Subcision®

Subcision® is a minor surgical procedure for improving the appearance of acne scars. It is also called "subcutaneous incisionless surgery.”

Certain acne scars, such as “rolling” or “boxcar” types, have tethering bands below the skin that pull the scar down making it look depressed. Subcision® is a technique that breaks these tethering bands, leading to a more even contour of the skin. Subcision can be safely performed in the outpatient setting and is usually well tolerated.

Subcision was originally described using a special hypodermic needle (Nokor Needle) inserted through a puncture in the skin surface. The sharp edge of the needle cuts fibrotic bands, tethering the scar to the underlying tissue. The main advantage of the Nokor needle is the sharp blade at the tip, which can easily dissect fibrotic bands. The downside is that it requires multiple entry sites and a greater risk of hematoma formation and nerve injury. Sometimes, a smaller gauge needle, such as a 25-gauge or 22-gauge needle is used if the scarring is localized and less severe.

A modified version of Nokor needle subcision uses a blunt-tipped Cannula (18 or 22 gauge). Studies have shown the effectiveness of this technique, with a reduction in the risk of hematoma formation and neurovascular injury. Also, a single-entry point can provide access to treat the entire cheek and temple. Our clinic has never seen any long-term adverse effects with a blunt-tipped cannula. Multiple sessions of subcision are typically required with a cannula since it pokes holes in the fibrotic bands rather than severing them.

A third instrument, the Taylor Liberator® (invented by Dr. Mark Taylor), is a steel instrument similar to a cannula but with one key difference- the tip is notched to snare and divide the scar bands much more effectively. Similar to a Nokor needle, there is a greater risk for bruising, hematoma formation, and prolonged numbness that can last weeks and even months. All numbness eventually resolves. The Taylor Liberator requires a single-entry point to reach all areas of the cheeks, jawline, and temples. Treatment of the forehead, however, would require a second entry point. The use of Taylor Liberator has become a subject of discussion in public chat rooms such as Reddit. Some have complained of ‘sagging’ of the skin after undergoing subcision by Taylor Liberator. Dr. Craig Singer trained with Dr. Taylor, learning the proper technique. If performed in the correct plane, the Taylor liberator will not disrupt deep facial ligaments or cause sagging. However, it is critical that tumescent anesthesia be performed to create a safe plane of dissection.

Subcision is performed with the use of local anesthesia (lidocaine) and sometimes oral sedation. If there is a large area of scar involvement, tumescent anesthesia will be used. The procedure is painless once the local anesthesia takes effect. The numbing involves injecting large amounts of dilute local anesthesia (saline, lidocaine, bicarbonate, and epinephrine) under the skin using a spinal needle. Your cheeks may look like a "chipmunk" for a couple days. Swelling resolves in 2-3 days. However, numbness may persist for several days, weeks, or even months depending upon whether Cannula or Taylor Liberator is used. An entry point in the sideburn is made for both the cannula and the Taylor Liberator which heals without a scar.