Subcision for Acne Scars
Subcision for acne scars remains as one of my favoured methods for scar revision. This treatment method is a specialist indication for the treatment of tethered, rolling, anchored and bound down acne scars. These scars typically form on the cheeks, chin and temple areas. Remember, the best results one can achieve is to match a treatment method with the scar type. In 8/10 cases, most scar types will respond to surgical subcision better than lasers, and micro needling- even with the newest and latest lasers! This is because the majority of patients will exhibit some form of tethering. This tethering needs to be broken down horizontally, and not vertically. Lasers, derma rollers, micro needling all work on a vertical axis- subcision works on a horizontal axis, cutting the scars that pull down on your skin- this causes a depressed acne scar.
How do I know that subcision for acne scars is the procedure for me?
The most important aspect of treating acne scars is to identify the scar type. Rolling as well as bound down and tethered scars can be visualised by animation. If you smile or animate and if you can see a depression it suggests that the scars are attached to the underlying structures such as the muscle layer and SMAS. These types of acne scars will need to be freed before improvement is seen. Lasers do not penetrate to this depth, even with deep microneedling devices, these bound down scars are often resistant to treatment.
What exactly is subcision?
Subcision was described by two New York dermatologists in 1995. The term subcision for acne scarring means subcutaneous incisionless surgery for skin scarring. In their original report they treated patients at intervals of three to six weeks. The original report described three to six visits would be sufficient for the majority of cases, however, additional visits to treat other depressed sites and partially elevated sites are scheduled at intervals of about four weeks apart. Hence in the original study, the majority of patients received between 3 to 10 treatment sessions.
What types of subcision procedures are there?
In this article I will describe the original subcision technique followed by numerous variations of subcision which have been described over the past three decades. The original subcision technique was with a tri-bevelled hypodermic needle. Needles of 25 to 27 gauge were reported. Since then, various other needle techniques have been described including various blade techniques, Nokor 18 gauge needle techniques as well as varying needle sizes ranging from 21, 18, 23, 27 and also 30-gauge needles. Two techniques were originally described, namely the windscreen wiper technique and the liposuction technique for acne scars. Essentially each of these techniques breakdown the bonds which hold the anchored scars to the surface.
What is the subcision for acne scars with autologous blood technique?
This technique was first described over 20 years ago. It involves subcision but also the use of autologous blood. Blood acts as a spacer that prevents scars from reforming. There are certain advantages with this technique, including better scar results; however, disadvantages include lumps in the area of scar revision. This technique has largely been replaced by other techniques.
What is the subcision for acne scars followed by dermal grafting technique?
This involves making a tiny incision where the depressed scar is. The incision itself frees up and bound down scar. The dermis is first harvested from behind your ear using a CO2 laser. This is then placed into the depressed scar and a suture is placed on top. The acne scar is then left in place for a period of three to four days. This is a good technique for the treatment of depressed as well as atrophic acne scars; however, the downside is that in 10% of cases granulomas may form. This means excision of the area or further intralesional steroid injections. Dermal grafting for acne scarring, together with subcision has largely been replaced, however, it is still a recognised form of therapy as described by Medicare. Medicare subsidies dermal grafting for acne scarring if it is performed by either a dermatologist or plastic surgeon.
What is the subcision for acne scars coupled with PRP?
This technique has been recently described. It involves traditional subcision but the injections of PRP as a spacer. PRP or platelet rich plasma contains many growth factors and cytokines from platelets which are derived from your blood. It acts very similar to autologous blood in the fact that once the anchored or depressed /atrophic acne scar is subcised, PRP is then injected into the area. Because PRP is less viscous than autologous blood, the side effects are much less. This is a good technique; however, more studies are needed to improve the efficacy of combining subcision and PRP in the context of treating acne scarring.
What is the subcision and fillers technique for the treatment of acne scars?
This technique was first described two years ago. To my knowledge, there is only one paper; however, this is my preferred way of treating scarring. Filler is not used as a treatment for the scar itself but as a buffer or spacer. The primary mode of treatment is to actually to free up the scar using subcision. Subcision itself gives permanent results while filler only lasts one to two years at maximum. I place a miniscule amounts of filler, namely 0.05 mL into each subsided scar. This essentially acts are a buffer which stops the bonds from reforming. I have started the research using Volbella but now I am also using various HA fillers from Merz. The results are very similar, the longevity so far is promising as at the three-year mark I am still seeing permanent acne scar correction. The results of this study will be published within the next six months once a cohort of 85 patients are reached.
What is the subcision for acne scarring coupled with vacuum extraction technique?
Once again, this is a novel report whereby vacuum extraction is placed upon the surface of the skin to stop bonds from reforming. This is a novel approach which yields a marginal improvement in subcision for acne scars revision compared to normal subcision. In my opinion, the use of PRP or filler makes more sense and yields more consistent gratifying results from a long-term point of view. It is also more convenient for the patient. I do acknowledge that some practitioners use the vacuum method for subcision and in there hands, it can be an excellent modality.
What is new in the horizon for subcision?
Combination treatments are the go for acne scar revision. Most patients who have acne scars will have a variety of scar types including rolling, atrophic, ice pick scars, together with boxcar scarring. I often perform subcision together with energy-based microneedling using either the Intensif system or preferably the Infini RF microneedling system.
In summary, subcision for acne scars is a very useful modality for the treatment of acne scar types. This is my preferred treatment for acne scarring. It certainly gives more predictable results than laser. I still perform laser surgery including fully ablative laser resurfacing but only for boxcar scarring or scars which lay in the same plane. I also perform fractionated laser resurfacing using various different lasers including profractional, Erbium as well as CO2 lasers. The future for scar revision looks bright as the US is now conducting stem cell research in regard to tissue regeneration for acne scarring. This will help remodel scars and stimulate collagen. There have been many advantages over the past decade in regard to acne scar revision and the future looks bright for patients.
Additionally, the new recommendations were published in 2017, in regard to the use of Accutane or Oratane and fractional devices including subcision shows that these procedures can be conducted safely at the same time. This means patients do NOT have to wait for the 6 to 12 month wash out period before undertaking scar revision procedures. The treatment of early scars, especially early tethered or anchored scars with RF mironeedling, subscision and other techniques can give better as well a less invasive acne scar revision procedures. This means patients do not need to live with the burden of acne scarring. The downside of subscision is that is is highly operator dependent. Realistically in Australia there are only half a dozen Specialist trained competently in this procedure. Subscision is a surgical procedure, having an instrument is one thing, but learning to use it to the best of its ability is another.
What does this mean to patients?
This means that acne scars can be treated earlier and more effectively. Remember, the earlier we get acne scars, the better the results. Prevention of acne scarring yields the best results as patients do not have to go through the pain, expense and downtime of acne scar revision.
Dr. Davin Lim