Fillers and acne scars; what you need to know.

Fillers and acne scars; what you need to know.

By Dr Davin Lim, Procedural Dermatologist, Brisbane & Sydney

Fillers and acne scars; what you need to know.

Here are my tips on fillers & acne scars:

  • Atrophic acne scars are due to focal collagen & fat loss
  • Dermal fillers are used to augment volume depletion in patients who are unlikely to self correct volume deficits
  • Volume can only be replaced with dermal fillers, fat transfer or weight gain
  • Dermal fillers for acne scars provide a predictable correction of volume & last 2-4+ years
  • Dermal injectables are another group of ‘fillers’ that stimulate collagen production
  • Fillers are also used to correct age related volume depletion. This is especially important in mature patients with acne scarring
  • Fillers are used in conjunction with other scar directed treatments including lasers, radiofrequency microneedling, surgical techniques & deep focal peels

What acne scar types are treated with fillers?

Dermal fillers are useful for correction of medium to large volume atrophic (depressed) acne scars such as rolling scars. They can also be employed to treat polymorphic & boxcar scars. 

Why fillers?

In the context of acne scar revision, dermal fillers function to fill up depressions under your skin (atrophic acne scars). They are most useful for medium to high volume atrophy due to collagen & fat loss. Lasers, peels, & microneedling only regenerate collagen & not fat, hence the use of dermal fillers for acne scars. Medium to large volume atrophic acne scars are primarily due to fat atrophy. To date the only two methods to replace fat loss is with dermal fillers, or fat transfer with adipose stem cells. 

Fillers are also used to stimulate collagen production. This aids in correction of small to medium atrophic acne scars that lie within the dermal layer of skin. Finally, fillers address age related volume loss; this especially applies to mature patients with acne scarring.

How long do fillers last?

Longevity depends on three factors. Firstly, the type of filler employed. Thicker fillers last longer, but they are not as malleable as thinner fillers (think paint thickness).  Secondly the acne scar location. Areas of less movement (temples) last longer than fillers adjacent to areas of more movement (around the mouth area). Intermediate lasting areas include the cheeks. 

Thirdly (and the most variable), is your metabolism. In some people, the same filler in the same location may last upwards of 4 years (as proven on MRI scans), whilst in others, fillers may only last 1.5 to 2 years. Active people will have a higher baseline metabolism.

What are other substitutes for dermal fillers?

Your choices to fill out an atrophic scar are limited to –

  1. Physical treatment to stimulate collagen including lasers, RF microneedling & deep focal peels. These treatments can improve dermal atrophy due to low volume collagen depletion, but they do not address fat atrophy as this lies deeper in the skin. These treatments are best used for boxcar, pick, & very superficial rolling scars.
  2. Fat transfer is an awesome technique to correct large volume defects due to fat loss. I employ fat if I need to correct more than 10 mls of deep atrophy. The economics of fat transfer is the primary reason. It is all about the cost to the patient & the probability of fat retention. The biggest disadvantage of fat is the amount that is resorbed. The variability ranges from 20% to over 70% resorption. Given the cost of fat transfer, for low volume atrophy, dermal fillers provide a much higher predictability.
  3. Other treatments that don’t work well include PRP, & dermal grafting (in the context of high volume atrophic scars). PRP is awesome for hair loss, & in some cases can aid in recovery following lasers & peels. In the context of correcting volume loss, the results are dismal. Dermal grafting is great for focal areas of low volume loss that is confined to the dermal areas (hence the name). The amount of dermis harvested can not efficiently correct fat atrophy. Stem cells? Again the amount required for predictable correction of large areas of atrophy is impractical, however they do have a role in improving skin quality. 

Simple classification of acne scars based upon Jacob, 2001 JAAD
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🔬Skin Science: You gotta start with baseline classification however in real life scarring is not monomorphic, hence why we use many different treatment modalities in the same sitting
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🥊Ice Pick scars: Can be treated with punch excision, TCA or phenol croton oil, laser to the walls can help
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📦Box car scars can respond to TCA, microneedling & various lasers
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🕳Rolling scars are best treated with subcision, #microneedling RF, microneedling as well as dermal fillers
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🗻Hypertrophic scars are best treated with steroid or 5 FU injections, vascular lasers or low density ablative lasers
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😎Dr Davin Lim
Brisbane Dermatologist🇦🇺
@drdavinlim @cliniccutis @the.formulated
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#subcision #rollingscars #acnescars #acnescarrevision #acnescartreatment #acnescarremoval #acnescarcure #brisbanedermatologist #icepickscars #acnescarring #TCACROSS #acnescarlaser #davinlim #drdavinim #dermatologistbrisbane #co2laser #laserresufacing #acnetreatment #acnecure
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What is the difference between dermal fillers and collagen stimulating injections?

Dermal fillers (in the strict sense of the word) add more volume as compared to stimulation of collagen. Though the latter often occurs, the relative ratio of volume to collagen stimulation is high. Examples include Juvederm, Boletero, & Restylane. Dermal fillers in the context of acne scars are primarily designed to fill out holes (known as atrophic scars). The main advantage of hyaluronic acid dermal fillers is that the results are relatively predictable, namely one session will give a volumetric decrease of between 30 to 70%. The large variation of volume correction depends on the location & amount of atrophy.  

Collagen stimulating injectables reverse the ratio of volume to collagen stimulation-skin tightening. This group of molecules add less volume, but provide stimulation of your immune system to generate collagen & hence skin tightening. They include bespoke concentrations of poly-L-lactic acid, calcium hydroxylapatite as well poly-caprolactone.

Injectable typeActionLongevityTypes
Dermal fillersReplaces volumeUp to 4 yearsRestylane, Juvederm
Collagen stimulating

injectable

TIghtens & stimulates 

collagen

Variable. Relies on your immune system for actionHyper Diluted PLLA, CAH, HA, PCL

Can fillers be performed with subcision?

In most cases yes, however it has to be limited to conservative subcision. Fillers follow the rules of fluid dynamics, meaning they trek to the area/s of least resistance. This means if there is tissue resistance (scars & tethers), filler often ‘donuts’ around tissue, hence the requirement for subcutaneous subcision. This is why it is important to break the bonds before filler is placed. 
For severe cases of acne scarring, subcision has to be restrained – if filler is placed during the same procedure. This is because extensive subcision is associated with bleeding under the skin, which can potentially lead to filler migration. 

Can fillers be performed with lasers & other treatments?

Depends on the level of filling & the depth of treatments. In most cases, yes. Fillers are placed in the high fat layer & the lower dermal layer of the skin. Fractional lasers (in the context of acne scars), reach between 0.2 to 0.8 mm deep. If my team & I are going deeper, for example 1.5 mm or more with radiofrequency microneedling (unlikely lasers), we will perform fillers or injectables at another date. This is based on safety as I don’t want a connection between the level at which filler is placed & the device depth. 

Dermal fillers are not affected by energy devices such as lasers, radiofrequency & HIFU. We published this research in 2018. Why? Fillers are sterilized at over 110 degrees for longer than 7 minutes. Devices reach up to 69 degrees for a fraction of a second. 

What is the recovery process with dermal fillers?

As I work under your skin, dermal fillers have the least amount of downtime of any procedures. As a guide-

  • Subcision with dermal filler: 0-1 day recovery, depending on the extent of subcision. More aggressive treatment will yield better results (in most cases), albeit longer bruising .
  • Collagen stimulating dermal filler-injectable: 0-1 day, depending on type of injection. PLLA, CAH & Profhilo have no downtime, whilst PCL injections may swell for 1-2 + days. 
  • Dermal filler to address age related issues: Nil downtime in 95% of cases. Filler is placed in the deep fat, bone or superficial layers of the skin. 

How do I choose what filler to use?

A simplified algorithm is as follows-

  • Big holes exceeding 0.2-0.3 ml of focal atrophy = hyaluronic acid dermal filler or a higher volume collagen stimulating injectable. 
  • Smaller holes= HA filler placed superficially or deep to support overlying tissue & dermal layer.
  • Atrophic scars with laxity & fullness= collagen stimulating injectable. 

A complex algorithm that I follow depends on many factors including- 

  • Scar location
  • Mobility of underlying tissue
  • Facial shape & volume
  • Degree of laxity (independent of age)
  • Age (as I predict what your skin will look like in the future)
  • Degree of sun damage
  • Dermal thickness
  • Previous treatments (in context of potential for collagen stimulation)
  • Number of sessions you can commit to
  • Duration of effects
  • Concomitant treatments during the time of filling

What is Sculptra & when do I use it?

Sculptra or PLLA (Poly L lactic acid) is an oldie but a goodie. I use this in more mature patients who would like mild to moderate skin tightening with a tiny bit of volume enhancement. I tend to use it less as there are better options, including calcium hydroxylapatite & HA injectables. Sculptra requires between 3-6 sessions spaced monthly for the best results.

What is Radiesse & when do I use it?

I prefer Radiesse over Sculptra, as the former gives better results & focal volumetric correction. Most patients require between 2-3 sessions, spaced 2-3 months apart for optional outcomes. Radiesse contains calcium hydroxyapatite, & typically lasts over 3 years. This collagen stimulating filler can be performed at the same time as limited subcision. 

What is Profhilo & when do I use it?

Profhilo is relatively new, first approved in Australia in 2022. It contains high & low molecular weight hyaluronic acid & is designed as a collagen stimulating injectable that provides skin tightening & collagen stimulation, much like Sculptra & Radiesse. 

As of early 2023 our group has treated over 500 cases of acne scarring, here is our opinion. 

  • Most acne scar patients require 2-4 sessions, spaced 4-10 weeks apart
  • Collagen stimulation is generally good, but variable.
  • Volume correction is minimal, hence ideal for tightening in patients who are already full.
  • It can be combined with limited subcision. 
  • Over 90% of acne scar patients recommend this injectable.

Hybrid lasers are the way of the future, and Alma is at the pointy end of R & D. This laser is great for atrophic acne scars, especially in darker skin types as the non-ablative is relatively forgiving in the treatment of atrophic scars
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👍🏻Alma Hybrid: combines two powerful wavelengths in the one device. It fires the CO2 & the 1570 in an almost infinite number of combinations. This before & after was the result of one session of subcision & focal excision (me), one session of Alma (Lara @cutis.dermatology )
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👉More on how we rock the Alma at the Alma Academy ASCD next week @ascd.org.au
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#alma #almahybrid #hybridlaserresurfacing #fractionallaser #laserrejuvenation #brisbanedermatologist #drdavinlim
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Another upper lip case. A bit more complex as I wanted to get a good blend without the milk mo- hence why the after results still show some wrinkles
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🔬Skin science: Upper lip lines or ‘smoker’s lines’ are multifactorial, namely dynamic action of the orbicularis oris, most often with some element of elastosis (collagen breakdown). Some cases can be treated with injectables such as microtox & dermal fillers. There are reports of limited subcision with soft tissue fillers but I am not convinced that breaking up vertical ‘bands’ in this context adds much to the outcome- simple ferning gives good results without adding too much volume
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🔫🍌Lasers vs peels: Believe it or not, deep peels such as phenol croton oil can give better results (at least histologically) compared to ablative CO2 lasers, however with resurfacing I can generally get a better blend. One heavy fully ablative will do in most cases. Downside is the downtime and redness for weeks-months. Alternatively a series of fractional ablative laser will give great results with much less downtime💯
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#liplines #liprejuvenation #lips #smokerslines #upperlip #skinrejuvenation #antiwrinkle #wrinkletreatments
...

Why cellulite happens
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🔬Skin science: three main factors that give rise to cellulite. Firstly a thinner dermal layer that does not hold back the extrusion forces in the hypodermis/fat layer. This leads to outpocketing of fat/undulations. Secondly larger adipocytes are present in the subcutaneous fat layer. Thirdly thicker septal bands are present. Other factors such as inflammation, decreased lymphatic drainage are sequelae
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👍🏻Things that work: subcision, collagen stimulating dermal fillers, radiofrequency devices, intermittent suctioning, collagenase / #Qwo / IR, pulsed electromagnetic fields, laser -RF-assisted subcision, deep tissue massage (adjunctive)
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😎Dr Davin Lim
Dermatologist
@drdavinlim @theformulated
Brisbane🇦🇺
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#dermatology #drdavinlim #davinlim #simpleskincare #skincarebasics #instaskincare #skincarecommunity #cosmeticdoctor #dermatologist #cellulitecure #cellfina #dermatologistbrisbane #cellulite #cellulitetreatment #cellulitecreams #venuslegacy
...

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What is the relative contribution with aging & acne scarring & how do fillers play a role?

If you have acne scars & fall in the mature age group, fillers play an important role in treating both acne scarring & age related volume depletion. After the age of 20, there is a linear decrease of collagen of 1-1.5% per year. In your 40s, you have ¼ less collagen than in your 20s. Additionally, the deep fat pads that provide facial volume are depleted. 

Dermal fillers play a critical role in replacing volume loss, both at the collagen level & the deep fat layer. Fillers support the overlying skin in addition to replacing tissue loss within atrophic acne scars. Think beyond acne scarring in mature patients. 

How do fillers work if you have genetically low facial volume?

Think of your skin as your bed. Bone & deep fat = the mattress, skin & acne scars lie superficially & represent the doona. If you have low facial volume (genetically thin mattress). Dermal fillers work by increasing the thickness of the mattress. This give support to the overlying doona, hence provides an indirect improvement of acne scarring (in addition to addressing facial aesthetics). 

In this context, fillers are strategically placed in the cheek bones, temples & around the jawline. They provide volume correction & volumetric displacement of skin, resulting in less laxity. Tractioning the skin reduces acne scars. Think outside the box.

How much dermal filler will I require? 

It depends on three factors. Firstly the amount of dermal & subcutaneous atrophy you have. Secondly the amount of age related tissue loss you exhibit. Thirdly your genetic or baseline facial volume profile. Let’s explore each of these.

Atrophic scar volume: It’s a lot more than you think. For deep rolling, high volume defects, tissue loss varies between 1 to 5 mls. The bigger the hole the more volume required. 5 mls is only a teaspoon.

Age related volume loss: As a guide, 30s-40s 1-2 ml, 40s-50s 2-3 mls, 50s & beyond, upwards of 4 plus mls of filler. 

Baseline or genetic profiling. Some patients are born with a ‘skinny face’, namely low facial volume. This is a relative contribution of deficits in the bone layer, deep & superficial fat layer as well as dermal thickness. Your baseline facial volume determines the amount of support for your acne scars. The ideal amount of dermal filler is the sum of all three factors. 

The number of filling sessions depends on the above factors & ranges between 1-5 sessions. For atrophic correction of scars, intervals are 1-8 weeks apart. For collagen stimulating injectables, 4 to 12 week intervals. 

What are the potential side effects of dermal fillers?

Fortunately side effects are rare, especially with collagen stimulating injectables & reversible hyaluronic acid fillers, however they include-

  • Over correction: occurs in less than 0.1% of my cases. Solution? Dissolve with hyaluronidase, or saline injections +/- 5FU or CS diluted. 
  • Arterial injection: occurs in less than 0.01% of my cases. Solution? HA fillers can be dissolved. 
  • Lumps, bumps, granulomas, infection & delayed nodules. Occurs in 0.1% of HA fillers (in my hands), never seen a case in collagen stimulating fillers such as Profhilo, though it has been reported. 

What are the costs of dermal fillers?

Cost largely depends on the type of filler or injectable used, the amount required, who performs the procedure & if other ancillary procedures are conducted. As a guide-

  • Hyaluronic acid fillers for acne scars: $820 to $1290 per ml. Variation depends on who does it. My nurses charge around $800, the higher amount is my quote.
  • Subcision + filler for scars: $890 to $1690 per ml, as above. 
  • Collagen stimulating fillers: $850 to $990 for Profhilo. 
  • Radiesse or PLLA: $1190 to $1690. 
  • For larger volumes, namely exceeding 2 ml, we offer discounts. 

*For volumetric filling, eg. secondary to aging or volume loss, my experienced nurses will give you a very similar result, hence will save you costs. My work is tiered towards more complex or bespoke cases of acne scar correction. 

When do I employ Botox to treat acne scars?

Botox or neuromodulation is useful for scars that have a contribution from the underlying muscles. Classic sites include the forehead, frown lines (between your eyebrows) & around the eyes. Muscles pull down on the dermal layer of skin, in turn making the appearance of scars worse. A simple solution that takes 20 seconds to perform is Botox. 

You are indeed correct, Botox does not last beyond 4-6 months, but your choices are limited. You can stop muscles moving with injections or if you would like to address things without injections, you can tape your forehead at night before you sleep, or undergo facial yoga to train your muscles. Google it, or YouTube it. 

Can I avoid dermal fillers for scar revision?

Absolutely, but realize the logic behind dermal fillers. Scar revision treatments including lasers, microneedling, RF microneedling, chemical peels & topical creams are designed to increase your dermal collagen production. This can lead to correction of small volume atrophic acne scarring. If your immune system is not efficient at producing collagen, or if the amount of atrophy is too large, fillers & collagen stimulating injections play the role of giving you a helping hand. 

Can lasers & microneedling replace dermal fillers?

Yes, in some cases lasers, microneedling, RF microneedling & focal peels can replace or reduce the need for fillers. These treatments work by stimulating your body’s immune response to generate collagen (not fat). Low volume atrophic acne scars tend to do better with these treatments. Additionally younger patients with a thicker dermis & average to high facial volume respond better. 

Why do some people respond better than others to dermal fillers?

Everything we do has variability, namely everyone lies on a bell curve. This includes height, longevity, IQ & biological responses to dermal fillers. Some patients ‘hold’ filler for longer, others do not. Some stimulate a whole lot of collagen, whilst others are slow responders. If you lie to the left of the bell curve, we may add other treatments to help you remodel scars more effectively, such as adding a more powerful biostimulator. 

Davin’s viewpoint on dermal fillers & acne scarring

Fillers & collagen stimulating injectables play a crucial role in managing acne scarring. Dermal fillers such as Juvederm, Restylane & other HA based fillers act in three ways to reduce acne scarring. Firstly they provide volumetric correction of high volume atrophic scars that frequently lie on the cheeks, temples & around the mouth & jawline. The job of fillers in this context is to augment the fat layer of your skin. Lasers & other treatments do not reach or stimulate this area, they are used to treat the upper dermal layer of skin. 

Dermal fillers also address age related volume depletion- especially important for the mature patient. In this age group, scars often worsen with depletion of collagen, fat & bone. The portfolio of fillers for these tasks include HA fillers, but also collagen stimulating injections such as Radiesse, Sculptra, Profhilo & newer PCL based injectables. 

Dermal fillers such as HA based injections as well as calcium hydroxyapatite fillers (Radiesse) also function as a way to correct genetic defects in patients with a ‘skinny’ profile. In this role, fillers act to support the overlying skin- hence support of scar tissue.

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