Scar formation is a process consequent to the healing of soft
tissues after a trauma. However, abnormal or disturbed collagen production can
cause anomalies of the cutaneous surface and textural irregularities. A
cosmetically acceptable scar is often at the level with the surrounding skin, a
good color match, soft, and narrow. Favorable lines of closure are usually
within or parallel to relaxed skin tension lines: lines due to dynamic action of
the underlying musculature.1

The scar abnormality will guide the choice of treatment technique. The surgical
strategy selected should be based on a correct evaluation of the scar’s
characteristics. In addition, while any scar with a suboptimal appearance can be
revised, greatest patient satisfaction is achieved with realistic expectations.2

CASE REPORT
In the presence of a depressed scar in deep tissue, we began to use a technique
which I believe is interesting to present. In fact, there are cicatricial
aftereffects that, though presenting a satisfactory aspect of the scar due to
the presence of an adhesion of the skin to the underlying plane, disfigure
somewhat in a disagreeable manner and therefore reconstructive plastic surgery
should be performed (Fig.​(Fig.11). Thus, in these cases especially when there
is not a lack of tissue secondary to trauma as for example the suffering of
sub-cutaneous adipose tissue, it would be sufficient to eliminate the single
adhesion without reopening the entire scar again.

Fig.1	Fig.2	Fig.3	Fig.4
An example of a depressed scar of the abdomen. Therefore, with this objective in mind, in the presence of adherent scars, after having infiltrated the whole area with a solution of Lidocaine 0.5% and Epinephrine 1:200,000 very close to one of the two edges of the scar, a small incision is performed so that an undermining scissor can enter inside (Fig.22).	A small incision with an undermining scissor inside it. The entire cicatricial area is undermined on a subcutaneous plane which, by separating the deep scar from the superficial one, completely frees it from the present adhesions so that the existing depression is totally eliminated (Fig.33).	The scar is completely undermined. At the end of this manoeuvre, in order to avoid the recreation of relapses, stitches formed in a U-shape are made in Nylon or Monocril 2-3/0 are made with a large needle and are placed close together so that a wide aversion is achieved at the margins of the scar and a deep wound closure is obtained by adhering to the undermined tissue (Fig.​(Fig.44). These stitches will then be removed about 2 weeks later. Afterwards, the patient should start to carry out massages on the entire treated area using moisturizing cream to aid the mobility of the recuperated tissue.	The final result

CONCLUSIONS
Subcision incision is a very effective technique for correcting atrophic scars.
Essentially, the physician inserts a needle and sweeps it back and forth
repeatedly to free the skin from the underlying scar tissue.

Normally, the dissection plane of subcision is rather superficial: it is a
subdermal dissection performed successfully in the treatment of acne scars. In
this novel technique, we perform a deeper dissection plane and it is designed in
order to remove adhesions that attach the skin to the floor below. Infact, the
use of the stitches in depth is performed in order to prevent that the adhesion
can recreate again: this relapse could promote the formation of a layer of
reactive collagen in the region below the treated area.

We therefore believe that this technique can be utilized as a simple and safe
technique that brings great improvement to the treatment of depressed scars.

AUTHORS
Francesco Inchingolo, Marco Tatullo, Fabio M. Abenavoli, Massimo Marrelli,
Alessio D. Inchingolo, Roberto Corelli, Angelo M. Inchingolo and Gianna Dipalma

AUTHORS’ CONTRIBUTIONS
FI: participated in the surgical treatment and in the follow-up of this patient.
MT: drafted the manuscript and reviewed the literature. FMA: participated in the
surgical treatment and in the follow-up of this patient. MM: participated in the
design of this case study and in the follow-up of this patient. ADI: revised the
literature sources. RC: participated in the surgical treatment and in the
follow-up of this patient. AMI: documented this case report with digital
pictures. GD: participated in the follow-up of this patient. All the authors
read and approved the final manuscript.

CONSENT STATEMENT
Written informed consent was obtained from the patient for publication of this
case report and accompanying images.

REFERENCES
1. Thomas JR, Prendiville S. Update in
scar revision. Facial Plast Surg Clin North Am. 2002;10(1):103?11. [PubMed]
2. Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification system and
review of treatment options. J Am Acad Dermatol. 2001;45(1):109?17. [PubMed]
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