Taylor Liberator Subcision

This is the stage of the acne scar management pathway illustrated above. It is highlighted in red. Dependent on the type of acne scar it is a first stage procedure:

• For tethered rolling or boxcar scars it is the first stage procedure that must be performed
• It can be combined in the same procedure with punch excision another technique that is used by DrH to remove deeper fibrotic boxcar scars and ice pick scars.
• Taylor liberator subcision or Taylor Liberator combined with punch excision is usually followed by full ablation laser resurfacing. The full ablation resurfacing will be used to remodel the acne scarring that remains within the skin once released by Taylor Liberator Subcision. Any punch excision surgically revised scars will also be further remodelled by the laser resurfacing.

As always understanding which methodology to apply reliesa on the appropriate classification of the scar type we are dealing with. This is why examination and appropriate diagnosis are essential first steps in managing acne scarring. Every procedure that Dr Hussein performs to manage your acne scarring is based on this approach.

The video below gives a comprehensive explanation about the role of subcision in acne scarring. Please watch the video for a full understanding of the role of subcision in the management of acne scarring.

Ultrasound of live procedure illustrating the anatomical level of the Taylor Liberator Subcision. The procedural Ultrasound shows the level of subcision just below the skin in the superficial subcutaneous plane and live dissection of fibrous tethering that adheres acne scarring.

The photos above show typical examples of tethered acne scars in men and women. The areas of skin that have been tethered down to the layers below are highlighted prior to the Taylor Liberator subcision procedure.

These patients have suffered with severe inflammatory cystic acne in the past. Inflammation within the skin spreads to the tissues below the skin as the base of the infected follicle is near the base of the skin. This inflammation causes destruction of tissue (atrophy) and fibrous tethering to develop between the undersurface of the skin and the layer of fascia (SMAS) that overlies the facial muscles. These fibrous tethers anchor the skin down to the SMAS layer causing indentation of the skin – this is part of the normal pathological process of nodulo-cystic acne.

To avoid the development of this, early management of acne with appropriate medication such as oral isotretinoin (Roaccutane) is essential. Sometimes concurrent treatment with steroids are required to calm the inflammation. Unfortunately in many patients this treatment is all too often administered too late and sometimes not at all. As a result tethered scarring is a common scar type in most patients who present with acne scarring. In fact it is common whilst I am taking patient history that patients’ recall the large cysts and nodules that originally caused the tethering.

Fibrous adhesion is a common pathological consequence of inflammation not only in the skin but elsewhere in the body. Pelvic Inflammatory Disease (PID) and Inflammatory bowel disease for example both result in fibrous scarring and adhesion inside the abdomen. This process is well recognised and not unique to acne scarring.

The tethering that forms during this inflammatory process can be seen in the diagram below.

As can be seen tethering occurs between layers 1 and 3. The position of tethering is represented by the red diamonds on the diagram. The inflammation causes fibrous bands to be formed between the base of the skin (layer 1) and the SMAS (musculoaponeurotic layer – Layer 3). These fibrous bands cause wider areas of skin to become stuck and creates indentations in the skin surface. These are the tethered acne scars that can be seen on the case photos I have included above.

In order to release tethered scars we have to be able to cut the fibrous bands that cause the adhesion and indentation of the skin. Subcision is an essential component of acne scar management – in fact if scars are tethered then there is no other way to release and treat the acne scar effectively other than subcision. We can now start to see the relevance of the acne scar pathway flowchart. Where scars are tethered subcision release is required.

As can be seen tethering occurs between layers 1 and 3. The position of tethering is represented by the red diamonds on the diagram. The inflammation causes fibrous bands to be formed between the base of the skin (layer 1) and the SMAS (musculoaponeurotic layer – Layer 3). These fibrous bands cause wider areas of skin to become stuck and creates indentations in the skin surface. These are the tethered acne scars that can be seen on the case photos I have included above.

In order to release tethered scars we have to be able to cut the fibrous bands that cause the adhesion and indentation of the skin. Subcision is an essential component of acne scar management – in fact if scars are tethered then there is no other way to release and treat the acne scar effectively other than subcision. We can now start to see the relevance of the acne scar pathway flowchart. Where scars are tethered subcision release is required.

Taylor liberator is a device that is used to perform subcision. It looks like a flat tipped screwdriver with two notches that gather and cut the fibrous tethering.

It is inserted through a 4mm incision at the side of the cheek in front of the ear. This is done under a form of local anaesthetic injected into the cheek called tumescent anaesthesia. Tumescent anaesthetic solution is used to inflate the cheek prior to the procedure. By inflating the cheek with tumescent we improve the safety of the procedure in the following ways.

• Create enlargement of the space that needs to be subcised and tensioning the fibrous bands that need to be cut.
• Reducing bleeding from the process due to the adrenaline/epinephrine content of the tumescent anaesthetic.
• Reducing post procedural inflammation and recovery from the procedure to a small amount of steroid anti-inflammatory agent in the tumescent solution.
• Tumescent makes Taylor Liberator a low pain procedure.
• Patients are usually well enough recovered to resume most normal activities by the next day, with the exception of sport/vigorous exercise – avoidance for 5 days is needed here.

Video footage of a live Taylor Liberator procedure can be seen below. In this video we can see that the liberator is being passed through the 4mm incision and runs directly under the skin surface (hypodermis) in the subcutaneous layer (layer 2).

In the video the Taylor Liberator device is cutting fibrous tethering. Once the subcision is complete then the device is pivoted in a windscreen wiper like motion in order for me to check that there are no remaining fibrous tethers causing the cheek to be stuck down.

Please note: This is a graphic video of a surgical procedure and is intended as reference for potential patients.

During Taylor Liberator Subcision or any other subcision for acne scars it is normal to cut the fibrous tethering. Some normal structures will also be cut such as small blood vessels and sensory nerves. These structures grow back as part of the healing process. Blood vessels are usually fully restored within days. Sensory nerves take a few months to regrow. It is therefore normal to experience a level of numbness in the treated area that is usually resolved by 3 months.

Suspensory ligaments of the face are not cut by Taylor liberator subcision. Subcision whether it be performed using Taylor Liberator, ‘Surgiwire’, Nokor Needle, Y-dissector or Cannula is performed in the same anatomical plane. The facial retaining ligaments are found between the periosteum and below the musculoaponeurotic layer (Layer 5 to Layer 4).

This is shown in the diagram below. These true ligaments (e.g. Zygomatic, Masseteric and Mandibular ligaments are safely below the plane of subcision. There is therefore zero risk to these facial suspensory ligaments and they are two deep to be interfered with by the Taylor Liberator Subcision.

There are certain structures that run and form ligament-like bands (Fibrous Retinaculae NOT true Ligaments) that run between the base of the skin and the Musculo-aponeurotic layer. These are not true suspensory ligaments but groups of fibrous structures that form boundaries between superficial fat compartments of the face. These can be seen in the diagram below. The territory for Taylor Liberator subcision has been marked and shaded in red.

The main aggregates of fibrous retinaculae / ligaments:

• Zygomatic Cutaneous band
• McGregors Patch/Zygomatic Ligament
• Mandibular Ligament
• Anterior Masseteric Ligaments

that pass through this subcision plane are not interfered with by the Taylor Liberator and form the natural boundaries of the actual subcision territory.

A sample of 17 MRI Scans performed after Taylor Liberator Subcision show:

• Normal distribution of superficial fat
• No distortion of facial retaining ligaments
• No fat pad herniation

This recent January 2023 publication compares subcision techniques and shows that Taylor Liberator is a safer and more effective subcision method when compared with more traditional methods. The patient satisfaction score for Taylor Liberator subcision is also greater than the traditional methods of subcision.

The only complications seen are prolonged mild swelling or blood clot formation. This as can be seen on MRI has fully resolved in all cases at between 3-6 months. Any complications of Taylor Liberator subcision would be the same in all subcision techniques as all techniques are designed to have the same outcome. That outcome is cutting of the fibrous adhesions that cause tethered acne scars in the superficial subcutaneous plane.

In short Taylor Liberator is the most effective subcision method available for the management of acne scarring and that is why it is our mainstay subcision technique at DrHConsult. It is safe, validated, published and evidence based. At DrH Consult 67% of our treatment volumes relate to acne scar management. We are proud to be the United Kingdom’s largest and most experienced acne scar management centre. DrH performs the most Taylor Liberator Subcision cases in the UK and is a internationally renowned expert in the field of acne scar management.

• Tethered acne scarring must be correctly identified and treated.
• Tethered scarring can only be treated by subcision.
• The subcision must also be correctly and safely performed.
• The subcision must be complete and not partial.

In order to treat tethered acne scarring effectively the four criteria above must be met. Unfortunately with the majority of acne scarring being managed in the aesthetic non-medical setting it is more than often sub optimally managed. The fact that many organisations that partially manage acne scarring do so with a single technique such as microneedling shows the general lack of understanding of the pathologenesis and structural anatomy of acne scarring. Therefore if tethered acne scarring is not correctly identified and treated then we are failing at the first hurdle.

In order to manage acne scarring effectively more invasive techniques have to be used. Clinics that perform subcision are already hard to find. So we can see that for patients suffering with acne scarring that involves a tethered component (which is the majority) the chances of finding appropriate treatment are already slim. So this is how acne scarring patients are failed systematically by the second hurdle.

The third hurdle requires experience. DrHConsult is a specialist acne scar management centre. Acne scar management can only be effectively performed by someone who performs a significant caseload routinely. Most UK dermatologists would struggle to show a significant volume of acne scar management cases performed.

Th most common methodology of subcision in the UK today is blunt cannula subcision. A blunt cannula is not an effective tool for the performance of subcision as it not capable of cutting. It is fragile and blunt. It was originally designed for injection of dermal filler. The reason for its development was to prevent bleeding and bruising when injecting filler.

Blood vessels are fragile structures and by making the cannula blunt trauma to blood vessels can be avoided. How therefore can a fragile tool that was designed not to damage fine blood vessels cut thicker, stronger bands of fibrous tethering. The answer that it is not capable of doing this. The improvement caused by blunt cannula subcision in tethered acne scars has more to do with the injection of Hyaluronic acid filler than solving the actual problem – the cutting of the tethering.

This is why centres offer the treatment will say that it needs repeating. Repeating subcision should never be necessary as long as the patient does not have ongoing active acne. That is why when properly performed subcision needs only to be performed once.

Patients are often mislead into believing that filler is injected to prevent re-adhesion. This sounds plausible but unfortunately is incorrect. Adhesion will only occur in the presence of long term severe inflammation. The filler injected in blunt cannula subcision is to merely create a temporary lifting effect that will disappear as quickly as the filler itself disappears.

Another question that one may reasonably ask is whether the inflammatory trauma caused by the procedure itself create re-adhesion. In Taylor Liberator Subcision this post treatment inflammation is rapidly subsided by the use of steroid anti-inflammatory agent in the tumescent. The dose used is sufficient to suppress inflammation and cause quick recovery but too dilute to result in fat atrophy.

Taylor Liberator Subcision need only be performed once. It has a permanent releasing effect and as long as the patient does not suffer with uncontrolled acne again it will not need to be performed again. Appropriate complete subcision no matter which tool used should only by definition be a once only procedure.

Repeat subcision is only required if the first subcision was not adequately performed.