How to Optimize the Outcome of Subcision in Acne Scars?

Dr. Neha Chaitanya Shukla

MBBS, MD

Consultant

Dermatologist, Cosmetologist and Laser Surgeon

EYE and SKIN Plus Advance Hospital

Gandhinagar, Gujarat

Introduction

Acne scars are the most common sequele of the inflammatory process of acne and affects almost 95 percent of the patients with acne vulgaris.

Hypertrophic scars and keloid scars result from excessive tissue formation; atrophic scars are characterized by loss or damage of tissue, which are further categorized into ice pick, rolling, and boxcar scars. Sometimes the skin loses its underlying support and develops fibrous bands of tissue between the skin and subcutaneous layer, which pull on the epidermis and cause a wavy texture called as rolling scar.

The principle of subcision is to break the fibrotic strands, which tether the scar to the underlying subcutaneous tissue. The depression is lifted by the releasing action of the procedure, as well as from connective tissue that forms during the course of normal wound healing.

Objectives

3 groups of patients with predominantly rolling atrophic acne scars treated with

• 18 gauge nokor needle subcision

• 18 gauge blunt cannula subcision

• Combination of both

The three groups were evaluated thereafter to

• Compare efficacy

• Compare safety

• Compare patient comfort

30 patients with predominantly rolling atrophic acne scars were divided into 3 groups of 10 patients each for 3 sessions of treatment at intervals of 6 weeks-

• Group A- needle subcision

• Group B-Cannula subcision

• Group C –Combination subcision

Assessment of results and adverse effects in each group was done at end of 6 weeks.

How to Optimize the Outcome of Subcision in Acne Scars?

Preoperative requirements

Eutectic Mixture of Local Anesthetic, Marker,Normal Saline, Lignocaine With Adrenaline, Blunt Cannula, Insulin Syringe, 18 Gauge Needle, 2.5 Cc Syringe, Sterile Water, Moisturizing Cream, Topical Antibiotic Cream.

Patients were evaluated using the following scores at end of 6 weeks.

Grade Level of disease

Clinical features

1 Macular Erythematous, hyper-or hypo-pigmented flat marks, with no contour issues.

2 Mild

Mild atrophic or hypertrophic scars that may not be obvious at a social distance of 50 cm or more, and maybe covered adequately with makeup, or the normal shadow of shaved beard hair in men or normal body hair if extrafacial.

3 Moderate

Moderate atrophic or hypertrophic scarring that is obvious at social distance of 50 cm or more, not covered easily by make-up, or normal shadow of shaved beard hair in men or normal body hair if extrafacial, but is still able to be manually flattened by skin stretching if atrophic.

4 Severe

Severe atrophic or hypertrophic scarring that is obvious at social distance of 50 cm or more, not covered easily by make-up, or normal shadow of shaved beard hair in men or normal body hair if extrafacial, and is unable to be manually flattened by skin stretching.

Grade (type)

1-10

A Milder scarring-macular erythematous, pigmented, mildly atrophic, dish like 1 pts

B Moderate scarring-moderately atrophic dish like, punched out small scars with, shallow bases but atrophic areas (<5mm>) 2 pts

C Severe scarring-punched out with deep but normal bases, punched out with deep abnormal bases, linear or troughed dermal scarring, deep and broad atrophic areas

D Hyperplastic papular scars

3 pts sq-6

VISUAL ANALOG SCORE

Area sq-12 pts Area >20 cm sq–18 pts

Results

At the end of treatment, improvement qualitative acne scar grades, Goodman and Baron’s quantitative acne scar scores, physician global assessment and visual analogue scale were significantly higher in patients treated with a combination of nokor needle subcision and blunt cannula subcision as compared to the remaining two groups, while the post procedure side effects were minimal in the group treated with blunt cannula subcision.

These findings were in concordance with previous studies published regarding blunt cannula subcision, mentioned in refrences during my presentation, which concluded that Cannula subcision appears to be a safe and practical technique that can enhance the efficacy of subcision without considerable complications.

One such study was done by Nilforoushzadeh MA, Lotfi E, HeidariKharaji M, Nickhah N, Alavi S, Mahmoudbeyk M. Comparing cannulabased subcision with the common needle method: A clinical trial.

Skin Res Technol. 2020 Jan;26 (1):39-44. doi: 10.1111/srt.12761.

Epub 2019 Aug 1. PMID: 31373077.

Its results showed that Subcision using the cannula showed good and very good improvement in about 83% of patients (n = 50, P < .05) based on dermatologists investigation and almost no side effects were observed in compared with needle subcision.

Adverse effects of subcision with blunt cannula-Post procedure edema

Adverse effects of subcision with nokor needle-Post procedure Crusting, erythema, echhymosis mean/avera difference b grou A(no need subcis p kor le ion) grou (bl can subc up B unt nula ision)

Considerin needle su g the compli bcision for ac ications and s cne scar treat atisfaction ra ment group noko and can sub tes, Blunt Ca

C (both r needle blunt nula cision) nnula Subcis treatment a scores efficient tha t ment

Considering the complications and satisfaction rates, Blunt Cannula Subcision was more efficient than needle subcision for acne scar treatment

Figure 1:

Goodman’s B

Baron’s quant itative score improvemen t after treatm ion was more ent ge of the etween pos nd pre treat n

Figure 1: Goodman’s Baron’s quantitative score improvement after treatment verage of the visual ana log scores

B (blunt nnula cision) gr n Axis Title avera oup C (both okor needle and blunt cannula subcision) oup C (both okor needle and blunt cannula subcision) score for t ee groups the improve ana 3 ) group C (b needle a cannula

.8 oth nokor nd blunt subcision) average of scores groups he three

.8 oth nokor nd blunt subcision) average of scores groups average three g he three hree groups average three g the visual ana of the scor roups the visual ana of the scor roups log e for the log e for the

Figure 4: Physician’s global assessment score for the improvement in the three groups ment in the t group A (Nokor needle Subcision) group B (Blunt cannula subcision group C ( Both nokor needle and blunt cannula subcision

Formation

group A (Nokor needle Subcision) group B (Blunt cannula subcision group C ( Both nokor needle and blunt cannula subcision

Edema Erythema Echhymosis Nodule Formation

group A (Nokor needle subcision group B (blunt cannula subcision group C (both nokor needle and blunt cannula subcision pain during the procedure burnin sensation immediately towards the end of the procedure feeling of heaviness during and immediately post procedure group A (Nokor needle subcision average recovery period (in days) group B (blunt cannula subcision group C (both nokor needle and blunt cannula subcision group A (nokor needle subcision group B (blunt cannula subcision group C (both nokor needle and blunt cannula subcision pain during the procedure overall poor patient cooperation burnin sensation immediately towards the end of the procedure feeling of heaviness during and immediately post procedure overall poor patient cooperation average recovery period (in days)

Discussion

Needle Cannula Both

Useful in shallow rolling/ box scars.

Useful for very deep rolling scars, by releasing the tethering fibres from the subcutaneous tissue.

Multiple entry points for anesthesia as well as subcision. Single entry point for anesthesia as well as subcision.

4-5 days downtime. Almost no downtime.

Useful for all kinds of rolling scars, deep as well as superficial, as double layer subcision focuses on subcutaneous as well as dermal component of the scar.

Single entry point for anesthesia and blunt cannula subcision, but multiple entry points for needle subcision.

4-5 days downtime.

Painful due to multiple pricks. Almost painless. Almost painless.

Multiple hematomas, crusting after the procedure, redness and swelling made the number of side effects higher in the needle subcision group.

Conclusion

The cannula based subcision could be performed safely in the temples and marionette regions. The needle can not be used safely on the temples or on the marionette region, due to the risk of injuring the blood vessels, being therefore used only in the cheeks.

• The combination approach for subcision using both needle and cannula gave better results compared to any of them used alone, though the safety profile was better for the group treated with blunt cannula.

• Subcision is a safe, simple, cost effective, quick, gratifying and time tested technique that provides significant long-term improvement in the "rolling scars" of acne scar patients.

• Patients who went only for blunt cannula subcision had the minimal side effects, only 10% had bruising, 20% had erythema and 80% had transient post treatment edema. Whereas in the group which was treated with both nokor needle and blunt cannula had faced post procedure redness, swelling and hematoma in 100%, 90% and 30% patients respectively.

Patients who had both needle and cannula subcision consistently reported experiencing less severe side effects after cannula subcision. Specifically, patients who underwent both types of subcision tended to develop hematomas after needle subcision but not after cannula subcision.

• Group A had almost 80100% patients experiencing pain during the procedure and burning sensation immediately post procedure, making the overall patient cooperation during the procedure poor. On the other hand, usage of blunt cannula made the procedure more comfortable to the patients with just a feeling of heaviness experienced by them after the treatment

• Adding cannula to the equation enhances the results, the patient comfort and physician’s access to the sites like temples and marionettes where high vascularity keeps us vary of using a needle. Subcision with the Cannula appears to be a safe method with high efficacy in the treatment and high satisfaction in patients as we observed an interesting cure rate (more than 50% after 2 sessions). It demonstrates to be a safe procedure because it performed by single perforation in each side instead of multiple perforations that helps to reduce the patients' pain and risk of scars. In other hand Cannula-based Subcision needs considerable fewer sessions of surgery and also less recovery time.

Limitations-

1. Long-term follow-up was not done as scars usually modulate over a long period.

2. There were a limited number of sessions.

3. Larger sample size and longer follow-up are needed that would

References

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How to Optimize the Outcome of Subcision in Acne Scars?

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