
  2. Hello! Its been a while since I posted on here so I wanted to post an update on my scaring. Today I went through my progression photos before starting any treatments, up until today where I have had a CO2 laser, 3 subcisions and several sessions of dermapen. Its always hard to get lighting the same each time, but I still think I have some good results. Looking at the first photo, on the right side the scars look very "sharp", I remember my plastic surgeon saying the laser would smooth the edges out. None of the photos have microswelling, as all photos are taken several months after treatments. Let me know what you think :).
  3. Hi guys, I am traveling to Korea and looking for doctors who perform subcision. It's difficult to find anything on the internet because I don't speak Korean. I'm not sure how to find the best doctors! Does anyone know where to start looking, or have any recommendations? Side note: I'm interested in one subcision treatment in order to replicate the results from this study on acne scars.
  4. V-Beam After Subcision?

    Forums Scar treatments 4 replies

    Is it ok to get Vbeam 2-3 days after subcision? Subcision causes blood to pool under the skin so I'm wondering if vbeam will have negative affect on the subcision outcome. My derm think its ok to have vbeam afterwards. Wondering if anyone has done that or heard about it?
  5. Have a nodule from subcision, and had 1 round of kenalog. When I touch it, seems to have flattened the nodule, but visually kinda looks the same. Does kenalog actually treat the nodule or just flatten all the skin?
  6. Hi! I have been lurking on this forum for a long time. It's my first time to post here so I apologize if I violated any rules or anything. Let me know so I can edit this. I need advice on what procedures should I get next to treat my acne scars. Last year, I had a couple sessions of TCA cross, microneedling and AGNES. In January, I had microneedling and my first subcision ever. There were improvements as far as ice pick scars are concerned but for the other scars, not so much and I think they got worse but I have poor memory lol so I really can't tell. I like to believe that my scars did improve no matter how insignificant and I am just being too critical. I have Asian brown skin. I tend to have hyperpigmentation but they go away with hydroquinone. When I had subcision, I didn't have any hyperpigmentation at all and things healed after 4-5 days So next week, I am planning to have a subcision for some of my scars and microneedling or RF microneedling (if my derma has it). I'll do the suction method too. I didn't know about it the first time so I wasn't able to do it. I bought those cupping cups and also this pore cleanser/blackhead vacuum thingy and I think the pore cleanser is better so I'll use that one instead of the cups. After 3 weeks-ish, I'll have a peel. Not sure what peel but I am thinking TCA. I've never really had strong peels. My derma used TCA last year but I didn't peel that much. I didn't ask her the strength she used but I'm thinking it was on the milder side since she tends to play it safe and only used 80% for my TCA cross. I use hydroquinone for when I get hyperpigmentation. After the peel (I usually wait 3-4 weeks before having another procedure), I'd probably have another subcision/microneedling then peel again. Hopefully, after all these, I'd see some improvements and then I'll have the Fractional CO2 which my derma says the gold standard for acne scarring but of course, I read stuff online so I don't believe it will help me unless I try to raise my scars more first. I want to ask for any recommendations or advice. Will a Fractional CO2 help me? What procedures should be good for my scars and in what order? I'd appreciate any help/tips/advice, especially from beautifulambition. Thanks! Please see below for my scar pictures.
  7. Hello all, I'm back at my scars again. I was looking good for a few years after Fraxel Re:pair, subcision, and various IPL type lasers in 2012-14. However, my scars have now returned again..ughh.. (no new acne, just reappeared) I am currently taking a break from Microneedling RF treatments (non-insulated). I've had 3 so far and of course, my scarring looks worse than ever. My current doctor does not do subcision but she does fillers. I am taking a break from the Microneedling procedures because they are taking a toll on my sanity (Dr. went so aggressive I lost volume). Moreover, I believe that I should have Subcision done as a must needed scar revision modality. Previously, in 2012-14 I used Dr. Ting (San Ramone) and he's so expensive (per scar) for Subcision. I have scarring all over my face and would like a doctor that is good at subcision and is economical in the bay area. I'm looking to do the suction technique at home after the procedure. I read many posts and I think @beautifulambition mentioned trivalleylivewell for fillers but would they do just subcision? Like you mentioned in your posts, many professionals don't want to do just subcision because they make so much with their 'energy machines' as you put it. Thanks for reading! Chow!
  8. Acne Scar Treatment

    Forums Scar treatments 15 replies

    Hello everyone, Introduction: I am a 27 year old female. The first zit appeared on my face when I was eleven. Since then it has been a continuous battle. I have seen good and bad days. While a doctor had advised me to take Accutane to knock it out for good, I decided against it given the side effects. Retina - A (0.025%), Clindamycin and general avoidance of dairy products seems to be keeping things somewhat under control (touchwood, I am going to say that a lot). I have some acne scars that are ten years old (very few).I was pretty clear before 2014 with the use of the same medicines. I thought my skin will be fine and hence stopped using these. In 2015, due to stress and poor eating habits, I started breaking out again. I was able to control that with the same topical medicines in around January this year. Now, I want to work on the scars. I have been told by dermatologists that it is a good idea to use tretinoin all over the face for the rest of my life to help with age, texture and further incidents of acne. Doctor: I have an appointment with Dr. Morganroth soonish (I live in the bay area). I was supposed to have been done by now (February) but he was traveling (which I was not aware of, I had taken the appointment back in November) and I was not comfortable about getting it done by his substitute. Hopefully he will be there on my next appointment and I can be done with one round of treatment. He was a nice man and answered my questions. Treatment modalities: I think I have a mix of rolling, ice pick and box scars. I failed to ask this to Dr. Morganroth. He said he will do subcision but not TCA Cross. He said it can lead to bad complications and the results we see could be the best cases. I asked him if he would be able to subcise all the scars. He said no, some of my scars are linear in structure. I am not sure what that means. He added that I can expect 25% improvement but some have seen 65% or more. I plan to do about two rounds of subcision before June. Supplements: I take three capsules of Hair, Skin & Nails vitamins every night. Every morning I drink about 400 ml of kale leaves, 1 tbsp flaxseed, 1 tbsp Vit C powder, 1 scoop of collagen peptides, a squeeze of honey, a splash of apple cider vinegar and some water all blended together. I also drink about two cups of green tea everyday. Topical medicines and cosmetics: bp face wash, clindamycin, a gel moisturizer, sunscreen in the morning. Salicylic acid face wash, tretinoin at night. I don't use makeup at all, primarily because I have no idea how to use any neither do I know what will suit my skin type. I use some eye cream as the are around my eyes tends to get very dry. Pre-treatment: The substitute doctor advised me to stop using retin A for about two three days after the treatment to avoid possible sensitivity issues. Apart from that he said I can continue to live the way I do normally. Post-treatment steps: I have bough a Chinese cupping set and hope to suction once the insertion points have closed. Any advice or ideas are very welcome. In the attached photo you will see active acne. But this photo was taken in November last year. I have residual scars now. I would love to know your opinion on what kinds of treatments would help. I am particularly thankful to this forum for giving me hope, Thank you. and to @beautifulambition for always being so patient and answering questions. The following are more recent photos:
  9. Korean Subcision Progress

    Forums Scar treatments 8 replies

    After going through highschool with a face full of horrible angry red pimples, I've been left with a bunch of tiny indents on my skin (all icepick/ boxcar scars). My acne scars have been bothering me for a couple years now so I thought I'd give subcision a try! I'll try to update this as often as possible so that others can see the results and consider if subcision will work for them or not. My scars a day before the procedure, with a cameo appearance of a nasty whitehead. The scars aren't huge but are scattered around my cheek areas, making them look rough instead of smooth. Day 1: A few hours after the subcision and extraction. The subcision was a bit painful at first because the doctor didn't wait for the local anesthesia to kick in. He just jabbed in a couple shots and went straight to the subcising. They put a bunch of hydrocolloid patches on the needled areas and instructed me to take them off tomorrow afternoon. As you can see, there is minor bruising and swelling as well as red marks from the extraction they did before the subcision.
  10. So this is Day 5 following a pretty aggressive subcision kind of procedure. Basically the doctor used a cannula to get under my skin all over and cut through scar tissue. She said it’s the worst scar tissue under the skin she has ever seen. It has caused previous fillers to be lumpy and make my skin worse. im convinces it is the reason my skin doesn’t heal anymore, why it’s so crinkly etc. as of now, my skin is too horrible to contemplate. I wanted some prp and I broke down and cried in the doctors sugery. She said this would help. I’m so desperate, and I kept crying and asking her if it would make my skin worse, after the disgusting effects of the procedures performed by a very ‘reputable’ doctor in Australia. My skin is a horrible atm. How is this level of unevenness and scars and just is this possible?
  11. I just had a consultation today with a plastic surgeon regarding subcision and fillers. I live in Toronto so it was hard to find someone that offers this, and he was one of the few and pretty close to me with free consultation. Anyways his nurse looked at my face first and immediately suggested a variety of lasers which I knew I did not want. I specifically asked for subcision and she said that yes, it will improve but you won't get as ~amazing~ results as lasers (what a load of bs). She said that one round of subcision should be enough for me and also suggested Bellafill. Now from what I've read here it is suggested to go with HA fillers so I didn't want to do that. Anyways the doctor came in later and looked at my face for like...5 min and said yeah, you can do subcision but I really recommend fractora laser. I thought he would be more thorough but he didn't even take a close look at my scars or look at them under angled lighting He didn't even tell me what scars I had According to the clinic nokor subcision is a common procedure he does, and the price they quoted was about $800 CAD for the full face. Does that sound reasonable? They said that if I do the subcision, I can go back and do the filler later, and it costs about $500-600 for a HA filler. Do you think I should get a second opinion or go with this guy? It bothered me a bit that he didnt really look at my scars closely. He's mainly a rhinoplasty surgeon and doesn't have many reviews on acne scar revision. Here are some pics of my scars for reference...thanks for all your help!
  12. Starting A Self Diary

    Forums Scar treatments 8 replies

    I'm making this post to track my future progress with my acne scars. I've posted here a few years ago and eventually just stopped trying altogether, but recently felt a few kicks in my self-confidence so I am back and going to try a few things. This will likely be a post that I come back to update on over a long period of time since results never come instantly. In high school I had terrible cystic acne resulting in many different types of scars on my cheeks, and some on forehead but I am not too worried about those. Since I have many types of scars I am looking into doing a few things, reading this article I grew a little hope that I could see some improvement. Any input would be awesome, but I have purchased a derminator to begin dermaneedling, as well as some tca 20% for a few peels like the article. Will also be looking into subcision because I think that was a major part of the study that shouldn't be ignored. When i receive my derminator I will probably be posting the intial day I do it, then post a follow-up a few weeks out after micro-swelling has gone down. I would like to try what they did in the study and do the TCA peel 2 weeks later (not sure what % I will do it at). I may actually spread it out to 3 weeks after because I don't want to add more harm and impact collagen production.
  13. How does one Dermastamp under a scar
  14. i had a subcision many years ago with excellent results. However recently I had a few rounds of subcision around my smile line for a couple scars and it seemed to just make things worse. The area where the needle was inserted created a tethered area and itcaused additional wrinkles and crooked smile lines. It basically looked like the skin was stapled along the three points the doctor insterted the needle, causing a brand new fold/wrinkle. I tried to get it fixed, and went to a new doc, who suggested further subcision. This resulted in nodules and further tethering around the smile line. I saw the doctor again a month later, and he went ahead and subcised under the same nodule! He seemed to be wanting to promote more scar tissue (which I understand is a goal in some acne scar subcicions). It's been 2 months now, and nodules haven't gone down much. I know kenolog is the popular choice for nodules, but I'm worried it would make the wrinkes worse? I may be crazy but I'm thinking a subcision with a very fine needle might do the trick in terms of untethering all the scaring I've developed. The nodule isn't too high and is only noticeable because it stays in place when I smile. Anybody have any advice and experience on nodules and additional scar tethering caused by subcision? Kicking myself because the original acne scars were really not that significant. Edited to add pictures: the top arrow is a straight up needle hole/divot (no nodule, don't care about the hole, do care about the crescent wrinkle it creates), second arrow the nodule is about 1 month old, 3rd arrow is about 2 months old. The red marks in the first picture are holes from the insertion of the needle.
  15. i had a subcision many years ago with excellent results. However recently I had a few rounds of subcision around my smile line for a couple scars and it seemed to just make things worse. The area where the needle was inserted created a tethered area and itcaused additional wrinkles and crooked smile lines. It basically looked like the skin was stapled along the three points the doctor insterted the needle, causing a brand new fold/wrinkle. I tried to get it fixed, and went to a new doc, who suggested further subcision. This resulted in nodules and further tethering around the smile line. I saw the doctor again a month later, and he went ahead and subcised under the same nodule! It's been 2 months now, and nodules haven't gone down much. I know kenolog is the popular choice for nodules, but I'm worried it would make the wrinkes worse? I may be crazy but I'm thinking a subcision with a very fine needle might do the trick in terms of untethering all the scaring I've developed. The nodule isn't too high and is only noticeable because it stays in place when I smile. Anybody have any advice and experience on nodules and additional scar tethering caused by subcision? Kicking myself because the original acne scars were really not that significant.
  16. Hey guys, I'm planning to do a subcision procedure soon. I also am planning to do suctioning. I just have a few questions to ask regarding the suctioning. I'm asking these questions mainly cuz i havent bought the cupping set and thus i do not know how to use them. I have read many forum posts on suctioning and i do not get it. For example, 2-3 pumps on each scar for 4-6 seconds, 4-8 passes. What does this mean? I place the cup on my face, pump it a few times for 4-6 seconds and do this 4-8 times? What does it mean by passes? Also how would i know that i have suctioned enough?
  17. Dear all, After a couple of years of silently observing (and learning so much) around here, I have finally decided to join in and share my story/upcoming journey of acne scars revision. First of all, let me share the pictures of my scars. As you can see, I have them both on the cheeks (mostly around the mouth, quite untypically) and forehead. The mouth area worries me the most as the dense scarring creates wrinkly, saggy, uneven and aged appearance. My acne scars treatments history: - Biostimulation laser (red light therapy) – hardly did anything but I was new to this and this was what my aesthetician recommended so I went with it - Countless sessions of dermarolling ( 0.75-1mm roller) - Several sessions of dermapen (1-2mm) in the last ½ year – I believe effects of which are really visible over time! I have been avoiding lasers so far – after reading experiences of fellow acne scarring sufferers it really doesn´t seem to me as an effective treatment. I am also scared of volume loss as a negative side effect. I am already starting to lose volume in my cheeks (sunken cheeks run in my family) and I have read that sometimes fat loss is a side effect of laser treatments. But I am certainly gonna research and educate myself more on this complex topic in the future. ___ SUBCISION Now, I have read a lot around here on subcision and decided I want to give it a shot since it is a treatment that really makes sense to me (releasing the scars) and since I have seen some amazing results. Unfortunately, I live in a country where no one performs it (actually there is no one specializing in acne scars in the whole country) but since I live in Europe, I saved up money and am travelling to Denmark in 2 weeks. Obviously, I haven´t had a consultation with the doctor yet (mid-January) as he doesnt do them via Skype but I am really hoping he will find me a suitable candidate for subcision and will perform the treatment right away. Also might combine it with TCA cross. If I do get subcision, I plan to do suction afterwards. Already ordered suction devices from owndoc and also a cupping set. Apart from documenting and sharing my journey here after I am done with the treatment (pictures), I would also like to ask you a few questions regarding your opininon about my scars (what types, what treatments you think might help me) and about subcision in general. Subcision–related questions: 1) Is there something I should/could do prior to subcision - with regards to skin care routine, dietary supplements - to prepare my skin and improve the results? 2) Is there something I should definitely avoid? (i.e. what ingredients in skin care, what supplements) 3) What can I do after the treatment to improve the results? I am planning to take collagen + HA supplements + enzymes that improve healing (they are recommended after surgeries but also illnesses in general to help the organism to jump start immune system and healing) 4) I am also planning to do practically the same routine as I do after dermapen – treat the skin with HA serum, peptide serums, or growth factor serums (not at the same time :)) maybe one thing in the morning, another in the evening) – to stimulate the repair process and collagen production. Is this desirable after subcision too, or it works differently? 5) Is dermapen session helpful like a week before and maybe 2-3 weeks after subcision? Im even thinking I might do PRP. 6) Will suction still be safe even if I do TCA cross along with subcision? I am sorry that this post is SO LONG – I actually really tried to be concise and structured since there are so many topics and questions and thoughts I have around acne scars. Thanks so much to anyone who is willing to share their comments and ideas.
  18. Waiting for treatment

    Forums Scar treatments 1 reply

    How long do people wait with subcision on new scars? Mine is 2 months old and am wondering if waiting 6 months is the right thing to do. Thanks.
  19. it's the fifth day after my subcision.... but my cheeks are turning green.... now the swelling is almost gone. should I start suctioning? does turning green seem right? I did subcision twice with another doctor, but I didn't see my cheeks turning green. I saw that this part of my face was going down like several days ago, but since other parts were still swollen, I didn't suction. is it too late?
  20. I have been considering TCA CROSS for a few icepick scars and one fairly wide boxcar scar that I have. I've been looking all over the internet trying to find some good examples of what I can expect my face to look like for the weeks following the treatment but I can't really find much documentation of what it will look like (btw I am a one on the fitzpatrick scale). Does anyone have a few good pictures or video of what this will look like? I was going to see a plastic surgeon to have it applied, but I am a bit apprehensive about any risks. As far as I can tell it seems like a fairly safe procedure, but I was just hoping for some reassurance on here... Also, I was wondering how the boxcar scar would be treated. If it is wide, long and shallow could TCA be used or would they use subcision on it? Thanks!
  21. Any thoughts on this?

    Forums Scar treatments 1 reply

    I have found a study on subcision, proving that subcision with suction can help it level the surface. Is there anyone here that has done this before? The study also states that it can cause raised scars from this surgery due needling closer to the epidermis. I'm wondering if anyone has experienced this themselves? Here is the study:
  22. Scarring from Subcision?

    Forums Scar treatments 6 replies

    Hello all, Hopefully some of you can help! I just subcision today and am worried that the entry points of the needle may scar. I had a 1cm by 1 cm area subcised and he entered from TWO points. He switched between the entry points, re-entering them multiple times, around 2-3 each. Is it common during a subcision to re-enter the needle into same entry points, like my doctor had done? Thanks,
  23. I posted this 2- years ago when I was asked for proof of successful treatments "pics", or has anyone had success. This is now included in my DIY Guide to Acid peels (Linked off the FAQ - top of the acne scar sub - first post - Under Peels). This post was made so you can see the treatments we offer do successfully work even if people do not post "pics". Acid peels are very successful as a alternative to laser at resurfacing the skin (without the side effects). If your doing DIY it takes many treatments over time ) 3 months it takes collagen to develop, or your Dr can do a "deep" sedated TCA or Penol peel to get under the scars. Microneedling without TCA is not effective they work synergistically together over time. This may be subsituated with RF Microneedling (Infini) if you have the proper scars and $$$$. Also be aware the above study exact method might not work for you or your individual case, this is why the FAQ was made (many studies like this hide secrets Dr's do for treatment or do things unsafe for home DIY. Do not attempt this without reading the FAQ and Acid Peel Guide. AS always a doctor can treat with much better results and quicker outcomes for your personalized scar types. Point anyone who wants proof to this post ("Pics" below). ______________________________ TCA, Microneedling, Subcision w/ Filler give the best results for Acne Scars! Combination Therapy in the Management of Atrophic Acne Scars Shilpa Garg and Sukriti Baveja J Cutan Aesthet Surg. 2014 Jan-Mar; 7(1): 18–23. doi: 10.4103/0974-2077.129964 INTRODUCTION Acne is prevalent in over 90% adolescents and it persists into adulthood in approximately 12%-14% of cases with psychological and social implications.[1,2,3] In some patients with acne, the inflammatory response results in permanent, disfiguring scars from either increased tissue formation or due to loss or damage of tissue. Hypertrophic scars and keloids are examples of scars that result from increased tissue formation. Scars with loss or damage of tissue can be classified into icepick, rolling and boxcar scars.[4] There is no standard treatment option for the treatment of acne scars. Medical management of atrophic scars can be done by using topical retinoids. Surgical management can be done using punch excision, elliptical excision, punch elevation, skin grafting and subcision depending on the type of scar. Procedural management includes microdermabrasion, chemical peels, percutaneous collagen induction by microneedling and dermabrasion. Tissue augmentation can be done using xenografts, autografts and homografts. Various ablative and non-ablative lasers and light energies are also available for treatment of atrophic acne scars.[5] Out of these multiple treatment options, treatment has to be tailored to patient's needs, tolerance, and goals along with the physician's assessment, skills and expectation. Patient should be counselled that the ultimate goal of any intervention is to improve the scars and no currently available treatment will attain total cure or perfection. In 1995, Orentreich and Orentreich described subcision as a method of subcuticular undermining of scars using a tri-beveled hypodermic needle. This results in lifting the scar by releasing the papillary dermis from the binding connections of the deeper tissues and by the formation of connective tissue that results from the course of normal wound healing.[6] It is mainly used for the treatment of rolling type of atrophic scars.[4] The mechanism hypothesised for action of percutaneous collagen induction using dermaroller is that it creates thousands of microclefts through the epidermis into the papillary dermis. These wounds create a confluent zone of superficial injury which initiates the normal process of wound healing[7] with release of several growth factors. This stimulates the migration and proliferation of fibroblasts resulting in collagen deposition[8] which continues for months after the injury.[9] Another hypotheses states that on penetration of skin with the microneedles, the cells react with a demarcation current which in addition to the needles own electrical potential results in release of various growth factors. This cuts short the healing process and stimulates the healing phase.[10] Dermaroller also opens pores in upper layers of epidermis and allows creams to be absorbed more effectively by the skin. Fifteen percent tricholoroacetic acid (TCA) peel is superficial peeling agent. It causes exfoliation, improves the skin texture and induces collagen synthesis.[11] The aim of our study was assessment of combination therapy using subcision, dermaroller and 15% TCA peel for the management of atrophic acne scars. The rationale for combining these three minimally invasive procedures was their additive action on acne scars. Subcision releases the scars from the underlying adhesions which should be the first step for any treatment for acne scars. Microneedling with dermaroller causes collagen induction along with enhancing absorption of tretinoin cream. Fifteen percent TCA peel causes improvement in skin texture as well as collagen induction. Hence by combining these three minimally invasive modalities one can release the scars, enhance collagen induction, increased penetration of topical agents and resurface the skin. MATERIALS AND METHODS Fifty patients with atrophic acne scars were enrolled in this study. Exclusion criteria were patients with active acne, active herpes labialis, patients on systemic retinoids, evidence or history of keloid scars, pregnancy or lactation, history of any facial surgery or procedure for scars and patients with unrealistic expectations. All the patients were counselled for surgical intervention and written informed consent was taken. The atrophic acne scars were graded by a single non-treating physician using Goodman and Baron Qualitative scar grading system [Table 1].[12] Table 1 Goodman and Baron Qualitative scar grading system Patient's skin was primed using topical tretinoin cream 0.05% at night along with sunscreen with a minimum SPF of 30 during the day for 2 weeks prior to starting the treatment. At the start of treatment, subcision was performed only once using a 24G needle. One day after the subcision, patient was called for the first sitting of microneedling with dermaroller containing 192 needles of needle size 1.5 mm. Eutectic mixture of lignocaine 2% and prilocaine 2% cream was applied under occlusion for 1 hour to the affected areas which was removed using gauze. Thereafter topical tretinoin cream 0.05% was applied to the affected area. Treatment was performed by rolling the dermaroller in vertical, horizontal and diagonal directions in the affected area until appearance of uniform fine pinpoint bleeding. Then the area was wiped with saline soaked gauze and tretinoin cream 0.05% was applied and washed off after 30 minutes. Two weeks after dermaroller, patient was called for 15% TCA peel. Whole face was cleansed using spirit and degreased using acetone. Fifteen percent TCA peel was applied with cotton tipped applicator on full face. Appearance of speckled white frosting was the end point of treatment with peel. After using dermaroller and 15% TCA peel, patient was instructed to apply sunscreen in the morning and mometasone furoate cream 0.1% twice daily for 5 days after which sunscreen was continued in the morning with tretinoin cream 0.05% applied at night time. Patient was asked to discontinue topical tretinoin cream application 2 days prior to TCA peel. Thereafter, dermaroller and 15% TCA peel were repeated alternately after every 2 weeks for six sessions of each and this was taken as the end point of our study. In some patients who developed inflammatory lesions of acne during treatment, capsule doxycycline or topical clindamycin cream 1% was given as and when required. Any adverse effects and interference in daily activities post-treatment were noted. Patients were evaluated for results 1 month after the last procedure was performed. Post-treatment scars were graded again by the same physician using Goodman and Baron Scale. Patient graded their response to treatment as poor, good, very good or excellent with 0-24%, 25-49%, 50-74% and 75-100% improvement, respectively, in their acne scars. The patients were followed up for 1 year at two monthly intervals to observe the sustenance of improvement in scars. Digital colour facial photographs were taken before treatment, during each visit of treatment, at 1 month after the last procedure and at 2 monthly intervals for 1 year after the last procedure. Patients were instructed to continue application of topical tretinoin cream 0.05% for 1 year after the last procedure. Statistical analysis Descriptive statistics such as mean and standard deviation are calculated. Data is presented in frequencies and their respective percentages. Data was entered and analysed using SPSS version 18. RESULTS Out of 50 patients, 49 patients completed the treatment. Out of 49 patients 2 patients were treated with capsule doxycycline during the treatment protocol due to active acne eruptions. Out of 49 patients there were 30 females and 19 males with age group between 18-39 years with mean age of 25.6 ± 5.2 yrs. 9 patients (18.4%) had Type III Fitzpatrick skin type, 32 (65.3%) type IV and 8 (16.3%) patients had type V Fitzpatrick skin type. Pre treatment melasma was present in 3 (6%) patients. Out of 49 patients who completed the treatment, 16 patients had Grade 4, 22 patients had Grade 3 and 11 patients had Grade 2 scars before treatment. The physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system is summarised in Table 2. In patients with Grade 4 scars, 10 patients (62.5%) showed improvement by 2 grades i.e., their scars improved from Grade 4 to Grade 2 of Goodman Baron Scale [Figure [Figure1a1a and andb].b]. Six patients (37.5%) with Grade 4 scars showed improvement by 1 grade [Figure [Figure2a2a and andb]b] with scars being obvious at social distances of 50 cm or greater. In 22 patients with Grade 3 scars, 5 patients (22.7%) showed improvement by 3 grades i.e., they were left with no scars at all [Figure [Figure3a3a and andb],b], Two patients (9.1%) improved by 2 grades and as per Grade 1 they were left with only hyper-pigmented flat marks [Figure [Figure4a4a and andb]b] and 15 patients (68.2%) showed improvement by 1 grade by moving to Grade 2 [Figure [Figure5a5a and andb]b] as per Grade 2 their scars were not obvious at social distances of 50cm or greater. All 11 patients (100%) who had Grade 2 scars before treatment showed improvement by 2 grades in their scars and were left with no scars [Figures [Figures6a6a–b and and7a7a–b]. Hence all 49 patients (100%) had improvement in their scars by some grade with no failure rate. In patients with Grade 4 scars [Table 3], 12 patients (75%) graded their response to treatment as very good with 50-74% improvement in their acne scars after treatment and 4 patients (25%) had good improvement in their scars with 25-29% improvement. In patients with Grade 3 scars, 8 patients (36.4%) graded their response to treatment as excellent with 75-100% improvement in their scars and 14 patients (63.6%) reported the response as very good with improvement between 50 and 74%. All 11 patients (100%) with Grade 2 scars graded their response after treatment as excellent with improvement between 75 and 100%. Poor response with 0-24% improvement in scars was reported by none of the patients. Improvement in scars was first noted in majority of the patients after completing two sitting of dermaroller and peel. At the end of 1-year of follow-up, it was observed that all the 49 patients sustained the level of improvement in their grade of scars which was attained at the end of the last procedure [Figure [Figure8a8a–c]. Although improvement in the scars as noticed by the patient and the physician continued in the follow up period of 1 year, there was no further shift in the grade of scars. Table 2 Physician's assessment of response to treatment based on Goodman and Baron Qualitative scar grading system Figure 1 (a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment Figure 2 (a) Grade 4 acne scars; (b): Improvement in acne scars from Grade 4 to Grade 3 after treatment Figure 3 (a) Grade 3 acne scars; (b) Post-treatment patient had no scars Figure 4 (a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 1 after treatment Figure 5 (a) Grade 3 acne scars; (b) Improvement in acne scars from Grade 3 to Grade 2 after treatment Figure 6 (a) Grade 2 acne scars; (b) Post-treatment patient had no scars Figure 7 (a) Grade 2 acne scars; (b) Post-treatment patient had no scars Table 3 Patient's assessment of response to treatment Figure 8 (a) Grade 4 acne scars; (b) Improvement in acne scars from Grade 4 to Grade 2 after treatment; (c): Sustenance of improvement in acne scars from Grade 4 to Grade 2 at 1 year of follow-up There was improvement in rolling, boxcar and linear tunnel type of scars with little or no improvement in ice pick scars. All patients tolerated the procedure well. Side effects were mild and transient. Post-dermaroller transient erythema and oedema lasted for 1-4 days with a mean of 2.4 ± 0.7 days. Post-peel exfoliation of skin was present from 2 to 7 days with a mean of 4.4 ± 1 day. Only three patients (6%) developed post-inflammatory hyper-pigmentation (PIH) which was treated with sunscreen in the morning and triple combination of tretinoin, hydroquinone and mometasone at night time. The PIH subsided after 5 months of topical treatment. One patient (2%) developed mildly tender cervical lymphadenopathy each time after dermaroller which lasted for around 3 weeks and subsided on its own. There was no interference in daily activity with no loss of days at work. DISCUSSION This study has shown good results in patients with severe Grade 4 and 3 acne scars with 10 (62.5%) patients with Grade 4 scars moving to Grade 2 and 5 (22.7%) patients with Grade 3 scars improving to have no scars at the end of treatment. In Grade 2 scars all the 11 patients (100%) showed improvement by 2 grades and were left with no scars. Hence, all 49 (100%) patients showed improvement in their scars by some grade with no failure rate. The physician's analysis also correlated with the patient's assessment of improvement in scars with 12 (75%) patients with Grade 4 scars reporting improvement as very good, 8 (36.4%) patients with Grade 3 scars as excellent and 11 (100%) patients with Grade 2 scars as excellent with poor response reported by none of the patients. The procedure was well tolerated by all the patients. Post-procedure there was no loss of work days and side effects were mild and transient. In spite of patients being of Type III, IV and V Fitzpatrick skin type, only three patients (6%) developed PIH during the treatment, which subsided within 5 months of topical therapy. It has the advantage of being an office procedure and in being cost-effective. Topical tretinoin 0.05% favours the development of a regenerative lattice-patterned collagen network rather than the parallel deposition of scar collagen found with cicatrisation. Since dermaroller opens pores in the upper layer of epidermis and allows creams to be absorbed more effectively, it is for this reason that topical tretinoin was applied during dermaroller and kept for 30 minutes post-procedure to maximise its absorption in skin. Also the improvement in the grade of scars was sustained in the follow-up period of 1 year. Although ablative laser resurfacing is generally considered to be the most effective option for scar resurfacing, it is associated with significant damage to the epidermis and basal membrane with associated inflammation which causes erythema, scarring and pigmentation problems.[13,14,15] It also has a long downtime. In comparison, percutaneous collagen induction does not induce post-operative dyspigmentation as the epidermis and basal membrane are left intact.[16] CONCLUSIONS As the demand for less invasive, highly effective cosmetic procedures is growing, this combination of treatment for acne scars has shown good results not only in Grade 2 but also in severe Grade 4 and 3 acne scars. The treatment is well tolerated in Fitzpatrick skin types III, IV and V with no failure rates or loss of days at work. There is a high level of patient satisfaction, minimal downtime and the treatment is cost-effective to the patient. To our knowledge, this is the first study using this combination of therapy in the management of atrophic acne scars and the first in which topical tretinoin cream was applied both during and immediately after doing dermaroller. __________________________________________________________________________________________________________________ Indian Dermatol Online J. 2014 Jan-Mar; 5(1): 95–97. doi: 10.4103/2229-5178.126053 PMCID: PMC3937506 Subcision plus 50% trichloroacetic acid chemical reconstruction of skin scars in the management of atrophic acne scars: A cost-effective therapy Jasleen Kaur and Jyotika Kalsy1 Treatment of acne scars is a dilemma both for the treating physician and the patient as no oral or topical medicine works and it is associated with emotional and psychological stress. Acne scars are classified into three different types: Atrophic, hypertrophic, or keloidal. Atrophic scars are the most common type of acne scars. They have been further classified into three types as described by Jacob et al.[1] into ice-pick scars, rolling scars, and boxcar scars. Most of the patients with atrophic acne scars have more than one type of scars. Various treatment modalities like punch excision and elevation, subcision, chemical peeling using various strengths of TCA, micro-needling, ablative, non-ablative lasers and fillers either singly or in combinations have been described in literature with varying results. Most of these procedures require costly equipment and materials and not affordable by many people. Subcision or subcutaneous incision-less surgery is a term coined by Orentreich and Orentreich[2] in 1995 as the treatment option for atrophic acne scars. Here hypodermic 18 no. needle is used to break the fibrotic strands that tethered the scars to the underlying tissues leading to uplifting of scars. Combining subcision with other scar revision techniques or repeated subcisions may be beneficial to the patients.[3] TCA chemical reconstruction of skin scars (CROSS)[4] is another useful method for treatment of atrophic acne scars. It involves focal application of 50-100% of TCA with a wooden applicator on the base of an atrophic scar, which causes precipitation of proteins and coagulative necrosis of cells in the epidermis. There is necrosis of collagen in the papillary and upper reticular dermis. Healing is rapid because of sparing of adjacent normal tissues and adnexal structures. So there is reorganization of dermal structural elements and increase in collagen content that leads to filling of the atrophic scar. While going through the literature, we found that different studies have used subcision and CROSS TCA alone or in combination with other techniques as well as their comparative studies but we did not find any study combining these two techniques together to the best of our knowledge. Encouraged by that, we combined subcision and TCA cross in all types of scars as subsicion breaks the dermal tethering of the scar tissue and TCA will remodel the collagen underneath the scar which treats the basic pathology of the scar to some extent. In our study, 10 female patients between the age group of 20-35 years of skin type 4 and 5 with atrophic acne scars on the face were randomly selected. Most of the patients had more than one type of atrophic scars of grade 4 severity as described by Goodman.[5] In all the patients, there were no active acne lesions and none of them were on oral isotretinoin 3 months prior to inclusion in our study. Patients with keloidal tendencies, bleeding diathesis, and history of recurrent herpes simplex were excluded. Complete hemogram, random blood sugar levels, and viral markers were done in all the patients. Written consent after explaining the risks and benefits of treatment was taken from all the patients along with pre-/post-procedure photographs. Subcision followed by 50% TCA CROSS was done at 4 weeks interval for three sessions. Patients were followed-up monthly for improvement in scars up to 6 months. Priming was done 2 weeks prior to the treatment with 2% hydroquinone and tretinoin 0.025% cream at night and sunscreen more than 30 sun protection factor (SPF) was given in the morning. Procedure was carried out after application of topical anesthetic cream for 45 min followed by infiltration of 2% Xylocaine with normal saline under aseptic conditions. A no. 18 hypodermic needle attached to a syringe was introduced horizontally underneath each scar and was moved back and forth till the snapping sound was heard. We used no. 18 hypodermic needle because it is cheap and easily available. Homeostasis was maintained by pressure. We cleaned the entire area with normal saline which was followed immediately by 50% TCA with the tip of a toothpick by pressing hard on the entire area of depressed atrophic acne scars irrespective of the type of scar and frosting was taken as the end point, antibiotic cream was applied, and patient was sent home. Patient was advised to apply antibiotic cream twice daily followed by sunscreen in the morning. Erythema, edema, and crusting lasted for 7-10 days in all the patients to varying severity. After 10 days, the patient was advised to apply azelaic acid 20% cream at night. Results were evaluated on the basis of global scar grading system, visual improvement by photographs and patient satisfaction. The global acne scarring classification is a four-category qualitative system by Goodman[5] based on scar morphology and ease of masking by makeup or normal hair patterns. Grade 1 means macular scarring only, Grade 2 is mild atrophy, which is not visible beyond 50 cm and can be easily masked by makeup, Grade 3 is moderate atrophy obvious at social distance not easily masked by makeup while Grade 4 is severe atrophy. Percentages in improvement were calculated as a combination of the three parameters, i.e. global scar grading system by Goodman, visual improvement by photographs showing the change in the grade and patient satisfaction, which was assessed by giving a questionnaire to the patient where they had to rate their improvement on 0-10 point scale. Excellent >70% Good 50-70% Fair 30-50% Poor <30% We labeled results as excellent when there was a two-grade change in the scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as more than 7 [Figures [Figures11 and and33]. Figure 1 Sites involved right cheek. (a) Post-acne scars mostly ice pick, boxcars and few roller scars. (b) Decrease in number and depth of scars Figure 3 Site involved is left cheek and left temple. (a) Many ice pick scars and a few boxcars and very few rolling scars. (b) Decrease in depth and size of scars Results were taken as good when there was one-grade improvement in acne scars observed by the dermatologist both by grading system, photographs, and patient rated his improvement as 5, 6, or 7 [Figure 2]. Figure 2 Sited involved right cheek. (a) Multiple post-acne ice pick and roller scars. (b) Decrease in size and depth of all the scars Results were taken as fair when there was improvement in acne scars observed by the dermatologist by photographs only and patient rated his improvement as 3, 4, or 5. Results were taken as poor when there was no improvement in acne scars observed by the dermatologist either by photographs or by grading system but it was only subjective improvement as told by the patient when they rated it between 1 and 3. In all the patients, scar grading improved from grade 4 to grade 2 and results were graded excellent, good, and fair in 6, 3, and 1 patients respectively [Table 1]. Although in various studies best results with CROSS TCA are seen in ice-pick scars but since in our study we combined it with subcision, results were equally good even in rolling scars and boxcars scars. Post-inflammatory hyperpigmentation was transient in three patients, which persisted for 15-20 days post-procedure, which further decreased over the time period with 20% azelaic acid and in one case, the mild hyperpigmentation persisted even at the end of 6 months in spite of the best efforts for reasons not known. The patients were also happy with the results except for the one where hyperpigmentation persisted. Although the procedure has a downtime in the form of erythema, edema, and crusting, it is comparable to all other resurfacing procedures and the problem of post-inflammatory hyperpigmentation can be judiciously tackled with the proper and repeated use of sunscreens and lightening agents. Each procedure when done individually has downtime of few days. So, we tried to reduce it by combining the two procedures. Hence, it can be concluded that subcision combined with TCA CROSS is a simple, safe, and cost-effective procedure, which does not require any specialized or costly equipments or materials or any special training and can be performed as an out-patient-department procedure by any budding dermatologist.
  24. So I have a hand-held pump device I bought from owndoc. How hard aka how many pumps and how long do I suction the area (my cheek) after subcision?
  25. Subcision Soon/ Documenting Procedure

    Forums Scar treatments 23 replies

    Hello all- I have moderate rolling and boxcar scars, and I am still on Accutane to treat my acne (I am on my final month currently, almost done!) I have been researching subcision because I want it to be the very first step in my acne scar revision plan, and have found that new evidence suggests that one does not have to wait the 6 month period after accutane to have this procedure. I contacted the facial plastic surgeon I wanted to preform this procedure on me, and he confirmed that there is no waiting period! I am so excited. I have my consultation in a few days. This allows me to get a head-start on improving the scars, and will give more time for collagen to form before I start doing TCA peels and microneedling. I am especially excited, because the scars that bother me most are the tethered rolling scars that create undulations or shadows in overhead or angled lighting. I intend to have at least 3 subcisions a few months apart, (one in January, one in May, one in August) and maybe another next year around Christmas time if I am not satisfied. I will definitely update this post with how my consultation goes and how the procedure goes