Subcision for acne scars

What is subcision for acne scars?

Subcision is a procedure which releases scars that have become stuck to the deeper tissues and bound down. When a scar forms, new collagen is produced. This collagen is not as supple or as neatly laid as normal collagen. Sometimes, this new collagen can stretch all the way from the scar to the deeper tissues, like a web, and pull the scar down. This makes the scar look more indented and causes shadows, divots and pits. Breaking these connections helps to lift the scar back up.

Our Clinic specialises in scar treatments in London and our doctors have a lot of experience in providing subcision treatments.

What kind of scars does subcision help with?

Subcision helps to improve any condition in which the skin is being pulled downwards by scar tissue. This includes:

  • Rolling acne scars
  • Tethered box-scar acne scars
  • Chicken pox scars
  • Surgical scars
  • Any scar that’s indented or has a depression

What else is subcision helpful for?

Subcision is also useful if normal connections between the skin and deeper tissues are too strong and cause cosmetic issues. Examples include for

  • Deep nasolabial folds
  • Deep marionette folds
  • Cellulite

How is subcision carried out?

We offer two main forms of subcision – cannula subcision and full field subcision under tumescent anaesthesia using the Taylor liberator. Both forms of subcision are performed as an outpatient procedure. In certain circumstances we may also carry out Nokor needle subcision.

How can I tell if I need subcision?

If you have a lot of rolling or box scars that don’t disappear when you stretch the skin or don’t smooth over when you smile. Subcision, especially full field subcision, is also helpful when the changes are only very subtle. Even those that appear to have very little tethering to their scars improve with subcision. This is because there is likely to be some tethering contributing to the depressions, and also the subcision itself may be stimulating new collage formation.

What kind of scars don’t need subcision?

Subcision is not a suitable treatment for ice-pick scars. It is also not a treatment for very red or pigmented acnes scars, stretched scars or keloid scars.

What is cannula subcision?

Cannula subcision is best for small areas that need subcision. As a rough guide this would apply to an area the size of postage stamp. A local anaesthetic injection is first given to make the area numb. A small hole is made in the skin with a needle. A cannula is carried through the hole to just below the skin. The cannula is used to separate the bands of scar tissue that are pulling the scar down.

We have a variety of cannulas of different sizes and lengths and your doctor will choose the most appropriate ones. One of our favourite cannulas for subcision is the Silkann GTI Cannula. GTI stands for Groove Tipped Injection because of the shape of the tip which has a groove. This cannula has been specially made to be able to work through scar fibres. The cannula is relatively blunt so it Is less likely to damage blood vessels and nerves.

Other cannulas used for subcision include the TSK range which have a dome shaped tip and are quite rigid.

A scar may be subsided from one direction. Sometimes a scar is also subsided from a second direction (and rarely a third too) to create a cross hatch. If multiple areas need subcision then full field subcision with the Taylor liberator is carried out.

Subcision Key Points

  • Why – To release tethered acne scars
  • Where – Face
  • Frequency – Once or twice
  • Results – Within a few weeks
  • Downtime – 1-2 days

What is full field subcision with the Taylor Liberator under tumescent anaesthesia?

The Taylor liberator has been designed specifically for subcision. We find this excellent for larger areas of subcision. It is slightly wider and longer than disposable cannulas and does the same thing but on a larger scale. The Taylor liberator has a 3 slightly blunted tips. The tips are able to break through scar tissue. For the cheeks, a small incision that is 3 to 4 mm is made somewhere in the sideburn area on each side. This usually heals without much of a trace. The same entry site can reach the temples, outer forehead, and upper neck. For the central forehead, the incision is made just into the hairline in the middle of the forehead. The Taylor liberator is inserted and runs just under the skin, where the skin touches the fat below it.The two V shaped notches catch any scar tissue within it and the gentle pressure breaks the scars down.

The Taylor liberator subcision procedure is very safe because it is done under tumescent anaesthesia. It is a very advanced technique and only a handful of doctors offer it in the world, as most Dermatologists are not familiar with this form of surgery and with tumescent anaesthesia. If not done correctly, there are risks of causing damage to blood vessels, nerves and deeper structures. The Taylor liberator is kept just below the dermis at all times.

What is subcision with the Nokor needle?

The Nokor needle was one of the earliest devices used for subcision. We offer Nokor needle subcision in cases where the scar is very hard and fibrotic and a very sharp device is required to break through this. The Nokor needle a small, sharp blade on a short needle. Multiple insertion points are required as the needle is quite short. The blade is also very sharp, which means the level of bruising and other side effects is significantly higher. In a study comparing the Nokor needle with a blunt blade, there was significantly more bleeding with the Nokor needle. 28.6% had bleeding with the Nokor needle and 7.1% with the blunt blade.

What is the evidence for subcision?

There is a lot o evidence to show that subcision is a helpful treatment for the right patients. A study of 114 patients with acne scars having full field subcision under tumescent anaesthesia and Taylor liberator subcision, fractional CO2 laser and 20% TCA peel showed a mean improvement of between 50 to 75%. There were no complications of severe bleeding, permanent nerve injury or facial paralysis (See reference 1 below). 90% were satisfied with their results and did not desire any further treatment.

What is tumescent anaesthesia?

This is when a dilute solution of local anaesthetic is used. A large volume of this is used so it gives ‘chipmunk cheeks’. These settle in a day or two. The large volume of tumescent anaesthesia allows the skin to lift off from deeper tissues. This means that the Taylor liberator can glide in the correct plane – which is just below the dermis. The tumescent anaesthetic also means that there is hardly any bleeding during the procedure, and the risk of bruising or a haematoma is very low even if large areas have been treated. The tumescent anaesthesia also firms up the skin – and by making the tissues taut, the procedure can be carried out more effectively.

How does subcision work?

The most obvious way is by breaking down the fibres which are pulling the scar down. The physical action of scraping under the dermis is also thought to stimulate new collagen formation which can help raise scars.

What are the benefits of subcision?

Subcision is the only procedure that can lift scars which have been tethered down. It therefore improves rolling and boxcars.

What are the risks of subcision?

Like any surgical procedure, there are risks. The risks are fortunately not very common. The main risk is of a bruise forming. There can also be bleeding, and if blood is trapped under the skin, then a haematoma may result. Using tumescent anaesthesia keeps this risk to very low levels. Temporary numbness in the subsided areas is common and can last 2 to 4 months. Permanent numbness is very uncommon. Sometimes a temporary nodule may form under the skin – these are thought to be collagen nodules and usually settle on their own or with massage.

What is the downtime after subcision?

With GTI cannula subcision, if a small bruise forms then it may take 2 to 7 days to settle. Most people will go back to work the next day following small areas of GTI cannula subcision. With tumescent anaesthesia the face will be puffy for a day or two, but the risk of bruising is very low. If this does occur it can also take a week to settle. Most people will go back to work in 2 days time after tumescent anaesthesia.

How many times does subcision need to be carried out?

A full field subcision with the Taylor liberator is usually only performed once, but sometimes it can be repeated. Cannula subcision may need to be repeated for different areas of the face, and each area is treated once or twice.

Does subcision needs to be done at multiple levels?

For acne scars, once the skin has been fully separated from the subcutaneous fat, there is no need to keep subcising at deeper levels. This would just increase the risk of damage to vessels and nerves. For deeper surgical scars, an argument can be made for multilevel subcision as the scar runs all the way from the skin to sometimes the bone. It is better to get good single plane separation – at the correct plane – then to go for multiple levels for acne scars.

What is the best timing for subcision if I am also having other treatments done?

Subcision can be combined with TCA cross and punch excision of acne scars. We carry out laser resurfacing or Tixel resurfacing 6 weeks after subcision.

Is subcision ever the only treatment required for acne scars?

Subcision will often be part of a treatment plan that includes other treatment. This is because subcision deals with the scars which are bound down and tethered. Other treatments such as TCA Cross, laser resurfacing and Tixel can be used to improve atrophic scars and make the skin smoother.

Can subcision be carried out while on Roaccutane (Isotretinoin)?

Subcision can be carried out while on Isotretinoin.

How long do the effects of subcision take to show?

The results of subcision can be immediately visible sometime. Usually there is quite a lot swelling from the anaesthetic. This can take a day or two to settle. The results are usually seen with in 1 to 3 months. The skin continues remodelling for upto a year after treatment so ongoing benefit can be seen too.

References

Single Session Treatment of Rolling Acne Scars Using Tumescent Anesthesia, 20% Trichloracetic Acid Extensive Subcision, and Fractional CO2 Laser (2016). 114 patients with rolling acne scars were treated with the Taylor liberator, TCA peel and fractional CO2 laser. This was by the inventor of the Taylor liberator, Dr Mark Taylor, and his colleagues. 90% of patients were satisfied with their final result and did not want to have any further treatments. While subcision was not the only treatment given, it is important to note there were no major side effects such as bleeding or haematoma.

Comparison of Two Methods of Subcision in Acne Scar Treatment (2019). In this small study of 28 patients, one side of the face was treated with the Nokor needle and the other with a blunt blade. There was more bleeding, bruising and haematoma formation with the Nokor needle.

Can Subcision with the Cannula be an Acceptable Alternative Method in Treatment of Acne Scars? (2015).  This small study of 8 patients showed that cannula subcision produced an 88% satisfaction rate and reduced the average number of scars from 24.8 to 12.8.

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