• Taylor Liberator Subcision

    Harley Street, London Clinic

Understanding Subcision (Subcutaneous Incisionless Surgery)

Subcutaneous incisionless Surgery or SUBCISION is a technique used in the dermatologic surgical management of acne scarring.

Subcision is a minimally invasive surgical technique where the scars can be released to raise up indented acne scars. These indented (atrophic) acne scars become stuck down to the deeper layers below the skin.

As a technique and its role in acne scar management is first described in the seminal paper published in 1995 by Norman & David Orentreich (if interested, please see ORENTREICH, DAVID S. MD1; ORENTREICH, NORMAN MD, FACP1. Subcutaneous Incisionless (Subcision) Surgery for the Correction of Depressed Scars and Wrinkles. Dermatologic Surgery 21(6):p 543-549, June 1995)

As you will see in this recent publication, The Taylor Liberator procedure is one of the more advanced techniques used in the management of indented acne scars. It is a safer technique that uses a specialised tool with dissection notches that are protected within a modified blunt flat end metal probe (see more on this below)

The use of this modified tool combined with the use of tumescent anaesthesia make the procedure a very safe procedure when compared with other older techniques such as Nokor needle subcision or ‘surgiwire’. These older techniques raise the potential for more risky blind sharp cutting sub-skin structures that also result in greater bleeding, clotting and downtime.

How do we treat this issue?

Dr Hussein is a specialist in laser skin surgery. He is the UK’s most experienced laser surgeon by case volume.

He uses the most advanced lasers to treat scarring.

Dr Hussein is the only UK laser surgeon with the skill, technology and experience to perform scar treartment in all skin types

taylor liberator recovery

Treatment at a Glance

For more information, please see the FAQs section.

Procedure Time

Typically allow 1.5 - 2 hours

Number of Treatments

A single treatment is sufficient


Two days to be medically fit for work

Before and After Photos

Tethered acne scarring example 1
Tethered acne scarring example 2
Tethered acne scarring example 3
Tethered acne scarring example 4
taylor liberator subcision 1 week post
taylor liberator subcision 26 day post

Frequently Asked Questions

How does this treatment work?
Taylor Liberator Subcision is used to cut the fibrous tethering of acne scarring that sticks the skin down to deeper layers. These fibrous adhesions must be released to raise the indented acne scarred skin.
Typical Issue/Treatment area
The cheeks are the most commonly affected area of the face in acne scarring. This is therefore the area of the face where we naturally perform the most subcision. The central forehead can also be treated with Taylor liberator subcision.
How long is the procedure?
Typically allow 1.5 – 2 hours total in clinic time for your procedure. On arrival you will see the team and Dr Hussein will answer any questions and take photos. A consent form identical to the one sent in your pre procedure reading materials will be completed by Dr Hussein and yourself.

Your scars will be marked and tumescent anaesthetic injected. Following this you will be waiting around 30 minutes with the tumescent anaesthetic injected. After this wait time the Taylor Liberator subcision procedure will be performed.

The subcision will last typically between 20-30 minutes. Following completion of your Taylor Liberator Procedure you will be taken to the recovery room.

After around 20 minutes of monitoring you will be checked by Dr Hussein and the Nurse in charge. After satisfactory checks you will be allowed to leave and travel home.

How many treatments do I need?
A single treatment is sufficient for release of tethered acne scars.
What results can you expect?
Any tethered scarring will be released. The degree of improvement will be dependent on what percentage of your total acne scar distribution is tethered. The greater the percentage of tethered acne scarring the greater the degree of improvement.
What is the recovery/downtime?
To be medically fit for work requires 2 days down time.

Swelling from anaesthetic injection will have resolved by the next day. It is normal to get some bruising, inflammation and low grade swelling. The extent of this is dependent on the amount of tethering needing to be released. If there is merely a small area you will recover from this within a couple of weeks.

If the areas of tethering are multiple and large and the Taylor Liberator Procedure is more extensive then prolonged low grade swelling can be expected for up to 3 months and in rare cases slightly longer.

What are the side effects / risks of complications
Expected side effects

  • Swelling from anaesthetic injection lasting 24 hours
  • Swelling from bruising, bleeding, inflammation lasting from 1 week to 3 months depending on procedure extent
  • Patchy numbness of the subcised areas for up to 3 months

Any rare complications of this procedure are described at length in the consent and pre-reading literature but can be summarised as follows:

  • Infection
  • Prolonged swelling
  • Change in facial contour of the cheek due to scar release
  • Nerve damage Motor/Sensory
  • Bleeding
  • Blood clot / Haematoma

How do we look after you?

  • The next day following your Taylor Liberator Procedure, DrH will check that everything is settling nicely using our ‘Virtual Ward Round’. This involves the use of photo checks and direct communication with the patient.
  • Following this you can notify DrH of any unexpected problems using the ward round phone. This however is unlikely.
  • You will usually be reviewed either at your next procedure or at 3 months following subcision in clinic.

What is the Pain Factor of the treatment?

  • Tumescent anaesthesia is slightly painful due to multiple small needle pricks
  • Following the tumescent the procedure is virtually pain free.
  • After the procedure, pain is not usually an issue. Opening the mouth wide or pressure can cause soreness in the first few weeks.
  • The face should not be washed until the day after the procedure and is not painful

What is your next step / What is our process?
If you have acne scarring and have read the information on the website regarding acne scarring then to book a consultation with Dr Hussein please do the following:

  • Click on the booking form link and complete
  • Information is not used for any marketing purpose – It is essential medical information
  • Follow the booking form process and you be will be contacted by one of my medical team to arrange your consultation.
  • Following consultation your treatment can be booked. This is usually no earlier than 2 weeks following the consultation. This time is important to allow full consideration of the procedure by the patient.

What does the treatment cost?

  • Consultation is compulsory prior to any treatment, preferably in person but can be arranged online – Cost £200
  • The Taylor Liberator Subcision procedure costs £2,250

In mixed pattern scarring:

  • If both Taylor Liberator and multiple punch excisions are required before resurfacing they can be combined into one procedure performed in a single session. Combined Taylor Liberator and Punch Excision costs £2,750.
  • Laser resurfacing will typically also be required after Taylor Liberator Subcision to treat the intradermal atrophic component of acne scarring. The cost of the Full ablation Laser Resurfacing procedure is £4,250

Combination of procedures will be determined by examination during the consultation. If the consultation is online Dr Hussein requests well lit high resolution photos to be sent prior to consultation. From experience Dr Hussein can make a good judgement of what is required from photos. Absolute confirmation will be made on physical examination.

If punch excision is required there must be a window of maximum 4-6 weeks before full ablation is undertaken. This is because optimum results for the punch excision revision scars require full ablation to be performed within this time frame. This must be taken into account during the procedure planning process.

It is Dr Hussein’s usual practice to allow at least a 2-3 week gap between Taylor Liberator subcision and any full ablative laser resurfacing. Given that Taylor Liberator subcision and fully ablative laser are mutually independent procedures for different aspects of scarring there is no fixed timeframe between them.

How is Taylor Liberator Subcision used in the pathway for acne scars

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.

Diagram of Acne scar management algorithm Taylor Liberator

Why do we perform Taylor Liberator Subcision for acne scarring?

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.

Examples of tethered acne scarring

Tethered acne scarring example 1
Tethered acne scarring example 2
Tethered acne scarring example 3
Tethered acne scarring example 4

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.

Diagram of fibrous tethering hypodermis to SMAS

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.

How is Taylor Liberator Subcision Performed

taylor liberator close upTaylor 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.

Taylor Liberator cross section

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.

Diagram of superficial fat compartments
Superficial facial fat compartments and their relationship to the retaining ligaments

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.

Why is this issue hard to treat effectively often?

  • 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.

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