Taylor Liberator Subcision for Acne Scars; At A Glance
- Best Results1-2 sessions
- Treatment Recovery5-10 days
- Procedure Time20-60 min
- Skin SpecialistDavin Lim
- Duration of ResultsLife (if acne controlled)
- AnaestheticBlocks, sedation
- Back to Work2-9 days
- Cost$$ Partial Medicare rebate in most cases
Taylor Liberator Subcision For Acne Scars
Subcision is a surgical procedure akin to keyhole surgery. It can be performed by dermatologists & plastic surgeons using many instruments including the Taylor Liberator, cannulas, modified blades, Nokor Needle, hook devices, flat instruments & sharp stripping instruments. This procedure is best reserved for severe tethered scars involving facial areas. Subcision is often combined with lasers, RF microneedling & deep focal peels.
FactsFacts on Taylor Liberator Subcision for Scars
- Subcision is keyhole surgery to revise scars
- An entry is made next to scar tissue & an instrument is introduced
- Instruments include cannulas, needles, stripping & cutting tools
- The Taylor Liberator is one such instrument invented by Mark Taylor
- This device can cut & breakdown the most severe of acne scars
- The large diameter & sheer heft is resistant to bending forces
- I reserve this instrument for extreme cases of scarring in the mid & lower one-third of the face
What is surgical subcision?
Taylor Liberator Subcision
Surgical subcision is a procedure that releases attachments to the mid layer of skin (dermis).
The majority of severe acne scars will have tethering that attach scars from the deep fat layer to the lower to mid dermal layer. Think of it as a cord of thick fibrous tissue that pulls the surface of the skin down. Subcision transects this tissue at various levels.
How to tell if you are a candidate for subcision?
Subcision is best reserved for acne scars with deep attachments. In most cases a real time clinical examination is required. Diagnostic clues include-
- Tethering or puckering at rest
- Tethering upon animation (smile, grin, frown)
- Inability to distend skin upon gentle stretching (Grade 4/B scars)
- Fibrosis upon palpation
- The dimple sign-squeeze either side of the scar. If there’s a dimple, there’s probably an attachment to the deep layers of skin
What is unique about the Taylor Liberator?
Surface area & force are the two stand out features of the Taylor Liberator. The heft of this instrument makes it a great device when I really want to break up severe scar tissue. Unlike fine cannulas & needles, the Liberator can withstand the greatest amount of resistance. It is not malleable, unlike cannula & needles.
For severe scars with thick fibrous tissue, I subcise with modified cutting & stripping cannulas ranging from just over 1.0 mm to 4.0 mm surface area. These cannulas allow me to ‘bend’ around a curved area. For scars that have more resistance, I employ the Taylor Liberator.
What types of scars respond best to Taylor subcision instruments?
Rolling, tethered & anchored scars respond best to this procedure. Severe rolling scars located in the middle & lower one third of the face is when I use the Taylor Liberator the most.
In most cases I combine other forms of subcision with the Liberator. This allows fine control of instrumentation based upon the depths of scar tissue.
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How is subcision performed?
Subcision, including cannula, cutting, Nokor, hook, & Taylor Liberator are all performed in an operating theatre. Depending on the instrumentation I deliver adjunctive anaesthesia.
For Taylor Liberator subcision I localise & block the areas. This procedure is conducted under partial sedation. This ensures you are relaxed & pain-free. The procedure takes between 20 to 60 minutes, depending on adjunctive procedures.
Most of my subcision procedures are conducted with other forms of instrumentation including blunt & sharp cannula as well as Nokor (if indicated). Combining different instrument sizes gives the best results.
Is subcision with the Taylor Liberator painful?
No. The procedure is painless. For this type of subcision I normally localise the area with anaesthetic, field block & provide sedation.
Post operatively you may be numb for a few hours. There is no pain after the procedure.
NFI what happened here. True story. No fillers or fat used in this revision
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🔬Skin Science: This is large volume atrophic scars, sure there’s subdermal fibrosis, but chances are there’s more than just collagen loss. Clinically acne took out a sh*t load of adipocytes with the inflammation. My plan years ago was to subcise / RF microneedle then either fat transfer or fill with dilute Ca Oh. After 3 sessions, I lost contact with the patient, he showed up towards the end of 2021. He denied any treatments after seeing me, including dermal fillers
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😲Sometimes the biology of skin is amazing. Given his age & clinical findings, I was certain that this degree of volumetric correction was not possible without a helping hand
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👊🏻No way of explaining this, so don’t expect miracles with this degree of atrophy, call it a fluke of nature💯
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#acne #acnescars #scarrevision #scartreatment #acnescarcure #acnescartips #drdavinlim #dermatoloigstbrisbane #skinscience
Fillers are invaluable in the management of atrophic acne scars. If there is too much collagen & or fat loss due to inflammation, some patients require a helping hand to correct volumetric deficits. In many cases soft tissue fillers accelerate the revision process. Filling in this patient was done over two sessions
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🔬Scar types: Atrophic rolling scars are amenable to fillers, especially if there is significant volume loss. In older patients fillers provide structural support to the overlying scars in addition to traction & countertraction in specified vectors
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⚖️Filler vs Fat: in the context of acne scars, I prefer to correct volume loss with fillers. Smaller volume defects with hyaluronic acid fillers, larger defects with hyper diluted calcium hydroxyapatite & larger defects with poly L lactic acid. I also employ autologous fat if volume loss exceeds 15 to 20 ml. The predictability of fat is the unpredictable nature of adipose resorption
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#drdavinlim #davinlim #PLLAfiller #acnescarcure #skinclinic #scareraser can’t fill #dermatologist #brisbanedermatology #hyaluronicacid #HAfillers #injectors #acnescars #scarrevision #dermalfiller #hyaluronicacidfiller #dermatologistbrisbane #facialanatomy
Multimodality treatment to address atrophic scars in this patient, skin type 3+
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🔬Skin science: Treat scars based upon morphology & merits. The primary scar types are rolling & atrophic. These were treated with subcision. Given the marked tethering I swapped instruments from my usual dovetails to Taylor Liberator (Mark’s device). Adjunctive TCA & CO2 laser resurfacing
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👍🏻Fillers: are an essential part of scar revision, especially in the more mature patient. Fillers can-
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1️⃣Support the overlying scars
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2️⃣Replace collagen & fat loss
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3️⃣Stimulate collagen production
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4️⃣Replace age related volume loss
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5️⃣Provide countertraction by volumetric displacement
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👉My choice in this patient was Ca Oh apatite in a hyper-diluted solution. The after picture was taken 6 months post final revision
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#acnescars #scarrevision #scareraser needs to learn to fill #drdavinlim #davinlim #dermatologistbrisbane #acnescartreatment #acnescartips #icepickscars #boxcarscars #rollingscars #subcision #taylorliberator
🙏🏼Thanks to my colleague dermatologist, @drclarepatterson for referring this patient to me for scar revision, with her help, we got this result. GIve her a follow for skincare tips
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👉This patient: Asian skin type 4. Ethnics scar easier, more prone to PIH. Every cloud has a silver lining. Flipside is that the fibroblast response is more brisk. This mean more efficient scar remodelling & neocollagenesis
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👉Acne: Management by @drclarepatterson 💯
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👉Scar revision: Sharp subcision, 2 levels. CO2 fractional, TCA paint & punches
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👍🏻Today: moped up a few remaining ice picks, next step is polishing with the pico, will keep you posted with the final results
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😎Davin Lim
Dermatologist
Brisbane🇦🇺
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#dermatology #brisbanedermatologist #drdavinlim #davinlim #acnescars #scarrevision #co2laser #fractionallaser #acnetreatment #acneskincaretips #acnescartips
What type of acne scars respond best to lasers?
Superficial scars such as box car, pitted, shallow pick, saucer & undifferentiated scars respond best to lasers, including CO2 & erbium lasers.
I use many types of CO2 lasers, depending on the job. They include the Mixto laser, CORE, eCO2, Ultrapulse Active FX & Ultrapulse CPG. I also use erbium lasers & non-ablative Fraxel lasers, if the job requires these devices.
Objectively mild scars are best treated with lasers & microneedling as well as focal peels. It is important to separate objectively mild scarring from subjectively severe scars.
Can subcision be combined with lasers, peels & other scar revision methods?
Yes. I often employ different instruments during the time of revision. In addition to the Taylor Liberator, I also subcise with 16g, 18g & 22g cannulas. I also use modified cannula & Nokor. My approach is to use many tools to get the job done.
For superficial scars I may also use TCA or Phenol Croton Oil deep peels, erbium & CO2 lasers, in addition to radiofrequency based microneedling.
Can subcision be combined with dermal fillers?
Yes, however subcision has to be focal & not extensive. This means isolated bands & attachments, usually in a one square inch area.
This is because with extensive undermining there will be swelling. This will result in filler migration & dissipation, beyond the boundaries of initial placement.
What is the recovery time following this procedure?
Typically, there will be extensive swelling for up to 4-7 days, depending on the area/s treated. As subcision works under your skin, recovery is limited to bruising & swelling.
In most cases I combine other procedures including lasers, radiofrequency microneedling, deep peels & surgical excisions to address surface changes including box car, ice pick, pick, & polymorphic scar types. Epidermal recovery in this setting ranges from 2-7 days.
Are the results from subcision permanent?
Yes. Once tethered or anchored bonds are released, the results are permanent. A few caveats apply-
- A minority of patients reattach scars. This is usually due to active inflammation, mostly due to subacute – chronic acne. Anti-inflammatories can be useful in preventing attachments.
- Active acne (even the smallest activity) can result in re-scarring. This is why acne should be in absolute remission during & post acne scar revision.
- Volume loss due to age will result in less fat padding & support. This may present at a later stage in life as perceived ‘worsening’ of scars. In this context you only have 3 choices. Firstly, do nothing (age), secondly, consider dermal fillers to replace age related collagen & fat loss, thirdly consider fat transfer.
What are the risks of subcision?
Any surgical procedure carries risks. Subcision with large bore devices including the Taylor Liberator, stripping cannulas, & NOKOR needles are associated with higher risks compared to blunt cannula dissection.
Risks associated with subcision include-
- Infection <0.1%
- Bleeding 5%
- Haematomas 1%
- Fibrosis <1%
- Nerve damage (especially to the mandibular & temporal nerves) <0.01%
How much is the procedure?
Medicare subsides most forms of acne scar revision, including subcision (if performed by a specialist & not a cosmetic GP). NOTE: subcision item number has been revised recently, read this more more.
Rebates apply of the following-
- Surgical subcision for the treatment of Grade 4B scars objectively measured.
- Excision of scars.
- Fully ablative CO2 or erbium resurfacing.
- Intralesional steroid injections of scars.
The following procedures do not carry a rebate-
- Fractional CO2, fractional erbium lasers
- Non-ablative fractional lasers
- Microneedling
- Microneedling radiofrequency
- Pico lasers
- Vascular lasers for early scars
- Microdermabrasion
*Deep focal peels are not defined under Medicare.
Davin’s Viewpoint; Taylor Liberator Subcision
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. The sharper & larger the gauge (diameter/surface area), the higher the incidence of haemorrhage, haematomas & resultant fibrosis.
