Cannula Subcision At A Glance
- Best Results2-5 sessions
- Treatment RecoveryNil to 7 days
- Procedure Time40-60 min
- Skin SpecialistDavin Lim, Dermatologist
- Duration of ResultsLife (if acne controlled)
- AnaestheticSedation, blocks
- Back to Work2-5 days
- Cost$$ Partial Medicare rebate in most cases
Subcision Acne Scars
Subcision is a surgical keyhole surgery for the treatment of deep acne scars. This method immediately ‘releases’ scar tissue attached to deeper facial structures. Subcision is the gold standard for the treatment of deep scars. This procedure is often combined with lasers, peels, energy devices & dermal fillers.
FactsFacts on Subcision Acne Scars
- This is a surgical procedure that addresses scars under the skin’s surface
- Cannulas are preferred to needles as this technique is more effective
- Blunt cannula has much less side effects compared to Nokor needle or needle subcision
- This procedure can be combined with other scar directed therapies such as lasers, microneedling & deep peels
- Downtime following cannula subcision ranges from 2-10 days
- This procedure is comfortable as it is usually performed under mild sedation
What is subcision?
Subcision Acne Scars
Surgical subcision was first reported in 1995 by two dermatologists practicing in New York. This first report was with a hypodermic needle inserted into the dermal – fat layer just below the scar. The needle was then manipulated in a horizontal sweeping action, in turn causing breakage of scar tissue. Since the initial reports, there have been numerous surgical techniques that have evolved including-
- 18, 21, 23 Gauge needles (various sizes)
- 18 G Nokor needles used facilitate cutting
- 18 G to 25 G cannulas designed to sever in addition to delivery of dermal filler-fat
- 12- 16 G instruments (blunt subcision)
I utilise everything from a 12 Gauge to a 30 Gauge, and everything in between. Majority of my cases involve concurrent treatment of superficial scars with other modalities.
Why is cannula subcision more effective than needle subcision?
The majority of dermatologists-plastics now use cannula over needle because;
- Cannula is more effective as bonds are broken in a front back cf side to side motion
- Cannula is safer as the tip is blunt (pushing)
- Cannula can be used to deliver dermal fillers or fat
- Cannula tactile ‘feel’ can be at different levels (subdermal, mid fat, lower fat)
Is the procedure painful?
The procedure is well tolerated by most. For regional (small area) subcision using small cannulas, only local injections containing anaesthetic are required. For large bore instruments, most patients are sedated with muscle relaxants & mild anaesthetic agents. Pain is NOT an issue as anaesthesia is planned prior to the procedure.
What is the recovery following surgical subcision?
This depends on the EXTENT of surgical subcision & typically ranges from 2-10 days. As I am primarily working under, not on the skin’s surface, downtime is kept to a minimum. For small areas of subcision, expect bruising for a day or two. For extensive areas of subcision, expect swelling &/or bruising for just over one week to ten days. I will give you an accurate time frame depending on the projected treatment/s. Restriction of exercise-activity will depend on the area treated.
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How many treatments are required?
The use of cannula subcision has markedly reduced the amount of treatments required. With the older needle subcision method, 5-8 sessions were required to receive a 50-70% global improvement in scars. Cannula & large bore instruments have halved the amount of treatments required to achieve the same results compared to needles.
As a guide most patients require between 2-4 sessions. The rate limiting factor is how one’s immune system responds to stimulation of normal collagen once older scars are broken up by subcision. Some patients efficiently remodel scars in a short time frame, whilst others may take a little longer. If your immune system has difficulty regenerating collagen, dermal fillers or fat transfer may help. See below.
What is ‘atrophy’ and how can dermal fillers help?
Atrophy can be dermal (superficial atrophy), deep (fat atrophy) or a combination of dermal & fat atrophy. This is due to inflammation of acne lesions. The amount of atrophy & the depth depends on your genetic makeup, propensity to scar, severity of your acne, time taken to effective control & absence or presence of picking during active disease.
Procedures including subcision, laser resurfacing, microneedling, radiofrequency, Dermapen, Derma Rollers, Dermastamping, & deep peels all rely on your immune system to remodel scar tissue & generate collagen (also fat, but to a lesser degree). If your immune system can NOT generate enough tissue, dermal fillers can help with the deficit.
There are 2 main classes of dermal fillers, firstly HA or hyaluronic acid fillers. These fillers include Juvederm, Restylane, & Belotero. They last between 18 to 36+ months in the context of acne scarring. The second family of fillers include collagen stimulating fillers, namely calcium hydroxylapatite & poly-L-lactic acid (Radiesse & Sculptra). These fillers work by volume displacement & delayed stimulation of collagen. The decision to use one or the other family is based upon clinical findings. HA fillers are reversible, Radiesse, Sculptra & Bellafill are not. Careful consideration is given to the application of each type of filler based upon age of the patient, amount of atrophy, location of scars, & most importantly age related changes, including fat- dermal thickness of the individual.
A new injectable has been approved for use in Australia in 2022. This injectable is termed biostimulatory, & works by stimulation of collagen.
Will I require dermal fillers if I have subcision?
Subcision has two main functions-
- Release of scar tissue that is adherent to deeper structures.
- Stimulation of collagen called neocollagenesis or fibrosis.
If your immune system is ineffective in stimulation of collagen, you may (as adjunctive therapy) require a helping hand, namely to replace lost collagen with fillers & or to assist your skin’s immune system in stimulation of collagen. This is via soft tissue collagen stimulating injectables. This group of injectables are different from HA based fillers. They include PLLA, PDLLA, CaOH apatite, PCL & hybrid complexes of HA (different from cross-linked HAs).
Fillers are also useful to address chronological ageing & genetic deficits of low facial volume. Both can, in some patients, contribute to the atrophic nature of scarring (indirectly).
How long do dermal fillers last, are there any other alternatives?
As stated, fillers last a little longer than normal in the context of acne scarring. Longevity depends on the type of filler used, the site, & your metabolism.
Another sensible option for large volume correction is the use of fat transfer. This procedure harvests fat around your abdominal area. I then process the fat cell and inject this in the dermal & hypodermis levels. The main disadvantage of fat is that it has unpredictable outcomes. If YOUR immune system absorbs fat, you may need 2-4 sessions. In most cases fat lasts longer than dermal fillers. Another disadvantage of fat transfer is that it lacks the finesse of superficial dermal fillers as the latter is more malleable.
How much is the procedure?
Surgical revision of scar tissue including acne scars is partially subsidised by Medicare. This included acne, traumatic & surgical scars that fall in the ‘severe’ end of the spectrum.
Severe scarring as defined by the Goodman Baron scale of scar classification is as follows. Scars seen at conversational distance, non-distensible, and can not be covered up with normal make up or by the growth of normal beard hair in men.
As a guide each procedure cost between $1900 USD to $3900 USD, depending on the complexity of surgery. Rebate will vary according to the use of item numbers pertaining to the patient’s severity of scarring & associated revision methods.
What will I look like after the procedure?
Depending on the instrumentation, technique, extent of scars, & other factors including bleeding time, dermal thickness & co-treatments, you will be very swollen after the procedure. Frequently I combine laser or RFM treatments on the same day. Expect swelling & bruising to improve within 2-10 days. I will give you an accurate guide as to recovery BEFORE the procedure.
What factors should you consider before subcision?
The most important factor to think about is -’ is this treatment appropriate for your scars?’ I do employ surgical techniques only in cases of severe scarring. This procedure is not suitable for superficial scar types such as monomorphic box car scars or shallow pits, ice-pick scars.
Large instrumentation subcision is akin to key hole surgery of the face & should be reserved for significant cases of facial scars. I do not perform this procedure on objectively mild scars, no matter how subjectively severe you may perceive your scarring to be.
What is Taylor Liberator submission, & is it better?
It’s like asking the difference between a spanner & a hammer- it depends on the JOB itself.
Taylor Liberator is a robust, effective & efficient method of subcision for thick fibrotic scars in the correct presentation (severe subdermal scars, mid cheek, more lateral in someone with a thickish dermal – fat layer). This method of subcision has much less finesse than other methods using finer cutting instruments- think sledge hammer to a nail. It is however more efficient at transaction of severe scars & is called upon if required.
This method of subcsion has POTENTIALLY more side effects compared with cannulas & novel cutting instruments.
Does subcision cause facial laxity?
Again is it akin to asking the question ‘can a pair of scissors cause bleeding? It depends on the context of how it is used & importantly, WHO yields the instrument.
Cannulas are far less efficient than the Taylor Liberator. The leading edge has much less surface area, making cutting scar tissue inefficient (not ineffective, as it requires more time/effort). With enough undermining, any device may transect the reticular cutis, leading to possible (not probable) sagging/facial laxity.
Repurposed cutting cannulas are more efficient compared to blunt cannulas & instruments.
To understand more about this, read our articles published in Dermatology Surgery, 2024.
How to prevent any chance of facial sagging or laxity with subcision?
It’s about executing the correct technique for the patient & not relying on one instrument using the same methodology.
Personalising a revision program for each acne scar patient will reduce the odds of collateral transaction of reticular fibres.
The art of subcision is to control the aggression of the procedure, meaning to restrict high gain, high risk & high cost procedures.
Davin’s take on cannula subcision
This is my go to procedure for the majority of acne scars I see in my scope of practice. I employ all sizes of cannulas & instruments from 12 gauge to 30 gauge sizes. This procedure is akin to key hole surgery, it should be applied accordingly. Most cases are combination treatments as i concurrently address superficial scars with procedures such as lasers, RFM, focal deep peels etc…
All procedures (apart from excision) rely on your ability to generate and remodel collagen. Subcision is primarily aimed at breaking down scar tissue holding or pulling the demis down. There is some element of dermal remodelling due to mechanically induced trauma (dermal or hypodermis scraped). In most cases I perform other treatments such as lasers, RF, RFM & deep peels, when indicated.
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