Australasian Journal of Dermatology (2016) 57, 19–23 doi: 10.1111/ajd.

12390

ORIGINAL RESEARCH

The modified tower vertical filler technique for the

treatment of post-acne scarring
Greg J Goodman1,2 and Amanda Van Den Broek3
1
Department of General Practice, Monash University, Clayton, Victoria, 2Skin and Cancer Foundation Inc
Carlton, Victoria, and 3Dermatology Institute of Victoria, South Yarra, Victoria, Australia

ABSTRACT
Background: Acne scarring remains a difficult
problem for patients and physicians. Often it is treated
as a two-dimensional disease with lasers and similar
devices, whereas it is really a three-dimensional
problem. Fillers have been used for many years but
recently fillers with more lifting potential have been
made available and serve the purpose of the selective
elevation of atrophic scars, adding the third dimen-
sion to treatment.
Methods: Five patients with atrophic acne scarring
were selected in this pilot study. Each patient was
treated twice with a 3-month follow up from the
second treatment. A vertical modified tower tech-
nique was used with a hyaluronic acid filler to lift
each scar and support the skin to adopt a more flat-
tened appearance.
Results: The mean scar count declined from 48.8
scars to 15.4 visible after the second session. The
mean volume to total correction with filler of all scars
declined from 1.144 mL to 0.525 mL from the first to
second session. Global subjective improvement was
assessed at 5.4 and 5.5 (−3 to +10 scale). The static
objective grading scale showed an improvement from
3.2 at time of first treatment to 3.0 at the second, to 2.6
at final review.
Conclusions: The relative speed, accuracy and effi-
cacy of high lift hyaluronic acid is shown in this
small case series with subjective and objective
measurement.
Key words: acne scarring, acne, dermal filler, filler,
hyaluronic acid, post-acne scarring, tower tech-
nique, Voluma.
Correspondence: Professor Greg J Goodman, 8–10 Howitt Street,
South Yarra, Melbourne, Vic 3141, Australia. Email: gg@div.net.au
Greg J Goodman, FACD. Amanda Van Den Broek MBBS.
Conflict of interest: none
Submitted 16 June 2015; accepted 30 July 2015.
INTRODUCTION
There are relatively few methods of atrophic post-acne scar
revision.
In simple terms, one may excise the scar when the scar is
dystrophic or has a white-scarred base. Common tech-
niques include simple excision and a variety of punch tech-
niques such as punch excision, punch grafting and punch
elevation. Alternatively, we attempt to coerce and alter the
body’s healing process to induce collagen formation. Induc-
ing collagen formation is a common pathway used by all
resurfacing techniques from the most minor home care
through to subcision, needling, fractional and non-
fractional ablative and non-ablative technologies.
All techniques relying on collagen remodelling have
several things in common. The degree of collagen remod-
elling seems to be proportional to the severity of the injury
and the result is hard to judge prospectively. The result is
also delayed and multiple therapies are often required.
The other underexplored method of scar revision is filling
the scar. This method has been employed for over 30 years
and dates back to collagen injections in the 1980s. However,
the advent of longer lasting hyaluronic acid products with
more vertical lift characteristics has allowed the authors to
develop a technique that may be expected to vertically
elevate and improve atrophic scars over 1–2 sessions. It may
offer the advantages of immediate effect and accuracy of
result that other techniques do not.
METHODS
Five patients with atrophic acne scarring on the face, aged
19–40 were enrolled in this proof of concept study. All the
patients’ atrophic acne scarring types, which included
rolling-type, boxcar, broad atrophic areas and ice-pick
scars, were deemed appropriate for treatment with dermal
fillers. Fitzpatrick skin types ranged from I to IV, but higher
skin types were not excluded. Patients were excluded from
the study if they had had treatment with fillers in the pre-
vious 2 years, any resurfacing procedures, isotretinoin
therapy in the previous 6 months or any active acne. The
following case reflects the treatment, assessment and
recording methods used for all five patients.
Materials and methods are illustrated using one of the
cases studied. A representative case is of a 39-year-old

© 2015 The Australasian College of Dermatologists

20 GJ Goodman and A Van Den Broek
Table 1 Mean atrophic scar count in and following treatment
sessions
At 2 weeks, At 1 month,
Before after one after two Reduction in scar count
treatment treatment treatments after two treatments
48.8 41.8 15.4 33.4 (68% decrease)
Table 2 Mean volume of filler required for complete correction of
scars (mL)
Reduction
between
Treatment 1 Treatment 2 treatments
1.144 0.525 0.619
This reflects indirectly the volume of scarring requiring
treatment.
woman who presented for treatment of moderately severe
facial atrophic acne previously treated with full facial abla-
tive carbon dioxide and erbium laser with punch grafting
and two fractional carbon dioxide treatments, the previous
3 years before this study commenced. The patient had mul-
tiple rolling-type, small and large boxcar, punched-out ice-
pick and broad atrophic scars over the forehead, cheeks,
and chin which were clearly visible from a social distance
and not concealable with make-up.
Preceding the first treatment the patient and a non-
injecting assessor both graded the acne using the qualita-
tive grading scale described by Goodman and colleagues.1
Both the patient and non-injecting assessor graded them as
grade 3, moderately atrophic acne (scars visible at a con-
versational distance to others but able to be manually
stretched flat). Each atrophic scar was then marked and
counted by the injector, totalling 58 scars requiring a filler
injection (Tables 1,2).
Topical lidocaine ointment (Compounded 10% xylocaine,
Compoundia Pharmacies, Melbourne, Victoria, Australia)
was applied to the involved area for 30 min. The area was
then cleansed with 0.1% chlorhexidine solution. Each
marked scar was then injected with hyaluronic acid filler,
Juvederm Voluma (20 mg/mL, Allergan Australia, Sydney
New South Wales, Australia) via insulin syringes with a
swaged 31-gauge needle using a modification of the tower
technique. The hyaluronic acid was placed in the BD Ultra-
fine 11 short needle insulin syringe (Becton Dickinson,
Sydne New South Wales, Australia) by injecting into the
back end after temporarily removing the injecting stem,
utilising the technique popularised in Australia by Lim.2
This technique optimises injecting control for this thick
form of hyaluronic acid. The injector positioned the needle
at 90° through each scar into the deep dermis, injecting
0.02–0.04 mL of product with a gradual tapering retrograde
deposition as the needle was withdrawn. This created an
inverted pyramid-like ‘pillar of filter’, starting deeply in the
scar with gradually more product deposited as one
approaches the skin surface, acting as a support to each
layer of the deficit. Broader atrophic scars were injected
© 2015 The Australasian College of Dermatologists
Table 3 Mean patient global assessment 1 and 3 months following
treatment
At 1 month, At 3 months,
after two after two
treatments treatments
5.4 5.5
Performed on an visual analogue scale with −3 < 0 negative
result; 0 no change; 3 fair improvement; 5 good improvement; 8 or
above excellent improvement compared to baseline.
several times 3–4 mm apart to create a network of columns
to support the deficit. Areas were massaged as required to
flatten the filler and ensure the correct placement. In the
first treatment a total of 1.05 mL of filler was required to
restore volume to the atrophic scars, 0.55 mL in the right
side and 0.5 mL in the left side.
This process was repeated 2 weeks later for the second
treatment. Both the patient and assessor again determined
the acne grading to be 3 (scarring visible at conversational
distance but able to be stretched flat manually), with an
atrophic scar count of 53. 0.8 mL of filler was required to
correct the volume deficit of the atrophic scarring, 0.45 mL
in the right side and 0.35 mL in the left.
One month after the two treatments the patient’s atrophic
scar count was reviewed and she was asked to re-grade her
skin and assess the global improvement using a scale
ranging from negative 3 to 10. The total number of atrophic
scars correctable with filler injection had reduced to 10 and
the patient reported a global improvement of 8. Both patient
and assessor again recorded an acne grading of 3 (Table 3).
Three months following the two treatments the patient
was again required to globally assess the improvement in
the appearance of her acne scars. At this appointment the
patient recorded a global improvement of 6 – good to excel-
lent improvement (Figs 1,2).
RESULTS
Other patients in this study showed similar results to our
index case (Tables 1–4). Among all the patients the mean
scar count dropped from 48.8 on the first injection to 41.8
two weeks later, to 15.4 after two injection sessions
(Table 1). This relates to the volume used at each injection
session with 1.144 mL used on the first and under half of
that (0.525 mL) being necessary at the next session
(Table 2). Although the scars were still visible at the second
treatment session, they were less deep and required less
product for treatment. This second session appeared to
further address the volume and the number of the residual
scars. Fewer than 30% of the scars were still visible after
these two injection sessions on review 1 month after these
two sessions. The degree of improvement (Table 3) accord-
ing to patient global improvement was assessed at +5.4, 1
month after two injection sessions on an indicator ruler (−3
to +10). This was maintained at the 3-month review post-
injections (+5.5), indicating good to excellent improvement
from the patients’ perspective.
 The modified tower filler technique 21

Figure 1 Representative patient showing

scarring before treatment.

Figure 2 Representative patient showing

scarring after treatment.

Table 4 Change in grading scale with filler treatments (mean The use of dermal fillers in atrophic acne scaring was first
results) described in 19804 and is accepted as an effective treatment
for rolling, dish and boxcar acne scars, whether used inde-
At 2 weeks,
at the time At 1 month, pendently or in conjunction with other treatments. Its
First of second after two success in the treatment of ice-pick type scars has been
treatment treatment treatments described only once, showing a mild improvement with
Dermicol-p35 (Evolence; Ortho Dermatologics, Skillman,
Patient determined 3.2 3 2.6
qualitative acne grade NJ, USA) a porcine collagen preparation.5 Generally, results
Assessor determined 3 2.6 2.4 with this scar type are best considered to be variable.
qualitative acne grade Dermal and subcutaneous filling for scars is an attractive
choice for both physicians and patients as it offers a simple
Grade 1, macular scarring, Grade 2, scarring present at less than
conversational distance eg in a mirror, Grade 3, scarring present at
and accurate non-surgical correction of atrophic scars that
conversational distance but may be stretched flat, Grade 4, scarring produces immediate improvements. Fillers raise the scar
at conversational distance that cannot be flattened by stretching; for deficit to the level of the surrounding skin thereby working
example, ice-pick scars. to even out skin texture and enhance overall contour.
Numerous types of fillers have been explored for their use
in acne scar treatment. The ideal filler would be one that is
Table 4 shows a commensurate decrease in the grading easy to inject, minimally painful, producing immediate and
scale according to the patient from 3.2 pretreatment, to 3 at long-lasting results and with few side-effects. Unfortu-
the time of the second treatment and 2.6 on final grading 1 nately, immunogenicity and sensitivity and a short duration
month after the two treatments. This is similar to the non- of effect has plagued the use of earlier fillers, in particular
treating investigator assessment (Table 4). those derived from animal collagen.
The use of permanent fillers such as liquid silicon and
later acrylate-based fillers, while producing a permanent
DISCUSSION
result, should be used cautiously due to the ongoing tissue
Acne scarring is a common and persistent complication of loss that will inevitably occur with ageing.6 Any inaccuracy
acne vulgaris affecting a large proportion of the population. of implantation will permanently annoy patient and physi-
Despite its high prevalence there is no single treatment cian alike. The persistence of volume in these fillers relative
modality that has been shown to be universally effective, to natural ongoing losses can cause an undesirable aes-
posing a significant challenge for the treating physician. thetic for patients despite earlier success. Achieving an
Due to the distressing nature of the condition and its psy- optimal result with these products is also often a slow and
chological impact on patients, a quick result is often sought. lengthy process. Multiple injections of small amounts over
Few of the treatments available can produce immediate several months are required to avoid under-correction or
results; however, the use of dermal filler injections has over-correction.7 However, complications with permanent-
been shown to improve the skin contour following the based fillers may become a long-term issue for both the
procedure.3 patient and their treating physician.

© 2015 The Australasian College of Dermatologists

22 GJ Goodman and A Van Den Broek
Figure 3 Tangential lighting highlighting atrophy.
Various horizontal injection techniques have been
described for elevating acne scars. Success has been shown
with linear threading, serial puncture and depot filling from
the base of scars and filling in combination with other treat-
ment modalities such as subcision or saline injections.8–10
Newer fillers composed of hyaluronic acid are well toler-
ated by patients. Hyaluronic acid does not have a species or
tissue specificity and therefore hypersensitivity to the
product is low. This low rate of immunogenicity with
hyaluronic acid products has eliminated the need for
routine pre-injection testing, leading to the faster initiation
of treatment.
Hyaluronic acid fillers have also been found to have a
longer duration of action as a structural support to the skin
than predecessors, lasting up to 24 months.11
A vertical tower filling technique that fills deficits from
90° and gradually tapers the deposition of product as the
needle is withdrawn has been described for filling aged or
volume-depleted skin but its treatment in the context of
post-acne scarring has not be described.12 The technique for
the vertical tower12 is subtly different from our inverted
funnel in its intention and product flow. When scars on
patients were in regions of high risk for fillers, the tower
technique was not used but instead a very superficial hori-
zontally administered intradermal injection was performed.
It has been noted by the author that these scars were cor-
rected but the longevity of improvement did not match the
tower technique. This may be because of the decreased
volume of injection per scar or the lack of deep support
offered by the more superficial injection method. Despite
the higher injection volumes required for the tower, these
injection volumes are still low and affordable with 1–2 mL
only being required over two injections.
The steps taken in our modification of this technique are:
1. Using adequate lighting to look from all directions at the
scars, mainly tangentially across the scars to highlight
any atrophy (Fig. 3).
2. Mark each appropriate scar, outlining where it is to be
injected.
3. Assessing the total volume likely to be required.
4. Assessing what structures may lie beneath the scar to
avoid injury.
© 2015 The Australasian College of Dermatologists
Figure 4 Injection utilising the tower technique.
5. Injecting each scar, very superficially in areas of higher
vascular injury risk such as the forehead, glabella,
temple or nose, but deeper and using the true tower
technique in other areas (Fig. 4).
6. Totally filling the scar, often ending with a small bump
that may be manually moulded into position at the end of
the injection.
7. Having the patient return at 2–4 weeks for a supplemen-
tal procedure usually requiring about 50% of the initial
corrective volume.
In dealing with acne scarring this technique is not a depot
or a bottom heavy tower. The scar is approached vertically
at its centre to a depth dependent on the depth of the scar.
It is designed to produce a vertical post of filler supporting
the lost structure of the scar. The principle employed is that
a relatively small amount of filler is placed deeply with
more and more filler injected in a purely retrograde action
as the needle is very slowly removed towards the surface. If
possible, one should linger just below the surface, produc-
ing a small intradermal bleb. Although the technique is at
its best for rolling and boxcar scars, it is sometimes effective
in sharply marginated scars and even occasionally in ice-
pick scarring. In these latter scar types it seems important to
emphasise the lingering near the surface, filling the scar
very superficially.
This is a rapid and efficient technique with the procedure
completed in less than 15 min and using 0.5–2 mL of
hyaluronic acid depending on the number and depth of the
scars. It is important to premark the scars and remove the
markings after injection. If this is not done, the minor swell-
ing from each injection may make the surrounding skin
appear troughed and chasing these pseudo troughed areas
is not necessary and will detract from the final result.
The efficacy of the treatment is at its best when the scars
are separated, deep or superficial, defined rather than
diffuse and rolling into each other.
This technique offers rapid improvement to many
atrophic scars over two sessions. Is a useful treatment in its
own right and as an adjunct to combine with other therapies
such as resurfacing. The two sessions seem required. The
results from first session include some decline in the
numbers of apparent scars (14%) but more so in individual
scar depth, as evidenced by the decreased volume at total
 The modified tower filler technique
correction. After the second injection the number of appar-
ent scars was markedly decreased (68%) from the initial
count. This was the parameter most noticeable to the
patient and appears to explain the non-linearity of the
result. It also might explain the slight discrepancy between
the investigator and subject evaluation of the global severity
at the time of the second treatment. The evaluator may have
been more objectively been able to assess both volume and
number than the patient, who may have been more con-
cerned that the scars were still individually visible.
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© 2015 The Australasian College of Dermatologists