Subcision for Acne Scars: Expert’s Guide to Effective Acne Scar Treatment in Singapore

Subcision for acne scars is one of my favourite methods for acne scar revision.

Let’s dive right in:

What is subcision?

Subcision is a treatment for acne scars in which the doctor uses a tiny needle to free up firm scar tissues that are pulling down your scar. Visible results of this procedure can be seen in 1 session. For best results, several sessions may be required. A combination of lasers and collagen stimulating fillers would also enhance the improvements.

Collagen production is then triggered in areas where fibrotic strands are released. This allows the area to heal, which also leads to the improvement of the scar.

The decision to perform a subcision treatment depends on the scar’s type, severity, and location. Subcision is usually used for treating depressed scars, bound down scars, cellulite dimples, wrinkles, and depressed skin grafts.

What is Subcision Acne Scar treatment?

Subcision Acne Scars treatment is a micro-surgical technique that breaks down skin scars that are depressed and tethered down within your skin. This term subcision for acne scarring means subcutaneous incisionless surgery for treatment of skin scarring. This treatment was first described by two New York dermatologists in 1995.

How does subcision treat acne scars?

Deep acne scars are released and lifted up using a special needle. This special needle is used to manually break down scar tissue that are anchoring down your skin.

Subcision acne scars treatment is performed in clinic and does not require hospitalisation. The subcision acne scar procedure is more than just the mechanical release of the strands of fibrous scar tissue.

In fact, multiple healing processes bring about acne scar improvement. The mechanical action of the needle and release of the scar tissue creates a pocket of blood beneath the skin. Blood vessels which are disrupted during the treatment allows blood to accumulate into the treated area. This blood clot prevents short-term reattachment of your scars and contains growth factors for healing. This creates an environment for collagen regeneration and improvement of your scar appearance over time.

Why is subcision my favourite Acne Scar Treatment?

1. No risk of Post-inflammatory Hyper-Pigmentation (Not a Laser)
2. Visible Results Instantly (versus weeks to months for Lasers)
3. Versatile – Treats almost all scar types

How do I know that this is the procedure for me?

The most important step to treat acne scars is to identify your scar type. 

Rolling scars as well as bound-down and tethered scars need subcision treatment. If you see a depression/ dent when you smile or talk, this means that your scars are attached to the underlying structures such as the muscle layer and SMAS. Lasers cannot penetrate to the depth of muscle layers – not even with deep microneedling devices. Hence, you will need more than lasers to remove these stubborn scars.

You need subcision to release those tethered scars.

What Type Of Scars Are Suitable For Subcision?

Subcision is an excellent treatment option for the following types of scars:

• Rolling acne scars
• Chickenpox scars
• Stretchable scars from injury or surgery

Who Is Not Suitable?

You cannot have this treatment if you have:

1. active skin infection,
2. prone to abnormal skin scarring such as hypertrophic and keloid scars,
3. blood thinners or bleeding disorder as this increases the risk of bleeding during subcision.

How Is Subcision Acne Scars Procedure Performed?

Step 1: Preparation

Your skin is cleansed and your scars are mapped out using a surgical pen. Local anaesthesia is injected to numb your skin.

Step 2: Treatment

We use a variety of needles/ tools catered to the scar type.

1. Sharp needles: Hypodermic 18-23G needle
2. Nokor needle: Nokor needle is a tribevelled needle designed specifically for subcision.

3. Blunt Micro-Cannula: less bleeding and swelling compared to using sharp needles. This is my preferred method. 

As the Key Opinion Leader and Physician trainer for DermaSculpt Micro-cannulas, my proprietary techniques minimise pain and shorten recovery time.

Upon insertion, the needle/cannula is directed to break the bands of scar tissue beneath your skin. You may feeling the ‘plucking’ sensation as the needles breaks away the scar tissue tethering the skin downwards. 

Step 3: Post-subcision recovery

Once the procedure is complete, pressure is applied to reduce bleeding and swelling. A topical antibiotic ointment is applied to prevent infection and encourage scar healing.

What types of subcision procedures are there?

With autologous blood technique

This technique was first described over 20 years ago. It involves subcision and the use of autologous blood. Blood acts as a spacer that prevents scars from reforming. The disadvantage is lumps in the area of subcision scar revision. 

Subcision followed by dermal grafting technique

This subcision technique involves making a tiny incision where the depressed scar is. The incision itself frees up and bound down scar. The dermis is first harvested from behind your ear using a CO2 laser. This is then placed into the depressed scar and a suture is placed on top for a period of 3-5 days.

This is a good technique for the treatment of depressed as well as atrophic acne scars; however, the downside is that in 10% of cases granulomas may form. Dermal grafting for acne scarring together with subcision is rarely used nowadays.

Subcision coupled with PRP

This involves subcision followed by injections of PRP as a spacer. PRP or platelet rich plasma contains many growth factors and cytokines from platelets which are derived from your blood. It acts very similar to autologous blood – PRP is injected into the subcised area. Because PRP is less viscous than autologous blood, the side effects are much less. 

This is a good technique; however, more studies are needed to improve the efficacy of combining subcision and PRP in the context of treating acne scarring. However, PRP is currently not allowed in Singapore for aesthetic treatments.

Radiofrequency (RF) subcision

Radio-frequency subcision involves a blunt cannula that emits Radio-frequency heat. Radio-frequency heat helps to melt old scars and stimulate collagen for enhanced scar healing. There is a small risk of skin burns. Hence, this treatment should be performed by an acne scar specialist.

Subcision and Fillers technique

This is my preferred way of treating deep acne scarring. 

Filler is not used as a treatment for the scar itself but as a buffer or spacer. The primary mode of treatment is to actually to free up the scar using subcision. Subcision itself gives permanent results while filler only lasts one to two years at maximum. When the filler is present, it also stimulates collagen production. I place a miniscule amounts of filler, namely 0.05 mL into each subsised scar. This essentially acts are a buffer which stops the bonds from reforming.

3 common types of fillers used with subcision are:

1. Hyaluronic acid – Juvederm, Restylane, Stylage
2. PDRN – Rejuran S
3. Calcium hydroxyapatite – Radiesse

Subcision under ANGLED LIGHTING

Some acne scars are only seen under angled lighting. Hence, I always do subcision under angled lighting without fail for more accurate subcision and better acne scar removal results.

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FAQ:

How long does it take to recover?

Immediately after the procedure, there will be some redness and swelling that lasts 2-3 days. Pain is minimal post-treatment. Bruising is common after the procedure and will fade in 2-10 days depending on your healing and skin type.

What is the cost/ price of subcision in Singapore?

The price of Subcision in Singapore ranges from $400 for small regions of treatment. Factors which affect price/ cost of subcision scar treatment:

1. Complexity/ Severity of Acne Scar – eg. large areas of deep scarring will cost more
2. Use of Specialised techniques – eg. DermaSculpt Micro-cannula
3. Doctor’s Expertise – ask to see Before/ After results of treatments
4. Addition of Healing Compounds/ Fillers – eg Rejuran S, Hyaluronic Acid Fillers (Juvederm, Restylane, Stylage), Calcium fillers (Radiesse).

Is it painful?

Subcision is well-tolerated by most patients. The treatment is done under local anaesthesia to minimise discomfort.

Are the results permanent?

Yes, the results of Subcision are permanent.

How many sessions do I need?

Generally, 2-4 subcision sessions spaced about 4 weeks apart give the desirable results. This varies among individuals, scar location, scar depth and skin type.

How much improvement can I see after subcision?

The majority of individuals improve in their acne severity by 1-2 grades after 6 months post-procedure. There will be continued scar remodelling 3-6 months after the subcision for acne scars procedure.

Can it be combined with other acne scar treatments?

Mixed acne scarring is the most common form of acne scars. Therefore, combination treatments are necessary for acne scar revision.

Most patients who have acne scars will have a variety of scar types including rolling, atrophic, ice pick scars, together with boxcar scarring. I usually combine subcision together with energy-based devices like the INFINI RF microneedling system.

In summary, subcision for acne scars is a very useful modality for the treatment of acne scar types. This is my preferred treatment for acne scarring. I still perform laser surgery for acne scars but I always combine laser treatments with subcision for optimal acne scar results.

Can I do Subcision while on Isotretinoin (Accutane)?

The latest research shows that it is safe to have subcision acne scar treatment while on Accutane or Oratane. This means patients do NOT have to wait for the 6 to 12 month wash out period before undertaking scar revision procedures.

The treatment of acne scars early means better final acne scar results. Prevention of acne scarring yields the best results as patients do not have to go through the pain, expense and downtime of acne scar revision.

How do I get the optimal results?

The results of Subcision acne scar treatment are highly dependent on the doctor performing the procedure.

How do I find an expert doctor for subcision in Singapore?

1. Find an Acne Scar Specialist

Not every dermatologist or aesthetic doctor specializes in Acne scar removal treatment. You need an acne scar specialist who performs subcision as one of his core acne scar treatments. As the appointed official trainer of DermaSculpt micro-cannula from the US, Dr Boey specialises in Subcision using blunt micro-cannula for FASTER recovery, LESS pain and Less bruising.

2. Ask your doctor for his technique for your scar

Subcision is a highly customized treatment. Your acne scar specialist needs to tell you in detail how he is going to treat each scar using the various subcision techniques.

3. Ask to see Before/ After photos of subcision acne scar treatments

Based on PHMC guidelines, licensed medical clinics and doctors in Singapore are NOT allowed to market Before/After photos. However, an expert acne scar specialist should have many successful before and after case studies.