Subcision with filler:
release first, support second

Why is subcision combined with filler at all?

Subcision and filler are combined because a tethered scar has two problems: a band pulling the surface down, and often a hollow beneath it once the band is gone. In subcision, a fine needle or blunt cannula is passed beneath the scar in the subcutaneous plane and swept to divide the fibrous cord that anchors the skin to the tissue below. The surface is entered through a small puncture and is not cut. Two things follow: the downward pull is released, and the controlled injury prompts new collagen in the space where the band was.

Release alone is sometimes enough. Where deep inflammation also destroyed fat beneath the scar, the released surface sits over a deficit and can settle back toward it, and the divided band can partly re-form through the same fibrotic process that built it. Support placed beneath the released scar holds the space open while healing happens. A collagen-stimulating filler such as Radiesse is often chosen, because the carrier gives early support and the microspheres then act as a scaffold for the body's own collagen; hyaluronic acid is chosen where reversibility matters more. The volume restoration page explains how the materials differ.

The combination is for rolling scars and tethered boxcar scars that stay pinned when the skin is stretched. It is the wrong plan for ice pick scars, which need TCA CROSS, for surface scars that flatten on stretching, which need resurfacing, and for raised scars. Scar type is decided scar by scar at assessment.

Which goes first, and why?

Release goes first, always. A filler placed beneath a scar that is still tethered pushes up against a band that is pulling down, so the product either spreads sideways, adding fullness without lifting the scar, or sits as a lump beside a dent that has not moved. The band wins because it is anchored and the gel is not.

Once the band is divided, the examination changes. Some scars sit level on their own and need nothing more. Others reveal a deficit that was hidden while the tether held the surface down, and that is the deficit support is placed into: a small amount, beneath the released scar, checked against the surrounding skin before more is added. Deciding how much support a scar needs before it has been released is guesswork; deciding after release is measurement.

Fractional CO2 resurfacing, where the plan includes it, comes after both, because resurfacing remodels skin in whatever position it finds it. The acne scar treatment page sets out the full sequence of release, support and resurfacing and why it is ordered that way.

“You can resurface a tethered scar indefinitely. The tether keeps pulling it down.”

Dr Sin YongOn why scar treatment plateaus

How is the spacing between release and support decided?

Whether support is placed at the same visit as subcision or at a later one is decided by the scars, the skin type and how bruising is expected to behave, and the decision is confirmed at review rather than fixed in advance. Subcision bruises, because tissue beneath the skin has been divided, and it swells. Filler placed into a plane that is bleeding and swollen is harder to judge, harder to place evenly and more exposed to inflammation. In Fitzpatrick III to V skin, where bruising and inflammation handled carelessly leave pigment of their own, staging is often the more conservative choice.

Staging also answers a question the same-visit approach cannot: how much of the improvement came from release alone. A scar that sits level once the bruising has gone does not need product, and placing it anyway adds fullness, cost and risk for nothing.

Where a scar is clearly tethered over an obvious deficit, bruising can be read easily and the area is small, same-visit support can be reasonable, and Dr Sin Yong says so at assessment. No interval is quoted here because the right one depends on how a particular face bruises and heals, and that is read at review.

Who should not combine subcision with filler?

Active acne is controlled first, because releasing and supporting scars while new ones are forming makes little sense, and inflamed skin marks easily. Active infection in the area, a cold sore, pregnancy and breastfeeding mean waiting for both steps. Anyone taking blood thinners or with a bleeding tendency is assessed carefully, because subcision divides tissue blind and filler is placed into the same plane; all medicines and supplements that affect bleeding are declared beforehand.

A tendency to keloid or hypertrophic scarring, a history of marked post-inflammatory darkening and recent isotretinoin are discussed before either step is planned. Earlier filler in the area, particularly non-resorbable filler such as silicone, must be declared, because layering new product over it raises the risk of nodules; where the history is unclear, the area is scanned with ultrasound first. Allergy to a filler component or to lidocaine rules out that product.

Some scars are the wrong target. Ice pick tracts, surface boxcar scars and raised scars are not tethered and gain nothing from release, so support beneath them is misdirected. Isolated scars too deep or wide for these methods may need a punch technique or surgical revision and are referred to a plastic surgery or dermatology specialist. Improvement, not removal, is the honest endpoint.

What are the risks of stacking release and filler?

The risks of stacking are the risks of each step plus the effect of placing product into tissue that has just been divided. Subcision commonly causes bruising, swelling and tenderness, and sometimes small firm lumps beneath the treated area as the space heals; less commonly infection, post-inflammatory pigmentation, raised scarring in those prone to it, or a scar that responds less than hoped. Filler adds its own: swelling, bruising, lumps, product that migrates or sits unevenly, a bluish tint under thin skin, and inflammatory nodules that can appear months or years later.

Placing filler into a freshly subcised plane compounds these. A bleeding pocket makes even placement harder and raises the chance of a lump or an uneven surface; inflammation already present raises the chance of a nodule or infection around the product; and bruising over the cheek in Fitzpatrick III to V skin can leave a brown mark if it meets the sun. The serious risk of any filler, vascular occlusion, applies wherever product is injected; the warning signs, skin that blanches or turns dusky and mottled, pain that worsens, or any change in vision, are set out under complication care and need same-day attention.

These risks are reduced, not removed, by marking tethered scars with the skin stretched, releasing with a blunt cannula where possible, applying firm pressure afterwards, staging support in skin that bruises easily, placing small amounts after release, and reviewing each scar before anything further is planned.

What determines the fee for subcision with filler?

The fee depends on how many scars are tethered and how dense and deep the bands are, the area involved, whether support is needed at all after release and in how many scars, which material is chosen and how much the deficit calls for, and whether the plan is staged or completed at one visit. Resurfacing, where it follows, is quoted as a separate step. Singapore's rules restrict price advertising, so no figure is published here.

A written, itemised quote is given at consultation after the scars have been examined, with support quoted as a decision to be confirmed at review rather than as a package. The how we quote page explains what the quote contains, and the consultation process page sets out the steps from enquiry to follow-up.