As a skin restoration specialist based in Newport Beach, California, I’ve dedicated my career to helping patients reclaim their confidence through advanced acne scar treatments. Over the years, I've worked with countless individuals suffering from deep scars, volume loss, and pigmentation issues. In this article, I’ll walk you through some of the most effective techniques we use at my clinic—particularly focusing on TCA (Trichloroacetic Acid) cross, subcision, CO2 laser resurfacing, and fat transfer—and how they can dramatically improve even the most severe acne scarring.
Understanding Acne Scars and Volume Loss
Acne scars are more than just surface-level damage—they penetrate deep into the dermis and often result in structural changes beneath the skin, including fat loss. This fat destruction leads to indentations that make scars appear deeper and more pronounced over time, especially as natural facial volume diminishes with age.
I recently treated a patient who had suffered from severe acne for many years. His scars were thick, fibrous, and deeply indented—especially across his forehead and cheeks. What made his case particularly challenging was significant fat loss, which meant that traditional resurfacing alone wouldn’t be enough to restore smoothness and fullness to his face.
The Role of TCA Cross in Scar Treatment
One of the most powerful tools in our arsenal is TCA cross . This technique involves applying high-concentration trichloroacetic acid directly into the base of boxcar or ice pick scars. The acid causes controlled inflammation, triggering new collagen production that lifts and fills the scar from within.
For this particular patient, we used TCA cross alongside other modalities to target specific scar types. It’s especially effective for boxcar scars—those with defined edges and a crater-like appearance. However, even rolling or ice pick scars can benefit when combined with complementary treatments like subcision and laser resurfacing.
It’s important to note that TCA cross should not be used lightly , especially on active pores. There's a risk of widening pores if applied improperly, so it must be performed by an experienced practitioner who understands the depth and structure of each scar type.
Breaking Down Scar Tissue with Subcision
Before we can rebuild the skin, we have to break down the existing scar tissue. That’s where subcision comes in. Using a small needle under the skin, we carefully release tethered scars that pull the skin downward. This allows the area to lift slightly and creates space for collagen stimulation.
In my patient’s case, subcision was critical for releasing the thick, fibrous bands pulling down his forehead and cheek areas. We did this first to prepare the skin for subsequent treatments and saw immediate improvement in texture and mobility.
Laser Resurfacing for Smooth Skin Texture
After mechanical release of scar tissue, we turned to CO2 laser resurfacing . This ablative laser removes thin layers of damaged skin while stimulating new collagen growth. The result is smoother, tighter, and more evenly textured skin.
We also used TCA cross in conjunction with the laser to enhance results. The combination of these two treatments gives us both vertical and horizontal rejuvenation—lifting scars from below while refining the surface texture.
Revolumizing the Face with Fat Transfer
Even after resurfacing and scar release, my patient still had noticeable depressions due to long-term fat loss. To address this, we performed fat transfer , harvesting fat from his flank area and reinjecting it into the face using micro- and nano-fat grafts.
Micro-fat provides structural support and volume, while nano-fat—rich in stem cells—enhances skin quality and texture. The result? A lifted, fuller appearance that complements the scar work we've already done.
Fat transfer isn't the only option for volume replacement. Some patients choose Bellafill , Sculptra , or hyaluronic acid fillers , but fat offers longer-lasting, natural-looking results—especially for those with extensive volume depletion.
Maintenance & Long-Term Results
Once a patient reaches their optimal results, maintenance becomes key. I recommend regular low-energy laser sessions twice a year to keep collagen production active. Topical skincare with tretinoin or adapalene helps maintain cellular turnover, while pigment-targeting creams reduce post-inflammatory hyperpigmentation.
Collagen stimulation continues for up to a year after procedures like phenol peels or fat transfer, so patience is essential. True transformation doesn’t happen overnight—it unfolds gradually, often becoming apparent only when you forget to obsess over your skin anymore.
Questions Answered
Below are answers to some of the most frequently asked questions about acne scar treatment, answered directly from my live session:
Question: When would you recommend doing a phenol peel—or is that more of a last resort option?
Dr. Qazi: Phenol peels are not a last resort—they’re a powerful tool for severe scarring and thickened skin. I perform them regularly, especially when jawline contraction and deep collagen remodeling are needed. They require downtime and careful monitoring, but the results are transformative.
Question: Can you use TCA Cross on a deep pore with a sebaceous gland at the bottom?
Dr. Qazi: It’s risky because it can cause the pore to widen. You want thicker walls around the pore before considering TCA. Otherwise, you may end up exacerbating the issue rather than improving it.
Question: Can scars fade over time?
Dr. Qazi: Yes, but not always in the way people hope. Sometimes scars become more noticeable with age or weight loss because underlying fat diminishes. Active intervention is usually necessary for meaningful improvement.
Question: What procedures did this patient undergo for the acne scarring?
Dr. Qazi: He underwent TCA cross, subcision, CO2 laser resurfacing, and fat transfer. These were staged about four weeks apart to allow healing and maximize collagen response.
Question: How many procedures would you do at the same time?
Dr. Qazi: I avoid combining fat transfer with subcision on the same day. However, TCA cross, subcision, and laser can often be done together—especially in the upper face.
Question: Would you be willing to do a consultation on live if someone was willing to do so?
Dr. Qazi: It’s possible, though coordinating multiple platforms can be logistically complex. Our team would need to evaluate feasibility on a case-by-case basis.
Question: What do patients do for maintenance after they achieve their maximum results?
Dr. Qazi: Maintenance includes topical retinoids, pigment control creams, and occasional low-energy laser treatments to sustain collagen production.
Question: Does microneedling cause fat or muscle loss?
Dr. Qazi: Regular microneedling doesn’t, but radiofrequency microneedling might affect fat if used excessively. I generally don’t recommend it for scar revision due to inconsistent results.
Question: Is halo a low energy laser?
Dr. Qazi: No, Halo has considerable heat and downtime. While effective, it carries a higher risk of hyperpigmentation, especially in darker skin tones. Erbium lasers at lower settings are safer for sensitive patients.
Question: Does radio frequency microneedling really work to kill sweat glands?
Dr. Qazi: It can destroy sweat glands off-label, especially in the axillary area. However, no device currently has FDA approval for this indication.
Question: I have KP and started using CeraVe SA lotion, but it seems worse. Should I stop?
Dr. Qazi: Yes, likely. Switch to a urea-based cream like “Rough and Bumpy” instead. It’s gentler and more effective for keratosis pilaris.
Question: Did you use TCA for this photo?
Dr. Qazi: Yes, along with laser and subcision. TCA was crucial for targeting boxcar and rolling scars.
Question: What treatment do you recommend for forehead scarring?
Dr. Qazi: Forehead scars respond well to subcision, TCA cross, and laser resurfacing. Fat transfer or fillers can also help restore lost volume.
Question: Is fat transfer the only way to deal with volume loss?
Dr. Qazi: No. Options include Bellafill, Sculptra, hyaluronic acid fillers, and fat transfer. Each has pros and cons depending on the patient’s needs.
Question: How did this patient in the picture get rid of his scars?
Dr. Qazi: Through a multi-step process: subcision, TCA cross, laser resurfacing, and fat transfer.
Question: Where is your office located?
Dr. Qazi: Newport Beach, California—just five minutes from John Wayne Airport.
Question: How long after a full syringe of Bellafill should you wait to see if you need more?
Dr. Qazi: Around four weeks. Some patients may need touch-ups earlier, but others wait three to six months depending on results.
Question: Do you offer FaceTime consults?
Dr. Qazi: Yes, we do virtual consultations via FaceTime or Zoom. Most of our patients come from out of state.
Question: Which HA filler is good for volume that doesn't have the risk of migration?
Dr. Qazi: All HA fillers carry some migration risk. Juvéderm products, in particular, are known for shifting over time. Choose carefully and trust an experienced injector.
Question: I have a deep ice pick scar on my forehead. Should I try TCA Cross or get it cut out?
Dr. Qazi: If it’s in a low-tension area, TCA cross works well. But if it’s in a dynamic zone like smile lines, excision might be better. Always go to someone experienced with both.
Question: Will fat transfer help pitted scarring in the apples of the cheek?
Dr. Qazi: It can help, but it’s tricky. Ice pick scars there usually need TCA cross and subcision first. Fat transfer supports volume but shouldn’t be the sole solution.
Question: How many sessions was this?
Dr. Qazi: Two main sessions spaced four weeks apart. Additional maintenance sessions may follow depending on results.
Question: Can we see a final result with the scars fully gone?
Dr. Qazi: Not entirely. Even with aggressive treatment, some textural differences remain. The goal is to make scars unnoticeable under normal lighting and social situations.
Question: Is there a way to do a free consultation?
Dr. Qazi: No, but your consultation fee applies toward your treatment if you proceed.
Question: Are phenol peels best for acne scars, or does it depend on the scar type?
Dr. Qazi: It depends. Phenol peels excel for thick, fibrotic scars and jawline contouring. They aren’t ideal for shallow or widespread scarring.
Question: Are anesthesiologists trained for phenol peels? How do you choose one for your practice?
Dr. Qazi: Yes, they should be trained. I quiz them on pharmacology and EKG interpretation to ensure they understand the cardiac risks associated with phenol.
Question: If I’m in my 20s and get a pitted acne scar from stress, can it get worse with age even if I use adapalene?
Dr. Qazi: Yes, especially if left untreated. Adapalene helps with turnover but won’t reverse structural damage. Early intervention with TCA cross or excision can prevent worsening.
Question: If TCA on a pore is risky, can it still permanently destroy a sebaceous gland?
Dr. Qazi: Unlikely. Permanent destruction of sebaceous glands with TCA is rare and difficult to achieve safely.
Question: My pores look large when my skin is oily, but smaller when it’s dry. I heard isotretinoin can reduce oil long-term, but does the oil come back after you stop using it?
Dr. Qazi: Isotretinoin reduces oil significantly, though some rebound occurs. Low-dose isotretinoin or topical retinoids can help maintain results.
Question: How many sessions are needed for 15 years of deep acne scars and significant volume loss?
Dr. Qazi: It varies widely but expect anywhere from 6 to 12 sessions over 1–2 years. Cost and complexity increase with severity, but payment plans are available.
Conclusion
If you're struggling with acne scars, know that there is hope—even for long-standing, severe cases. With the right combination of TCA cross , subcision, laser resurfacing, and volume replacement, you can transform your skin and regain your confidence.
To learn more about what we do or to book a virtual consultation, visit DoctorQazi.com . Let’s start your journey toward clearer, smoother skin today.
