Accepted: 9 February 2018

DOI: 10.1111/jocd.12523

ORIGINAL CONTRIBUTION

Blunt cannula subcision is more effective than Nokor needle

subcision for acne scars treatment

Mehdi Gheisari MD | Behzad Iranmanesh MD | Bita Saghi MD

Skin Research Center, Shahid Beheshti

University of Medical Sciences, Tehran, Iran
Correspondence
Bita Saghi, Department of Dermatology, Skin
Research Center, Shahid Beheshti University
of Medical Sciences, Tehran, Iran.
Email: dr.saghi2020@yahoo.com
Funding information
Skin Research Center; Shahid Beheshti
University of Medical Sciences
Summary
Background and aim: A comprehensive study comparing two different modalities,
Nokor needle subcision (NNS) and blunt cannula subcision (BCS), for treatment of
acne scars, has not been reported previously. The aim was to compare the effec-
tiveness of these two methods based on patient’s and doctor’s satisfaction mea-
sures, in addition to the late complications 3 months postsubcision.
Method of intervention: Patients had 18-65 years old, with acne scars on both
malar sides. They were treated at one malar side with NNS and with BCS at another
side. They were monitored during the first week, at one and 3 months postinterven-
tion. Patient’s and two dermatologist’s satisfactions were compared during
3 months, for each modality and between modalities.
Results: From 34 patients, 29.4%, 55.9%, and 14.7% had mild, moderate, and sev-
ere acne scars, respectively. Ecchymosis, nodule formation post-NNS, and edema
after BCS were the complications. Patients were satisfied with BCS during 3-month
monitoring (P = .021), but not with NNS (P = .353). Physician-1 was satisfied from
the outcome of both BCS and NNS procedures (P = .044 and .006, respectively).
However, physician-2 was only satisfied with NNS at the month 3 than the month
1 (P = .002). All patients and physicians were significantly more satisfied with BCS
than NNS (P = .000). Anyway, at the month 3, physician-2 had no significant differ-
ent points of view about applied methods (P = .25).
Discussion: Considering the complications and satisfaction rates, BCS was more
efficient than NNS for acne scar treatment. Then, we suggest BCS as a good
replacement for NNS.

KEYWORDS
acne scar, blunt cannula, Nokor, subcision

1 | INTRODUCTION
Acne scars disfigure the appearance of a person and affect the
quality of social communication.1-4 Investigators had classified acne
scars types since 1987, descriptively, clinically, or histologically.
Today, another classification system, which is routinely used in
clinical practice, is based on both clinical and histological criteria.
Accordingly, three types of acne scars based on width, depth, and
three-dimensional structure are recognized in practice: (1)ice pick
scars which are not deeper than 2 mm and have sharp margins
with depressed tracks oriented vertically to the subcutaneous tis-
sues; (2)boxcar scars that have round or oval shapes with sharply
demarcated vertical boundaries, may be shallow or deep with 0.1-
0.5 mm or ≥0.5 mm depth, respectively. The diameter of such
type of acne scars varies from 1.5-4.0 mm. They have wider sur-
face than ice pick scars and are not tapered to a point at the
basis; and (3)rolling scars originate from dermal tethers and com-
monly had a diameter around 4-5 mm.4

J Cosmet Dermatol. 2018;1–5. wileyonlinelibrary.com/journal/jocd © 2018 Wiley Periodicals, Inc. | 1

2 | GHEISARI ET AL.

There are various methods for treatment of acne scars includ-

ing the following: dermabrasion, laser resurfacing, radiofrequency,
subcision, skin needling, punch techniques, and chemical peels.5
Nokor needle subcision has beneficial outcomes for treatment of
acne scars.3 However, mild to moderate efficacy and recurrence
of scars in many cases, side effects, and inflammatory responses
make the Nokor needle subcision (NNS) outcome and efficacy
1
questionable.
Blunt cannula has been proposed as a potentially proper alterna-
tive for Nokor needles,1 and others have implied that cannula may
be more efficient in treating acne scars; even laser cannula is
1,6,7
employed for treatment of cellulite.
As comparative studies reporting the effectiveness criteria of
atrophic rolling scars treatment using Nokor and blunt cannula are
rare, this study aims to assess that which tool has better out-
comes and lesser side effects during 3-month monitoring postpro-
cedure.
2.4 | Treatment monitoring
Patients were monitored at first week, 1, and 3 months post-treat-
ment to evaluate the procedure outcome and satisfaction of patients
and physicians in addition to the complications. In each visit, pictures
were taken using a high-quality camera and scores were recorded to
evaluate the procedure outcome.
2.5 | Statistical analysis
In addition to descriptive analysis for demographic variables, to com-
pare satisfaction percentages between two applied procedures
(Nokor/blunt cannula) and during the 3-month monitoring, indepen-
dent samples t test and paired t test were used, respectively. At
least 95% confidence interval was considered for statistical analysis
that was performed using SPSS software Ver.24.

2 | METHOD OF INTERVENTION
2.1 | Population and inclusion/exclusion criteria
Patients were man and woman who were admitted to the dermatol-
ogy clinic of two hospitals in Tehran, the capital of Iran. They were
18-65 years old and were diagnosed with atrophic rolling scars on
both sides. Exclusion criteria were pregnancy, autoimmune diseases,
coronary artery disease, coagulation disturbances, presence of any
inflammation or infection at the procedure site, history of hyper-
trophic scars, and inflammatory diseases such as psoriasis. Alto-
gether, 34 split-faces of admitted patients were treated with blunt
cannula subcision (BCS) or NNS method and monitored at 1 week,
1, and 3 months postprocedure.
3 | RESULTS
Thirty-four patients (73.5% female and 26.5% male) were under acne
scars’ remediation procedure. About 29.4% of patients had mild,
55.9% had moderate, and 14.7% had severe acne scars. Complica-
tions included ecchymosis and nodule formation after NNS or edema
after BCS procedures.
Patients and physician satisfaction rates were compared at one
and 3 months after procedures visits. As Table 1 shows, patients
were significantly satisfied with BCS (P = .021) but not with NNS
(P = .353), during 3-month monitoring. Physician-1 was satisfied with
both BCS and NNS outcomes (P = .044 and .006, respectively); how-
ever, the satisfaction rate was higher for BCS, after 3 months than
1-month monitoring. Physician-2 was only significantly satisfied with
NNS at 3 months than 1-month visits (P = .002); however,

2.2 | Ethics and blinding

T A B L E 1 Paired comparison of satisfaction percentages recorded
As the study design was interventional, all patients were informed from point of view of patients and two physicians after 1 and
about study details before starting the procedure. Patients did fulfill 3 months after blunt cannula or Nokor subcision
the consent form and declared their acceptance about the study cir- Monitoring Mean  SD of
cumstances. Blinding was not possible for physician because of the Type of monitoring time satisfaction (%) P-value

study design; however, patients were blinded about the therapeutic Patients under BCS 1 month 55.73  14.77 .021
method used for each malar site. 3 months 57.64  15.23
Patients under NNS 1 month 41.47  12.82 .353
3 months 42.05  12.43
2.3 | Intervention and monitoring
Physician-1 monitored BCS 1 month 57.35  13.32 .044
After primary physical evaluation and controlling inclusion/exclusion 3 months 58.52  13.84
criteria, intervention was carried out. Each patient with atrophic roll-
Physician-1 monitored NNS 1 month 40  13.48 .006
ing scars in both malar sides was treated using Nokor needle at one
3 months 42.05  13.65
side, against blunt cannula at the another side. Briefly, tumescent
Physician-2 monitored BCS 1 month 63.67  14.63 .068
solution (1 mL epinephrine in 1000 mL normal saline + 10 mL bicar-
3 months 58.52  13.11
bonate+50 mL lidocaine) was injected for local anesthesia. After
Physician-2 monitored NNS 1 month 45.44  13.50 .002
15 minutes, subcision was carried out and suturing was performed
3 months 53.82  19.69
followed by gentamycin ointment treatment as the antibacterial pro-
phylactic agent. BCS, blunt cannula subcision; NNS, Nokor needle subcision.
GHEISARI ET AL. | 3

F I G U R E 1 Pictorial comparison of Nokor needle subcision one F I G U R E 2 Pictorial comparison of blunt cannula subcision one
week after procedure; left picture relates to before and right picture week after procedure; left picture relates to before and right picture
depicts one week after Nokor needle subcision depicts one week after blunt cannula subcision

satisfaction percentages were higher in BCS-treated than NNS-trea-

ted sides (compare Mean  SD of both BCS and NNS) (Table 1).
Figures 1 and 2 show two image samples of before and after
treatment, a week postprocedure using Nokor needle subcision and
blunt cannula subcision, respectively; left images represent before
and right images represent after treatment outcomes (Figures 1 and
2). Figures 3 and 4 compare treatment results at 3 months postsub-
cision using Nokor needle and blunt cannula, respectively.

4 | DISCUSSION

Patients and physicians consider acne scars as a distressing prob-

lem.8 Many innovative methods have been introduced past decades
for acne scar treatment that attempts to enhance the therapeutic
effect and reduce the complications.9 Most common treatments for
acne scars include the following: punch excision, punch elevation,
subcision, laser skin resurfacing, elliptical excision, skin graft, and tis-
sue augmentation.10,11 Anyway, there are not enough evidences to
support these therapeutic strategies outcome, especially emphasizing
the treatment complications reduction while remaining perfectly effi-
cient. In the current study, we have compared two methods of acne
scars treatment including NNS and BCS. In total, our results were
promising about the usage of BCS when considering satisfaction of
patients or physicians and treatment complications. We have shown F I G U R E 3 Pictorial comparison of Nokor needle subcision
that subcision procedure using blunt cannula could be an acceptable 3 months after procedure; left picture relates to before and right
substitute for Nokor needle when treating rolling scars. picture depicts 3 months after Nokor needle subcision
4 |
F I G U R E 4 Pictorial comparison of blunt cannula subcision
3 months after procedure; left picture relates to before and right
picture depicts 3 months after blunt cannula subcision
Lee and colleagues have used trichloroacetic acid (TCA), as a
chemical reconstructing agent for acne scars remediation. They
reported that this method did not show any complication such as
persistent erythema, permanent hyperpigmentation, hypopigmenta-
tion, scarring, or keloids.12 However, they have not reported that
whether complications such as nodular lesions and edema become
evident post-treatment using trichloroacetic acid.
Fulchiero and coworkers have used subcision and 1320-nm Nd:
YAG nonablative laser resurfacing for treatment of acne scars in one
patient and reported that dual therapy was highly effective for
improvement of facial scars compared to subcision alone. However,
they noted minor bruising and transient hyperpigmentation at site of
subcision which were evident about 1-2 weeks postprocedure. Dur-
ing 12 weeks after laser application, hyperpigmentation was persis-
tent in right side compared to left side.13 They have used laser
therapy biweekly, whereas we have used Nokor needle and blunt
cannula only in one therapeutic session; further, we exclusively mon-
itored the treatment during 3 months postprocedures. As we have
reported in the results section, hyperpigmentation, due to the ecchy-
mosis, was only evident 1 week after NNS. Nonetheless, there were
not similar complications, except edema at the BCS malar site.
Kang et al have used a combination method of dot peeling, subci-
sion, and fractional laser to treat the acne scars; the therapy was con-
tinued for 1 year with dot peeling, and subcision was repeated twice
each 2-3 months apart in addition to laser therapy every 3-4 weeks.
They have suggested this therapeutic regimen as a safe and highly
effective method in acne scar remediation.14 However, we think that
GHEISARI ET AL.
long-term period of treatment in this study is not favorable for
patients. In our report, a single session treatment and 3-month follow-
up could be dominant aspects of our study, especially using BCS which
associated with higher satisfaction and milder complications.
AL-Dhalimi and Arnoos have used subcision for treatment of roll-
ing acne scars in Iraqi patients. They have treated 40 patients includ-
ing 21 males and 19 females, with an 18-G needle for subcision.
Erythema, bruising, and swelling were the complications of treatment
that were resolved 3-4 days in 32 (94.12%) patients, 1 week in only
2 (5.88%) patients, postintervention. Other complications were sev-
ere facial swelling, erythema on the lower eyelid, and postoperative
mild pain; further, all patients were shown firm bumps under the
treated scars. Investigators have implied that, at 2 weeks postproce-
dure, all complications were disappeared, except the firm bumps
which were resolved at 12 weeks. Investigators also have reported
that 20.59% of patients were partially or moderately satisfied, 64.7%
were greatly satisfied, and 14.7% were fully satisfied.2 The results of
AL-Dhalimi and Arnoos study confirm our findings about the subci-
sion procedure, but we think that, using blunt cannula, we have
reached more potent outcomes with lesser complications and higher
satisfaction rates. Furthermore, we have considered the physician’s
satisfaction as a valuable variable; our results showed that physicians
were satisfied with BCS compared NNS.
Nilforoushzadeh and colleagues have performed subcision proce-
dure on 8 patients with acne scars. They used Cannula No. 18 and 21
for two sessions and compared patient’s satisfaction with the blinded
dermatologist’s opinion about the treatment outcome. Around 88% of
patients had improvement, and all patients were satisfied with the
treatment result. Researchers have implied that cannula subcision is a
safe method with high efficacy and patient’s satisfaction because of
single perforation instead multiple injections in other methods which
reduces the patient’s pain and risk of scars. Furthermore, treatment
sessions and recovery time will be reduced compared to most of other
conventional methods.1 In the present study, we have compared two
methods of subcision, one with Nokor and another with cannula, but
with a higher sample size than Nilforoushzadeh and coworkers. As it is
seen, both studies confirm the usage of cannula and emphasize on the
lesser treatment sessions. However, Nilforoushzadeh and coworkers
have not reported clearly the side effects of subcision procedure,
whereas we have. Furthermore, as the sample size of our study was
higher, we think that the results of presented interventional survey are
more potent than compared study.
Barikbin and coworkers recently have used blunt blade subcision
for acne scars treatment. In this report, 66.7% of patients had high
satisfaction, 27.8% and 5.5% of patients were moderately satisfied
and not satisfied with the treatment, respectively. Early postopera-
tive complications included pain or tenderness (61.1%), swelling
(72.2%), and ecchymosis (83.3%).15 Although, we have reported les-
ser satisfaction percentages compared to Barikbin and coworkers,
less complications, limited to the edema, were evident in our work,
with blunt cannula. However, we have compared two procedures
and shown that blunt cannula subcision is preferred by both patients
and doctors.
GHEISARI ET AL.
5 | CONCLUSION
Blunt cannula subcision has promising outcomes including lesser or
milder complications and single session treatment instead repeating
perforations compared with other conventional surgery-based meth-
ods for acne scar remediation. Furthermore, in the current study, we
have seen that blunt cannula subcision is preferred than Nokor needle
subcision considering the point of view of dermatologists and patients.
ACKNOWLEDGMENT
This study is supported by Skin Research Center, Shahid Beheshti
University of Medical Sciences. Then, investigators appreciate the
staffs of the research center and so dear patients who help us to do
this valuable interventional study which its results will be promising
in the field of clinical dermatology.
ORCID
Bita Saghi http://orcid.org/0000-0003-4655-2022
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How to cite this article: Gheisari M, Iranmanesh B, Saghi B.
Blunt cannula subcision is more effective than Nokor needle
subcision for acne scars treatment. J Cosmet Dermatol.
2018;00:1–5. https://doi.org/10.1111/jocd.12523