When subcision goes too far
Subcision — The Art of Controlled Aggression
Two complications of aggressive, wide-field subcision are turning up in my clinic as referrals from elsewhere, and neither is well recognised: facial swelling that persists past six months, and increased sagging of the lower face.
What we found
Persistent facial swelling, lasting more than six months.
It presents as diffuse soft-tissue swelling of the lower face and cheeks, with no lump you can feel. That distinguishes it from fibroplasia, which has a distinct firmness on examination and shows identifiable features on imaging. This swelling shows none.
Increased facial laxity, often alongside that swelling.
Sagging of the lower face after extensive field subcision in that region. It is likely to have more than one cause: the persistent swelling itself, extensive cutting across the plane where the masseteric and mandibular ligaments insert, and — since the patients presenting with it are usually middle-aged — a degree of age-related descent that was already under way.
Both follow the same pattern: one aggressive session, one broad instrument.
Most frequently these have occurred after a single aggressive treatment session using a wide-headed dissector. Not exclusively — but the association is consistent enough to be worth naming.
The likely mechanism is lymphatic.
Wide undermining may disrupt the lymphatic network. Patients with severe acne and scarring often already have compromised lymphatic drainage — chronic inflammatory conditions such as acne and rosacea are thought to impair lymphatic vessel integrity through granulomas, histiocytic infiltrates and mast cell dysregulation. Extensive subcision on top of that may tip it over.
It responds, but variably.
In my experience persistent swelling responds variably to low-dose isotretinoin and dilute intralesional corticosteroid. Some cases resolve with a prolonged course of tetracyclines combined with lymphatic massage.
What this means for you
More aggressive is not automatically better
There is no consensus on how far the undermining of a scar field should extend. The trend toward broad instruments is driven by shorter treatment times and better results in the right hands — but the extent of undermining is where the risk sits.
Staged sessions over one big one
Both complications described here followed a single aggressive session. Several conservative sessions achieve the same release with far less disruption to the tissue in between.
The ligaments hold your face up
The retaining ligaments of the face are what prevent sagging. Cutting extensively across the plane where they insert has consequences that are not immediately visible on the day.
Why this matters
Subcision has moved steadily toward larger, broader instruments. They transect scar tissue efficiently and cut operating time, and the published results support them. What has not kept pace is any agreement on how extensive the undermining should be.
This letter describes two complications I have seen referred in from other clinics over the past two years. Neither is common. Both are, I think, avoidable — and neither appears in the usual list of things patients are warned about.
The argument
It is crucial to respect the structures that hold the face together. Subcision should be performed with a balanced technique and controlled aggression — the emphasis being on controlled.
What this study cannot tell you
Every study has a boundary, and it is fairer to state it than to leave you to guess.
- This is a letter describing clinical observations, not a study. There is no denominator, so no rate can be calculated.
- The reports are anecdotal, with no standardised photographic documentation, because the original procedures were performed by other clinicians.
- The proposed lymphatic mechanism is a plausible explanation, not a demonstrated one.
- The cases are not solely linked to a single instrument, although the association with broad-headed dissectors was consistent.
Questions people actually ask
Can subcision cause long-term swelling?
Rarely, yes. This letter describes swelling that persisted beyond six months after extensive field subcision — diffuse, without a palpable lump, and without the imaging findings that would point to fibroplasia.
It is uncommon, and it appears to follow aggressive single-session treatment with broad instruments rather than subcision in general.
Can subcision make your face sag?
It has been observed after extensive subcision across the lower face, and the likely reason is that the procedure cuts through the plane where the facial retaining ligaments insert.
The picture is usually mixed: persistent swelling, ligament disruption and pre-existing age-related descent all contributing. It is an argument for conservative technique in the lower face, not for avoiding subcision.
How is persistent swelling after subcision treated?
Response is variable. In my experience low-dose isotretinoin and dilute intralesional corticosteroid both help some patients, and some cases settle with a prolonged course of tetracyclines combined with lymphatic massage.
There is no established protocol, which is part of the reason for writing this up.
Cite this paper
Lim DS. Subcision — The Art of Controlled Aggression. Journal of Cosmetic Dermatology. 2025. doi:10.1111/jocd.16746
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Published 2025 · Summary written and reviewed by Dr Davin Lim, FACD · General information, not personal medical advice.
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