Background
The Taylor Liberator Subcision technique is recognised worldwide for successfully managing atrophic acne scaring. The procedure is also known as ‘blunt blade subcision’ as the Taylor Liberator is a specific blunt blade tool which is utilised to release the tethering which anchors the skin to the layers of the tissue below and therefore releasing the skin. This tethering can be easily visualised under tangential light. In order to safely and effectively remove this anchoring and liberate the skin, it is vital to use the appropriate tool.
It is one of the more advanced and safer techniques when used in combination with tumescent anaesthesia, as the instrument has dissection notches which are protected within a modified blunt flat end metal probe. In comparison to previous older techniques for instance Nokor needle subcision or ‘surgiwire’ which carry a greater risk of cutting sub-skin structures which will subsequently result in increased bleeding, clotting and downtime.
The Taylor Liberator has been designed to effectively release the existing tethering which has resulted from the inflammatory process which occurs from Acne, whilst simultaneously minimising the risk of trauma to other surrounding structures when utilised with Tumescent under the guidance of a specialised expert. The use of tumescent anaesthetic is to minimise both the bleeding and inadvertent damage to blood vessels and nerves (Baribin, et al 2017). The areas which are considered as high risk entail the temples and lateral forehead therefore these are avoided due to elevated motor nerve risk.
Dr H has successfully performed over 1500 cases of the Taylor Liberator Subcision procedure since 2015-2023, in which there have been no infective complications experienced. Following a social media post in made in September 2022 by Dr Hussein there was a sudden surge in patient’s complaining of swelling. Dr Hussein suspects this may be due to a comment made on the post which is an information video showing Taylor Liberator Subcision being performed on a patient who consented to the video of the procedure being published. This comment appeared to imply that the procedure was dangerous and would result in damage to the deep retaining ligaments of the face which would result in facial deformity.
The appearance of a Taylor Liberator Support Group coincided with this and many of the patients who presented with the facial swelling had referred to discussions on the group. This triggered Dr Hussein and his team to launch a more detailed investigation into the patient concerns of perceived swelling. The trigger for this investigation was the sudden surge in these complaints in a very short space of time. Prior to this period even though patients may have suffered with some degree of inflammation post procedure there had been no significant volume of concern to trigger an investigation.
Scar Management Algorithm
Taylor Liberator Subcision forms a crucial part of surgical acne scar management. Acne scars that have a component of fibrous tethering secondary to the original inflammatory process must be subcised.
Taylor Liberator Subcision Procedure
Inclusion Criteria
- 18-60 year of age
- Male or Female
- All ethnicities and all skin types can be successfully treated.
- ASA classification 1 & 2
Indications for the procedure
- Presence of tethered scars which have been caused by fibrotic adhesion of the hypodermis to SMAS (Superficial Musculo-Aponeurotic System), this is identifiable on the patient through use of a tangential light examination.
- Presence of diffuse rolling scars, which will have a tethered component
- Presence of Traumatic scars or surgical scars.
Contraindications
- Active infection or inflammatory process which is localised in the area requiring surgery
- Concurrent infection both systemic or localised
- Anticoagulants / coagulopathy
- Under the age of 18years
Benefits
- Full releases the scar bands thus allowing the indented skin to be release and results in a smoother appearance of skin.
Risks of subcision – similar to other facial surgical procedures including:
- Bleeding
- Haematoma (collection of blood under the skin)
- Infection
- Scarring
- Temporary or permanent nerve damage to motor and sensory nerves
- Transient discolouration of the skin due to bruising
Taylor Liberator Video
DrH demonstrates the release of tethering in the video that contains footage of a Taylor Liberator procedure. This was published to social media. It can be clearly seen that the probe itself is moved from side to side in a ‘windscreen wiper’ motion illustrating that there is no obstruction from fibrous tethering which highlights the completeness of the TL technique. This results in completely releasing the tethered skin from the SMAS layer below. This is effectively the goal of all acne scar subcision and it has clearly been achieved following this procedure.
Ultrasound Video – Taylor Liberator performed with the use of ultrasound.
TL procedure is performed whilst using Ultrasound, clearly highlighting that the TL has dissected through the resistances/tethering which can be seen as black fibres and restoration of parallel tissue planes post release of tethering.. The position of Taylor Liberator probe can be seen at all times during the procedure. This clearly shows the anatomical plane of the subcision procedure. This superficial subcutaneous plane is maintained continually throughout the whole subcision process.
Case Distribution
Since June 2021, it is evident that the vast majority of TL cases treated female patients, of which when considering the age distribution, the highest percentage (31%) consisted of 30-34 years age. The distribution of Taylor liberator procedures performed in scope consisted of a mix of 63% female in comparison to 37% male. From this overall scope, a total of 9 patients complained regarding the TL procedure, represented a 4.3% rate consisted of 89% females who collectively were under the age of 35years, of which 88% were between 18-34years of age and the remaining 11% male was under 30 years of age.
High Resolution MRI Scan requests
The 9 patients mentioned previously complained of perceived prolonged facial swelling most specifically in the cheek area following a Taylor Liberator Subcision performed to address acne scaring. These complaints were taken extremely seriously and in order to investigate the patient concerns, an individual consultation was arranged with each patient evaluate as well as examine the area of concern. Initially facial ultrasound examination was performed by Dr Zaid Aldin (Consultant Radiologist). In the absence of any obvious space occupying lesions or abnormalities all investigated cases were followed up by a high resolution facial MRI which was arranged by Dr Hussein. Each patient had a high resolution MRI scan of the face. The scans were reported by independent consultant head and neck specialist radiologist Dr Kunwar Bhatia.
High Resolution MRI Summary Findings
Dr Bhatia, Consultant Head and Neck Radiologist reported on the MRI scans that were conducted on a total of number of 14 patients. It was reported that in all cases the deep retaining ligaments were normal, there was no evidence of oedema or post procedural abnormality. In addition, there was no significant thickening or other signal abnormality in the dermal and subcutaneous tissues of both cheeks including along the expected sites of subcision. The results have been summarised below under their respective areas, to provide a more in-depth analysis highlighting the specific findings and number of patient cases (n)
Deep retaining ligaments
- There were no abnormal findings in the deep retaining ligaments (n=14)
Adipose tissue
- Although the 71% (N=10) were reported to have no abnormal adipose tissue present. In the remaining 28% (N=4), there was an enhancement in the cheek adipose tissue in comparison to previous scans in 7% (N=1), mild reticulations and tiny vessels present within the superficial adipose tissue suggestive of dilated capillaries in 14% (N=2) and mildly prominent volume of adipose tissue in both cheeks in 7% (N=1) although within the normal limits 7% (N=1)
Soft tissue thickening
- There was no significant soft tissue thickening in the dermal or subcutaneous tissues present (100% n=14)
Buccal fat pads
- Overall, in 79% (n=12) buccal fat pads, muscles of expression, parotid glands and ducts appear unremarkable. In 14% prominent buccal pads were present bilaterally causing smooth bulging in the subdermis of the lower lateral cheek resulting in a visible bulge (n=2 ). In 7% (n=1) buccal fat pads were prominent on the right side, where it may have contributed to the convexity of the lateral cheek however there was no abnormal signal to indicate a pathological process including prior injury or oedema.
Presence of inflammation
- There was no evidence of significant inflammation in the dermal and subcutaneous tissues in 93% cases or markedly high T2 signal suggesting fluid collection or oedema. However, there was mild perivascular and periadnexal chronic inflammatory infiltrate in the superficial dermis in 7% (n=1).
Extraneous bodies
- The presence of cosmetic filler material was found in 21% (n=3) of cases. Globular, streaky, and coalescent T2 hypertense material in the deep subcutaneous tissues of both cheeks, created more voluminous cheeks as well as medially towards the nasolabial folds. The use of filler is noted to be slightly asymmetric in distribution and greater in volume in superiorly in the left mid cheek and inferiorly in the right cheek, when compared to the levels of the opposite sides (n=2). Whilst a greater quantity of filler was present on the left side overlying the zygomatic arch anteriorly in another patient, resulting in a local mass effect, elevating the upper aspect of the left cheek when compared to the right creating asymmetric fullness of the upper left check contour (n=1)
Additional findings
- There were additional incidental findings, in which a mucus retention cyst, a small retention cyst in both maxillary sinuses and mild inflammatory mucosal thickening in paranasal sinus was identified ((21% n=3). However, these were noted to be asymptomatic and of no clinical significance. In one patient multiple tiny low T1 and T2 weighted foci within superficial subcutaneous fat of lateral premolar regions was identified, this is consisted with post treatment changes, the remainder of the findings were in line with the previous MRI which no evidence of fluid collection, substantial oedema or other significant complications.
Conclusion
We can see from the MRI results above that there is no evidence of pathological findings. Following the TL procedure, the shape of the cheek themselves will alter due to the release of the tethering under the cheek however there is no damage to surrounding ligamentous structures, oedema, thickening or inflammation in the dermal or subcutaneous tissues. There were no abnormalities present in buccal fat pads, muscles of expression, parotid glands and ducts. The additional mucus retention cysts and mild inflammatory mucosal thickening was asymptomatic and clinically unremarkable.
There were cases in which extraneous bodies were identified, which specifically indicated that filler was used in several sites across the face (i.e lateral cheeks, nasolabial folds, margin of the upper lip). It should be noted that the use of fillers may alter the shape of the cheek and appearance of the face and problems with foreign bodies cannot be controlled by the operator.
Independent Reports
Independent Report by Dr Mark Taylor
Board Certified Dermatologist, Founder and Medical Director of Gateway Aesthetic Institutee and Laser Centre in Salt Lake City, Utah USA.
Dr Taylor invented the Taylor Liberator Subcision instrument, which he has used to perform thousands of procedures for the treatment of tethered acne scaring. Dr Taylor states Dr Husseins practice and experience in operative management of acne scarring is recognised worldwide. Both Dr Taylor and Dr Hussein use the same technique to perform subcision using the Taylor Liberator in which tumescent anaesthesia is used to control pain, reduce bleeding risk and stabilise the tissue ensuring an accurate subdermal subcision in superficial subdermal plane.
The patient complaint referred to swelling and facial changes which were believed to be due to an excessively aggressive subcision resulting in damage to retaining ligaments. Dr Taylor states that this is an entirely incorrect assertion and not possible given the subcision is a in the superficial plane of subcision. Simply as, the major retaining ligaments are located below the SMAS (Superficial Musculo-Aponeuotic System) layer and the Taylor Liberator Subcision procedure itself if not used in this deep plane and therefore it isn’t possible to traumatise the retaining ligaments of the face during a Taylor Liberator subcision.
Dr Taylor concluded that Dr Husseins protocol is consistent with the standard of care that has been established for more than 14 years by both himself and other highly trained acne-scar specialists. In addition, the procedure is both a safe and effective method for treating tethered acne scars with minimal adverse effects, which has been validated my multiple peer reviewed studies.
Independent Report by Dr Zaid Aldin – Consultant Radiologist, Sub speciality interest in Vascular Intervention
Dr Aldin performed facial ultrasound scans on the patients that presented with facial swelling following the Taylor Liberator procedure. The scans were conducted without delay and Dr Aldin concluded that there were no signs of abnormality. On occasion there were changes suggestive of mild inflammation.
Dr Hussein promptly communicated the results of the ultrasound scan to each patient. A quantity of patients remained concerned and wanted additional tests to be conducted. In response to the concerns raised by his patients Dr Hussein investigated further and referred these patients on to have an MRI scan of the face. These scans were reported by Dr Bhatia. Dr Bhatia is a specialist head and neck radiologist. Dr Bhatia concluded that the MRI scans conveyed no evidence of any changes which would account for facial swelling, this was then communicated to the respective patients by Dr Hussein in a timely manner.
Independent Report by Mr Charles Nduka, Consultant Plastic Surgeon
Mr Nduka, addresses the rationale, nature and efficacy of surgical subcision. Mr Nduka refers to the Comprehensive review of Surgical Instruments (Vempato et al. 2023) in which Taylor liberator Subcision was found to be more effective technique which provides greater scar improvement outcomes and found to have a lower incidence of haematoma formation. The Taylor Liberator Subcision methodology is an accepted practice when performed by an appropriately trained and qualified professional and the patient has been appropriately informed and counselled in regard to risks, benefits, side effects and post procedure aftercare.
Conclusion
In the absence of any pathological findings in these cases the cause of the perceived swelling was concluded to be non- inflammatory and is essentially a change in the sub zygomatic/buccal skin contour due to release of tethered scarring. This would naturally account for the increased fullness of the cheek that these patients had become aware of post procedure.
It was finally decided to adjust the consultation process and consent forms in line with these findings and include information about the potential for facial shape/ sub zygomatic contour change post Taylor Liberator Subcision. Taylor Liberator has not been aborted or put on hold.
In summary Taylor Liberator is safe and efficacious procedure that has been performed over many years in order to release tethered scars. Subcision in acne scarring and its rationale for treatment are well understood. Taylor Liberator is a safe and well understood subcision technique as documented in numerous peer reviewed studies. Based on the findings of these investigations Dr Hussein and his acne scar specialist colleagues see no reason why it should be discontinued. As of February 2024 Dr Hussein has resumed the performance of Taylor Liberator in his practice. Consultation, consent forms, website literature and pre reading materials have been amended and improved to highlight the potential for change of sub zygomatic / buccal contour (essentially cheek fullness) that can consequently occur following subcision and release of acne scarring. Naturally this would be a consequence of any effective subcisional scar release not just Taylor Liberator.
As a result of these changes Dr Hussein believes that his patients are now more adequately informed regarding the risks of Taylor Liberator Subcision and can make a better informed judgement on whether they wish to proceed with this procedure despite the possibility of face shape / contour change.
References
Vempati, A., Zhou, C., Tam, C., Khong, J., Rubanowitz, A., Tam, K., Hazany, S., Vasilev, R., Hazany, S (2023) Subcision for Atrophic Acne Scarring: A Comprehensive Review of Surgical Instruments and Combinatorial Treatments. Clinical, Cosmetic and Investigational Dermatology (18:16) 125-134 doi: 10.2147/CCOD.S397888
Barikbin, B., Akbari, Zahra., Yousefi, M., Dowlati, Y., (2017) Blunt Blade Subcision: An Evolution in the Treatment of Atrophic Acne Scars. Dermatologic Surgery 43():p S57-S63 DOI: 10.1097/DSS.0000000000000650