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 –
- 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.
- 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.
- 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
Understanding the rate limiting acne scars is super important. This can predict outcomes and decrease downtime, the primarily method of treatment in this case was surgical subcision, devices including RF & laser come in at a very distant second
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🔬Skin Science: Scars occur from the papillary dermis, extending to the reticular dermis, often into the SC tissue, & in severe cases to the SMAS layer. Rate limiting factors include skin type, downtime, scar type, and scar location
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🔫RFM: Radiofrequency #microneedling treats deep, with relative sparing of the epidermis. The 3.5 mm depth of needles in the Genius RF allows me to treat rolling scars with minimum collateral damage to the epidermis
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👍🏻👉CO2 lasers are great for shallow scars including boxcar scars. With higher density I can fully ablate the epidermis, down to the mid papillary dermis
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👀👉Erbium Lasers are used for relatively shallow scars as I normally employ this wavelength in the fully ablative setting
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🔪🗡💉Subcision: Is a surgical method of revision, I use everything from 12 G to 30 G instruments, blades & modified cannulas. Size is dependent on the job
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🎬Procedures: Scar directed, everything from topicals, lasers, RFM, #microneedling, #subcision, surgery, #TCA & phenol peels, etc...Another way to look at it is to address the scar based upon histology (depth, abnormal collagen, amount of atrophy). In the context of bespoke revision it is not trying to fit the device to the scar itself, it is the other way around. Devices are only tools to get the job done 👌🏻
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😎Dr Davin Lim
Dermatologist Brisbane🇦🇺
@the.formulated @101.skin
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#acnescardoctor #dermatologist #scarrevision #acnescartreatment #scars #davinlim #acnescarring #nomorescars #scareraser #fraxel #lutronic #laseMDUltra #nomorescars #confidence #acnetreatment #brisbanedermatologist #cosmeticdermatologist #laserdermatologist #fractionallaser #laserresufacing #RFM #drdavinlim
This statement is based in the context of objectively severe acne scars. However it can be argued that mild scarring with disproportional subjective impact can be classed as #bodydysmorphic, thus a medical problem. .
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❎Why the rant: #Acne is classed as a #skindisease, however a minority will have significant scarring. Hence the sequelae of a ‘disease’ is medical. Cosmetic treatments are performed to improve or enhance #aesthetics or age related changes. Botox for wrinkles, that’s cosmetic. #juvederm or #restylane for bigger lips, that's 100% cosmetic. Treating scars from burns & trauma, that’s medical. The aim is to normalise facial texture & contours with medical procedures. The same applies to #acnescars. (Ever seen a Grupon Voucher to treat scars by a Specialist?😉)
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▶️Rant is this: I can understand why pts. visit spas & aesthetic centers, as procedures (whether effective or not) provides hope & emotional well being. Access, both financially & the wait list to see #dermatologists & #plasticsurgeons may hinder a visit to a specialist. Far easier to click on a Google Ad
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⏭Duty of care should be practiced by all clinicians from therapists, nurses, doctors & specialists. If providing effective treatments for patients is beyond your level of expertise, refer on. That’s good medicine
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🌏Acne Scar Treatments: In the context of severe scars, procedures are directed AT THE SCAR TYPE. It’s never about the device! #icepickscars = #TCA /Phenol, rolling scars = subcision/#microneedlingRF, shallow boxcar scars = laser resurfacing, #atrophicscars= fillers/fat/dermal grafts. etc...Most patients will have a collection of scar types, hence different techniques. As with medical conditions, the expected PROGNOSIS & expected outcomes should be addressed prior to treatments. .
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😡This rant brought to you by a patient I just saw who had a dozen microneedling sessions at a local spa for ice-pick scarring. If the scar doesn’t go after the fourth treatment, it sure as hell will be there after 7 more.
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Dr Davin Lim @cliniccutis😎
BrisVegas, AU🇦🇺
#scarrevision #acneorg #dermatology #brisbanedermatologist #skincare #healthyskin #microneedling #microdermabrasion
Acne scars in ethinic skin type🙋🏾, before the days of #microneedlingRF.
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🔬Clinical features: Early scars (less than 4 months old), you can see the redness in the base of #boxcarscars. The literature describes ‘box car scars’ as scars with sharp edges however in reality there are many variations including shallow, deep, broad, narrow, linear, intermediate, fibrotic, etc...Treatments for fibrotic scars will be different compared to say, narrow-linear scars. With atrophy there is usually an element of tethering, hence the need for subcision.
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💡Treatment: Photo is nearly a decade old. Old fashioned #TCACROSS to deep scars, #fractionalco2 with #erbiumlaser in the one procedure. Old fashioned point #subcision windscreen wiper style. Now a days I would perform TCA Paint or spot #phenolpaint, together with 360 degree CO2 fractional and possibly RF microneedling. Definitely multi-level 2-3 entry cannula subcision- far more effective and safer than needles/Nokor. Still room for improvement in the after picture- ideally superficial #dermalfiller 💉to the remaining atrophic scars.
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📚Discussion: Many ways/methods to treat scars, namely many doors to the same destination. Specialist will adapt their method over time, based upon the scientific literature and skill sets they develop. What we do this year may not be the ideal choice in years to come. Our work should be constantly evolving. 😎Dr Davin S. Lim, @cliniccutis
Brisbane, Australia🇦🇺
#acnescars #nomorescars #dermatology
GOOD BYE #ACNESCARS👇🏻
👨🏻⚕️ Prodecure: Erbium, CO2 laser and subcision
👩🏻✈️ Back to work: 9 days
💆🏼♀️ Anaesthetic: Sedation and blocks
📈 Duration of results: infinite. Scars do not return after laser !!
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E: admin@cutis.com.au
PH: (07) 3088 6985
Summary of treatment 👇🏼
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✍️ Procedure: Subcision & filler
🔢 No. Of sessions: 2 x 30 mins
💆🏼♀️ Anaesthetic: Lidocaine in filler (Juvederm)
💼 Back to work: Immediately
📨 admin@cutis.com.au
📞 PH: (07) 3088 6985
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 type | Action | Longevity | Types |
| Dermal fillers | Replaces volume | Up to 4 years | Restylane, Juvederm |
| Collagen stimulating injectable | TIghtens & stimulates collagen | Variable. Relies on your immune system for action | Hyper 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
This new injectable has the most robust studies for the treatment of atrophic acne scars with two good papers in the past 2 years. It has recently been TGA approved for cosmetic treatment of the face, with off label indications for the neck, hands, chest &....acne scars. It is now available in Australia
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👉How is it different from dermal filler? Unlike HA fillers that improve volume, this injectable stimulates your cells to produce collagen, fat & also new skin cells to improve skin quality. This in turn improves the reflectance of light which can add to the perceived improvement of acne scars, without volumetric changes. It can also stimulate ASCs or adipose stem cells to further improve outcomes
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🤔What types of scars can be treated? Atrophic rolling acne scars with low to medium amounts of tethering do best. If you have lots of tethered scars, subcision should be performed prior or during treatment with this product
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💉How many treatments are required? 2-3 sessions
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👉Can I still have it done if I have active acne? Yes, but you will get much better responses if your acne is in absolute remission
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💵How much does it cost? It is super affordable at $850 AUD for the entire course of treatment; 2-3 sessions. Each session is spaced out by 3-5 weeks. The price gets you 2 mls of highly concentrated hyaluronic acid. For mild to moderate acne scar surface area only one syringe is required (0.7 to 1.0 ml per session).
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⏱Downtime? About 2-3 hours of redness. In some cases bruising may last 3-6 days, depending on the location of scars. Treatment time? 10 min
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🔫Does it replace all other treatments? No, but it offers good correction of atrophic scars with minimal cost & downtime, the usual methods apply depending on the signature of your scars
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📩How to book? Send me a DM for me to triage to my nurses & colleagues. This procedure is primarily performed by our skilled nurses, I do get involved in complex surgical cases or deep resurfacing for objectively severe scars
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
#drdavinlim #davinlim #acnescars #acnescartreatment #acnescartips #profhilo #dermalfiller #collagen #scarremoval #brisbanedermatologist
@profhilo_aunz
The biggest traction you can get with acne scar revision is to have your acne in remission whilst undergoing scar treatments
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🔬Skin Science: with reduced background inflammation, dermal remodeling is most efficient
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👉This patient: underwent scar treatments over the years, including RF microneedling, ablative lasers & surgical subcision
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📸Photos: different lighting. It’s really hard to get the same lighting as the patient, camera & lighting all occupy a XYZ axis in real time. It’s hard to replicate all 3 variables in the same axis. Part of the solution is to measure volumetric changes, but then surface changes will require other forms of photography
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😎 Davin Lim
Dermatologist
Brisbane🇦🇺
@drdavinlim
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#acne #acnescars #scarrevision #acnescartreatment #acnescarlaser #microneedling #scarcure #scars #acnescartips #drdavinlim #dermatologistbrisbane
Katie @katies_skin has been super brave to inform us about the potential side effects of acne scar revision. In her case, nodules or fibroplasia following extensive subcision. This before & after shows the outcome of scar revision in the context of pigment. The pigment changes are NOT a side effect, it is expected outcomes after aggressive erbium laser resurfacing
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🔫Laser Depth: Whether I go super deep or superficial does not take significantly more time. My erbrium is ‘clocked’ to 220-230 microns per pass, hence going super deep only takes me an extra 5 minutes of op time. What is significant however is the healing time & PIH for the patients😩😩
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👊🏻Concept: It is a risk benefit ratio. Dermatologists & plastic surgeons would like to complete the job effectively and efficiently. We have to weigh up the risks vs the benefits of each case & treat appropriately. We take all the necessary precautions to reduce the chances of side effects, however if they do occur, in most cases they can be rectified💯
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👉This case of PIH will resolve over the next few months with a combination of pico & vascular lasers. Be guided by your dermatologist or PS with your revision journey💯
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😎Dr Davin Lim
Dermatologist
Brisbane🇦🇺
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#scartreatments #acnescar #acnescartips #acnescarrevision #scarremedy #scarring #cureacnescars #acne #drdavinlim #davinlim #dermatologistbrisbane #dermatology #brisbanedermatology
Rolling, highly atrophic acne scars in skin type 4, Asian. Zero acne activity which makes my job infinitely easier💯
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👍🏻Treatment: multi-laser sharp subcision, fractional CO2 to remodel scars, followed by super -deep fully ablative erbium laser
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😩Post inflammatory changes: present for nearly 4 months. I have initiated pico & vascular lasers to normalize skin texture
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👊🏻Concept: I can treat aggressively, but skin color changes WILL occur in darker skin types, or I can be super gentle & not give color changes. If you choose the later, the job may take 3-6 times longer
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😎Dr Davin Lim
Dermatologist
Brisbane🇦🇺
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#scartreatments #acnescar #acnescartips #acnescarrevision #scarremedy #scarring #cureacnescars #acnescarskincare
Some gnarly scars here
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🔍Types: Ice pick, linear, rolling, tethered, polymorphic scars with background genetic low facial volume (some element of lipoatrophy secondary to scars), compounded with a negative vector (reduced maxillary projection). The later two factors compounds the problem
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👍🏻Today: tumessent hydrodissection, punch excision, sharp two level subcision- dissection, super deep CO2 fractional (given dermal thickness measure with dissection instrument), higher density superficial CO2 given pits/pores & superficial scars
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👉Next appt: probable fat transfer given the high volume loss (will probably need 2 sessions), option to augment with dilute Ca Oh next few months. Fat-filler will support the scars, & overlying skin, address volumetric loss (genetic), improve aesthetics & negative vector👍🏻
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#laserdermatology #acnescar #scars #subcision #scarrevision #acnescarrevision #acnescartreatment #icepickscars #drdavinlim #dermatoloigstbrisbane #skinscience
Ever wondered how ice pick scars form?
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🔬Skin Science: Ice picks are part of the classic description of acne scars including boxcar, rolling, (atrophic) & hypertrophic. In reality there are many more scar types including saucer, bridging, hypopigmented, & commonly, polymorphic undifferentiated scars
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👍🏻Think histology to effectively revise scars: icepicks are a paradox. They are ‘superficial but deep.’ Going under the scar itself with subcision often releases the base of ice picks, hence in some, pathology is in the subcutaneous layers
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👌🏻Solutions: Contrary to the literature, ice picks are relatively easy to treat. Accurate TCA or phenol placement will improve. It’s a matter of treatment sessions & proper selection.
Faster options include punches. 🔫Small diameter lasers can hit the side walls, causing remodeling in shallower icepicks
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🚬🔥Smoking & scars: anecdotally this scar type is more common in smokers. I suspect changes in the microcirculation may predispose genetically susceptible individuals to this scar morphology
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🎬Action: book an appointment with Alison or Katie @cliniccutis They can assess your scar types & come up with a treatment plan. Alternatively I am more than happy to be involved in more challenging cases
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#dermatology #icepickscars #acnescars #drdavinlim #davinlim #scars #acnescartreatment #nomorescars #pockscars #laserdermatology #dermatologist
#skinclinic #brisbanedermatologist
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
Not fair is it? Females have upper lip lines, men do not. How so?
Here are the reasons-
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1️⃣The hair follicle is the key to this mystery. Yup this terminal hair or pilosebaceous unit plays a key role in support for the dermis (& hypodermis). It acts as pylons to support lax skin. What would be super interesting is a split face study over a decade with laser hair removal on one side of the lip and no treatment on the other. I wonder hair removal contributes to premature wrinkles
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2️⃣Dermal thickness. Males have thicker skin than females. More collagen, elastin & ground substance
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3️⃣A mo, in theory, provides shade. UVR is the number one culprit for collagen breakdown
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4️⃣Shaving is a form of dermaplaning. Dermaplaning stimulates collagen production. Most men dermaplane several times a week since adolescence. If they don’t, even better, shade from the sun with a dense beard
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5️⃣Dynamic wrinkles are due to muscle movement. 🗣📢One paper suggests that women speak on average about 20,000 words per day. Men? A whisper over 7,000. Don’t shoot the messenger. Yes, there are other studies that refute this claim😜😜
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👉Practical solutions: Peels and or lasers can help. Microbotox for early dynamic lines, small aliquots of filler, or ferning to the upper lip with HAs can give a good result. Though reported in the literature, subcision by itself does very little. Threads plus heating post (RF) can help in some cases. I do think that combination treatments gives the best outcomes
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
#upperliplines #liplines #smokerslines #skinrejuvenation
#lipfiller #liprejuvenation #lips
Multimodality treatment to address atrophic scars in this patient, skin type 3+
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🔬Skin science: Treat scars based upon morphology & merits. The primary scar types are rolling & atrophic. These were treated with subcision. Given the marked tethering I swapped instruments from my usual dovetails to Taylor Liberator (Mark’s device). Adjunctive TCA & CO2 laser resurfacing
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👍🏻Fillers: are an essential part of scar revision, especially in the more mature patient. Fillers can-
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1️⃣Support the overlying scars
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2️⃣Replace collagen & fat loss
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3️⃣Stimulate collagen production
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4️⃣Replace age related volume loss
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5️⃣Provide countertraction by volumetric displacement
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👉My choice in this patient was Ca Oh apatite in a hyper-diluted solution. The after picture was taken 6 months post final revision
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#acnescars #scarrevision #scareraser needs to learn to fill #drdavinlim #davinlim #dermatologistbrisbane #acnescartreatment #acnescartips #icepickscars #boxcarscars #rollingscars #subcision #taylorliberator
🙏🏼Thanks to my colleague dermatologist, @drclarepatterson for referring this patient to me for scar revision, with her help, we got this result. GIve her a follow for skincare tips
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👉This patient: Asian skin type 4. Ethnics scar easier, more prone to PIH. Every cloud has a silver lining. Flipside is that the fibroblast response is more brisk. This mean more efficient scar remodelling & neocollagenesis
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👉Acne: Management by @drclarepatterson 💯
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👉Scar revision: Sharp subcision, 2 levels. CO2 fractional, TCA paint & punches
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👍🏻Today: moped up a few remaining ice picks, next step is polishing with the pico, will keep you posted with the final results
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#dermatology #brisbanedermatologist #drdavinlim #davinlim #acnescars #scarrevision #co2laser #fractionallaser #acnetreatment #acneskincaretips #acnescartips
This job took awhile as acne was largely uncontrolled. The biggest leap was when she controlled her acne 5 months ago
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🔬Skin Science: This is one of the more challenging jobs, skin type bordering on 5. Deep polymorphic scars, atrophic rolling, box car as well as focal areas of fibrosis (central cheeks, hypopigmented atrophic)
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👊Methods: Subcision, high power but low density CO2 plus RF microneedling, TCA paint to well demarcated scars. Pico recently for PIH & textural remodelling
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👨🏾🦲PIH is universal if surface treatments are conducted. This also applies to high powered RF microneedling (Genius RF, Infini RF, Morpheus 8 RF). Pico lasers are useful for adjunctive treatment, along with the usual tyrosinase inhibitors & SPF as primary methods to prevent/reduce/treat
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🏡Take home: control acne, during or prior to scar revision. This means ABSOLUTE control, you will go further, faster. Neocollagenesis ain’t efficient if your immune system is fighting off c.acnes next to your scars
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#acnescars #dermatologist #scarrevision #fractionallaser #dermalscience #dermatology #scartreatment #acnescartreatment
This is lupus profundus. Lupus is latin for WOLF, profundus is DEEP. Patient was referred by my colleagues in Melbourne
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🔬Skin science: Inflammation from lupus can affect most organs. The skin is frequently involved. In this case it is fat layer
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👉The solution: make sure lupus is in remission prior to any transfer. I did just over 40 ml of fat transfer into the area. Fat is ideal for large volume defects. I do prefer filler over fat for smaller volumes as it gives finesse & predictability. Extensive subcision prior to transfer. Got to watch closely as trauma can lead to Koebner & re-activation of lupus. Correction is not 100%, as he will require a second procedure
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👉Background scars: from acne. Believe it or not, this type of acne scarring, namely deep boxcar, icepick & picks are not that difficult to treat. Using focal peels with sensible fractional lasers my nursing team should be able to improve 80-90% of this pattern of scarring within 5-7 months. For lupus patients, we do need to keep a close eye on their recovery, as trauma can reactivate their condition. For more invasive treatments, I cover with a tapering dose of prednisone for 14+ days.
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
#scars #lupus #acnescars #dermatologist
Many treatments for acne scars
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🔬Skin science: Modality of choice depends on skin type, downtime, scar type. Everything from lasers, RF, RFM, #microneedling, #TCA CROSS, paint, focal #chemicalpeels, excision, subcision, & dermal fillers
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👉💉Fillers: Essential skill set to treat scars. In this context I used HA fillers in the lateral cheeks. Simple points 1ml per side. This causes traction below, in turn distending scars. Obviously can only do this if the patient will benefit from this technique aesthetically
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👍🏻Injectors: Nurses & physicians, you are in a good position to make a difference, fillers are the game changer for the revision of atrophic scars. Filling is an invaluable skill set, think beyond the scars themselves
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😎Dr Davin Lim
@drdavinlim
Brisbane🇦🇺
#dermatologist #dermalfillers #acnescars #scarrevision #scartreatments #acnescar #juvederm #restylane #sculptra #radiesse #drdavinlim #davinlim #brisbanedermatologist #dermed #cosmeticclinicbrisbane #cliniccutis
I expected to improve her scars, but not this much in only one treatment. The after photo was taken at week 6. There is no swelling. At different angles & vectors you can still see some residual scarring, especially anteriorly
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🔬Skin Science: Given her skin type I could laser really deep. I used fully ablative erbium and finished with 15% fractional CO2 laser. The redness at week 6 is expected. With super aggressive treatments, erythema can persist for 6 months or longer. I intervened with vascular laser today
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👉This patient: Had subcision & ablative laser in the same session. Heal time for epidermis to re-epithelialize was 8 days, as expected
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📅Future: May need some gentle fractional CO2 (will get my nurses to finish off) in three months time. She will continue to improve over the next few months. Redness will fade with the short pulse delivery of 595 pulse dye laser (3 ms PD, given clinical findings & skin type)
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👊Biology of scars: Everyone lies on a bell curve. This patient lies to the right- remodels scars efficiently. The lack of acne also helps potentiate her immune system to remodel collagen. This is one of the biggest rate limiting factors that can be controlled
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😎Dr Davin Lim
Dermatologist
Brisbane🇦🇺
@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 #acnescarcure
Sometimes you have to attribute the improvement based upon the individual’s ability to remodel collagen over the ability of the operator. This case is an example. I expected this sort of improvement with 2 or 3 sessions, not one. Credit to the patient’s immune system💯🙏🏼
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🔬Skin Science: Subcision was the treatment of choice. 2 levels, 14 G lower, 22 G upper. Adjunctive CO2 fractional (the easy bit). No fillers were used (I expected it required CaOH or PLLA). Ethnic skin types are more prone to scarring, flipside is that collagen regeneration is more vigorous in darker skin types
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👉Atrophic scars: if your immune system can not regenerate collagen, filler or fat (or limited dermal grafting) are sensible choices
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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 #acnescarsnomore #acnescarsbegone #scareraser is a wank #acnescarlaser #davinlim #drdavinim #dermatologistbrisbane #dermalscience #co2laser #laserresufacing
Subcision combined with fully ablative laser resurfacing was used in this patient
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🔬Skin Science: Subcision is a very useful procedure. First reported by 2 dermatologists (the Orentriech brothers) in NY in 1995. This procedure has evolved to use instrumentation of many different calibres. I use a lot of tumescent (50 to 80 mls) for each cheek. Hydrodissection helps with ease as well as safety. Erbium fully ablative laser was employed, followed by fractional CO2. Healing for this case? About 7-9 days. Red for possibly 6-12 weeks given the depth of ablation. I had to call the ball at this depth as the deepest superficial scars were just out of reach for deeper ablation
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⏳Future: Most likely will require 1-3 more procedures, depending on the rate of neocollagenesis & remodelling
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😎Dr Davin Lim
Brisbane Dermatologist🇦🇺
@drdavinlim @cliniccutis @the.formulated
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#subcision #nokor #rollingscars #acnescars #acnescarrevision #acnescartreatment #acnescarremoval #acnescarcure #brisbanedermatologist #acnescarsnomore #acnescarsbegone #scareraser #acnescarlaser #davinlim #drdavinim #dermatologistbrisbane #dermalscience #co2laser #laserresufacing
Temple scars can be challenging. The fast way to treat is subcision & dermal fillers. Big gains can be made in a short period of time
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👍🏻Subcision is the treatment modality for rolling & often tethered acne scars. Deep scars including rolling acne scars will usually have elements of attachments to the deep dermis & fat layer.The extent can be guessed on examination, but only confirmed intra-operatively
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🔬Science: Atrophy (holes-volume deficits) can be dermal, sub-dermal (fat) or both. In the context of fat atrophy, energy devices do not reliably correct volume loss. They can remodel & replace dermal collagen/matrix loss. If you have significant atrophy your choices are limited to - dermal fillers,or fat transfer. That is it. Mild to moderate rolling scars can be markedly improved without dermal fillers, provided subcision is performed correctly. Dermatologists or plastic surgeons only manipulate scar tissue, #collagen synthesis is up to the patient’s innate immune responses. Exception is when we excise tissue/scars
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🗡🍴Instrumentation for subcision: I do not limit to one size, I use everything from 12 G to 30 G from tunescent to hydrodissection. From intradermal hydrodissection to deep fat dissection. Correct tool for each job. To limit a procedure to ONE instrument is like saying a sledgehammer is the only tool for a carpenter 🔨
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🔫Devices: are all secondary in this pattern of scarring. #Co2Laser. RF #microneedling etc..
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😎Dr Davin Lim, Dermatologist
Brisbane,🇦🇺
@drdavinlim @cliniccutis
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#nomorescars #dermatologistbrisbane #scarrevision #brisbanedermatologist #acnescartreatments #brisbaneskin #brisbanedermatologist #rollingscars #skinscience
#scareraser #drdavinlim #davinlim
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
Field subcision 2 layers, erbium fully ablative & fractional CO2 laser resurfacing.This is one of the many combinations I employ for the treatment of acne scars. The algorithm based upon skin type, scar type & downtime
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🔬Skin Science: I use everything from 12 G modified canulas to 30 G needles & ophthalmic corneal blades to cut scars. Choose the right instrument for the job. Release can be seen immediately. In this patient I chased the scars with erbium & CO2, healing time 7 days, probably PIH for 3-6 weeks. Pico can sort that out if needed🔫
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🤔👍🏻Who to see? BE guided by your #dermatologist or plastic surgeon. For superficial scars that do not require surgery, book a consult with my nurses @cliniccutis. Ask for Katie, Alison or Marisa as they have extensive experience & training in lasers & deep peels for treating #boxcarscars, ice pick & shallow atrophic scars. If you require surgical procedures, or volumetric correction, I am happy to be involved
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😎Dr Davin Lim
Dermatologist
Brisbane 🇦🇺
@drdavinlim
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#scars #acnescars #scartreatments #nomorescars #boxcarscars #subcision #eco2 #scitonlaser #acnescartreatment #scarsurgery #scareraser #icepickscars #drdavinlim #dermatologist #dermatoloigstbrisbane #skinbrisbane #subcision #cosmeticdoctorbrisbane #brisbanedermatologist
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.
