Comparison of Results of Wire Subcision
Performed Alone, With Fills, and/or
With Adjacent Surgical Procedures
Gordon H. Sasaki, MD
Background: Because of the fixed attachments (or muscle–superficial musculoaponeurotic system [SMAS]
insertions) to the undersurface of wrinkles, folds, and retracted scars, the use of fills alone has resulted in
unpredictable and unsatisfactory improvements.
Objective: To demonstrate that use of a wire dissector to completely release these attachments, accompanied
by an immediate fill and/or an adjacent aesthetic surgical procedure, may optimize final results, improving
deep wrinkles, folds, and scars.
Methods: The subcision wire was positioned under various wrinkles, folds, and scars in a triangulated outline
and then zigzagged to uniformly release any subdermal attachments. Patients were divided into 4 categories
based on the treatment received: group 1, wire subcision only; group 2, wire subcision plus immediate fill with
a strip of autogenous filler or xenograft material; group 3, wire subcision without fill but with an adjacent aesthetic surgical procedure; and group 4, wire subcision, fill, and an adjacent surgical procedure. Results were
rated with a photographic wrinkle/fold assessment scale (mean ± standard deviation) by 2 blinded evaluators
after at least 6 months. Assessment was based on a quartile grading scale that indicated improvement (0 =
<25% improvement; 1 = 25–50% improvement; 2 = 51–75% improvement; and 3 = >75% improvement).
Results: Eighty-five patients experienced 338 wire subcisions at 8 facial, 1 posterior neck, and 4 thigh (cellulite) sites. The longest follow-up was 1.5 years (mean, 6.3 mos). The cumulative quartile grading scale was
recorded as follows: group 1 (1 ± 1.5 SD); group 2 (3.1 ± 0.1 SD); group 3 (2.5 ± 0.2 SD); and group 4
(3.6 ± 0.2 SD). When fills were employed as spacers under the release tracts in group 2 and 4 sites, strips of
SMAS, dermis, and microfat droplets were the favored fills in the areas of nasolabial and marionette folds
because of the capacity of the graft’s volume and tissue acceptance. For shallower depressions, such as the
glabellar frown lines and crow’s feet, strips of deep temporal fascia or muscle were more effective.
Complications after wire subcision with or without fill were few and transient.
Conclusions: The use of wire subcision for resistant wrinkles, folds, or scars can result in a satisfactory outcome with minimal complications when used as a solitary procedure. Results may be further optimized with
the immediate addition of fill into the released tract. An adjacent aesthetic surgical procedure that impacts at
the subcised site may provide additional benefit to the site, but not as much as observed with the usage of an
immediate fill. Autogenous fills that are substantitive provide longer lasting effects because of volume and tissue acceptance. (Aesthetic Surg J 2008;28:619-626.)
he use of volumetric fills alone has resulted in
variable and unpredictable long-term improvements because of the presence of fixed subdermal
attachments or muscle-superficial musculoaponeurotic
system (SMAS) insertions to deep wrinkle lines, folds,
and retracted scars. The use of subcision instruments1-3
—Nokor needles (BD, Franklin Lakes, NJ), scalpels, and
forked cannulas—may significantly improve results by
T
Dr. Sasaki is Clinical Professor of Surgery, Loma Linda University
Medical Center, Loma Linda, CA.
Aesthetic Surgery Journal
releasing these attachments, whether these instruments
are used alone or in combination with a fill. Failure to
uniformly release sites of fixation and to simultaneously
provide an intervening fill, however, may produce inadequate correction with less than optimal results. Recent
experience with braided subdermal wire dissectors4-6 has
shown a more complete and minimally invasive release
of these restraining structures.
The purpose of this study was to compare the effectiveness of wire subcision (ReleaseWire dissector; MicroAire
Surgical Instruments, LLC, Charlottesville, VA) alone, wire
Volume 28 • Number 6 • November/December 2008 • 619
subcision with concomitant autogenous filling, wire subcision in conjunction with an adjacent aesthetic surgical procedure, and wire subcision in combination with an
adjacent surgical procedure and autogenous filling, to
improve deep wrinkles, folds, and scars.
50cm 12-strand braided wire
Diamond
trocar tip
PATIENTS
The patient population consisted of 80 females and 6
males, including 65 white, 9 Hispanic, and 11 Asian
patients, ranging in age from 33 to 83 years (mean, 59.5
yrs). Those with active infection, collagen-vascular disorders, pregnancy, or with facial surgery, filler injections,
Botox injections, or photochemical or dermabrasive procedures within the preceding year were excluded from
the study.
MATERIALS
The ReleaseWire dissector consists of a 50-cm, 12-strand
braided wire with an attached single 10-cm diamondshaped trocar tip straight solid needle (Figure 1). The
specially designed needle permits smooth and precise
penetration in and out of the skin with minimal needle
drag during tissue passes. The tightly wound braided
wire allows for efficient and controlled subcision dissection and the complete release of connections between
skin wrinkles, folds, and the underlying planes of
attached subcutaneous fat and muscle.
10cm solid needle
Figure 1. The ReleaseWire dissector (MicroAire Surgical Instruments,
LLC, Charlottesville, VA) consists of a diamond-shaped trocar tip at the
end of a 10-cm straight solid needle to which is attached a 50-cm,
12-strand braided wire.
METHODS
In group 1, wire subcision procedures only were performed under local anesthesia to selected facial wrinkle/fold sites or depressed scars on the face or body.
With the patient in a sitting position, a triangular marking was outlined over an area 0.5 to 1.0 cm wider than
the depression (Figure 2). Cooled compresses were
applied to the sites for about 5 minutes before the injection of buffered 1% xylocaine with 1:400,000 concentration of epinephrine. (Cool compresses may be reapplied
for another 15 minutes to maximize vasoconstriction,
reducing subsequent ecchymosis and hematoma formation.) The needle and attached braided wire were inserted through the skin perpendicularly at the apical
marking into the immediate subdermal tissue, passed
under the skin, and exited at one of the triangular base
markings. The needle and wire were reintroduced
through the same exit site and exited at the opposite
base marking. The needle was reinserted into the same
site, exiting at the original apical entry site (Figure 3).
With countertraction, the wire ends were crossed, zigzagged through the tissue, and removed, thereby attaining a complete subdermal release (Figure 4). The tract
was irrigated immediately through one of the puncture
openings with cooled saline with epinephrine until clear.
(Cool compresses may be reapplied under pressure for
another 5 minutes.)
In group 2, wire subcision procedures and an immediate fill to selected facial wrinkles, folds, or retracted scars
were performed. (These procedures were performed
620 • Volume 28 • Number 6 • November/December 2008
Figure 2. For any wrinkle, fold, or scar, a triangular skin marking is
outlined over an area 0.5 to 1.0 cm wider than the depression. The
effectiveness of wire subcision is determined by the degree of fibrosis
of the scar bed. If an area of multiple wrinkle lines (crow’s feet) or
fold irregularities (acne scars) is greater than 2.5 cm, a series of overlapping triangular outlines may be necessary to efficiently subcise the
entire area.
under local or general anesthesia in combined surgeries
in which aesthetic facial procedures did not impact the
subcision sites.) In these cases, 1- to 2-mm wide strips of
orbicularis muscle (blepharoplasty), SMAS (face/neck
lift), or dermis (face/neck lift and body contouring) were
threaded through the created tract, attached to a graft
passer from MicroAire Surgical Instruments or to a small
diameter suction cannula (Figure 5). Available tissue glue
may be instilled into the filled tract to further reduce
ecchymoses or hematomatous collections.
In group 3, wire subcision procedures without fills
were combined with an adjacent facial aesthetic procedure that impacted the subcision sites, such as SMAS
rhytidectomy and malar fat pad elevation, with release
of the nasolabial and marionette folds. This group of
combined interrelated surgical procedures added potential effects of surgery on the released depressions without benefit of fills to the evaluation process.
Aesthetic Surgery Journal
In group 4, wire subcision procedures, immediate
fills, and an adjacent facial aesthetic procedure that had
a salutary effect on the subcised sites were performed.
This combination of procedures was expected to provide
optimal results at the released sites.
Assessment
Figure 3. The needle and attached wire are inserted through the skin
at the apical marking into the immediate subdermal (2- to 3-mm
depth) tissue, exiting at one of the triangular base markings (1). The
needle and wire are introduced through the same exit site and
brought out at the opposite basemarking (2). The needle is reinserted
through the same exit site and retrieved at the original apical entry
point (3).
Figure 4. The wires (1 and 2) are crossed, zigzagged through the tissue, and removed to create a separation of the skin depression from
the underlying retracting structures.
Figure 5. After creating a tract under the wrinkle or fold, a 1- to 2-mm
strip of orbicularis muscle, superficial musculoaponeurotic system,
dermis, or deep temporal fascia is attached to the graft passer or a
small suction cannula and threaded into position.
Results of Wire Subcision
Pretreated facial wrinkles, folds, or scars were rated on
the modified wrinkle/fold scale5 and assessed by 2 blinded evaluators more than 6 months after treatment by
comparing the pre- and postoperative patient photographs with standardized photographs. Assessment was
based on a quartile grading scale as follows: 0 = <25%
improvement; 1 = 25–50% improvement; 2 = 51–75%
improvement; and 3 = >75% improvement. A cumulative score (mean ± standard deviation), derived from
the averages at each of the measured sites, was calculated for each of the 4 groups.
RESULTS
Representative results are illustrated in Figures 6 through
9. Eighty-six patients underwent 340 wire subcisions distributed over 8 facial sites, 1 posterior neck site, and 4
sites of thigh cellulite (Figure 10). The longest follow-up
was 1.5 years (mean, 6.3 mos). The percent distribution
of facial procedures from highest to lowest include
nasolabial folds (44%; 152/340), marionette folds (25%;
86/340), lip lines (11.0%; 37/340), crow’s feet (7.0%;
22/340), glabellar frown lines (6.0%; 20/340), facial scars
(3.0%; 10/340), horizontal forehead lines (2.0%; 6/340),
and cat’s whiskers (0.5%; 2/340). There were 4 wire subcision procedures to cellulitic sites on posterolateral thigh
areas (1.0%; 4/340) and 1 wire subcision procedure to a
depressed posterior midline neck scar (0.5%; 1/340).
To determine the degree of effectiveness in smoothing
out these areas, when this procedure was used alone or in
conjunction with fills and/or combined surgical procedures, the clinical experience was divided into 4 patient
groups and each case was assessed after 6 months by
quartile grading (Figure 11). The quartile grading result of
wire subcision alone at 59 sites, including horizontal forehead, glabellar frown, marionette, and lip lines; crow’s
feet; nasolabial folds; retracted scars on the cheeks, posterior neck and abdomen; and cellulite was 1.5 ± 0.2 after 6
months of follow-up. The quartile grading result of 3.1 ±
0.1 with wire subcision and immediate fill at 27 sites
(glabellar frown and lip lines, nasolabial and marionette
folds, and facial and brachial scars) was significantly
greater than that observed after wire subcision alone, suggesting the importance of a fill after release. The salutary
effect of an adjacent surgical procedure (foreheadplasty,
blepharoplasty, or face lift) on release of 109 sites that
involved an adjacent wrinkle or fold without a simultaneous fill (horizontal forehead and glabellar frown lines,
crow’s feet, and nasolabial and marionette folds) recorded
a quartile grading of 2.5 ± 0.2. This value is not only significantly higher than that seen after wire subcision alone,
but also is significantly lower than the value observed after
Volume 28 • Number 6 • November/December 2008 • 621
B
A
Figure 6. A, Pretreatment view of a 57-year-old woman with deep and prominent nasolabial folds. B, Clinical improvement 1 year after undergoing wire subcision without fill.
A
B
Figure 7. A, Pretreatment view of a 67-year-old man with brow ptosis, horizontal forehead and
interbrow rhytids, dermatochalasia to the upper lids, acquired ptosis of the right upper lid, excess
skin and fat to the lower lids, and deep nasolabial folds. B, Clinical improvement of the forehead
and brow complexes 1 year after an endoscopic forehead and periorbital lift that included surgical weakening of the 5 interbrow depressor muscles. Although the upper two-thirds of the
frontalis muscles were not weakened, the use of wire subcision on these transverse forehead
rhytids resulted in a significant smoothing out of these standing rhytids without filling. In addition, blending of the deep vertical frown lines occurred with both the use of surgical weakening
of the corrugator muscles and wire subcision procedure without fill. In contrast, the combination
of wire subcision and muscle strip fill to each nasolabial fold improved their appearances. A septal reset procedure satisfactorily addressed the lower lid concerns. The patient is scheduled for
an elective correction of his upper lid ptosis.
wire subcision plus immediate fill. In contrast, the quartile
grading of 3.6 ± 0.2 after wire subcision plus immediate
fill plus adjacent facial surgery at 145 sites (glabellar frown
lines, crow’s feet, nasolabial and marionette folds, cat’s
whiskers, and midface scar) was statistically higher than
the values obtained from the other 3 categories.
As depicted in Figure 12, the 165 fillers consisted of
strips of SMAS (51%; 85/165), deep temporal fascia
(15%; 24/165), microfat (11%; 18/165), orbicularis muscle (11%; 18/165), dermis (11%; 18/165), or porcine
xenografts (1.0%; 2/165). The type of filler selected for
622 • Volume 28 • Number 6 • November/December 2008
each site was determined by volume need and tissue
acceptance, and the limited results were evaluated at
least 6 months later by quartile grading assessments
(Figure 13). Therefore, strips of SMAS and dermis or
microfat injections were the fillers of choice for deeper
nasolabial and marionette folds. The volume need of
these autogenous fillers could be clinically determined
and tailored from the donor sources. These volumetric
fillers under the nasolabial and marionette folds resulted
in a higher success value (3.0–3.5 on the quartile grading
assessment scale) than those values (2.0) observed with
Aesthetic Surgery Journal
A
B
Figure 8. A, Pretreatment view of A 68-year-old woman with midface and neck ptosis, malar fat
pad descent with deepened nasolabial and marionette folds, and radial lip lines. B, Clinical
improvement after a superficial musculoaponeurotic system (SMAS) face and neck lift with polytetrafluoroethylene suture suspension of the malar fat pads. Wire subcision with a SMAS strip
further improved the nasolabial lines. In addition, wire subcision separated the attachments of
the upper depressor anguli oris muscle and the lower adhesions of the mandibular ligaments,
leading to further smoothing of marionette folds with normal tissue healing. The subcision wire
was passed under the vermillion rolls of the upper and lower lip, freeing the orbicularis oris muscular attachments to the white rolls and improving the appearance of the radial lip lines.
orbicularis muscle or deep temporal fascial strips at the
same sites. On the other hand, strips of orbicularis muscle resulted in a quartile grading assessment value of 3.0
under the shallower glabellar frown lines. Strips of deep
temporal fascia were selected in areas, such as crow’s
feet lines, that required thinner and more pliable fills and
resulted in a quartile grading assessment value of 3.0.
COMPLICATIONS
Early complications observed at 340 wire subcision sites
included 1 localized hematoma in the nasolabial fold,
which responded to drainage and steroid injections, and
limited downward migration of autogenous strip grafts
in 3 patients (in 2 nasolabial folds and 1 marionette
fold). This latter complication responded to massage and
ultrasound treatments over 3 months and was subsequently prevented by incorporating the grafts with the
skin closure at both the proximal and distal ends. None
of the patients experienced sterile or infected collections
at the released sites, either with or without fills, including liquefied fat after micrografting. There were no early
or delayed sensory or motor nerve injuries observed
throughout the evaluation period, especially asymmetrical motion to normal facial expression of the lips, periorbital, and perioral areas. A few patients exhibited limited
incisional scars that resolved with microdermabrasion.
DISCUSSION
The use of wire subcision procedures in the face and
body has the potential to result in a more complete and
less traumatic elevation of wrinkles, folds, and scars
than using previous methods. In 2000, Sulmanidze et al4
published their experience, using the wire scalpel techResults of Wire Subcision
nique without fills in 132 depressed forehead lines,
nasolabial and marionette folds, vertical lip lines, and
acne scars. After follow-up periods ranging from 2
months to 4 years, good or satisfactory results were
observed by subjective and photographic evaluations in
79.7% and 16.6% of 54 patients, respectively. In 2006,
Gravier5 employed the use of wire subcision alone in 8
patients and, in 27 other patients, the simultaneous use
of wire subcision with various simultaneous fillers
(microfats, Radiesse [BioForm Medical, San Mateo, CA];
Sculptra [Dermik Laboratories, Bridgewater, NJ]; and
AlloDerm [Life Cell Corporation, Branchburg, NJ]) for
improvement of their transverse forehead and glabellar
lines, nasolabial and marionette folds, radial lip and
neck lines, and retracted facial and body scars. Five
patients received simultaneous laser resurfacing immediately following their subcision procedures. After 1 to 19
months all patients demonstrated persistent correction
with few postoperative complications (1 hematoma, 1
localized abscess, and 3 overcorrections).
In contrast to previous publications, this study represents the first investigation to assess the outcome of wire
subcision alone and how its effects may be influenced or
enhanced with the addition of fills and/or combined
adjacent aesthetic surgical procedures. Although the
wire subcision technique was performed at 340 sites in
86 patients, 87% percent of the sites involved the
nasolabial and marionette folds and lip lines. In this
study, 48.5% of 340 sites were filled using an autogenous strip graft, microfat material, or a porcine xenograft
strip. Of these 165 fillers, all except 1 (porcine) were
obtained from patients during surgical procedures, consisting of deep temporal fascia (endoscopic periorbital
Volume 28 • Number 6 • November/December 2008 • 623
A
B
C
D
Figure 9. A, C, Pretreatment views of a 30-year-old woman with left panfacial nerve paresis
(from Bell’s palsy 10 years ago) with asymmetrical forehead brow ptosis, upper and lower lid
excess fat and skin, malar fat descent, incompetent left lip commissure, and a malpositioned scar
to create a left nasolabial line. B, D, Clinical improvement 1 year after an asymmetrical endoscopic forehead and periorbital lift (favoring the left side), right upper lid blepharoplasty, bilateral
transconjunctival lower lid blepharoplasties, asymmetrical superficial musculoaponeurotic system
face lift with malar fat pad suspensions (polytetrafluoroethylene sutures), and a palmaris longus
tendon graft suspension to the left upper and lower lip commissure complex. Wire subcision satisfactorily elevated the right nasolabial fold (followed by a deep temporal fascia fill) and the left
nasolabial iatrogenic scar, with liposculpture under the scar, and other soft tissue deficient sites
in the lid–cheek junctions, midface, lateral upper brows, lips, and chin.
lift), orbicularis muscle (upper lid blepharoplasty), dermis or SMAS strips (face/neck lift), or microfat tissue
(lipoaspiration from the neck, abdomen, or medial
knees). The rationale for autogenous fill was based on
tissue compatibility, availability, and cost. The optimal
fills for deeper nasolabial and marionette folds consisted
of SMAS and dermis and microfat injections, which provided the potential of a longer lasting and volumetric
replacement. Shallower lines and areas that would not
accept larger volumetric fills, such as the glabellar frown
lines and crow’s feet, were generally filled with muscle
or deep temporal fascial strips.
Although the quartile grading scale resulted in a subjective appraisal of outcome assessment, it demonstrated
the safety and effectiveness of the various types of pro624 • Volume 28 • Number 6 • November/December 2008
cedures. The use of wire subcision alone was likely to
provide a variable and unpredictable result because the
deep reattachments of the various released areas
recurred without a fill. In spite of the absence of a discernible spacer, the normal healing processes after
release can result in a modest salutary effect (1.5 ± 0.2
on the quartile grading scale) in some cases. When an
immediate fill was added to the subcised site, the effectiveness of the combined procedures was significantly
improved (3.1 ± 0.1) after a 6-month to 1.5-year follow
up. The impact of an aesthetic procedure on the adjacent wrinkle, fold, or scar was greater than wire subcision alone but less than the benefits observed after
subcision and immediate fill. The most efficient technique appeared to be the combination of wire subcision,
Aesthetic Surgery Journal
152 (44%)
86 (25%)
37 (11%)
22 (7%)
20 (6%)
10 (3%)
Nasolabial Marionette Lip Lines
Fold
Fold
Crow’s
Feet
Glabellar
Frown Line
Facial
Scars
6 (2%)
4 (1%)
2 (1/2%)1 (1/2%)
Horizontal Cellulite
Cat’s
Forehead
Whiskers
Lines
Body
Scar
Figure 10. Site distribution of wire subcision procedures by number and percentage
at 340 areas in 86 patients.
Quartile Grading Scale
4
Quartile Grading Scale for
Clinical Improvement
3.5
0 = <25%
3
1 = 25-50%
2.5
2 = 51-75%
2
3 = >76%
1.5
Data expressed as mean±SEM
1
0.5
0
Re
lea
se
Wi
re™
Rel
eas
eW
ire
™+
Rele
Rele
ase
ase
Wire
Wir
™+
e™
Imm
+A
edia
djac
te Fil
Im
e
me
nt F
l+A
dia
acia
djac
te F
l Su
ent
Facia
rger
ill
y
l Sur
gery
Figure 11. The subjective quartile grading assessment demonstrates grading after (1) wire
subcision alone, (2) wire subcision and immediate fill, (3) wire subcision and adjacent
aesthetic surgery, and (4) wire subcision, immediate fill, and adjacent aesthetic surgery.
85 (51%)
24 (15%)
18 (11%)
18 (11%)
18 (11%)
2 (1%)
SMAS
Deep
Temporal
Fascia
Muscle
(Upper Lid)
Dermis
Fat
Porcine Strip
Grafts
Fillers
Figure 12. The number and percentage of autogenous strips and xenograft strips
selected in 165 fillers.
Results of Wire Subcision
Volume 28 • Number 6 • November/December 2008 • 625
Nasolabial
Folds
Marionette
Folds
Glabellar Frown
Lines
Crow’s Feet
Figure 13. The quartile grading assessment is demonstrated after 6 months to 1.5 years
at 4 surgical sites and in 5 types of autogenous fills.
immediate fill, and an adjacent aesthetic surgical procedure, which resulted in a quartile grading score of 3.6 ±
0.2 over time.
The use of these various techniques to improve resistant wrinkles, folds, or scars was accompanied with not
only a low number but also few types of complications.
There appeared to be no advantage for delayed filling
after 3 to 6 weeks. The use of wire subcision for smoothing out areas of cellulitic dimpling did not result in any
significant benefit to the sites and may result in more
postoperative irregularities.
4. Sulamanidze MA, Salti G, Mascetti M, Sulamanidze GM, Burres SA.
Wire scalpel for surgical correction of soft tissue contour defects by
subcutaneous dissection. Dermatol Surg 2000;26:146–151.
5. Gravier M. Wire subcision for complete release of depressions, subdermal attachments, and scars. Aesthetic Surg J 2006;26:387–394.
6. Sasaki GH. ReleaseWire system subcision and fill for wrinkles folds
and scars. Presented in poster form at the Annual Meeting of the
American Society for Aesthetic Plastic Surgery, New York, NY, May 1925, 2007.
Accepted for publication October 7, 2008.
Reprint requests: Gordon H. Sasaki, MD, 800 S. Fairmount Ave., Ste. 319,
Pasadena, CA 91105. E-mail: [email protected].
Copyright © 2008 by The American Society for Aesthetic Plastic Surgery, Inc.
CONCLUSIONS
1090-820X/$34.00
The use of this established but minimally invasive subcision technique has been shown to offer more reliability
and safety in selected patients when combined with
immediate autogenous fills and simultaneous aesthetic
surgery. The efficacy of the various autografts and other
xenograft materials will be determined through lengthier
longitudinal follow-up. The addition of alternative longer
acting injectables or botulinum toxin injections at the
release sites is currently under evaluation. ◗
doi:10.1016/j.asj.2008.10.005
DISCLOSURES
Dr. Sasaki is a paid consultant for MicroAire Surgical Instruments,
LLC and received ReleaseWire devices for completion of the study.
He received no other financial support other than the disposable
wires and has no financial interest in the manufacturers of other
products mentioned in this article. Microaire had no part in the
study design or data development of this article.
REFERENCES
1. Orentreich DC, Orentreich N. Subcutaneous incisionless (subcision)
surgery for the correction of depressed scars and wrinkles. Dermatol
Surg 1995;21:543–549.
2. Sulamanidze MA, Britun YA, Savchenko SV. Subcutaneous dissection
and liquid-gel dermotension. Ann Plas Reconstr Estet Khir (Rus)
1997;21:35–40.
3. Snow SN, Stiff MA, Lambert DR. Scalpel sculpturing technique for graft
revision and dermatologic surgery. J Dermatol Surg Oncol
1994;20:120–126.
626 • Volume 28 • Number 6 • November/December 2008
Aesthetic Surgery Journal