The latest in acne scar removal is a technique combining both subcision and dermal fillers. This provides instant acne scar reduction with no downtime. With the event of new cross-linked fillers, and gentle, painless surgical subcision, scars such as atrophic and tethered acne scars, chick pox scars and depressed scars can be corrected. Fillers are sugar- collagen molecules, replacing the lack of natural collagen found in scars. This subcision procedure is well tolerated with virtually no down time.
- Dermal fillers are also known as Hyaluronic Acid or HA fillers
- HA fillers are synthetic forms of collagen
- New cross linking of molecules within fillers developed in the past year has increased the longevity by nearly 10 times compared to first generation fillers
- Fillers are ideal for most forms of acne scars, including rolling, atrophic, and tethered scars
- Dermal HA fillers can also be used to treat depressed scars and chicken pox scars
- Fillers are almost painless because they contain lidocaine anaesthetic within the solution
- Results with fillers are instant with minimal downtime
- Identifying the type of acne scars is the very first step as some deep ice pick scars are not suitable for dermal fillers
- Subcision along with dermal filling can give long lasting, even permanent results
Most patients will have a mixture of acne scars, and chances are some scars such as rolling, mixed, atrophic, tethered, and depressed scars will respond nicely to dermal fillers. Dr Davin Lim will guide you as to what scars can be treated with this method.
Rolling and depressed acne scars- most of these scars with be tethered and hence subcision will be successful
Mixed acne scars- do well with subcision, especially anchored scars
Box car scars- these respond poorly to subcision and best to fully ablative lasers
Acne scars can be filled by stimulation of collagen, releasing scar tissue, or replacing collagen.
Lasers or energy devices such as radiofrequency can stimulate collagen-producing cells to start laying more collagen. The disadvantage of this process is that it takes time and several treatments for the best results. Downtime, meaning skin recovery can take between 2-10 days. Results from energy based devices like lasers and micro needling RF rely on your owns immune system to stimulate collagen production – this means results are only seen after 6-8 weeks, and maximal at 3-4 months after the procedure.
Secondly, if your scars are tethered or bound down, surgical release known as subcision can free up the scar tissue. I normally perform this procedure during the filling process. Once scar tissue is raised, the results are permanent. I also micro-needle in a horizonal manner, this further stimulates collagen (see my YouTube videos on the procedure).
The third method of replacing collagen is with fillers. These are synthetically produced molecules known as Hyaluronic Acid or HA. HA fillers such as Restylane or Juvederm (my favourite), have a long safety record. In the process of dermal filling, I often use fillers as a ‘buffer’ after my subcision procedure- hence this explains why they last over 2 years in some scar types.
I use a special form of HA filler known as crossed linked HA’s. There are different types of cross-linked HA fillers, each having unique properties. I use thick fillers for support, and thin fillers for filling fine areas such as the temples and tiny open pores. For most of my patients I use what I call a ‘layered technique’- support for deep scars, and finesses for fine scars, and hence I combine two types of cross-linked HA fillers.
More on the fillers I use for acne scars
This is one of the most well tolerated procedures in acne scar revision! Most patient rate the pain as ‘mild or minimal’, some patients do not even feel any discomfort. This is because the fillers I use contain a premixed local numbing substance called lignocaine. I also use a special method of injection to introduce this mixture before ‘subcision.’
Instantly! Fillers work by instantly replacing loss volume, including volume loss due to scars. You will notice an immediate difference after this 10 minute procedure. Most patients require several filling sessions to obtain the best results. Dermal fillers for acne scars can be carried out at weekly intervals if needed, as downtime is virtually zero!
Fillers technology has taken a HUGE step forward in the past one year. Due to a process called cross-linking, the new generation of fillers last up to 10 times longer than first generation HA fillers. Expect results to last between 18-36 months. In some cases, if ‘subcision’ is performed, the results can be permanent. (See my videos on how I combine surgical subcision with fillers). In some cases, I use PRP as a filler just after surgical subscision. In other cases I use saline. There are many methods to subcise and fill at the same time. I use a variety of instruments including Nokor Needles, 18g, 21, 23, 29, 30, 31 G needles. Additionally I subscise and fill using various cannulars from 21G to 27G. As everyone has a particular pattern of scars I adopt my method to best suit your scar type and amount of tethering.
The biggest advantage of dermal fillers over procedures such as Fraxel or Fractional laser is that fillers are associated with no downtime. Treatment takes 10-15 minutes to perform, and you can go to work immediately after procedure. In some patients, bruising may occur, however this is usually mild and will settle over 72 hours.
The only limitations I place is that you cannot exercise for 12 hours after the procedure.
My approach to acne scarring is to firstly identify your scar type, then discuss treatment options for your specific scars. If you have rolling and mild atrophic scars, laser treatment (or high power radiofrequency) can induce natural production of collagen. Several treatments maybe needed, and maximal collagen production can take up to 4 months. Filler can then be used to fill up the remaining scars. Some forms of deep acne scars called ice pick scars are best treated with a process called TCA CROSS.
Another method of using permanent filling is a process called Dermal Grafting– here we use your own collagen harvested from the back of your ear to fill up atrophic scars. This procedure has significant downtime, it involves multiple sessions over 12-18 months, followed by laser resurfacing.
I never use permanent fillers due to the increased rate of serious side effects associated with these fillers. Bellafill is PMMA filler approved in the US, however I am still awaiting the final safety data regarding this filler. Because Bellafill is not an HA based filler, there is no ‘antidote’ or reversal agent. If PMMA finds its way into an artery, it may cause skin death in the area. If HA fillers such as Juvederm enter an artery, early reversal is possible with good outcomes. My practice in acne scar revision is always safety first.
In the majority of cases, most patients will have a significant degree of tethering or anchored scars. These acne scars are usually located on the temples and cheeks, and can be identified by stretching the skin under angled light. If you do have tethering, my first step is to break the ‘ropes’ or bonds that create this depression. I use a small needle to subscise each scar individually, and place a tiny bit of HA filler as a ‘spacer’. This technique is a permanent method of acne scar revision. The upside of this method is that there is minimal or no downtime.
Yes. Dermal fillers are compatible will all skin colours. Unlike laser treatments, fillers are NOT associated with skin colour changes because no heat is produced. Fillers can be used in all ethnic races.
As dermal fillers target the loss of collagen deep in the skin, it spares any superficial damage and eliminates the chances of skin colour changes.
Educating patients about the importance of assessing their own acne scar type will give them an idea of what other treatment are available to treat scars. All acne scar treatments are compatible with dermal fillers these include-
TCA CROSS– this procedure is used to treat deep ice pick scarring. This is a form of chemical peeling designed to reduce the depth of acne scars.
Laser resurfacing- I have access to over a dozen lasers designed for acne scar removal- this includes CO2, Erbium, Fraxel, Picosure, and many more energy devices.
Insulated microneedling using energy based radiofrequency coupled with PRP is showing tremendous promise. I use this procedure to treat atrophic, rolling and tethered scars, often combining subscision during the procedure. INFINI with PRP has shown some great results, and halves the recovery time compared to laser resurfacing. This is the game changer for 2016 for my work on acne scar revision. Medical papers with a follow up series due for publication in 2017.
Subcision is a surgical procedure that is most commonly performed at the same time of filling. This allows channels of filler to spread out evenly through out the scar, and also ‘frees up’ bound down scars. Most patients will have a multitude of acne scar types, and hence a targeted approach of scar revision will give the best results.
More on treating acne scarring
Dermal grafting is an old procedure that can be effective in managing atrophic scars, especially if scars are very small. This process replaces atrophic scars with your own collagen. Over the past 5 years, dermal grafting has been replaced by longer lasting dermal fillers- the process of dermal grafting outlined below will help you understand why this procedure is now considered outdated.
The process of Dermal Grafting is as follows-
- A small area from the back of your ear is harvested
- The top layer of harvested skin is stripped with a CO2 Laser
- The dermal layer is then ‘harvested’ and processed
- A tiny incision is made on the top of your atrophic scar
- A tiny bit of ‘harvested collagen’ is placed into the scar
- One or two stiches closes up the incision
- Stitches are taken out 4-5 days later
- Scars can be improved by 50-70% after one graft
- Incision line of the graft site can be resurfaced with laser 3-6 months later
- Any atrophic scars can then be finely corrected with filler after laser
The advantage of dermal grafting is that you use your own collagen and not a synthetic variety. In good hands, this can be a very effective method in treating atrophic acne scars.
There are several disadvantages to dermal grafting-
- Multiple incision will be made, resulting in multiple ‘nick’ ie. Trading a scar for another scar.
- These incision lines can be reduced with laser, but that involves another procedure down the line.
- In 10-15% of cases, a granuloma can form- this is due to a tiny bit of skin called epidermis from the donor site being transplanted to the scar site. This usually settles down with very dilute steroid injections, but in some cases may require excision.
In reality, even though dermal grafting has been very successful in the past, the combination of fractional laser and new generation dermal fillers have largely replaced this method of acne scar revision. With modern technology, the process of treating atrophic scars is simpler, more effective but importantly safer for patients.
Dermal fillers and subcision start from $390* out of pocket ranging to $1790. The cost and number of sessions will depend on the extent of scarring. Some patients with only a few scars will require only one session, other patients may require several treatments for optimal outcomes. In the majority of time I will perform subcision at the same time as filling, as the majority of acne scars will have some tethering.
*This applies to some insurance companies, and Medicare Threshold regulations.
Dr Davin Lim
Laser and aesthetic Dermatologist
I have been sub-specialising in acne scar revision for nearly two decades. In the early years, scar revision started off with full dermabrasion, followed by fully ablative lasers such as CO2 and Erbium. I started skin needling or skin rolling in the early 2000s then introduced fractional laser resurfacing to my practice in 2006. A decade later, the addition of new cross linked HA fillers has given acne scar patients another modality to improve their scars. Acne scar revision is always based on 3 factors- acne scar type, skin type and downtime of the patient. Fillers are primarily used for atrophic, rolling, and tethered acne scars, and can be used in all skin types. This means skin colour does not play a rate limiting role for filler treatment.
Fillers have a clear and distinct advantage over lasers in that they provide ‘instant’ collagen and scar correction with no downtime. The procedure takes only a few minutes to perform, and patients can resume exercise the next day. The procedure is well tolerated as I combine a local anaesthetic together with the filler. I started several research papers in June of 2013 on the use of Juvederm filler for acne scars. As of late 2016, I am still collecting data as I am seeing a percentage of patients who still exhibit clinical improvement after 2.5 years. Having said this, I think that we should conservatively say that filler last between 18-24 months on average.
I am confident that with increasing research and development we will be seeing a newer generation of HA fillers in 2018 that will last beyond 3-4 years. In the context of scar revision, fillers remain at the forefront of the procedures I conduct on a daily basis. Fillers are NOT a substitute for my other procedures such as laser ablation, fractional lasers, subcision, surgery and TCA CROSS, however this technique adds another avenue for scar revision for suitable candidates. Fillers provide instant results with no downtime.
My acne treatments and research has shifted the paradigm of ‘letting acne scar’- I address both acne AND acne scarring with programs that work.