Combined treatment of atrophic scars using radiofrequency microneedling and hyaluronic acid fillers with subcision

Introduction. Atrophic scars may be associated with significant psychological stress and a substantial negative impact on quality of life. Despite the great relevance of the atrophic scars therapy, existing treatment methods do not always provide their complete elimination.

Aim. To study the efficacy of combined therapy of atrophic scars with radiofrequency microneedling (RF-MN), subcision and hyaluronic acid filler injection.

Materials and methods. Ten female patients aged 28–44 years with a clinical diagnosis of atrophic scars were randomly assigned to two groups. Group 1 received RF-MN alone, while Group 2 received a combination treatment comprising RF-MN, subcision, and hyaluronic acid injections. Clinical effectiveness was assessed using the Goodman-Baron scar rating scale and the Global Aesthetic Improvement Scale (GAIS). Ultrasound was used to determine the changes in dermal thickness. The volume of depressions and skin texture were measured using the Antera 3D®. The safety of the treatment was evaluated by recording adverse events.

Results. The combined method demonstrated superior efficacy compared to RF-MN alone in the majority of efficacy parameters. In Group 2, a statistically significant reduction in Goodman-Baron scale was observed in 100% of patients (p = 0.026). 3D measurements of the face demonstrated a more pronounced improvement in skin texture in Group 2 relative to Group 1. Statistically significant changes (p = 0.027) in the Face-Q scale were exclusively observed in the group that received the combined treatment. Ultrasonic imaging demonstrated a restoration of dermal thickness following treatment. No serious adverse events were observed. Expected local adverse events (pain, erythema, swelling, and bruising) were mild and resolved spontaneously within 1–7 days.

Conclusion. The combined treatment with RF-MN followed by subcision and hyaluronic acid filler injections demonstrated its efficacy in patients with atrophic scars.

1. Белоусов АЕ. Очерки пластической хирургии. Т. 1. Рубцы и их коррекция. СПб.: КОМАНДОР-SPB; 2005. 128 с.

2. Baitinger VF, Paityan KG. Morphologic and functional characteristics of pathologic skin scars: state of the art. Issues of Reconstructive and Plastic Surgery. 2013;(1):28–33. (In Russ.) Available at: https://journals.tsu.ru/uploads/import/1151/files/1,2013_web_30.pdf.

3. Moon J, Yoon JY, Yang JH, Kwon HH, Min S, Suh DH. Atrophic acne scar: a process from altered metabolism of elastic fibres and collagen fibres based on transforming growth factor-β1 signalling. Br J Dermatol. 2019;181(6):1226–1237. https://doi.org/10.1111/bjd.17851.

4. Parks WC, Wilson CL, López-Boado YS. Matrix metalloproteinases as modulators of inflammation and innate immunity. Nat Rev Immunol. 2004;4(8):617–629. https://doi.org/10.1038/nri1418.

5. Darby IA, Laverdet B, Bonté F, Desmoulière A. Fibroblasts and myofibroblasts in wound healing. Clin Cosmet Investig Dermatol. 2014;7:301–311. https://doi.org/10.2147/CCID.S50046.

6. Wilkinson HN, Hardman MJ. Wound healing: cellular mechanisms and pathological outcomes. Open Biol. 2020;10(9):200223. https://doi.org/10.1098/rsob.200223.

7. Kim GH, Lee WJ, Jung JM, Won CH, Chang SE, Lee MW, Moon IJ. Morphological characteristics of facial scars: A retrospective analysis according to scar location, onset, age, and cause. Int Wound J. 2024;21(4):e14453. https://doi.org/10.1111/iwj.14453.

8. Abdel Hay R, Shalaby K, Zaher H, Hafez V, Chi CC, Dimitri S et al. Interventions for acne scars. Cochrane Database Syst Rev. 2016;4(4):CD011946. https://doi.org/10.1002/14651858.CD011946.pub2.

9. Zaleski-Larsen LA, Fabi SG, McGraw T, Taylor M. Acne Scar Treatment: A Multimodality Approach Tailored to Scar Type. Dermatol Surg. 2016; 42(2 Suppl.):S139–S149. https://doi.org/10.1097/DSS.0000000000000746.

10. Alam M, Han S, Pongprutthipan M, Disphanurat W, Kakar R, Nodzenski M et al. Efficacy of a needling device for the treatment of acne scars: a randomized clinical trial. JAMA Dermatol. 2014;150(8):844–849. https://doi.org/10.1001/jamadermatol.2013.8687.

11. Fife D. Practical evaluation and management of atrophic acne scars: tips for the general dermatologist. J Clin Aesthet Dermatol. 2011;4(8):50–57. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168245/.

12. Vempati A, Zhou C, Tam C, Khong J, Rubanowitz A, Tam K et al. Subcision for Atrophic Acne Scarring: A Comprehensive Review of Surgical Instruments and Combinatorial Treatments. Clin Cosmet Investig Dermatol. 2023;16:125–134. https://doi.org/10.2147/CCID.S397888.

13. Ivanovskaya EV, An OI, Martyanov AA, Ivanovskaya YuA, Gazitaeva ZI, Sveshnikova AN. Theoretical study of the pharmacodynamics of a crosslinked product of high molecular weight hyaluronic acid in the intercellular matrix. Eksperimentalnaya i Klinicheskaya Farmakologiya. 2023;86(11S):64. (In Russ.) https://doi.org/10.30906/ekf-2023-86s-64a.

14. Болдова АЕ, Ивановская ЕВ, Сидорина АН, Ан ОИ, Мартьянов АА, Ивановская ЮА и др. Фагоцитоз поперечно-сшитых продуктов высокомолекулярной гиалуроновой кислоты клетками человека. В: XXIV съезд физиологического общества им. И.П. Павлова: сборник тезисов съезда. Санкт-Петербург, 11–15 сентября 2023 г. СПб.: ВВМ; 2023.  С. 105–106. Режим доступа: https://rusphysiol2023.iephb.ru/wp-content/uploads/2023/11/sbornik-xxiv-sezda.pdf.

15. Almukhadeb E, Binkhonain F, Alkahtani A, Alhunaif S, Altukhaim F, Alekrish K. Dermal Fillers in the Treatment of Acne Scars: A Review. Ann Dermatol. 2023;35(6):400–407. https://doi.org/10.5021/ad.22.230.

16. Owczarczyk-Saczonek A, Zdanowska N, Wygonowska E, Placek W. The Immunogenicity of Hyaluronic Fillers and Its Consequences. Clin Cosmet Investig Dermatol. 2021;14:921–934. https://doi.org/10.2147/CCID.S316352.

17. Turlier V, Delalleau A, Casas C, Rouquier A, Bianchi P, Alvarez S et al. Association between collagen production and mechanical stretching in dermal extracellular matrix: in vivo effect of cross-linked hyaluronic acid filler. A randomised, placebo-controlled study. J Dermatol Sci. 2013;69(3):187–194. https://doi.org/10.1016/j.jdermsci.2012.12.006.

18. Levy LL, Zeichner JA. Management of acne scarring, part II: a comparative review of non-laser-based, minimally invasive approaches. Am J Clin Dermatol. 2012;13(5):331–340. https://doi.org/10.2165/11631410-000000000-00000.

19. Kapuler OM, Razumovskaya EA, Murakov SV, Glavnova AM. Ultrasound characteristics of hyaluronic acid fillers tissue integration and hyaluronidase-mediated degradation. Russian Journal of Clinical Dermatology and Venereology. 2024;23(3):322–331. (In Russ.) https://doi.org/10.17116/klinderma202423031322.

20. Tahiliani S, Mysore V, Ganjoo A, Udare S, Rajendran SC, Reddy R et al. Practical Aspects of Acne Scar Management: ASAP 2024. Cureus. 2024;16(3):e55897. https://doi.org/10.7759/cureus.55897.

21. Kruglova LS, Kolcheva PA, Korchazhkina NB. About modern methods of acnescars correction. Journal of New Medical Technologies. 2018;25(4):155–163. (In Russ.) https://doi.org/10.24411/1609-2163-2018-16316.

22. Connolly D, Vu HL, Mariwalla K, Saedi N. Acne Scarring-Pathogenesis, Evaluation, and Treatment Options. J Clin Aesthet Dermatol. 2017;10(9):12–23. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5749614/.

23. Stenko AG, Talybova AM, Kovalenko AA, Strekozova AE. Effective therapy for cicatricial deformities. Medical Alphabet. 2019;2(26):62–66. (In Russ.) https://doi.org/10.33667/2078-5631-2019-2-26(401)-62-66.

24. Perry DM, McGrouther DA, Bayat A. Current tools for noninvasive objective assessment of skin scars. Plast Reconstr Surg. 2010;126(3):912–923. https://doi.org/10.1097/PRS.0b013e3181e6046b.

25. Dill-Müller D, Maschke J. Ultrasonography in dermatology. J Dtsch Dermatol Ges. 2007;5(8):689–707. https://doi.org/10.1111/j.1610-0387.2007.06453.x.

26. Bondarenko IN. New outreach of ultrasound in aesthetic medicine: a systematic review. Kuban Scientific Medical Bulletin. 2021;28(6):73–89. (In Russ.) https://doi.org/10.25207/1608-6228-2021-28-6-73-89.

27. Bondarenko IN. Ultrasonic diagnosis of skin, facial, neck and hand soft tissue in women of different age: a non-randomised observational cross-sectional study. Kuban Scientific Medical Bulletin. 2021;28(3):16–28. (In Russ.) https://doi.org/10.25207/1608-6228-2021-28-3-16-28.

28. Artzi O, Cohen S, Koren A, Niv R, Friedman O. Dual-plane hyaluronic acid treatment for atrophic acne scars. J Cosmet Dermatol. 2020;19(1):69–74. https://doi.org/10.1111/jocd.12991.

29. Dierickx C, Larsson MK, Blomster S. Effectiveness and Safety of Acne Scar Treatment With Nonanimal Stabilized Hyaluronic Acid Gel. Dermatol Surg. 2018;44(1 Suppl.):S10–S18. https://doi.org/10.1097/DSS.0000000000001689.

30. Hasson A, Romero WA. Treatment of facial atrophic scars with Esthélis, a hyaluronic acid filler with polydense cohesive matrix (CPM). J Drugs Dermatol. 2010;9(12):1507–1509. Available at: https://pubmed.ncbi.nlm.nih.gov/21120258/.

31. Siperstein R, Nestor E, Meran S, Grunebaum L. A split-face, blind, randomized placebo-controlled clinical trial investigating the efficacy and safety of hyaluronic acid filler for the correction of atrophic facial scars. J Cosmet Dermatol. 2022;21(9):3768–3778. https://doi.org/10.1111/jocd.15153.

32. Clementoni MT, Azzopardi E. Specific Attention Areas in Scar Management: Management of Atrophic Scars. In: Téot L, Mustoe TA, Middelkoop E, Gauglitz GG (eds.). Textbook on Scar Management: State of the Art Management and Emerging Technologies. Cham (CH): Springer; 2020, pp. 353–362. https://doi.org/10.1007/978-3-030-44766-3_41.

33. Ebrahim HM, Nassar A, ElKashishy K, Artima AYM, Morsi HM. A combined approach of subcision with either cross-linked hyaluronic acid or threads in the treatment of atrophic acne scars. J Cosmet Dermatol. 2022;21(8):3334–3342. https://doi.org/10.1111/jocd.14675.

34. Dastgheib M, Heidari S, Azizipour A, Kavyani M, Lajevardi V, Ehsani AH et al. Investigating the impact of added Profhilo mesogel to subcision versus subcision monotherapy in treating acne scars; a single-blinded, splitface randomized trial. J Cosmet Dermatol. 2024;23(6):1992–2000. https://doi.org/10.1111/jocd.16258.

35. Mohammed GF, Al-Dhubaibi MS. Triple steps acne scar revision technique: A new combination therapeutic modality for atrophic acne scars. J Cosmet Dermatol. 2022;21(10):4659–4668. https://doi.org/10.1111/jocd.14944.

36. Choi SY, Lee YH, Kim H, Koh HJ, Park SY, Park WS et al. A combination trial of intradermal radiofrequency and hyaluronic acid filler for the treatment of nasolabial fold wrinkles: a pilot study. J Cosmet Laser Ther. 2014;16(1):37–42. https://doi.org/10.3109/14764172.2013.854636.

37. Kim H, Park KY, Choi SY, Koh HJ, Park SY, Park WS et al. The efficacy, longevity, and safety of combined radiofrequency treatment and hyaluronic Acid filler for skin rejuvenation. Ann Dermatol. 2014;26(4):447–456. https://doi.org/10.5021/ad.2014.26.4.447.

38. Ko EJ, Choi HG, Kim H, Park WS, Kim BJ, Kim MN. Novel Treatment Using Intradermal Radiofrequency and Hyaluronic Acid Filler to Correct Marionette Lines. Ann Dermatol. 2015;27(3):351–352. https://doi.org/10.5021/ad.2015.27.3.351.

39. Lolis MS, Goldberg DJ. Radiofrequency in cosmetic dermatology: a review. Dermatol Surg. 2012;38(11):1765–1776. https://doi.org/10.1111/j.1524-4725.2012.02547.x.

40. Płatkowska A, Korzekwa S, Łukasik B, Zerbinati N. Combined Bipolar Radiofrequency and Non-Crosslinked Hyaluronic Acid Mesotherapy Protocol to Improve Skin Appearance and Epidermal Barrier Function: A Pilot Study. Pharmaceuticals (Basel). 2023;16(8):1145. https://doi.org/10.3390/ph16081145.

41. Gladko VV, Izmaylova IV. The use of the combined method of microneedling and radiofrequency therapy and dermal fillers for atrophic scars treatment in the facial area in the context of post-acne syndrome. Bulletin of the Medical Institute of Сontinuing Education. 2023;3(2):20–23. (In Russ.) Available at: https://med.mgupp.ru/wp-content/uploads/2023/06/Вестник_МИНО_2_2023.pdf.

42. Talybova AM, Stenko AG, Kruglova LS. The effectiveness of the combined use of fractional microneedle RF-therapy and pharmacophoresis of hyaluronic acid in the treatment of patients with atrophic scars. Russian Journal of Physiotherapy, Balneology and Rehabilitation. 2020;19(1):32–39. (In Russ.) https://doi.org/10.17816/1681-3456-2020-19-1-5.

43. Cucu C, Butacu AI, Niculae BD, Tiplica GS. Benefits of fractional radiofrequency treatment in patients with atrophic acne scars – Literature review. J Cosmet Dermatol. 2021;20(2):381–385. https://doi.org/10.1111/jocd.13900.

44. Bhargava S, Cunha PR, Lee J, Kroumpouzos G. Acne Scarring Management: Systematic Review and Evaluation of the Evidence. Am J Clin Dermatol. 2018;19(4):459–477. https://doi.org/10.1007/s40257-018-0358-5.

45. Boen M, Jacob C. A Review and Update of Treatment Options Using the Acne Scar Classification System. Dermatol Surg. 2019;45(3):411–422. https://doi.org/10.1097/DSS.0000000000001765.

46. Kravvas G, Al-Niaimi F. A systematic review of treatments for acne scarring. Part 1: Non-energy-based techniques. Scars Burn Heal. 2017;3:1–17. https://doi.org/10.1177/2059513117695312.

47. Min S, Park SY, Yoon JY, Suh DH. Comparison of fractional microneedling radiofrequency and bipolar radiofrequency on acne and acne scar and investigation of mechanism: comparative randomized controlled clinical trial. Arch Dermatol Res. 2015;307(10):897–904. https://doi.org/10.1007/s00403-015-1601-z.

48. Huang L, Liu Y, Fang W, Liu L, Sun Q, Lin X et al. Efficiency and safety of microneedling fractional radiofrequency in the treatment of Chinese atrophic acne scars: A retrospective study of 3 consecutive treatments with 1-month intervals. J Cosmet Dermatol. 2023;22(2):497–504. https://doi.org/10.1111/jocd.15454.

49. Kim CNT, Thi LP, Van TN, Minh PPT, Nguyet MV, Thi ML et al. Successful Treatment of Facial Atrophic Acne Scars by Fractional Radiofrequency Microneedle in Vietnamese Patients. Open Access Maced J Med Sci. 2019;7(2):192–194. https://doi.org/10.3889/oamjms.2019.002.

50. Nitayavardhana S, Wanitphakdeedecha R, Ng JNC, Eimpunth S, Manuskiatti W. The efficacy and safety of fractional radiofrequency nanoneedle system in the treatment of atrophic acne scars in Asians. J Cosmet Dermatol. 2020;19(7):1636–1641. https://doi.org/10.1111/jocd.13484.

51. Bulbul Baskan E, Akin Belli A. Evaluation of the efficacy of microneedle fractional radiofrequency in Turkish patients with atrophic facial acne scars. J Cosmet Dermatol. 2019;18(5):1317–1321. https://doi.org/10.1111/jocd.12812.

52. Elawar A, Dahan S. Non-insulated Fractional Microneedle Radiofrequency Treatment with Smooth Motor Insertion for Reduction of Depressed Acne Scars, Pore Size, and Skin Texture Improvement: A Preliminary Study. J Clin Aesthet Dermatol. 2018;11(8):41–44. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6122511/.

53. Cho SI, Chung BY, Choi MG, Baek JH, Cho HJ, Park CW et al. Evaluation of the clinical efficacy of fractional radiofrequency microneedle treatment in acne scars and large facial pores. Dermatol Surg. 2012;38(7-1): 1017–1024. https://doi.org/10.1111/j.1524-4725.2012.02402.x.

54. Kolcheva PS, Talybova AM, Stenko AG. Innovative methods in treatment of patients with atrophic post-acne scars. Medical Alphabet. 2020;(6):47–51. (In Russ.) https://doi.org/10.33667/2078-5631-2020-6-47-51.

55. Flegontova E, Kreindel M, Vranis NM, Mulholland RS. Correction of age-related changes in the skin at the dermal and subdermal level using radiofrequency macroneedling therapy. J Cosmet Dermatol. 2024;23(7):2401–2410. https://doi.org/10.1111/jocd.16361.