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Patients with depressed acne scars and inflammatory post-acne flaccidity, before (B) and after (A) dermal tunneling (TD ® ) treatment.
Source publication
Depressed facial scars are still a challenge in medical literature, despite the wide range of proposed treatments. Subcision is a technique that is frequently performed to improve this type of lesions. This article proposes a new method to release depressed scars, reported and named by the author as dermal tunneling. This study presents a simple an...
Citations
... Inchingolo et al. [6] introduced a method to correct scar depression by making a U-shaped suture after direct dissection of the adhesion with a surgical scissor. A new technique called dermal tunneling was proposed by Lima [7] to treat scar depression by loosening the fibrotic tissue in the dermal layer, but it was only reproducible in the transepidermal depth. In addition, Graivier [8] reported treatment methods using diamond wire, SurgiWire, and wire scalpel, in which the dissection was performed through an insertion made into the subcutaneous tissue below the dermal-subcutaneous junction [8]. ...
Scars are still a challenging problem in medical practice, despite advancements in treatment modalities. Numerous treatment modalities, ranging from simple revision, Z-plasty, and W-plasty to laser treatments, have been used to treat scar deformities. However, for wide depressed scars, additional methods are needed to completely restore the contour of the depression caused by tissue adhesion. We report on the case of a 34-year-old woman with a wide depressed scar deformity on the left upper buttock and the encouraging results of an autologous fat graft injection technique that utilized a cutting wire to form a pocket for the fat graft site, while simultaneously resolving the adhesion caused by the tissue. This method is safe and easily reproducible, making it a useful addition to the surgeon’s toolkit when dealing with such lesions.
... 6,7 Other options include scar revision with fat or dermal augmentation through a local skin flap technique such as Z-or W-plasty. [8][9][10][11][12] Correcting these deformed scars is challenging. To reduce and prevent the recurrence of the depressing force, a de-epithelised dermal layer of skin is created between the scar and the abdominal fascia to prevent adhesion and augment the depressed scar. ...
Surgical procedures performed during neonatal period or childhood that result in vertical midline, transverse left upper quadrant, or central upper abdominal scars create significant psychological concerns in adulthood. Various surgical techniques correct depressed scars, including scar revision, Z- or W-plasty flaps, sub-incision tunnelling, fat grafting, and autologous or alloplastic dermal grafting. This article describes a novel technique for repairing depressed abdominal scars using hybrid double-dermal flaps. We included patients with psychosocial concerns who underwent abdominal scar revision because of wedding plans. Hybrid local de-epithelised dermal flaps were used to correct the depression of the abdominal scar. Superior and inferior skin flaps, medial and lateral to the depressed scar, were de-epithelised for 2 to 3 cm and sutured using the vest-over-pants technique with 2/0 nylon permanent sutures. Six female patients who want to marry were included in this study. Depressed abdominal scars were successfully fixed using hybrid double-dermal flaps, either from the superior-inferior aspect for transverse scars or from the medial-lateral aspect for vertical scars. No postoperative complications were noted, and the patients were satisfied with the outcomes. De-epithelialised double-dermal flaps in the vest-over-pants technique are an effective and valuable surgical technique for correcting depressed scars.
... 27 Thus, only one incision point near the hairline was required to reach most scars, reducing the probability of adverse events associated with multiple entry points. 19,20 Cannulas have also been reported to be more effective than Nokor needles. Gheisari et al discovered in a split-face study that both physician and patient satisfaction scores were higher for areas treated with blunt cannula subcision than for those treated with needle subcision, especially at a three-month follow-up assessment. ...
Subcutaneous incisionless surgery, also known as subcision, is a minimally invasive procedure that is commonly indicated for the treatment of atrophic acne scars. In recent years, many new techniques have been developed to maximize results from this procedure. This review article aims to identify an updated list of instruments and combinatorial treatments available for atrophic acne scar patients undergoing subcision. We constructed a comprehensive PubMed search term and performed triple-blinded screening on all resulting studies for mentions of subcision as indicated by acne scarring. Our results show that there are four main categories of subcision tools that are commonly employed to treat atrophic acne scars: needles, cannulas, wires, and blunt-blade instruments. Usage of these devices varies by scar depth, personal preference, and combinatorial treatment options. Overall, subcision is a particularly effective treatment for atrophic acne scars, and there is vast potential for further innovation with this technique.
... The needle was moved back and forth to form close parallel tunnels at dermal level, according to a subcision technique variant called "dermal tunneling". 9 On day 12 postop she presented with firm local bumps on the treated area ( Figure 1), which were punctured with a 22G needle and the blood was drained. ...
... 9,10, 11 One of its adverse effects are residual indurations. Around 5-10% of patients develop hypertrophic response within 2-4 weeks post-operatively, 9 especially in the glabellar region. This happens due to an exaggerated wound healing response or to an unrecognized and untreated hematoma 3 that can evolve to hypertrophic scars. ...
Hematomas are common following cosmetic surgery. When minor, they are treated with observation only as they are most often reabsorbed. However, even with small collections of blood, if no early intervention is adopted, poor aesthetic outcomes may occur. Early drainage has been especially described in otorhinolaryngology and radiology journals. The authors present an approach to early treating hematomas. Special emphasis is given to the use of hyaluronidase, which is well known by dermatologists and plastic surgeons for its ability to dissolve hyaluronic acid, but its utility in the treatment of hematomas is not so commonly known by these experts.
... [78] When a wide area of depressed scars is involved, a diamondshaped subcision can be made using a sterile aspiration needle, called dermal tunneling. [79] In this technique, the area to be treated is marked in a diamond shape and subcision is carried out from all four corners. Spinal needle cannula has also been used to reduce the number of pricks. ...
... PDL Erythematous and hypertrophic I A [68,69] 1,064 Q-switched Nd:YAG II B [62] Subcision All types II B [74][75][76][77][78][79][80][81] Punch techniques Moderate to severe III C [83] PRP and related treatments PRP with dermaroller I A [85][86][87] PRP with fractional lasers I A [88] PRP with subcision I A [90,91] Autologous fat grafting II B [92][93][94][95] Synthetic fillers HA II B [96][97][98] PLLA II B [101,102] PMMA I A [103,104] CH II B [99,100] Botulinum toxin A injection Hypertrophic III C [107] Combination treatments Subcision with MNRF I A [112] Subcision with fractional CO 2 I A [56] Subcision with microneedling II B [91] Microneedling with GA peel I A [113] Fractional ablative with MNRF I A [45] Fractional CO 2 with autologous fat II B [114] Punch elevation with fractional CO 2 III C [115] PRP with nanofat I A [89] PLLA = Poly-l-lactic acid, CH = Calcium Hydroxyapatite [Downloaded free from http://www.jcasonline.com on Saturday, June 20, 2020, IP: 106.223. ...
Acne scars are the reason for significant morbidity among dermatology outpatients. With more modalities being introduced every year, it is important to choose the best one suited for a particular type of scar for each patient to obtain an optimum result. Guidelines on acne scar management in the skin of color are not available where the therapeutic effect and side effect profile of the modalities can vary significantly. This narrative review looked at critical evaluation of the available modalities to find the level of evidence and therapeutic ladder of management of different types of acne scars. Treatment options for different types of scars have been described. Evidence level for each type of modality for the individual type of scar was calculated using the Strength of Recommendation Taxonomy (SORT) developed by editors of the US family medicine and primary care journals. In addition, various newer and emerging treatment options, such as dermal cell suspension, jet volumetric remodeling, and radiofrequency subcision, have been discussed. The highest level of evidence is available for microneedling, fractional radiofrequency, fractional CO 2 , and erbium:yttrium aluminum garnet laser for mild to moderate grade scars. Trichloroacetic acid chemical reconstruction of skin scars showed efficacy in ice pick scars. Grade 4 scars improve poorly with resurfacing procedures, where punch excision and punch elevation can be tried. Platelet-rich plasma therapy was effective in combination with lasers and microneedling. Overall there is lack of high-quality data in the management of post acne scars. Combination treatment has shown better efficacy compared to single modalities.
... Twenty-one papers were related to the application of subcision in the treatment of acne scar and other scars (Table 1). 1,2,[8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] Four articles were about the application of subcision to treat cellulite 4,[27][28][29] (Table 2). Another 8 articles were related to other applications of subcision such as the treatment of striae or nasolabial fold [5][6][7][30][31][32][33][34] (Table 3). ...
... In this procedure areas to be subcised are first prepared by topical antiseptics such as chlorhexidine 2% or povidone-iodine and anesthetized by either topical eutectic mixture of local anesthesia or injection of 2% lidocaine with 1:1 000 000 epinephrine solution. 15,24 After waiting adequately for maximal vasoconstriction, a needle is inserted a few millimeters from the depressed area and advanced underneath the scar. The freehand guides the procedure and is used as needed to stretch, pinch, or stabilize the treatment area. ...
Background:
Subcision, also known as subcutaneous incisionless surgery, is a surgical intervention used to treat a variety of skin conditions including atrophic acne scars, depressed scars, cellulite, and wrinkles.
Aims:
We plan to prepare a review article about the indications of subcision, its adverse reactions, and pearls.
Patients/methods:
We searched the literature for the information about subcision and its applications from papers published up to March 2019. The search was performed through the databases of the National Library of Medicine.
Results:
After a thorough review of the published papers about subcision, we finally chose to review 40 articles that had proper sample size and design to prepare this review article. Twenty-one papers were related to the application of subcision in the treatment of acne scar and other scars. Four articles were about the application of subcision to treat cellulite, and eight articles were related to other applications of subcision such as the treatment of striae or nasolabial fold. The remaining seven articles include published review papers about subcision or acne scar classification.
Conclusion:
Subcision seems to be effective on various skin conditions including acne scar, other depressed scars, and cellulite. It is easy to apply and inexpensive with short downtime and no significant complications. Subcision needs proper technique and adequate experience.
... The goals of minimally-invasive methods for depressed scars are to disrupt the connection underneath the skin and to prevent re-adhesion [7]. Dermal tunneling and subcision are mainly used with fat grafts or hyaluronic acid fillers [8,9]. ...
Background Various methods have been reported for the improvement of widened or depressed scars. However, scars can be complex at presentation. If a widened but flat portion is combined with a tethered or a depressed area, a scar revision method that can effectively resolve all issues is needed. The authors utilized a dermal portion of the widened scar as a re-adhesion barrier and filled tissue after the release of the tethering or depression. Methods From July 2014 to December 2017, a total of eight patients presented with combined scars with both widened and depressed areas and underwent scar revisions with scar dermal transposition flaps. The scar flap of the widened scar was de-epithelialized, leaving the dermo-cutaneous pedicle near the depressed area. Without any additional skin incision on the depressed site, the tethering was released by making a skin incision at the scar flap. The de-epithelialized scar dermal flap was transpositioned under the depressed area of the scar. Results The surgical wounds of all eight patients healed without any complications. The mean follow-up period was 5.25 months. The filling effect of the scar flap persisted without the conspicuous relapse of a depression or tethering. The patients were satisfied with the final results and the fact that no additional incision was needed for the tethered and depressed scar. Conclusions If the depressed site is near a widened scar, a scar dermal transposition flap may be a versatile option for improving the depression without an additional skin incision.
The ability of percutaneous induction of collagen (PCI) with needles to produce whitening and improvement of skin quality is already well studied. In parallel, intense pulsed light (IPL) whitens melanoses and also improves the appearance of the skin. The author then proposed the association of these two techniques for areas such as the face, neck, and limbs. The first observations already presented, by the dermatological evaluation and perception of the patients, results superior to those of the procedures performed alone. Later, the authors identified an advantage in the speed of recovery of the skin, with elimination of the crusts in a smoother way and uniformity of skin color more quickly, when compared to the isolated use of IPL. In order to further optimize its results, the author decided to add the well-known retinoic acid. See the following protocol description. PCI has its effect well demonstrated on scars. The author considers its introduction in the therapeutic arsenal of these lesions a water divisor, regardless if they are depressed or elevated scars. The association of IPL with PCI is chosen when dealing with recent high, neovascularized, or keloid lesions.
Several treatments have been proposed that offer better results in reddish striations when compared to alba striations. Topical tretinoin in cream in high concentrations, applied as home therapy, improves the appearance of these lesions; however, it may not be well tolerated by the patient, considering climatic conditions and maintenance of her average activities. Interventions such as chemical peelings, microdermabrasion, fractionated lasers, and intense pulsed light, alone or in association, are some of the therapeutic options used by dermatology for the management of these lesions. However, there is no treatment considered ideal, and the results many times modest signal its challenge. PCI, regarding treatments with microneedles that induce collagen production, offers a stimulus in the production of this protein, without causing the deepithelialization observed in ablative techniques. The epidermis and dermis are perforated but not removed. Thus, the penetration of its needles in the skin causes micropunctures in the stretch marks, modifying their surface, destructuring the abnormal collagen and favoring neovascularization and neoangiogenesis. Both violent and white stretch marks respond to PCI, but the former commonly present satisfactory results with a smaller number of sessions, while the former need a longer time to achieve such results.
During treatment, needles pierce the stratum corneum and create the microchannels without damaging the epidermis, making it possible to create an accessible means of transporting macromolecules and other hydrophilic substances to the skin. The microchannels facilitate drug delivery efficiently and can increase the absorption of larger molecules by up to 80%. The application of drugs by the transdermal drug delivery system has been used as an alternative to the oral or parenteral administration of various substances. Transdermal patches can, for example, be useful for the application of vaccines and medications that require slow and controlled release into the skin. However, the transdermal route of drug absorption faces a major challenge, which is the barrier function of the skin, mainly exercised by the stratum corneum, which limits the absorption of many actives. PCI is a simple, safe method with low incidence of side effects. The association with drug delivery has the advantage of being a safe, low cost, and effective procedure that enhances the results of dermatological treatments.
