This is a very useful instrument if the job calls for it. I cannot understand how some surgeons advertise that they are the only one in the country performing this procedure. It is like a carpenter advertising they exclusively use a sledgehammer for every job. 

The Taylor Liberator is indicated for severe acne scars with marked tethering in the hypodermis. Subcision is much better (more extensive, easier, more efficient) with the Liberator in this context. I employ very large volumes of hydro dissection tumescent as this provides an easier & much safer plane. Most of my subcision procedures are in at least 2 levels, with finer instruments in the upper & lower most level.

One has to be mindful of potential side effects including intra & post-operative bleeding with any form of subcision. Thesharper & larger the gauge (diameter/surface area), the higher the incidence of haemorrhage, haematomas & resultant fibrosis.

OK, what about facial laxity & retaining ligaments? I acknowledge everyone is an expert on Reddit, & they all have their own viewpoints, but here is mine. Here is the proposed pathology & possibly a method of reducing the incidence of this side effects.

1. Pick the patient that requires this procedure. Not everyone requires this instrument. I do employ it for extreme scarring in patients with a thick dermal – subcutaneous layer. In most cases I use a finer cutting instrument. It is balance between efficient operating times, vs side effects vs results.
2. Subcision is a procedure of controlled aggression. The extent (depth, area covered) is controlled by the surgeon. For extensive scarring in patients with possibly lower facial volume or bulk or those who are predisposed to age related laxity (eg. patients over the age of 30, higher facial volume), consider subcision as a 2, possibly 3 step procedure. High yield, high cost, higher risks. Simple as that. Does it target or cause collateral damage to the true retaining ligaments? No, as the depth of subcision is at level 2 (subcutaneous). Dive deeper, & the answer is that it can knock out the mandibular, as well as the zygomatic retaining ligaments at the base,  & at the same time take out the facial nerve (mandibular area). Hence for the intended level of dissection, subcision is safe (relatively). Here is the catch, if one has extensive subcsion (surface area) the retinicular cutis (branches of both true & false ligaments) is compromised. The greater the surface area, the more extensive the dissection. Think of it as transection of the upper branches of a tree. This flows on on to point 3.
3. Swelling is universal. Post subcision swelling is dependent on a). extent of subcision, which can be related to efficiency of instrument, acknowledging that if one employs an inefficient instrument like a blunt 22 gauge cannula b). pre-op methods to reduce swelling (we all have different ways to do this). c). post operative methods to reduce swelling, compression, anti-inflammatories, photobiomodulaiton etc… In some, but not all cases, laxity maybe due to prolonged swelling.
4. Predisposed patients. We know that acne causes inflammation, & in some cases inflammation causes ‘damage’ to the lymphatics & their drainage. Think metophyma, mid facial swelling- solid oedema, rhinophyma & other phymas. This has been known for over 5 decades, so it is not a new concept. Active acne (it’s absolute not relative) can also cause this phenomenon. When things align, namely patients with an already compromised lymphatic system, combined with active inflammation, & the recent insult of soft tissue swelling due to subcision, can all lead to the physical signs of prolonged swelling, which is gravity dependent. The result? Sagging.
5. Combine factors 1, 2, 3 & 4, & there you have it, facial sagging. With prolonged swelling, plus the factors described above, the fibres of the reticular cutis may heal up in a translated position, namely more inferior as compared to their usual position (it is not rocket science). Hence sagging ensures.

How to mitigate or more correctly how to reduce the chances of side effects including facial laxity & prolonged swelling?

1. Use an instrument when it is called for. Not all cases require the Taylor Liberator. I frequently subcise with a multitude of instruments (Refer to the article I published in 2023).
2. Control the extent and aggression.
3. Pre, intra-post op. swelling mitigation measures (a whole new topic).
4. Identify patients at risk, high facial volume, age, those who have active acne. Another concept to understand (it’s really not rocket science) is the fact that if we treat 30 patients in their early to late 30s, at least 2-4 will have unrelated facial ageing (it’s cyclical) during the time of healing. Hence it’s all about the odds.

In summary, I do not believe the focus should be on an instrument alone (though I can see the logic of the cause & effect of say a ban on assault rifles as an analogy with the Taylor Liberator).

I digress for this topic. The AR platform has been the number one weapon of choice for mass shooters. Banning it will reduce the number of shootings, acknowledging that there are probably better weapons out there that can do more damage, example a modernised AK 47, or even a high powered optic on a SCAR Heavy chambered in 308 with someone trained to deploy it, or even a G36 used with precision. The flip side is that the AR is an excellent platform to execute a job conducted by professionals when it is called for. Hence, don’t focus on the instrument, focus on the user. I still have my Taylor, but use it carefully when it is called upon. In most other cases, there are even more efficient instruments I employ to get the job done.

Davin Lim