Questions on divots in the skin.

A lady messaged you about divots in her face from poor Thermage. You added an asterisked note suggesting she wait 6 months for her skin to self correct before attempting fillers, etc. Will the face self-correct? Have you experienced someone having a divot that self-corrected? I ask because I read several conflicting suggestion to frequency of treatments. Some said once a week was best for the first few treatments. Another said no more than once a month. I have a spot on a bracket that now has new fine lines and stays indented if I push it there with a fingertip. I had four treatments over the course of 4-5 weeks. I assume divots are from fat loss because the facial rf was too high or deep. What is the highest numbers fr should be on face? Pretty sure she used numbers like 22-27 at one point. My face was slightly swelled from the first session but the other three sessions left no sign several minutes after the treatment, although I was burnt above my lip. I see no divot there, though. Is it logical to conclude it should be a divot there where it burnt the most?

At we are definately getting more questions on this topic.  Let’s talk about this because it’s causing worry and concerns.  But to reassure, divots are created by many things….and most of them are temporary and will self correct.  A divot is a small depression in the skin.  Divots can be temporary or permanent.  Once permanent some people may refer to them as a scar.  Acne scarring is the most common cause of permanent divots on the face.

What can cause divots?

  1. Skin biopsies, and skin cancer surgeries.  For example, if I need to biopsy a patient’s nose and the problem goes fairly deep. To get an adequate biopsy for our pathologist, I made take enough tissue to create a divot.  Often that divot can be corrected over time. See below.
  2. Injecting anti inflammatory meds like Kenalog into acne lesions.  These can cause a temporary (or occasionally permanent) divot that will often correct itself over time, because the volume loss is in the dermis and it will regenerate.
  3. Acne.  When acne is healing it will often cause temporary discoloration (post inflammatory hyperpigmentation or PIH).  When acne starts to cause divots or scars, it’s more concerning. So please see a doctor, preferably a dermtologist, right away.
  4. Infections.  For example, if someone let’s their dog sleep on their bed after a CO2 laser (we tell them not to :)), they may get an infection.  Certain bacteria, for example, will burrow into the skin and leave a depressed divot that is a scar and can be permanent.
  5. Radiofrquency procedures like Thermage, or Ultherapy as mentioned above.  If the skin is too thin, or the energy is too high the fat underneath may “melt”.   Or in a few instances the cells may die.  Usually the fat cell is just damaged and the fat leaks out causing a divot. The cell membrane will repair itself, and the fat can reaccumulate.   This process can take 3-6 months.
  6. There are many, many other causes of divots in the skin including certain disease processes.

What to do if you think you have a divot?

  • See your dermatologist right away to determine the cause of the divot first!  Different types may need no treatment, or treatment right away!
  • So yes, many times divots are temporary and will self correct in 6 months as the cells repair themselves and regenerate.  This is true both in the dermis where more collagen is created.  And also in the fatty layer if the cell was just damaged and leaking, but not dead. Often the best approach is to allow the body’s natural healing ability to take place first, in my opinion.  But you need a correct diagnosis of the cause first!
  • Acne scarring is a different process and if there are divots, needs attention from a doctor right away.
  • We don’t recommend Thermage any closer than every 3-6 months.  You won’t see full results from the first one for 3-6 months, so what’s the rush?   Sometimes just being patient saves time and money for you.
  • Settings for all anti-aging technologies are best customized for each patient, so it’s really not possible to comment on those.

Hope this helps,

Dr. Brandith Irwin

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