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Original Article

Treatment of Skin Depression with Combined Upward Suture Traction and Percutaneous Subcision

Pereira, Osvaldo MD*; Bins-Ely, Jorge PhD; Paulo, Elizabeth Machado MSc; Lee, Kuang Hee MD§

Author Information
Plastic and Reconstructive Surgery - Global Open: October 2015 - Volume 3 - Issue 10 - p e534
doi: 10.1097/GOX.0000000000000486


There are many causes of scar retraction and soft-tissue depression including infection, tissue necrosis after injections, breast radiation therapy, trauma, tumor excision, and gynecoid lipodystrophy. The soft-tissue changes compromise aesthetics and may cause social embarrassment.

In a previous report,1,2 we described combined upward suture traction and percutaneous subcision to treat inverted nipple grade I and II. In this approach, the nipple is pulled up vertically with sutures and the retracted bands were released using 16- and 18-gauge needles that are placed percutaneously at the areolar border. During healing, the space created is progressively filled with connective tissue, with improvement of nipple anatomy.

We used the same technique to treat different soft-tissue depressions and retracted scars at multiple body sites. With this approach, the retracted zone was pulled vertically with looping sutures to provide traction, and the retracted bands were released percutaneously with circular motions using needles or miniblades.

The purpose of this study was to evaluate the results of treating soft-tissue depressions or retractions at varied anatomic regions with this percutaneous or minimal incision method combined with upward traction with looping stitches.


There were 40 patients (age: mean, 39 years; range, 22–25 years; 39 women and 1 man) comprising n = 77 soft-tissue lesions, who had treatment with the present technique from 1996 to 2013. Postoperative follow-up was from 6 months to 2 years. The treated anatomic areas were evaluated in 5 groups: (1) face (8 patients; 8 lesions); (2) gluteal (16 patients; 45 lesions); (3) breast (7 patients; 10 lesions); (4) abdomen (7 patients; 7 lesions); and (5) lower limb (2 patients; 6 lesions).

Surgical Technique

The surgical area was infiltrated with local anesthetic (lidocaine 0.5% with epinephrine 1:800.000). A 2-0 nylon monofilament suture with a curved needle (2–3 cm) was inserted 0.5–1 cm deep at the core of the depression at a single, crossed, or serial looping suture. The needle holder was used to pull the looping suture vertically upward, providing a virtual plane in the scar or depressed tissue. A 16- or 18-gauge needle (BD 30 × 12; Nokor needle; Becton Dickinson, Franklin Lakes, N.J.) that was attached to a syringe (10 mL) was inserted at the periphery of the retracted area. Circular motions of the needle were applied to release adhesions, and the bidigital patency sign confirmed the absence of residual retracted bands. In areas with retracted soft tissue >5-cm diameter, the needle was used with a miniblade (Doris model R-807; Richter Surgical, São Paulo, Brazil) (Figs. 1, 2).

Fig 1:
A 32-year-old woman treated for gluteal skin depression with the technique of combined upward suture traction and percutaneous subcision. A, Intraoperative view showing type 1A (subcutaneous lipoatrophy) of the left buttock and type 1B (fibrosis) of the right buttock caused by abscess during childhood. B, Upward traction of the adhesion with looping sutures placed in a crisscross fashion. The BD 18G pink needle is inserted in the deep plane through the external border of the type 1A depression. C, Improvement of the buttocks contouring at the end of the procedure. D, Palpation maneuver to confirm the releasing of the retracted bands.
Fig. 2:
Patient from Fig. 1 at 14 months after surgery. A, Preoperative view shows depression type 1A (lipoatrophy) at the left buttocks and type 1B (fibrosis) at the right one. B, Postoperative view shows improvement of the buttocks anatomy.


In 27 (67%) of the total 40 patients, 1 treatment was done. In 10 cases (25%), 2 treatments were done. In the group 1: face (8 cases, n = 10 sites), and group 4: abdomen (7 patients, n = 7 sites) were submitted to only one treatment. In the group 2: gluteal region (16 patients, n = 45 sites), 7 patients (43%) had 2 or 3 treatments. The same with 5 of 7 patients (70%) of group 3, breast. Depression <5-cm diameter was successfully released in all patients. Bruising around the treated areas persisted for 2–3 weeks. Moderate induration persisted until 3 months. In the gluteal region, 6 patients who had retracted area with diameter >5 cm developed seroma after treatment [buttock × lesions (13%)], which was resolved after needle aspiration in 2–3 ambulatory visits. Penrose drain for 2 weeks was indicated in 2 patients.

The results were also classified as poor, fair, and good according to clinical examinations, photographs, and patient testimony. In the 40 patients presenting soft-tissue depression, 26 were classified as having a good result (65%) and 12 as having a fair result (30%) (Table 1).

Table 1:
Clinical Cases—Type of Lesions, Topography, Sessions, n = sites, Follow-up, Result


The present results confirmed the efficacy of the subcision combined with upward traction method at the diverse body sites, as previously reported for inverted nipple in the breast.

Scar depressions at the face, especially those that developed after external drainage of alveolar abscess along the mandibular border, were corrected satisfactorily.3 These retractions were typically at a diameter around 1 cm, and 1 surgical session usually corrected the soft-tissue irregularity. They may be difficult to treat because thin layer of the local tissue may be insufficient for regional flap transposition performed with open approaches. However, the present technique preserved the thin local soft tissue (Fig. 3) (See video, Supplemental Digital Content 1, which displays a 40-year-old female of the group 1 (facial region) during transoperative combined subcision with upward traction to treat mandibular soft-tissue retraction secondary alveolar abscess. This video is available in the Related Videos section of the Full-Text article on or available at

Fig. 3:
A, A 36-year-old woman with an adherent facial scar at the mandibular border caused by sequelae of alveolar abscess drainage. B, Postoperative view shows satisfactory result after combined upward suture traction and subcision.
Graphic 1. See video, Supplemental Digital Content 1, which displays a 40-year-old woman of the group 1 (facial region) during transoperative combined subcision with upward traction to treat mandibular soft-tissue retraction secondary alveolar abscess. This video is available in the Related Videos section of the Full-Text article on or available at

The technique may be indicated for subcutaneous lipoatrophic (type 1A) and fibrotic gluteal retractions (type 1B). At rest, both types have tissue depression, which is aggravated with muscle contraction. These retractions are caused by adipose tissue atrophy after local fibrosis secondary abscess drainage, toxic effect of injections in the buttocks, or idiopathic causes. The present approach may be limited indication for fascial (type 2) and muscle retractions (type 3). In these cases, the gluteus retractions are normal at rest and do not change with muscle contraction. When the thigh is flexed, the fascia may cause a plaque-like depression, and muscle variation may cause linear depression parallel to the gluteus maximus fibers. In these patients, an open approach with fasciectomy and incision of the hardened fibers may be indicated.4

The fat grafts in the group 2 (gluteal) were indicated in cases after subcision with the purpose of smoothening the anatomic contouring of buttocks. Figure 4 shows the case of a 38-year-old woman presenting sequelae of multiple injections during her childhood. Diagnosed as type 1A retractions (lipoatrophy), 1B (fibrosis), and a large depression >5 cm and mixed with points of cellulite grade 3. In the first session, it was indicated that combined subcision with traction should be performed. Four months later, the same procedure was done together with fine syringe lipoplasty with 1- and 2 mm cannula to level the surrounding tissue.

Fig. 4:
A, Preoperative view of a 39-year-old woman who had multiple gluteal retractions from gynecoid lipodystrophy, grade 3 (cellulite) associated with retractions type 1A(lipoatrophy) and 1B (fibrosis). B, Postoperative view after 1.5 years showing partial improvement after 3 sessions of combined upward traction and subcision. In the last session, it was associated with lipoplasty refinement using 10 cm3 syringe with 1mm or 2mm diameter cannula to equalize surface levels.

In patients who had gluteal retractions, satisfactory results were obtained when the tissue depression diameter was <5 cm. For those who have larger depressions, complications of treatment may include seroma, observed with 6 patients who had buttock depressions. However, vertical tissue suspension with suture optimized the procedure in patients who had prominent scar retraction caused by a previous inflammatory event, because tissue suspension created space that preserved a minimum subcutaneous layer and facilitated the excursion of the needle or miniblade.

Retracted tissue depressions in the abdomen typically were caused by scars after Cesarean section, laparotomy, or placement of drains, and the scar layer usually was very close to the muscular aponeurosis. The present subcision method was more effective than techniques that use cannulas during lipoplasty. In pure fibrotic zone, subcision associated with vertical tissue suspension facilitates the disruption of the adhesions.

Similar efficacy was noted in breast adhesions that were caused by mastectomy, axillary dissection, and radiotherapy. In these conditions, fat grafting may be unsuccessful because of fibrotic scar at the axilla. Releasing the adhesions with subcision and vertical traction may cause an inflammatory connective tissue response that may improve the nutritional supply of the region (Fig. 5). Concomitant use of a fat graft may increase the potential for integration of adipose and mesenchymal cells. In retracted axillary scars caused by nodal resection or radiotherapy, current methods may include fat graft infiltrated in tunnels or fillets or an external expansion system, but there is controversy, because of the integration of fat grafting and potential complications.5–105–105–105–105–105–10

Fig. 5:
A, A 41-year-old woman presenting axillary retraction after mastectomy with concomitant axillary limphadenectomy, and radiotherapy. B, The retracted bands at the axilla were cut using a pink needle combined with upward traction of the depressed area after tumescent infiltration. C, Axillary configuration normalized after 2 sessions of combined upward traction.

Vertical traction with subcision method has the advantages compared with other traditional subcision techniques that use wire or suction.11–1411–1411–1411–14 These approaches affect the soft tissue in a static plane with the skin layers juxtaposed. The proposed strategy stretches the tissue layers and enables the release of the retracted bands in a deeper plane, which will be replaced with connective tissue (Fig. 6). As shown in guinea pigs, the scar tissue grafting causes tissue formation that fill the space created.15

Fig. 6:
A, Simple subcision compared with combined upward suture traction and percutaneous subcision. B, Traction with looping suture preserves the superficial layer and enables free excursion of the needle or miniblade at the deep part of the adhesion.

The needle used was effective for smaller depressed tissue lesions, and the miniblade works better in lesions with diameter >5 cm. Although other instruments have been suggested, their effectiveness has been questioned.16

Complications of the present technique were noted primarily in the gluteal region, including fluid collection (seroma) at retracted areas of type 1A, 1B, and 1C lesions (diameter >5 cm). These complications usually resolved after ambulatory drainage except in 2 patients who required an indwelling Penrose drain for 2 weeks. In large soft-tissue retractions or linear type 3 or 4 lesions with retracted fascia or muscle adherence located on the buttocks, it may be advisable initially to release the central area, allow 2–3 months to healing, and later release the peripheral zone. This 2-stage approach may minimize dead space, the primary cause of seroma. Figure 7 shows the case of a 36-year-old patient presenting a transverse idiophathic type 2 (subfascial) >5-cm retraction. Three treatments were planned. In the first treatment, only the central part of the retraction was released. In a late date, 3–6 months apart, we released the periphery of the retraction and refined the contouring using 10-cm3 syringe with 1–2-mm cannula.

Fig. 7:
A, A 36-year-old woman presents a transverse idiophatic type 2 (subfascial) > 5cm retraction at the right buttock and type 1A (lipoatrophy) at the left side. B, Result at 2 years after 3 sessions of ambulatory combined upward traction and subcision. The depressed area was >5 cm in diameter and initially was released in the central area. Subsequent sessions released the peripheral part of the depression.

In patients who had treatment of gluteal lesions, induration in the treated area was the most frequent complaint at follow-up. In 2 patients, this induration persisted for 3 months. Patients may be advised that releasing the retracted bands may induce a healing response including initial bleeding, clot formation, and scar maturation.17 This healing response may be controlled with triamcinolone (20 mg/mL) diluted 1:2 with lidocaine (2%) applied with a 30 × 7 brown needle at a depth of 15–20 mm, preserving the dermis; this injection may be used once or twice (minimum interval between 2 injections, 45 days) to prevent fat atrophy or telangiectasia. Late refinement with lipoplasty and superficial fat grafting with 1–2-mm cannula may help provide a smooth boundary at a chin and large gluteal depressions (type 1A, 1B, 1C) (Fig. 8).

Fig. 8:
A, Profile view of a 45-year-old woman who had severe retraction at the chin. This occurred after resection of a granuloma and was an iatrogenic complication of methacrylate cement. B, Second stage of combined upward suture traction and percutaneous subcision of adhesions. C, Postoperative view 20 months later after 3 sessions of combined subcision with upward traction refined with lipoplasty to smooth contour.

In the gluteal region, the skin retractions were manifestations of gynecoid lipodystrophy, grade 3 (cellulite).18,19 In this condition, septa between the dermis and gluteus maximus fascia may cause multiple retractions. The vertical traction with the suture created a virtual space and enables the disruption of the septa while preserving a minimum layer of subdermal fat (thickness, 0.5–1 cm) that contributed to a smooth contour after treatment. The connective tissue healing created adequate tissue bulk at the previously retracted area. The most accepted current cellulite classification grade 0 is the absence of alterations of cutaneous surface; grade 1: the surface of the affected area is flat when the patient is lying on her back or standing up; grade 2: an “orange peel” or “padded” appearance is evident without any pinching or muscular contraction when the patient is standing up; grade 3: the alterations described in the grade 2 are present with elevations and nodulations. Considering the complex etiology of the gynecoid lipodystrophy, different grades may be present in the same patient. In our data, we indicated the procedure for cases with predominance of grade 3. In these cases, there is a correspondence of the theories that best explain the clinical expressions of the cellulite—the protusion of fat in the dermohypodermal junction due to the presence of vertical bands, according to Nürenberger and Müller.20 Other authors postulated that the alteration is a genetically determined extension of those fascial bands.21 These alterations allow the protusion of fat into the dermohypodermic junction, causing the dimple skin. So, the tractioned subcision demonstrated in this investigation allows us to break these bands easily.

We did not register any seroma in the patients treated for cellulite in the group 2 (gluteal), probably because all the regions treated are <5-cm diameter and there is no association with previous scar.

The cellulite cases were classified mainly as a fair result. As a practical evaluation, we could consider reduction in 1 or 2 degrees, eg, grade 3 for grade 1. But, considering this entity as a multifactorial event that contributes to the gynecoid lipodystrophy, we suggest a generic classification. Video 2 (See video, Supplemental Digital Content 2, which displays a 39-year-old female of the group 2 (gluteal region) presenting grade 3 cellulite, lipoatrophy (type 1A), and fibrosis (1B), 18 months after 2 sessions of combined subcision with upward traction. This video is available in the Related Videos section of the Full-Text article on or available at shows a 38-year-old woman presenting a predominant grade 3 cellulite at the buttocks, before and 18 months after 2 sessions of ambulatorial subcision with upward looping suture without fat graft. This case at rest and dynamic view was classified as fair result (See video, Supplemental Digital Content 2. This video is available in the Related Videos section of the Full-Text article on or available at

Graphic 2. See video Supplemental Digital Content 2, which displays a 39-year-old woman of the group 2 (gluteal region) presenting grade 3 cellulite, lipoatrophy (type 1A), and fibrosis (type 1B), 18 months after 2 sessions of combined subcision with upward traction. This video is available in the Related Videos section of the Full-Text article on or available at

In summary, the present technique combining subcision after vertical suspension with looping suture may be effective in treating soft-tissue retractions. This approach may be indicated for varied lesions at diverse anatomic sites of soft-tissue depression, including gluteal retractions type 1A, 1B, and 1C. The simple method may provide satisfactory results with low risk of complications.


Percutanous subcision combined with upward traction with stitches, as previously reported by the authors for treatment of inverted nipple type II and III, confirms its versatility to correct soft-tissue depression at diverse anatomic areas. Although retractions types 1A, 1B, and 1C of the group 2 bigger than 5 cm presented an incidence of seroma, it did not compromise the final outcome. The average result, classified as good in 65% and fair in 30%, makes the strategy an option in the treatment of soft-tissue depression.


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