Prominent nasolabial folds can be esthetically improved using various treatment modalities. To obtain optimal results, the treatment plan should be individualized according to the patient's age, aesthetic needs, anticipated downtime, and even economic status [
2]. Subcision, which is incisionless subcuticular undermining, was first introduced by Orentreich and Orentreich [
3]. The authors reported that subcision with tribeveled hypodermic needles was effective in correcting various types of skin depressions. They postulated that a depression could be lifted by the releasing action of the procedure and the formation of fibrotic tissue in the normal course of wound healing. The individual propensity for fibroplasia in the subcised area depends upon skin tension, which may cause internal hypertrophic scarring [
4]. The wire scalpel instrument consisting of a braided wire attached to a straight needle that was introduced by Sulamanidze et al. [
7] has been used for subcision in the clinical field. The authors concluded that subcutaneous dissection using a wire scalpel is a simple, safe, and effective method for improving the appearance of scars or age-related contour defects. Several other authors [
4-
6] have reported that subcision with a wire scalpel is effective for depressed scars, wrinkles, or folds. Furthermore, they reported that better results were obtained by simultaneous filling with fat [
5,
6] or other autogenous tissues [
4] after subcision. To improve the appearance of nasolabial folds, we used a modified subcision technique using a 20-gauge spinal needle cannula and a 4-0 Vicryl suture, which are less expensive and easily accessible when a wire scalpel is not available. The use of a cannula with a larger than 20-gauge bore might be more convenient but has a higher possibility of leaving a needle mark. The 4-0 Vicryl suture is durable enough to overcome the resistance at the modiolus during subcision. Mutifilament sutures such as Vicryl seem more proper for tissue sawing than monofilament sutures.
This procedure, which we call thread subcision, can be applied in patients who want prominent nasolabial fold correction alone; it can be performed in bilateral nasolabial folds as well as in a unilateral fold for asymmetric fold correction. It can also be performed as an ancillary procedure to a face-lift operation for better correction of nasolabial folds. We have used a wire scalpel before for the same purpose. The reason that we use thread instead of a wire scalpel is because thread is less expensive and more easily available in South Korea than wire scalpels. Based on our clinical experience, thread subcision was demonstrated to be as effective as wire scalpel subcision in improving the appearance of nasolabial folds. To obtain optimal results from subcision, it is essential to induce the formation of adequate amounts of scar tissue in the subcised area. The amount of fibroplasia after subcision varies with skin tension and the number of subcision procedures [
3]. When optimal results cannot be obtained with a single procedure, the procedure can be repeated at regular intervals of 2 to 3 months for more favorable results. In addition, simultaneous intradermal subcision using a hypodermic needle might be helpful to improve the appearance of nasolabial folds in patients with fine wrinkles. The width of the subcised area might also influence fibroplasia. Hence, we suggest that approximately 7 to 8 mm is an adequate width for the subcision area. More extensive undermining might induce hematoma and even internal hypertrophic scarring, whereas less extensive undermining causes undercorrection. There were only minor complications such swelling, bruising, and minor irregularities. However, they resolved spontaneously with conservative management. Based on the favorable results of our study, our modified subcision technique may be considered effective for nasolabial fold correction. However, further study of the various factors influencing fibroplasia is needed to obtain better and more consistent results from subcision.