Step-by-Step Procedure for Subcision in Acne Scars
Subcision is performed by inserting a needle or cannula beneath the scar to release fibrous bands tethering the dermis to deeper structures, with the procedure requiring proper patient preparation, precise technique, and post-procedure management to achieve optimal outcomes. 1
Pre-Procedure Preparation
Patient Selection and Assessment
- Identify appropriate scar types: Subcision works best for rolling scars, followed by deep boxcar scars, while ice pick scars respond poorly 1, 2
- Map and mark all treatment areas with skin-safe single-use markers before beginning 3
- Document baseline scar severity using photography with patient consent 3
- Assess for contraindications including active infection, bleeding disorders, or anticoagulant use 1
Anesthesia
- Apply compounded topical anesthesia (pharmacy-based, not over-the-counter) for at least 30 minutes prior to the procedure 4
- Completely remove all anesthetic cream before starting to avoid interference with the procedure 4
- Consider nerve blocks or local infiltration anesthesia for larger treatment areas 1
Subcision Technique
Instrument Selection
Use a 23-gauge needle for standard subcision, or alternatively an 18-21 gauge cannula for reduced trauma and fewer perforations 1, 5. The cannula technique requires only single perforation on each side rather than multiple entry points, reducing pain and scar risk 5, 6.
Execution Steps
Entry point creation: Insert the needle or cannula at the scar edge at approximately 45 degrees to the skin surface 1
Undermining technique: Advance the instrument in a fan-like pattern beneath the scar, using a back-and-forth sawing motion to release fibrous attachments 1, 2
Depth of undermining: Work in the superficial dermal plane, just beneath the scar base, avoiding deeper structures 1
Coverage: Ensure complete release of all tethered areas by working systematically across the entire scar 2
Endpoint assessment: Adequate subcision is achieved when the scar surface elevates to the level of surrounding skin 1
Post-Subcision Management
Immediate Post-Procedure Protocol
Begin suction therapy on the third day after subcision for any scars that remain flat or begin depressing 1. This critical step dramatically improves outcomes:
- Start suction on day 3 post-subcision for scars showing early recurrence 1
- Continue suction at least every other day for minimum 2 weeks 1
- Patients who follow this protocol achieve 60-90% improvement (mean 71.73%) versus only 30-60% improvement (mean 43.75%) in those who delay or have irregular suction sessions 1
Expected Recovery Timeline
- Local edema and bruising are transient and resolve within days to weeks 2
- Most improvement becomes apparent within 3 months as neocollagenesis occurs 5, 6
- Cannula-based subcision demonstrates less inflammation and erythema with faster recovery compared to needle technique 6
Combination Therapies for Enhanced Outcomes
Adjunctive Treatments
Combining subcision with concentrated growth factors (CGF) or platelet-rich plasma (PRP) produces superior outcomes compared to subcision alone 7:
- Apply CGF/PRP immediately after subcision into the undermined space 7
- The combination shows significantly greater ECCA score reduction and higher patient satisfaction 7
- Side effects include increased ecchymosis and pain, but these resolve within acceptable timeframes 7
Microneedling Integration
- When combining with microneedling, perform subcision first, then apply platelet concentrates before microneedling to allow deeper penetration 4, 8
- Use microneedling depth of 1.5mm for acne scars 9
- Schedule combination treatments 1 month apart for 3-4 sessions 4, 9
Treatment Expectations
Efficacy by Technique
- Standard needle subcision: Mild improvement in 60% of patients, moderate improvement in 40% 2
- Subcision with suction protocol: 60-90% improvement in depth and size, with 28.2% achieving excellent (≥80%) improvement 1
- Cannula-based subcision: Good to very good improvement in 88% of patients after 2 sessions, with >50% lesion reduction 5
- Subcision with CGF: Superior ECCA score reduction compared to subcision monotherapy 7
Common Pitfalls to Avoid
- Inadequate follow-up suction: Failure to implement the suction protocol results in high recurrence rates and suboptimal outcomes 1
- Delayed suction initiation: Starting suction late or using long intervals between sessions reduces efficacy from 71.73% to 43.75% improvement 1
- Wrong scar type selection: Ice pick scars respond poorly; focus on rolling and boxcar scars 1, 2
- Insufficient undermining: Incomplete release of fibrous bands leads to persistent tethering 2