A newer technique called “chemical reconstruction of skin scars” (CROSS) has risen in popularity as an effective treatment for atrophic scars. In this method, a high concentration of chemical or acid is focally applied to the base of each scar, rather than a lower concentration applied across the entire face. The meticulous application of acid causes local inflammation in scarred tissue, leading to the destruction of scar tissue and the formation of new collagen fibers. The scar tissue lifts back up towards the level of your normal healthy skin. More importantly, we only target the base of scar tissue, leaving healthy tissue unaffected by the strong acid.

Our CROSS treatment uses a specific formula specially mixed in our office. The main component, phenol, is a chemical compound that is highly effective at remodeling scar tissue. Phenol is a safer and effective alternative to other chemicals used in CROSS, such as TCA, which may cause widening or deepening of scars. Phenol has been shown in several outside studies to reliably penetrate deeper into the skin compared to other chemicals. We have further evaluated the effectiveness and safety after refining the application methods. As a result, our phenol mixture is able to travel deeper into the dermal layers and break down tougher scars. 

Typical chemical treatments used for atrophic and macular scars include the application of Jessner’s peel, trichloroacetic acid (TCA), glycolic acid, salicylic acid, and enzyme peels. These peels are generally applied across your entire face at a low concentration to cause inflammation. This controlled inflammatory process weakens scar tissue that tethers the superficial layer of skin to the subdermal layers.

The overall recovery process is painless. However, you can expect reddening of the skin and scab formation on top of your scars. Over the next 1-2 weeks, these scabs will fall off naturally and reddening will subside. In addition, try to avoid wetting the affected areas for the next 48 hours to allow the phenol to properly function.

Chemical peels may increase your skin’s sensitivity to sunlight. As a result, part of the recovery process for CROSS treatment involves staying indoors and avoiding as much sunlight as possible for the next two weeks. If you must stay outside for prolonged periods of time, we recommend that patients apply sunscreen to their face and wear a hat.

Our CROSS treatment uses a specific formula specially mixed in our office. The main component, phenol, is a chemical compound that is highly effective at remodeling scar tissue. Phenol is a safer and effective alternative to other chemicals used in CROSS, such as TCA, which may cause widening or deepening of scars. Phenol has been shown in several outside studies to reliably penetrate deeper into the skin compared to other chemicals. We have further evaluated the effectiveness and safety after refining the application methods. As a result, our phenol mixture is able to travel deeper into the dermal layers and break down tougher scars. 

Although the recovery process takes only 1-2 weeks, reduced visibility of your scars can take up to several months to become noticeable. As you heal, we will assess the need for other treatments such as subcision and Sculptra, which work in conjunction with CROSS treatment to achieve your desired results.

Rare complications of phenol include temporary cardiac arrhythmias, hyper- and hypopigmentation of the skin, as well as deepening of the scars. However, careful and minimal application of phenol minimizes the risks. During your consultation, we will go over the potential risks and benefits, as well as the actions we take to minimize all potential complications.

Collagen stimulators are injectables that contain the chemical “poly-L-lactic acid”, a compound that promotes collagen production. This is an effective treatment for skin that has gradually lost collagen over time, which results in wrinkling, sagging, and thinning of the skin. This boost in collagen production restores the volume and elasticity in our skin, giving skin its youthful and full appearance. Because many types of scars are characterized by the local depletion of collagen around the scarred tissue, collagen stimulators are highly effective.

Collagen is the most abundant protein in your body and is the substance that holds the body together. For the skin, collagen provides a scaffold or framework for healthy skin to rest on, giving the appearance of a smooth surface. However, inflammation associated with active acne can result in dermal collagen and fat loss. As the body resolves active breakouts, collagen is no longer present to support the skin, which contributes to the appearance of atrophic or pitted scars.

Once scars are lifted with CROSS and subcision, collagen stimulators can be injected. By promoting the body’s own collagen production, the collagen that once supported the pitted areas are replenished. This leads to the maintenance of the lifted areas and prevents scars from lowering again.

The procedure itself is painless. The collagen stimulator comes in a vial that we will premix with an anesthetic to make the procedure comfortable for the patient. The patient will also be given ice before, during, and after the procedure to further reduce any pain or excessive bleeding.

Upon treatment, your body requires several months to fully boost its collagen production and produce noticeable results. This is because our fibroblasts, our collagen-producing cells, need time to develop a physiological memory to continually produce more collagen. Moreover, patients will find that the additional natural collagen has longer lasting effects – up to 5 years – than synthetic filler injections that have immediate effects on appearance but only last 2 years. To maximize results, patients usually require several rounds of collagen stimulator injections.

Immediately following treatment, patients may experience bruising, soreness, and swelling where the collagen stimulator was injected. This typically resolves within a week of treatment. In the meantime, facial massages, icing, and avoiding UV light from the sun are essential for recovery. During your consultation and procedure, we will inform you of detailed post care instructions that will help you achieve your desired results.

The cost of treatment depends on the severity of the patient’s scars. Deep scars that cover multiple areas likely require more vials and rounds of collagen stimulators for patients to observe substantial results. 

Subcision is a process in which a hypodermic needle is inserted into the skin to manually break fibrotic strands that tether the scar tissue to the sub-dermal layer. Hypodermic needles of various sizes are used to mechanically break scar tissue residing in the superficial, middle, or deep layers.

Subcision is an outpatient procedure that is usually accomplished within a few hours. A local anesthetic is injected to numb the treatment area. In addition, the patient is given an anti-anxiety medication to make them more comfortable during the procedure. In addition, a special tumescent anesthesia mixture is administered to further numb the area and also prevent excessive bleeding. During this time, a hypodermic needle is inserted into the skin and moved back-and-forth and side-to-side to untether the scar tissue from the underlying basement layer. This allows scarred areas to lift to the level of normal skin. This form of “controlled trauma” also stimulates collagen production, which provides support underneath the scarred areas.

Subcision can be performed in several layers: superficial-layer, mid-layer, and deep-layer. 

• Superficial-layer subcision: the skin is infiltrated with a 25-gauge needle right below the epidermis. 
• Mid-layer subcision: a blunt cannula (usually a 22-gauge cannula slightly larger in diameter than a 25-gauge needle) is used to penetrate deeper into the dermis. 
• Deep-layer subcision, a special metal tool, called the Taylor Liberator, is inserted into the deepest parts of the dermis to separate the toughest scars from the underlying tissue. 

Since mid-layer and deep-layer subcision are more invasive than superficial-layer subcision, an “introducer”-needle is inserted into the skin to create a small opening for the cannula or Taylor Liberator to be inserted. 

To determine how many layers of subcision need to be performed, we have to examine the depth and severity of your scars. Very mild cases will only need superficial-layer subcision, which only requires local anesthetic injections, whereas more severe cases will require superficial and mid-layer subcision or subcision in all three layers. For these patients, a tumescent anesthetic mixture will be administered.

Cannula-based subcision is a more robust and safer alternative to needle-based subcision. In this technique, a 70-mm long 18-gauge cannula is inserted subdermally to break apart the fibrotic tethers. Cannulas present less risk to deep neurovasculature structures due to their blunt tips. Additionally, the length of the cannula enables subcision through a single perforation site as opposed to multiple entry points required of needle-based subcision. Cannula-based subcision can be combined with Taylor Liberator subcision to correct deeper atrophic scars.

Deep-layer subcision typically uses a special surgical tool called the Taylor Liberator. The Taylor Liberator is a long, blunt instrument with notches at the end which facilitate the breaking of fibrous bands that tether the scars down. To perform deep-layer subcision, a small incision is first made near the hairline to insert the Taylor Liberator into the deepest layers of the dermis (the superficial subcutaneous plane). As the tool is moved back and forth, the deepest and robust scars are transected. Deep layer subcision using the Taylor Liberator is a highly effective technique that allows for complete untethering of fibrotic bands and long term results when performed correctly.

Because scars can vary in depth, deep-layer subcision using the Taylor Liberator is generally most appropriate when patients have scars that are tethered to the deeper layers below the skin. Patients with boxcar scars or rolling scars typically benefit the most from deep-layer subcision.

Swelling generally dissipates within the first 24 hours. After 48 hours, the face can be washed normally, and patients can generally return to work with little bruising. Because deep layer subcision with the Taylor Liberator is a more invasive technique, sensory disturbance may be observed. Any disturbances usually completely resolve within three months of the procedure.

The speed of recovery will depend on how many layers of subcision the patient received. Generally, more layers translates to a longer recovery time. Overall, however, during the initial 48 hours after the procedure, it is normal for patients to experience some swelling and soreness in the treatment areas. A stronger painkiller can be prescribed to make recovery more comfortable if OTC medications are insufficient.

Patients should also expect to observe scabbing at the sites where the hypodermic needles or cannulas were inserted. It is important that patients do not apply make-up or get the area wet for 48 hours and do not pick at the scabs as this can hinder the healing process. Additionally, applying lightening cream 72 hours after the procedure and completely avoiding UV exposure for 2-3 weeks are other required precautions enforced to avoid hyperpigmentation. Patients can expect a full recovery within 1-2 weeks.

Although the recovery process takes only 1-2 weeks, reduced visibility of scars will take several months to become fully noticeable as the body continues to heal. In the meantime, other procedures, notably Sculptra, can be performed. This can further enhance results in the months to come.

Subcision is a vital component of our phases. Although patients can already expect reduced scarring from CROSS, chemicals in isolation may not fully untether the scar tissue and instead serve to weaken or partially damage it. On the other hand, using subcision alone may not be sufficient due to strong scar tissue being resistant to manual abrasion. Subcision and CROSS work synergistically to eradicate scar tissue and reduce the appearance of pitted areas.

In very rare cases, infection, ruptured blood vessels, and hyperpigmentation can occur. Infections can be quickly resolved with antibiotics. Bruises caused by damage to blood vessels will usually resolve within a week. Lastly, temporary post inflammatory hyperpigmentation is known to be a risk to people of color. Usually this can be avoided by putting patients on a strict lightening cream regimen before and after the treatment. During your consultation, we will go over the potential risks and benefits, as well as the actions we take to minimize all potential complications.

The cost of subcision is highly dependent on the number of areas and the depth of scar tissue. Deeper layers require more invasive techniques and thus will cost more. If some areas of your face are not as extensively scarred as others, we may combine multiple areas into one – for example, your two temples could be counted as one temple. During your consultation, we will discuss how many areas and layers should undergo subcision.

Lasers are high-energy beams that are directed at the skin to promote neocollagenesis and remove dead skin. Lasers can come in a variety of wavelengths and intensities, which correlate to their depth of penetration and remodeling effects.

At our clinic, we use the Fotona4D laser, which has both non-ablative (Nd:YAG) and ablative (Er:YAG) settings. Nd:YAG lasers emit shorter wavelengths of concentrated light, which allows them to penetrate deeper into the skin to target veins, hair follicles, and melanin, where they reside. On the other hand, Er: YAG lasers emit longer wavelengths of light, specifically infrared light, to ablate and thus remodel the top layers of skin. Er:YAG lasers are thus more applicable for scar treatment.

Although visible improvement can be seen with ER:YAG laser treatment, lasers essentially “sands down” healthy skin around acne scars to match the level of the pitted scars. This allows a more even appearance. As a result, our firm belief is to avoid laser treatments as a first line treatment for acne scars. Instead, we believe that laser treatments are best used as a final “touch-up” treatment that smooths out your skin after your scar revision and healing during the phase system. This way, laser treatments can be used as an effective refining and enhancing treatment to fine tune your skin’s appearance to your desired goals.

Moreover, laser treatments can be effective for patients with non-acne scars, notably hypertrophic scars from burns, surgery, or other forms of trauma to the skin. In these cases, we would use a higher ablative Er:YAG setting to remodel the raised skin lesions to flatten them to the level of the surrounding healthy skin. However, in cases where the scar is severely raised and continually growing, as seen with keloid scars, lasers may not be the most viable treatment option. 

To learn more about the above scars mentioned and what treatment options are best, click here.

Although we use a mild setting for our laser, some risks include temporary redness, swelling, and irritation. In rare cases, infection may occur following treatment. All these risks are mitigated or entirely prevented with careful use and proper aftercare. For people of color, lasers can cause post-inflammatory hyperpigmentation. As a countermeasure, patients should avoid UV exposure and apply generous amounts of sunscreen following treatment, especially during the spring and summer months.

Patients will start to notice results 3 to 6 months after treatment. Afterwards, the results will persist anywhere between 3 to 5 years. Some patients may need a touch-up during that time period for results to last longer.

As this is an optional and very last phase of treatment for patients, most will only require one round of laser treatment, but this will vary for every patient. At your consultation and throughout the treatment process, we will discuss laser options depending on how much treatment is required to finalize your scar healing process.

Anti-inflammatory peptides are injectables that are administered directly into active acne to reduce redness and swelling. Because these peptides are strong anti-inflammatory agents, they can also be used to treat both active acne breakouts and hypertrophic and keloid scars, all of which are inflammatory disorders of the skin.

Peptides can be mixed with other strong anti-inflammatory agents, such as steroids (or Kenalog). Together, these compounds stunt the body’s natural inflammatory response at the site of injection, effectively reducing redness and/or swelling. This flattens out the raised acne or scar lesions within 4 to 8 hours of treatment. Injections are performed with a very small needle, so no anesthetic or downtime is required.

People with more severe acne breakouts are the best candidates for peptide injections. Notably, people who have recurrent cystic or nodular acne (painful types of acne that burrow deep into the skin) can benefit most from these injections. 

The same process can be done for hypertrophic and keloid scars. These scars are chronically inflamed lesions that respond well to peptide injections. Because these injections are non-invasive, these are an excellent first-line therapy before surgical procedures are considered.

However, if you are a patient who has a peptide/steroid allergy, then other treatment options, such as manual acne extraction, should be explored. Patients with any active skin infection or disease should also avoid peptide injections until they have resolved their skin condition.

Peptide injections are known to be a highly safe and effective treatment option for patients with active acne or hypertrophic scarring. In rare cases, patients receiving peptide injections may experience redness, irritation, pain, dryness, flaking, crusting, hypopigmentation, and/or local hair growth. These are often signs that your body is acclimating to the peptide treatment. We will cover the side effects and actions we take to minimize complications during your consultation.

Peptide injections work rapidly and can noticeably reduce inflammation within hours of receiving the injection. However, the overall number of peptide injections that you will need depends on how often you break out. Some patients have occasional acne breakouts and thus only receive peptide injections as needed. Other patients have recurrent acne breakouts, requiring regular peptide injections. At the Scar Healing Institute, we try to avoid giving you frequent peptide injections by placing you on a special diet with herbal supplements, which are proven to be effective in maintaining clear skin.

The number and concentration of peptide injections for hypertrophic scars will depend on their severity. We will have to evaluate your scars during your consultation before we determine the frequency and intervals for your peptide injections.

The cost of peptide injections are based on a variety of factors, including the number and severity of the acne. During your consultation, we will determine these factors and work with you to determine how many sites require treatment.