Subcision for acne scars

Subcision for acne scars in Birmingham and Solihull

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.

Scar collagen is not as supple or as neatly laid as normal collagen. This new collagen can stretch 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.

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

How is subcision carried out?

Subcision is carried out with a cannula, Taylor liberator, or Nokor needle, depending on the scar type.

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 with very little apparent tethering to their scars may 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 collagen formation.

Which kind of scars doesn’t need subcision?

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

What is cannula subcision?

Cannula subcision is best for small areas that need subcision. 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. Cannulas are relatively blunt. Hence, they are less likely to damage blood vessels and nerves.

What is subcision with the Taylor Liberator?

The Taylor liberator has been designed specifically for subcision. It is slightly wider and longer than disposable cannulas and does the same thing but on a larger scale.

The Taylor liberator has three slightly blunted tips. The tips can break through scar tissue.

For the cheeks, a small incision 5 mm long is made somewhere in the sideburn area on each side. This usually heals without much of a trace.

The Taylor liberator is inserted and runs just under the skin, where the skin touches the fat below it.

The Taylor liberator subcision procedure is safe because it is done under tumescent anaesthesia. It is a very advanced technique, and only a handful of doctors offer it worldwide.

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 is 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, meaning bruising and other side effects are 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 tumescent anaesthesia?

This is when a dilute solution of local anaesthetic is used. A large volume of this is used to give ‘chipmunk cheeks’. These settle in a day or two. The large volume of tumescent anaesthesia allows the skin to lift off from deeper tissues.

The tumescent anaesthetic also means there is hardly any bleeding during the procedure. 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.

Tumescent anaesthesia will numb the treated area and temporarily reduce muscle movements, mimicking paralysis for 8 to 10 hours. It can be difficult to blink or purse lips for this short period.

How does subcision work?

The most obvious way is by breaking down the fibres 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 that have tethered down due to the acne scarring process. It, therefore, improves rolling and boxcars acne scars. The degree of improvement can be in the range of 10-50%.

What are the risks of subcision?

Like any surgical procedure, there are risks which you should be aware of. The risks are fortunately not very common. The main risk is a bruise forming. There can also be bleeding, and a haematoma may result if blood is trapped under the skin. Using tumescent anaesthesia keeps this risk at very low levels. A haematoma may require further treatment.

Temporary numbness in the subsided areas is common and can last 2 to 4 months. Permanent numbness is very uncommon.

Other uncommon risks include the following:

• Nerve damage leading to muscle weakness – an infrequent complication of subcision.
• Infection may occur.
• Sometimes one or many nodules may form under the skin – these are thought to be collagen nodules and usually settle on their own or with massage and time. Sometimes nodules arise from inflammation and can require steroid injection to settle. Occasionally nodules may be long-lasting though this is uncommon.
• Scarring can result from subcision, with hypertrophic or keloid scarring (red lumpy or deep scars) developing at the entry site and at the areas of subcision.
• There can be a colour change in the subcised areas
• Persistent swelling and lymphedema
• Sagging has also been reported

A guarantee of any particular degree of improvement can not be provided, and sometimes there is only a minimal improvement.

What is the downtime after subcision?

With cannula subcision, if a small bruise forms, it may take 2 to 7 days to settle. Most people will go back to work the next day following small areas of cannula subcision. With tumescent anaesthesia and larger areas of subcision (such as the cheeks), the face may be puffy for a day or two. If this does occur, it can also take a week to settle. Most people will go back to work in 2 days after tumescent anaesthesia.

How many times does subcision need to be carried out?

Cannula subcision may need to be repeated for different areas of the face, and each area may be treated once or twice, or more, depending on the severity and extent of scarring. An average patient may require between 2 to 3 subcision treatment sessions.

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

Subcision can be combined with TCA cross and punch excision of acne scars. We carry out  Tixel or laser resurfacing a minimum of 3 weeks after subcision.

Is subcision ever the only treatment required for acne scars?

Sometimes, a course of subcision alone may be the only treatment needed.

However, subcision will often be part of a treatment plan that includes other treatments. This is because subcision deals with the scars which are bound down and tethered. Other treatments, such as TCA Cross, fractional laser resurfacing, and fully ablative laser resurfacing, can 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 in certain circumstances. For the majority, it is carried out a few months after coming off Roaccutane (Isotretinoin).

How long do the effects of subcision take to show?

While the results of subcision can be immediately visible sometimes, it usually takes 2 to 4 months for results to be apparent. As the scar tissue continues to remodel, further results can be seen for up to a year after treatment.

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.