The Legal Blemish of Acne Scar Treatment

Patients who have paid thousands of pounds for these treatments have been left with larger scars, swollen, heavy and sagging lower faces, and severe burns from the powerful lasers.

In this blog, we address some of legal issues in relation to this type of cosmetic treatment.

The impact of acne

If you've ever suffered with acne, you'll understand the emotional and physical toll it can take on your quality of life. You may have received acne treatment from the NHS, which typically includes a variety of creams, serums, and topical treatments. As well as having had numerous visits to your GP, been prescribed antibiotics or other oral medications to help balance your skin from within, and maybe been fortunate enough to see an NHS dermatologist.

Acne means dealing with the painful, swollen cysts, nodules and pustules, at times leaving scars  – anything from faint marks to uneven texture or significant dents in the skin. It may feel never-ending.

Unfortunately, treatment for acne scars isn’t readily available on the NHS. This leaves people seeking other private clinical or cosmetic options. This can range from microneedling and chemical peels to more aggressive treatments like acne scar subcision and laser skin resurfacing.

Social media has become a lucrative marketing tool for private skin clinics to promote their work and bring in new clients. Photographs showing ‘miraculous’ before and afters appeal to those desperate for results-based treatments, whatever the cost. The danger is that social media often trivialises the invasive nature of the treatment and fails to show prospective patients the true extent of the surgery – and what can happen if performed in the wrong hands.

What is subcision and how does it work?

Acne Scar Subcision can also be referred as subcutaneous incisionless surgery. The term was coined 30 years ago, but the technique has been used to treat acne scars for much longer. It’s where an instrument, usually a needle or cannula, is inserted into the skin via a 4mm incision near the hairline.

The procedure aims to detach the scar tissue that has become tethered to the subcutaneous layers of the skin. These fibrous bands pull down the skin’s surface, creating crater-like indents and uneven skin texture.

There are four instruments that can be used for subcision: needles, cannula, surgical wire, or blunt blades. Which one is most suitable will depend on the scar depth and fibrous band thickness. However, needles are often the instrument of choice as they are less invasive due to their narrower diameter. Cannulas are sometimes used to reduce the risk of bleeding and bruising, but they only puncture the tethers rather than fully severing them, so effects are temporary.

Whichever instrument is used, subcision will be performed using local anaesthetic. It is also recommended that tumescent anaesthetic is used. This is where a large amount of water-based anaesthesia is pumped into the skin to separate the fat from the muscles. This aims to reduce the risk of damage to the nerves and blood vessels during the procedure.

Once the fibrous bands are severed, it can improve the rippled contours of scarring by up to 70 percent. However, it’s important to know that scarring won’t fully disappear. To further improve skin texture, most patients will benefit from a triple technique combining subcision with laser resurfacing therapy and chemical peels.

What about Taylor Liberator subcision?

Liberators are a more recent addition to subcision surgery. These blunt bladed instruments look a bit like a flat-headed screwdriver. Because liberators are blunt, they require greater force to push through the scarring.

Dr Mark Bowen Taylor, an American dermatologist and cosmetic laser surgeon, patented his own liberator in 2016. This has a ‘W’ shaped head, with the three-pronged tip able to effectively capture the fibrotic tethers of the scar tissue.

These patented Taylor Liberator instruments have the CE kitemark and are an approved medical device. They cost $299 to buy. Before purchasing, the physician is required to undergo specialist training in America costing $10,000.

However, there are also non-patented versions on the market. These are made in India and are considerably cheaper to buy. There is also no recommendation regarding training or experience before purchasing. They can be bought online by anyone. As there is no patent, the quality cannot be established and so there is no CE kitemark to approve their safety.

One tell-tale sign to differentiate between the two is the colour: the non-patented version is gold-coloured while the patented is silver.

The patented Taylor Liberator technique should also involve CO2 laser skin resurfacing and a 20% TCA chemical peel during the same appointment. These concurrent treatments peel the top layers of the skin to eliminate damaged cells and smooth out textural changes caused by acne scars.  

Who is suitable for acne scar subcision?

Subcision shouldn’t be a first-choice treatment; it should be considered a last resort. Subcision is only recommended for patients whose scars haven’t improved with other treatments like topical retinoids, microneedling, dermarollers, or fractional laser therapy.

Taylor Liberator subcision should only be used on rolling acne scars, those scars that give the surface of the skin a rolling and uneven appearance.

Boxcar scars respond better to non-ablative lasers, while icepick scars may benefit from punch grafting or excision to replace the holes in the skin for smaller ones.

Who can perform acne scar subcision?

Subcision should not be performed by anyone other than a competent, fully-trained plastic surgeon, dermatology surgeon, or head and neck surgeon. Because of the risks involved, you need a deep understanding of the anatomy of the skin and its subcutaneous tissues. This is further enhanced by ensuring that practitioners have learnt the techniques from other competent, qualified surgeons.

A lot of private skin clinics promote their practitioners online with claims like ‘UK’s leading specialist’, ‘UK’s most experienced surgeon in these areas’, or ‘Internationally renowned expert in cosmetic dermatology’. But patients need to be mindful that just because someone calls themselves a skin specialist or dermatologist, it doesn’t mean they have the appropriate qualifications to back this up.

Unfortunately, ‘Dermatologist’ isn’t a protected title in the UK. It is shocking that anyone with a basic medical degree can claim to be a dermatological expert. A dermatology diploma doesn’t make someone a consultant dermatologist.

To qualify as a consultant dermatologist, a doctor must have had at least 13 years training. Their qualifications are higher than general medicine, and they’ll have trained specifically in dermatology, including four years in a registered and supervised NHS dermatology department.

They will also be listed on the General Medical Council’s (GMC) specialist register. So always check their credentials on the GMC website first before agreeing to any type of acne scar treatment.

What are the risks of acne scar subcision?

There are various adverse outcomes from acne scar subcision.  Some of the more common side effects include swelling, bleeding, bruising and blood clots. Some patients may also experience facial numbness for a few months afterwards.

Post-operative infections are also another risk factor, especially if there were multiple incision sites rather than just one to the sideburn area.

Patients should also be aware that it can cause nodules under the skin that could be permanent. They should also be made aware that the treatment may not work, or that it could in fact worsen the existing scarring.

Major complications are nerve and ligament damage.  Patients can be left with permanent weakness on the lower face and around the mouth, or to the muscles that control the eyebrows and forehead.

If ligaments are damaged or disturbed, this can cause the face to sag, leading to an aged appearance. Some patients who have experienced this are resorting to undergoing a face lift in their 20s or 30s.

Because of the tumescent anaesthetic, the blade or needle is meant to remain in the dermis layer and must not slide deeper into the fat and muscle. But even the most skilled practitioners could still cause nerve or ligament damage. However, poor technique, lack of training, or lack of anatomical knowledge of the subcutaneous will inevitably increase the risk of nerve damage.

Before agreeing to acne scar treatment, patients should be fully informed of all risks and provide informed consent.

What does the GMC say about acne scar treatment?

The GMC has guidelines and professional standards for cosmetic surgery such as acne scar subcision. It states that:

• Doctors should work within the limits of their competency and not mislead patients re. their skill, experience, qualifications, professional status and current role
• Their marketing should not trivialise the risks of the treatment or claim it is risk-free and they should always gain written consent for photos or videos used for marketing purposes
• They should undergo training and supervision for new interventions
• They should consider past medical history in relation to assessment and consent and ensure patients are adequately assessed and examined
• They should give clear and accurate information re. adverse reactions and discuss alternative options, including less risky ones, and even those from other practitioners
• They should decline treatment if the desired outcome or benefit to the patient is unlikely to improve the scarring
• They should send the patient’s GP information regarding the treatment unless the patient objects
• They should provide and prescribe pre- and post-operative medication only with adequate knowledge of the patient’s medical history
• They should report any adverse incidents regarding medical devices to the MRHA, even if caused by human error

Medical Solicitors: Here for you

If you have been the victim of negligent acne treatment such as subcision or laser treatment, our experienced medical lawyers are ready to help you make a claim for compensation.

We are currently investigating a number of potential claims against a Harley Street clinic that performs both Taylor Liberator subcision and CO2 laser surgery techniques.

Following receipt of a number of complaints regarding unexpected changes in patients’ physical appearance, the GMC is investigating this clinic. The lead practitioner at this clinic has had conditions on their medical license since October 2023 and is unable to perform these treatments unsupervised.

Our team of specialist lawyers work with consultant dermatologists and other experts in facial surgery to assess whether negligent or substandard practice has resulted in the adverse outcomes our clients have experienced.

If you believe your acne scar subcision, Taylor Liberator subcision, or fully-ablative CO2 laser therapy was negligent, please contact us to see if we can support your claim.