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J Cosmet Dermatol. 2020;00:1–4. wileyonlinelibrary.com/journal/jocd
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1© 2020 Wiley Periodicals LLC
1 | INTRODUCTION
Acne scarring, a common complication of acne, affects people both
emotionally and physically worldwide unrelatedly of age, sex, and or-
igin.1 While the best way to manage acne scars is to inhibit them by
appropriate acne control, many acne cases go untreated. As a result,
these patients in the future develop atrophic ulcers, which are de-
forming and so that it can cause emotional suffering.2 Treatment of
acne scars comprises multiple modalities such as surgical procedures
(punch excision, punch grafting, and Subcision), resurfacing meth-
ods (ablative laser treatment, dermabrasion, and chemical peels),
nonablative laser treatment, injection of autologous fat, or dermal
Received: 20 October 2020
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Revised: 18 Nove mber 202 0
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Accepted: 24 Nove mber 2020
DOI: 10.1111/jocd.13876
ORIGINAL CONTRIBUTION
Efficacy evaluation of Endolift-based Subcision on acne scar
treatment
Mohammad Ali Nilforoushzadeh MD1,2 | Tannaz Fakhim MD2 |
Maryam Heidari-Kharaji PhD1 | Amir Reza Hanifnia MD2 | Somayeh Hejazi MD2 |
Elham Torkamaniha MSc1,2
1Skin and Stem Cell Research Center, Tehran
University of Medical Sciences , Tehran, Iran
2Jordan Dermatology and Hair
Transplantation Center, Tehran, Iran
Correspondence
Tannaz Fakhim, Jordan Dermatology and
Hair Transplantation Center, Tehran, Iran.
Email: tannaz.fakhim60@gmail.com
Abstract
Background: People with acne scar suffer from destruction to the surface of the skin.
Treating acne scars is a challenge that might need several methods.
Aims: Subsection is a method that has been informed to be a useful method in treat-
ing rolling acne scars. While Subcision is a valued procedure, its effect is mild to
moderate due to its high reappearance rate, and patients' dissatisfaction with some
of the side effects such as inflammation after procedure.
Patients/Methods: In this pilot study, 9 rolling acne scar patients underwent
Subcision with the Endolift (200-nm fiber) and followed up for 3 months. Outcomes
were evaluated by 3 dermatologists (Blind). Also, the patients’ satisfaction was as-
sessed to compare with dermatologist's opinions.
Results: Our results indicated that Subcision with the Endolift displayed good and
very good improvement in about 90% of patient with a good and ver y good satisfac-
tion in the patients. Photographic data evaluation indicated 100% improvement in
scar depth, topography, and total acne scar appearance. The average numbers of
lesions before the treatment were 25.5 ± 12.1, and after treatment, it was reduced
to 11.4 ± 2.1 (P < .05).
Conclusion: Subcision with the Endolift seems to be a safe and effective method
for acne scar treatment. It is done with a single perforation on each side (instead
of several perforations), which reduces the pain and scar risk in the patients. Also,
Endolift-based Subcision needs fewer surgical sessions and less recovery time with
less inflammation and erythema.
KEY WORDS
acne scars, efficacy, Endolift, subcision, treatment
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NILFOROUSHZA DEH Et AL.
fillers.3 Subcision is a method first presented in 1995 and used com-
monly to improve depressed scars. It purposes at freeing the fibrous
attachments under the scar to lift it up. Also, Subcision stimulates
the creation of connec tive tissue by normal physiological curing.4
Cannula or needle-based method can cause bruising, pain, and occa-
sionally hematoma. Additionally, the infection risk or long-term pain
is high. As an alternative to these methods, we evaluated the effect
of Subcision with Endolift. This tool is safer than other previous tools
with minimal side effects without hematoma and less recover y time
and less inflammation and erythema. The highest purpose of this
pilot study was to assess the efficiency of this method, side ef fect s,
treatment duration, and satisfaction of patient and physician after
applying this tool as a needle or cannula replacement. We are seek-
ing a tool by high performance and efficiency, minimal side effects,
and low recurrence rate that is available and appropriate for patient s
and doctors. In the current pilot study, we tried to evaluate the effi-
cacy of Endolift-based Subcision for treating atrophic acne. Endolift
is based on diode laser (1470-nm diode laser).
2 | MATERIALS AND METHODS
The study was done in the Jordan Dermatology and Hair
Transplantation Center, Tehran, Iran (2019). 9 patients, 4 males and
5 females, with rolling acne scars, were enrolled in the study. The
mean age of the participants was 30 years. An informed consent was
gained from patient s before starting the treatment. Patients with
history of diabetes, keloids, collagen disease, bleeding tendency, and
neuromuscular disease and pregnant women were not included. The
use of any treatment in the preceding 6 months was exclusion cri-
teria. The area to be subcised (about 10 mm wide) was sterilized,
outlined by a surgical marker, while the patients were sitting in a
fixed and comfortable position. For this study, we used EndoliftTM
(LASEMAR1500TM machine from Eufoton s.r.l.). The Endolift-based
Subcision (energy: 50-500 J, power: 2.5-3 watt, pulse: 25-50, fiber:
300 micron) was used for acne scar treatment without any incisions
or anesthetic. The 300 micron was easily inser ted under the skin
directly in the superficial dermis and passed via the subdermal plane
parallel to the skin surface. Rapid repetitive back and for th motion
of the fiber was done to scrape the underside of the dermis and
disconnect scar sub-surfaces such as the base, walls, borders, and
shoulders. After that, side-to-side fiber motion was also performed
to completely release fibrous tissues. After the final step, ice com-
pression was applied to the site of treatment for 20 minutes Patient
was instructed to apply antibiotic every 6 hours for 5 days after
treatment. This procedure was performed one time. Patients were
evaluated for results 1 month after the last procedure. Photographs
of patients were taken using Vision-face before the start of treat-
ment and after the final step of treatment. The results of Subcision
procedures were measured by 3 board-certified dermatologists
(blind). Patients’ satisfaction was assessed at the end of the process
of treatment. Patient graded their response to treatment as follows:
poor: 0, fine: 1-3, good: 4-6, and very good: 7-9.
2.1 | Statistical analysis
The data on target were analyzed using the SPSS 18 software.
3 | RESULTS
All patients were enrolled in the study and under went Subcision with
the Endolift. Af ter analyzing the results of photograph evaluation
(were taken before and after the treatment) by dermatologist, the
results showed good and very good improvement in about 90% of
patient. The patient satisfaction results showed good and very good
improvement in all of the involvements (100%). Photographic docu-
ments displayed a significant improvement in level of scar depth, to-
pography, and overall acne scar appearance in all 9 patients (Figure 1
and Figure 2). Patients with mild active acne experienced a decrease
in the development of scar after active phase of disease throughout
the treatment and follow-up inter val. The average numbers of le-
sions before the treatment were 25.5 ± 12.1, and after treatment, it
FIGURE 1 A 27-y-old female patient
before (A) and after (B) treatment
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NILFOROU SHZAD EH Et AL.
was decreased to 11.4 ± 2.1 (P < .05). Passing post–procedure mild
inflammations were identified among the patients that were cleared
wholly after 2 days of therapy. No sever swelling and bruising was
observed in the cases of underexamined patients. Also, the evidence
of skin infec tion was not reported. There was no evidence of hyper-
trophic scar or hyperpigmentation. The patients were followed up
for 3 months, and they were not revealed any side effect or recur-
rence throughout the course of the study.
4 | DISCUSSION
Treatment of acne scar with a new base device is challenging. All
surgical methods are continuously modified with the aim of reaching
the best results through easier, convenient, and prac tical techniques
to achieve the best final outcome with fast recovery and minimal
complications. With a wide range of treatments, prominent skin scar
depression can be significantly improved. To achieve the desired re-
sults, treatment design should be scheduled giving to the patient's
conditions such as age, sensitivity, aesthetic needs, and predicted
downtime.5 Subsection is an appreciated surgical procedure that
can be used to reduce depressed scars, cellulite, wrinkles, striae, and
boxer.5 This method is generally used to control depressed scars.
As explained by S. Orentreich and N. Orentreich in 1995, the pur-
pose of Subcision is to remove the fibrous components under the
scar, in the subcutaneous stage. This helps to lift up scarring and
connective tissue formation through normal physiological healing.4
It was performed by utilizing a Nokor or hypodermic needle (gauge
of needle depends on the scar size). Recently, several adjustments
to this surgical procedure have been prepared via many surgeons to
make it more ef fective and easier. One of the modifications made by
Al-Ghamdi was the use of a needle holder for the Nokor needle to
preser ve its horizontal direction without the need to remove from
the entr y point to visualize the orientation and change the direction
of the needle.6 Another modification performed by N. Khunger and
M. Khunger was the bending of the needle with a 90-degree angle
arter y forceps to avoid skin penetration or damage to the dermis.7
Also, Nilforoushzadeh et al reported that Subcision with the Cannula
is an acceptable alternative method for acne scar treatment.8 In an-
other study by Nilforoushzadeh et al, the effect of cannula Subcision
was compared to common needle method.9 In the present study,
we evaluated all sides of the use of another special device (Endolift
technique using a 1470-nm diode laser) for acne scar Subcision. We
concentrated on the acne scar treatment through Subcision proce-
dure with the Endolif t to break up fibrous bands that cause rolling
scars. Endolif t is based on the diode laser and can remove the f ibrous
components under the scar, induce the creation of connective tis-
sue, remodel the derma, and activate the collagen production. In our
knowledge, this is the first time that Endolift was used for Subcision
of the acne scars.10 -14 We detected an effective cure rate data (more
than 50% af ter 2 weeks). Hyperpigmentation, hypertrophic scar,
swelling, inflammation, ecchymosis, and redness are common side
effects among Subcision with common needle that are informed in
50% of patients (even up to 70%-80% of patients), but Subcision
with the Endolift seems to be a safe technique with high efficacy for
acne scar treatment and high patient's satisfaction. Another advan-
tage of our new designed technique is that Subcision with Endolift
has been done through single perforation in each side in place of
multiple perforations that can decrease the patients’ pain and risk of
scars throughout and after the process. Additionally, Endolift-based
Subcision compared with other Subcision techniques requires sig-
nificant fewer sessions of surgery and also it needs less recover y
time. Generally, all these useful tips increase patient satisfaction.
However, more controlled trials should be performed to evaluate
the efficacy and side effects of Endolift compared with needles and
other techniques.
5 | CONCLUSION
Acne scars can be a significant cosmetic concern, and many indi-
viduals seek treatment for this common condition, but there is
FIGURE 2 A 29-y-old male patient
before (A) and after (B) treatment
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NILFOROUSHZA DEH Et AL.
limited research on their therapy. We showed that Subcision with
the Endolift seems to be a safe technique with high efficacy for acne
scar treatment and high patient's satisfaction.
5.1 | Study limitation
Even this study was performed for free, but the cost of this therapy
is high, and it can be a problem for the patients.
ACKNOWLEDGEMENTS
We appreciatively acknowledge the colleagues and st affs in Skin and
Stem Cell Research Center, Tehran University of Medical Sciences,
Tehran, Iran.
CONFLICT OF INTEREST
The authors declare no conflicts of interest.
AUTHOR CONTRIBUTIONS
N.MA , F. T, H. AR, and H. S. performed the research. N. MA and T.H
designed the research study. H-K.M analyzed the data. T.E collected
the data. H-K. M wrote the paper.
ETHICAL STATEMENT
The authors state that the patients have given their informed con-
sent for the photographs and details.
DATA AVAIL ABI LIT Y S TATEM ENT
The data that support the findings of this study are available on re-
quest from the corresponding author.
ORCID
Mohammad Ali Nilforoushzadeh https://orcid.
org/0000-0001-6143-8039
Tannaz Fakhim https://orcid.org/0000-0003-2206-6177
Maryam Heidari-Kharaji https://orcid.
org/0000-0001-6954-7942
Elham Torkamaniha https://orcid.org/0000-0003-3116-3163
REFERENCES
1. Fried RG, Wechsler A. Psychological problems in the acne patient.
Dermatologic Ther. 2006;19(4):237-240.
2. Goulden V, Stables G, Cunliffe W. Prevalence of facial acne in
adults. J Am Acad D ermatol. 1999;41(4):577-580.
3. Hay RA, et al. Inter ventions for acne scars. Cochrane D atabase Syst
Rev. 2016;4:CD011946.
4. Orentreich DS, Orentreich N. Subcutaneous incisionless (subci-
sion) surgery for the correc tion of depressed scars and wrinkles.
Dermatol Surg. 1995;21(6):54 3-549.
5. Jordan R , Cummins C, Burls A. Laser resurfacing of the skin for the
improvement of facial acne scarring: a systematic review of the ev-
idence. Br J Dermatol. 2000;142(3):413- 423.
6. Al Ghamdi KM. A better way to hold a Nokor needle during subci-
sion. Dermatol Surg. 2008;3 4(3):378-379.
7. Khunger N, Khunger M. Subcision for depressed facial sc ars made
easy usin g a simple modif ication. Dermatol Surg. 2011;3 7(4):514 -517.
8. Nilforoushzadeh M, Elahe L, Elmira N, Bahareh S, Marjan S. Can
subcision with the c annula b e an accept able alternative method in
treatment of acne sc ars? Med Arch. 2015;69(6):384.
9. Nilforoushzadeh MA, Lotfi E, Heidari-Kharaji M, Nickhah N, Alavi
S, Mahmoudbeyk M. Comparing cannula-based subcision with
the common needle method: A clinical trial. Skin Res Technol.
2020;26(1):39-44.
10. Lehman JW III, G erstein H. An evaluation of a new mechanized
endodontic device: the Endolift. Oral Surg Oral Med Oral Pathol.
1982;53(4):417-424.
11. Crassas Y. Full face Endolift: 10 years evolution. J Cosme t Laser Ther.
2003;5(3–4):223-225.
12. Tazbir M. Endolifting 4d.
13. Shilov B , Eaves FF, Bostwick J, Nahai F, Bried JT. Endoscopically-
assisted face and neck lift : anatomical considerations. Eur J Plast
Surg. 1997;20(1):1-3.
14. Scrimali L, Lomeo G . Endolaser soft lift: from theory to practice.
Union of Aes thetic Medicine–UIME. 2015;27.
How to cite this article: Nilforoushzadeh MA , Fakhim T,
Heidari-Kharaji M, Hanifnia AR, Hejazi S, Torkamaniha E.
Efficacy evaluation of Endolift-based Subcision on acne scar
treatment. J Cosmet Dermatol. 2020;00:1–4. ht t p s: // do i .
org /10.1111/j ocd.13 876