Acne scars: Subcision
J Piquero-Casals
Dermatologist
Dermik: Clinica Dermatologica Multidisciplinar. Barcelona, Spain
Jaime Piquero-Martin
Dermatologist
Professor Hospital Vargas de Caracas, Venezuela
Introduction
Subcision is a simple and minimally invasive procedure useful for atrophic acne scars 1. This method
involves the use of the Nokor needle, a tri-beveled or very sharp small hypodermic needle that is
inserted into the periphery of a scar2. It is used to free tethering, adherent, fibrous bands from
underlying papillary skin. It releases the epidermis from dermal attachments Fig 1. The controlled
trauma leads to wound healing and to long-term improvements in scar appearance 3-6. Many times is
used in combination with other technique or resurfacing procedures as lasers, punch elevation or
chemical peels7.
Initially described by Orentreich and Orentreich (1995), this technique is based on the rupture of
fibrotic tissue and the trigger of an inflammatory reaction, with bleeding, which culminate in the
production of collagen1.
Material and methods
Nokor needle or a regular 19G needle (could be used several needle size depends the
experience and features of the scar).
Topical cream or pach anaesthesic or infiltrative lidocaine.
Clorhexidine or another antiseptic solution.
Methods and techniques:
The area to be treated is cleansed with micellar solution to remove make-up and antiseptic solution.
The scar margins may be defined with a surgical marker Fig 2.
Topical or infiltrative anesthetic is performed.
Needles with unique characteristics have been used by different authors to perform this technique,
including 19 G, 20 G, 21 G, and 18 G 1.5
The other, more specifically needle, is the Nokor needle, providing specific technical advantages.
An 11-bistoury blade, could be a possibility. The procedure could be repeated in several sessions
depending on the depth and improvement of the scar and could be associate with different other
scars treatment like chemicals peels or ablative lasers. The instruments commonly used for
subcision are wire scalpels and hypodermic needles Fig 3.
The needle is inserted nearly the scar at an acute angle adjacent to the scar and use in a back-and-
forth manner underneath the base of the scar to loosen the fibrotic adhesions that depressed the
scar. A snapping sound is heard, as the fibrous bands are broken. The bleeding and inflammation
created a potential space for future collagen deposition.
Clinical follow-up
1) Immediately after the procedure, is normal to see a local inflammation and sometimes a blood
pocket formation in dermal layer with a clinical small hematoma. This wound healing process lasts
one or two weeks. It could be associated ablative lasers or augmentation fillers to improve the
results with the synergistic effects and to create a more uniform improvement of lesional skin
surface.
2) The collection of blood by the injury, many times causes the black-and-blue color. As bruises
heal, usually within 2 to 4 weeks, they often turn colors, including purplish black, reddish blue, or
yellowish green.
3) Several times is important ice application on the operated site on the day, antibiotics and anti-
inflammatory drugs for 5–7 days if is necessary.
3) The scar remodeling is a continuous process and the results differ at two months and until six
months after subcision.
Side effects, complications, and their management
A small percentage of patients may develop a post-subcision localized fibrous nodule at the site of
treatment.
Haematoma due to bleeding (a small haematoma is normal)
Pain/tenderness of treated sites.
Infection usually presents as localized acneiform pustule. Topical Clindamicine could be useful,
however sometimes systemic antibiotics with antiinflamatory drugs have to be used.
Temporary post-inflammatory hyperpigmentation (advise sun protection/avoidance)
Injury to nerve or blood vessel, which is most likely in mandibular, temporal and pre-auricular sites.
In most of this cases, just explain to the patient and keep calm for the total restitution of the injury.
Tip box
Individual scars should be treated using separate multiple puncture sites.
Patients should be counseled properly about haematoma and bluish discolouration. A sign consent
form to verify that he has engaged in a dialog with a health care practitioner about the procedure is
desirable.
If many scars need subcision, few scars may be treated at a time, like on one cheek to avoid severe
edema.
Procedure is preferably done before a weekend or holiday for working patients.
Subcision is a simple technique, minimally invasive, safe, permanently effective, and economical
office procedure to improve box car and rolling scars of selected patients. It can be easily combined
with other treatments and procedures for acne scars like TCA CROSS technique.
References
1) Orentreich DS1, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction
of depressed scars and wrinkles. Dermatol Surg. 1995 Jun;21(6):543-9.
2) Alam M, Omura N, Kaminer M. Subcision for Acne Scarring. Technique and Outcomes in 40
Patients Dermatologic Surgery Volume 31(3), March 2005, p 310–317
3) Chandrashekar BS Nandini AS. Acne Scar Subcision. J Cutan Aesthet Surg. 2010 May-Aug;
3(2): 125–126.
4) Graivier M. Wire subcision for complete release of depressions, subdermal attachments, and
scars. Aesthet Surg J. 2006 Jul-Aug;26(4):387-94.
5) Goodman GJ. Postacne scaring: a review of its pathophysiology and treatment. Dermatol Surg.
2000;26:857-71.
6) Werschler AlGhamdi KM. A better way to hold a Nokor needle during subcision. Dermatol Surg.
2008;34:378-9.
7) Aalami Harandi S, Balighi K, Lajevardi V, Akbari E. Subcision-suction method: a new successful
combination therapy in treatment of atrophic acne scars and other depressed scars. J Eur Acad
Dermatol Venereol 2011: 25: 92–99.
Index words
Acne scars, subcision, nokor needle, depressed facial scars, intracision, rolling scars, atrophic
scars
