Boston Cosmetic
Boston Cosmetic

















Boston Cosmetic


Subcision and Excision in Boston

shutterstock_119151157[1]Skin texture irregularities such as acne scars, cellulite, traumatic scars and deep facial lines or folds tend to cast unflattering shadows and age the appearance of skin. Subcision is a simple and safe office surgery procedure performed by Dr. Edwin Ishoo for treatment of depressed lines and scars. It can easily be combined with other treatments such as dermal fillers and fat transfer, LASER resurfacing, dermapen and scar revisions for maximum efficacy.

Subcision is a treatment for pitted scars such as atrophic acne scars, skin folds such as nasolabial folds and irregularities such as cellulite where the scar or bands tethering the skin down are freed from the underlying tissue, allowing it to float back toward the surface of the skin and creating a smoother visual appearance. The procedure is performed in our Boston or Marshfield offices. After the site heals, people can receive skin treatments to make the scar itself smoother and less visible.

Limited Scar Subcision Technique (Traditional Subcision)

In Dr. Ishoo’s experience, regular subcision works best with rolling acne scars and nasolabial folds. Rolling acne scars have normal skin over the rolling scar, but have fat loss due to cystic acne that burst and caused fat loss under the skin. The traditional subcision technique works best when the tissue loss is under the skin within the subcutaneous fat, and the collagen build up from the blood clot is in the subcutaneous layer.

subcision Surgery for Acne Scars from Dr. Ishoo on Vimeo.

Many patients can undergo the procedure on the date of their first consultation with Dr. Ishoo. After discussing the procedure with his patient, Dr. Ishoo applies a topical numbing gel to reduce any discomfort associated with injecting the local anesthetic. After injecting local anesthesia, Dr. Ishoo uses a hypodermic needle to puncture the skin and undermine the outer layer of skin, thereby releasing it from the facial tissue. Using a back and forth motion, Dr. Ishoo is able to break the fibrous tissues causing the indentation. The procedure takes no longer than 15-20 minutes and has minimal discomfort associated with it. There is about a week of recovery time with patients experiencing bruising, swelling, and redness for a several days following the procedure.

The more bruising the patient experiences, the better this procedure seems to work. If there is too little bruising, the improvement is less. Why? After the scarred area is untethered, the skin needs to pop up. However, without a “spacer” of filler, fat, or a blood clot, the untethered skin can simply heal back into the depression. The result is less visible improvement compared with a subcised area where sufficient bruising and bleeding resulted in a large enough blood clot to keep the skin untethered.

Large Area Scar Subcision (Laser-assisted subdermal release)

In patients with extensive deeply indented face or body acne scarring, large traumatic scar or extensive cellulite, Dr. Ishoo can perform a minor surgical procedure to release the scarred down pits and folds and make them less indented using an nd:yag LASER fiber introduced under the skin after a solution of dilute anesthetic is injected in the area to cause lysis of the fibrotic attachments tethering the dimpled scar to the underlying tissue. Dr. Ishoo uses the Smartlipo Triplex LASER machine for this treatment in his joint commission accredited surgical facility. This procedure can be combined with autologous fat transfer, PRP and dermal fillers to improve volume as well as dermapen, fractional LASER skin resurfacing and plasma or serum topical treatment to further improve skin texture in a large area such as entire face, back, thighs or chest.

Subcision with Fillers or Autologous Fat Transfer

Injecting acne scars and nasolabial or marionette lines with fillers or person’s own fat can be a very satisfying procedure with relatively minimal downtime. However, because scars and skin septae may tether down the skin, some of these indented scars cannot be smoothed out with filler alone. Because the center portion of the indented acne scar is tethered down with collagen fibers, the filler tends to extrude around the tethered area to create a “doughnut effect.” In other words, the indentation barely improves, and the edges of the acne scar become filled and rise up higher, worsening the overall appearance.

In these cases, some subcision is helpful in untethering the collagen fibers to allow the filler to lift up the central portion of the indented scar. Without subcision, the filler does not have enough “hydraulic” pressure to push out the indentation. Typically Dr. Ishoo will attempt to conservatively fill the indented acne scars, and if the scar does not lift easily, Dr. Ishoo will perform some light subcision with the same small needle used to inject the filler to release the collagen fibers before adding more filler. This helps avoid the “doughnut effect.” This technique allows patients to experience the benefits of subcision with relatively little recovery time.

Subcision of Acne Scars – Before & After from Dr. Ishoo on Vimeo.

Punch Excision

Alternatively depressed scars can be treated with punch excision of the most depressed and tethered segment after which, the defect may be filled by a punch graft. Harvested from another area, commonly the post auricular sulcus, a punch graft is pressed into the created defect and either sutured or glued in place. Punch grafting creates a secondary defect and risks poor color and texture match between donor and recipient sites. However, by filling the dead space at the excision site, punch grafting may reduce the likelihood that scar excision and closure will fail because of excessive tension in the closure.

An Effective Approach to Cellulite Reduction

Cellulite is a skin change that appears as dimpling in the thighs and buttocks. This is frequently genetic. The dimpling is the result of tension placed on the skin by fibrous bands that course through fat. Manual or LASER – assisted (using Smartlipo Triplex – Cellulaze) Subcision is an effective, long-term treatment option newly available to our patients that is used to achieve long-term improvement of the appearance of cellulite. Dr. Ishoo performs this process in the Boston Cosmetic Surgery Center facility using tumescent local anesthesia. In certain cases when the dimple is deeper, we usually combine subcision with fat injection or PRP for better results. Recovery is fast with minimal downtime. Bruising is fairly common, which could take up to a week to resolve. Otherwise, the patient can return to normal activities within the same day.

Subcision and Excision Frequently Asked Questions

What is subcision?
Subcision is a minimally invasive surgical procedure performed where a needle is used to puncture through the surface of the skin and cut the fibrous scar tissue pulling down the surface skin. This allows the skin to be lifted since it is not bound down anymore.

How is Subcision performed?
In a subcision treatment, Dr. Ishoo administers local anesthesia for your comfort before using a fine needle to cut through the bands of fibrous tissue attaching the scar to the underlying fatty tissue. Instead of being bound to that tissue, the scar will float freely. Over time, the space underneath will fill, pushing it up to the level of the surrounding skin. People can inject a small amount of filler underneath the scar to speed this process.

What can be treated with subcision?

  • Atrophic Acne scars such as rolling and Box car scars
  • Traumatic, depressed scars
  • Facial folds such as nasolabial and marionette lines
  • Cellulite
  • Stretch marks

Can I bruise after a subcision procedure?
Yes. Bruising after the procedure is not only expected but also desirable for better results.

How many subcision sessions do I need to see results?
This depends on what is being treated. Typically, several sessions of subcision are required for acne scars to achieve satisfactory results, whereas, cellulite or nasolabial folds may only take one to two treatments. The results will be better if subcision is combined with other treatments, such as dermal filler or fat injection.

Can subcision be combined with other procedures, like CO2 laser resurfacing?
Yes. Dr. Ishoo typically performs the subcision procedure 2 weeks prior to the Fraxel LASER resurfacing.

Can I have subcision for rolling and boxcar scars?
Yes. Subcision will work for rolling and boxcar scars. The goal of subcision is to remove the fibrous bands that are pulling down the skin and causing the depressed scars.

Can I have subcision for icepick scars?
Subcision will not work for icepick scars. TCA CROSS technique is the gold standard treatment for icepick scars. In this technique, TCA 80% is applied sparingly in the icepick scar and let it frost. This will induce collagen production in the scar and lift it up.

What is a saline injection technique?
Saline injection is form of a subcision, where bacteriostatic saline in injected within the skin. The act of injection will stretch out the scar. When this process is performed multiple times, the act of stretching the scar will ultimately loosen up the scar underneath the skin, thus allowing the skin to rise.

What is Cellulaze?

This is a LASER-assisted subcision technique performed using the 1440 nm Nd-Yag wavelength to cut the fibrous bands creating cellulite. It can be combined with LASER lipolysis; PRP and post-operative Velashape treatments to further improve skin smoothness and tone.

Subcision treatments are performed at Boston Skin Essentials and Cosmetic Surgery Center by Dr. Edwin Ishoo as a stand-alone treatment or in combination of other advanced modalities for the treatment of depressed scars or fold including acne scars, cellulite and deep nasolabial folds. Dr. Ishoo has extensive expertise and experience, having performed thousands of facial rejuvenation, acne scar treatments and body contouring procedures. To find out if you are a candidate for subcision treatment contact Boston Skin Essentials.