This section of the forum is dedicated to discussions on managing, treating, and correcting acne scarring. (Of note, Dr. Lam is focused principally on acne scarring rather than on managing the ongoing condition of acne, which a dermatologist would be better equipped to address.)
I would like to fix the scars on my face caused by teenage acne. I have been looking into CO2 surgery but I can't seem to find the time to be in â€œhidingâ€ for 10-14 days. I know Pixel is being offered as an alternative to the laser surgery and the downtime is significantly less. Do you think Pixel will give me the same results as CO2? I know 100% results are not realistic with either but I would like to know what would give me the best results regardless of down time. Thank you!
Thanks for the question. Here are my feelings about CO2 laser first. I think that CO2 laser can improve acne scars but oftentimes without much benefit but with significiant downtime and risk. Patients can lose skin color over time and continue to do so for many years. Also, there is redness that lasts 3 months plus. Listen to one of my acne scarring testimonials and you can hear about a patient who looked like a burn victim with NO IMPROVEMENT until I fixed her permanently with micro silicone droplets. Please listen to her testimonial also about how she continued to lose skin color and can't even go in the sun anymore. That being said, it is a MASSIVE recovery for Asians and Hispanics and absolutely unsafe in darker skin types. When I did CO2 laser I would almost never do it in an Asian because the recoveries exceed a year if not more. The two major problems are hyperpigmentation (turning darker) and redness that can linger for a year or more. My colleague uses the CO2 laser in San Francisco on Asians only in very select patients because of the risk profile and really the long recovery times and specializes in Asian skin types as she is Asian herself. Finally, the risk of skin color loss is much more profound in Asians as well. Here is the crux of the issue, if you are treating a light skinned Asian like a Caucasian you will encounter serious problems in the recovery phase because skin color is not a predictor, race is! Okay, enough about darker skin patients.
As far as Pixel is concerned, I think the jury is still out. I have been trying it on patients with mixed success. I officially would not endorse the Pixel as a primary treatment for acne scarring. I don't think it will deliver the results sufficiently. As an adjunct perhaps but not as a primary treatment method. Please review my new video I posted over the weekend under virtual consultations called "acne scarring treatments" for a more detailed review of my strategies for acne treatments, none of which are perfect but I get pretty good results. Hope that helps.
As I discussed in detail on my new virtual consultation for acne scarring, I use two principal methods to get someone improved with acne scarring that is quite the opposite of what most doctors do (I elevate abnormal skin rather than depress surrounding normal skin). For the tiny little holes, I use the CROSS 100% TCA treatments and for the rolling conform deformities and larger pits, I prefer microdroplets of liquid silicone to correct the acne scarring.
As far as the CROSS Acne Scar treatments are concerned, most patients typically require about 2 to 5 treatments to get them there. Unfortunately, the CROSS treatment works by creating microscars to elevate the tiny depressions that require about 90 days AFTER each treatment to see the difference. Also, unfortunately, to build enough collagen to see the difference you need to have at least 2 treatments or 3 treatments if the pits are more severe. That means you may not see any difference for 3 to 4 months, which is a long waiting game. Also, there is more of a recovery time involved in the sense that especially with darker skin types, the area can hyperpigment (turn a bit darker) for even up to several months. Fortunately, the treatment areas are microscopic so usually if it does turn darker the treated areas are very small like less than 1/2 a mm in size. Also with darker Hispanic and Asian skin types, you can have some lingering redness. Hopefully, these are smaller prices to pay for long-term success. One more thing, oftentimes to see the best result, you need to wait an entire year to see the desired change. The cost per treatment is $500. You usually need about 3 to 4 week interval between treatment sessions.
Silicone has a lot of controversy because most people have seen the bad work done with it through bad technique. In order to safely perform silicone you need a lot of experience with it. That means little microdroplets performed sequentially also over several months. Btw, the CROSS treatments and silicone can be performed on the same day if you are from out of town if performed on different types of scarring, i.e., different areas of the face. Unlike CROSS, you will have to wait at least a full 4 weeks before the second treatment only because the way to do silicone safely is you must permit each microdroplet to be securely walled off by collagen so that the next treatment won't clump with the previous one. Also unlike CROSS, many people see a result immediately after the first treamtent unless you have very deep pitting then you may need a second round to see the improvement. Most people need between 1 to 5 treatments to get them there at a cost of $700 per treatment. The recovery is very minimal unless you have a little bruising which could linger for a week or more. If you are in town, I can laser any bruising but most people don't bruise very much or at all. Also, like CROSS, the needle injections with silicone actually promotes ongoing collagen growth which can make your result even better months to a year later after you have finished your last session.
hope all of that helps a bit.
Samuel M. Lam, M.D., F.A.C.S.
Diplomate, American Board of Facial Plastic & Reconstructive Surgery
Diplomate, American Board of Otolaryngology Head & Neck Surgery
Diplomate, American Board of Hair Restoration Surgery
When percentages of improvement are discussed on these procedures, I get a little confused. For example, does 30% improvement mean that the depression is brought up by about 30% or is it that 30% of the all the scars are virtually gone?
I am always careful when I provide percentages since they really don't mean very much and can be deceiving. For example, when I say the result could be 30 to 80% better, most people forget the number 30% and focus on the 80%, as I know human psychology well. Also, that range or any range is not very helpful. When I say 30% I mean 30% better not 30% of acne scars are left, if that makes sense. Basically, what I want to convey is that I do get very good results treating acne scars perhaps better than a lot of people treating acne scars simply because my method is exactly the opposite of what almost every physician does, i.e., I bring the abnormal skin up to the level of the surrounding normal skin using either silicone or acid treatments whereas most of my colleagues take the normal skin and try to sand it down to the level of the abnormal skin. All things considered what I am trying to convey with my percentages is that I do my very best but I would have you expect a conservative improvement. I hope this answers helps.
After meeting with you last week, it seemed as if the CROSS would be the best option for my type of acne scars. I have done a lot of research and read other blogs concerning the procedure and everything I have seen looks good. There are a couple of concerns that I do still have. The main one with this procedure is downtime. It is going to be really hard for me to be unpresentable for a period of 5-7 days each month for 3 months in a row. I think I can make it work with the holidays around the corner. What days do you typically schedule patients for this procedure. Also after the procedure, at what point is it okay to on put on makeup? Also do you know if the scars are easily covered with makeup? Because I am Asian, I am assuming my spots will turn brown. Thank you for your time!
Since this procedure is office based, I can do this procedure any day of the week preferably in the afternoon (since I do surgery in the morning). To limit weekday downtime, you may want to do this on the close of a Friday afternoon. Be sure to purchase, Cetaphil cleanser (without sunscreen) and Vaseline (clean jar not one used on your toes) before you come in. That way you are ready to go.
Generally, you can wear makeup after 3 to 5 days. The first time I do it, I have you come back in for me to check it 2 times or so that first week to show you the healing phases so in the future you can make up your own decision regarding when you can put makeup on. Yes, you can turn these brown and perhaps it is not entirely coverable with makeup. I just want to be upfront with you. I think you should be okay though.
Dr. Lam, thank you for this blog. I bet it is helping thousands out there to get more informed. I have about a dozen acne scars on each temple of my face. They are a combination of rolling scars and "box car" types. The depressed areas are about 1/16th to 1/8th of an inch in width, and they also happen to be quite close together, in clusters one might say. What is your overall recommendation as I'd like to find the best solution to significantly reduce these scars. What are your thoughts on: N-Lite ,Smoothbeam, Fraxel, CoolTouch, Thermage, and Rhytec Portrait? Also, will subcision alone likely be enough? I am male, 32, mixed asian/mediterranean, oily skin, tan complexion. Once again, thank you so very much -S
I hope in fact that I am disseminating accurate information to the best of my ability. As far as your condition is concerned, I obviously have experience within the spheres of what I do. However, I don't have significant experience with the full gamut of lasers/radio-frequency/light devices you mentioned. At least, let me comment on the ones that I know about. As far as N-Lite, that machine is really now off the market. It has proven to be pretty much useless, and for acne scars, forget about it. The Thermage theoretically could be beneficial but I would be very cautious with that machine. I think that there can be a high risk of problems depending on the protocol used or no benefit whatsoever. As far as the fraxel or fractionated technology, I have seen mixed benefit, sometimes some improvement sometimes none. I own a version of one but do not sell it for acne scarring. I own the Rhytec Portrait plasma machine too but would be highly cautious to sell it as an acne scar treatment. I have seen limited improvement with this technology. It is great for bad texture and tone but for acne scars I would not sell it as a primary method of treatment. As far as Smoothbeam and Cooltouch, I don't have any experience or even anecdotal remarks to make so sorry about that.
Just be careful in believing the hype and also be careful when looking at acne scarring before and afters as many companies really cheat with their lighting. Even a slight change in lighting can alter the results to make them look better than they really are. I personally take offense at that. I only take my photographs in the same room, same distance, same camera, same settings, with no ambient light. I even control for makeup when photographing women. This is so important when you are dealing with something like acne scarring.
As you probably see in my blog responses, I get very good results for acne scarring but they are not "home runs". Very diifficult to achieve "perfect" results. In your case, I most likely would recommend silicone treatments plus or minus the CROSS acid treatments at the end to touch-up any remaining smaller box car holes. As far as subcision, that is okay but really not a great thing in the temple area in general. Subcision alone does very little. I only use it to prepare the area for silicone treatments. I hope my answer helps a bit. As you know, we all have biases. My biases are based on my experience with my methods as well as failed methods like dermabrasion and CO2 laser in the past.