What is subcision and how does it repair the skin?

Subcision (Subcutaneous Incision Less Surgery) is one of the most specialized outpatient and minimally invasive surgical procedures in dermatology, which was invented with the aim of releasing subcutaneous fibrotic connections. In various types of indented scars, especially deep acne scars, the main factor in the downward pull of the epidermis is the formation of dense and stiff fibrous bands in the deep dermis or subcutaneous tissue. These deformed collagen fibers act as an anchor, keeping the skin connected to the underlying tissues and preventing the skin surface from being smoothed with creams or superficial treatments.

In the subcision procedure, the doctor inserts a special, sharp-tipped needle or flexible cannula beneath these bands, cutting them horizontally and removing them. This not only interrupts the downward pull of the skin, but also initiates two important biological repair events:

Types of scars and clinical symptomatology of candidates

The success of subcision is directly related to the correct diagnosis of the type of scar. Different types of atrophic scars respond differently to this procedure:

People who have active acne with active bacteria, have a history of keloids, are taking anticoagulants, or have taken isotretinoin (Roaccutane) in the past 6 months require more specific evaluations before intervention.

Equipment and methods of the day: Nucor needle vs. cannula

Subcision has evolved over recent decades with the evolution of instrumentation, moving from earlier more invasive modalities to very safe methods with minimal vascular damage.

Currently, the subcision technique with an 18- to 22-gauge cannula has become the preferred method of dermatologists due to the extensive surface coverage from just one or two entry points.

Step-by-step steps of outpatient subcision surgery

This process is carried out in a sterile environment in a specialized office or clinic and based on the following standard protocols:

• Dynamic marking under angled light: Indented scars are not visible in direct light; therefore, the doctor uses tangential light to outline the boundaries of fibrotic junctions.
• Local anesthesia and tomicant infiltration: Injection of tomicant solution (containing lidocaine, epinephrine, and normal saline buffer) in addition to completely eliminating pain, causes vasoconstriction and inhibits bleeding and hematoma.
• Instrument insertion and fan-shaped incision (Fanning Technique): The instrument is guided horizontally and at a slight angle parallel to the skin surface into the dermo-subcutaneous depth. The continuous butterfly motion causes the tough fibers to rupture, and the cracking sound of these fibers is evidence of the end of the tensile tissue graft.
• Hemostasis and compression: At the end of the procedure, excess blood is gently drained and gentle pressure is applied to the site along with a cold pack to prevent the hematoma from spreading.

Complementary combination therapies for maximum efficiency

One of the most fundamental strategies in modern dermatology is to combine subcision with other reconstruction methods, as simply cutting fibers without additional stimulation may cause tissue reattachment.

Pre- and post-operative care protocols

The patient's role in complying with health and medication requirements ensures 50% of complication-free treatment outcomes.

Pre-procedure care

• Discontinue blood-thinning supplements (vitamin E, omega-3, garlic, and ginger) and anti-inflammatory painkillers such as ibuprofen or aspirin, in consultation with your doctor, at least 7 days in advance.
• Avoid alcohol and tobacco for 48 hours to prevent excessive vasodilation and long-term edema.
• Avoid using creams containing retinol and exfoliants at least 3 days before the treatment session.

Post-procedure care

• Intermittent use of indirect cold compresses during the first 24 to 48 hours to limit swelling and bruising.
• Keeping the cannula entry sites clean with sterile washing solution and careful use of prescribed antibiotic ointments.
• Absolutely avoid heavy massage, manipulation, or scratching until new tissue has coalesced.
• Avoid strenuous exercise, saunas, hot tubs, and direct sunlight for at least a week.
• Continuous use of broad-spectrum sunscreen (SPF 50+) on treated skin to prevent post-inflammatory spots.

Possible complications and clinical management strategies

Subcision is considered a very safe procedure, however, being aware of the recovery process and common symptoms helps to provide peace of mind and speed up treatment:

• Hematoma and ecchymosis (bruising): This is the most common natural effect and will resolve within 5 to 14 days. Using arnica or bromelain gels can shorten this period.
• Temporary swelling and tightness under the skin: This is caused by the formation of hemostatic clots and collagen stimulation in the area, which usually resolves and softens within a few weeks.
• Post-inflammatory hyperpigmentation (PIH): Occurs more often in darker skin types and is easily controlled with sunscreen, heat avoidance, and melanin-inhibiting creams.
• Superficial infection: Very rare and tends to zero with proper hygiene of the entrances and careful sterilization.