Published 9 September 2026 · Reviewed by Dr Sin Yong
A familiar story: several rounds of laser, real improvement at first, and then a plateau — the same few depressions refusing to budge. The usual explanation is not that the laser failed. It is that those particular scars were never a surface problem to begin with.
Of all the scar patients I see, the largest single group is not people starting out. It is people who have already had treatment — often good treatment — and stalled.
The pattern is consistent. Resurfacing improved the overall texture: the shallow scars softened, the skin's finish evened out. But a handful of depressions survived every round unchanged, and eventually the improvement curve went flat. At that point most clinics offer more of the same, at higher energy. That is usually the wrong direction — more energy into a scar whose problem is not at the surface adds inflammation without addressing the cause, and in darker skin types inflammation has a cost of its own.
The scars that survive resurfacing are very often tethered — held down from below by fibrous bands that run from the underside of the dermis to deeper tissue. Resurfacing works on the surface, and the surface was never these scars' problem. The classification behind this, and the other scar types that share a cheek, is set out in my guide to acne scar types.
Understanding this one distinction explains most stalled scar journeys I see, which is why it deserves its own page.
When deep acne inflammation heals, it does not always heal cleanly in layers. Scar tissue can form as a vertical band — a cord of fibrous tissue anchoring the underside of the skin to the tissue beneath it.
The mechanics are the same as an upholstery button. The fabric of a cushion is smooth and intact; the dimple exists because a thread pulls it down from inside. You can steam, brush or replace the surface fabric indefinitely — the dimple returns, because its cause is the thread.
This is also why tethered scars behave distinctively. They deepen on animation, because the band transmits the pull of movement in the tissue beneath. And they resist flattening when the surrounding skin is stretched, because the anchor point does not move. Both behaviours are visible in an examination, and neither is visible in a photograph — one of several reasons scar plans made from photos go wrong.
Tethering is not confined to the classic rolling scar, either. A boxcar depression can be tethered at its base; so can a traumatic or surgical scar years after the original injury. The question is never what the scar is called. It is whether something below is holding it down.
“You can resurface a tethered scar indefinitely. The tether keeps pulling it down.”
Dr Sin YongOn why scar treatment plateaus
You can get a first approximation of your own scar map with nothing but a mirror and two fingers.
Place a finger either side of a scar and stretch the skin gently apart. Watch the base of the depression. If the scar fades or flattens as the skin tightens, its problem is predominantly at the surface — the kind of scar resurfacing is designed for. If the base stays pinned down while everything around it stretches, something is holding it there, and that something is below the reach of any surface treatment.
Then smile broadly and watch again. A scar that becomes more obvious with animation is declaring its tether.
This is a screening observation, not a diagnosis — depth, direction and the number of bands still need proper examination. But if your stubborn scars fail the stretch test, you have your explanation for the plateau, and more surface energy is unlikely to change it.
Subcision — subcutaneous incisionless surgery, described by Orentreich and Orentreich in 1995 — addresses the tether directly. A needle or blunt cannula is passed beneath the scar, in the subcutaneous plane, and the fibrous band is divided. The skin above is left intact; the work happens entirely below it.
Two things follow from the release. The mechanical downward pull is gone, so the surface is free to sit level. And the controlled injury beneath the scar triggers its own repair response — new collagen forming in the space where the band used to be, which helps support the released skin from below.
Sequence is the part most plans get wrong. Release comes before resurfacing, because resurfacing remodels skin in whatever position it finds it — resurfacing a still-tethered scar polishes a dimple that is being actively held down. Within my 4D Scar Reconstruction protocol, subcision is the foundation step: tethers first, then volume support where it is needed, then the scar walls and surface texture. Each stage prepares the ground for the next.
Not every scar needs subcision, and not every tethered scar needs everything else. Which scars qualify comes out of the assessment, scar by scar. In Fitzpatrick III to V skin — most of what I treat — the technique, the depth of work and the aftercare are also planned around pigment risk, because bruising and inflammation handled carelessly can leave their own marks.
Subcision is a treatment people understandably want to see evidence for, so the absence of photographs deserves a direct answer.
Under Singapore's Healthcare Services Act, before-and-after imagery in advertising for licensable healthcare services is prohibited. There is no consent form or disclaimer that permits it, and after-only images fall under the same rule. The prohibition applies identically to every licensed clinic in Singapore — a site displaying such images is not demonstrating better results, only weaker compliance.
What can be shown is your own skin, in person, under directed lighting and stretch — which is the only examination that identifies a tether reliably anyway.
Prices for licensable healthcare services cannot be advertised in Singapore, including as ranges or "from" figures. What the cost depends on can be stated plainly.
The factors are the area involved, what the assessment finds — how many scars are tethered, how dense and deep the bands are — whether subcision is performed alone or as one stage of a combined protocol, and how the plan is staged over time. Releasing three tethered scars on one cheek and rebuilding a decade of mixed scarring across a whole face are not comparable pieces of work.
Fees are set out in full at consultation, once your scars have actually been examined and there is something specific to cost.
If your scar treatment has plateaued, the likeliest explanation is not that you need a stronger laser. It is that some of your scars are tethered, and the tether has never been addressed. Release is the step that changes what every subsequent treatment can achieve — and it has to come first.
Dr Sin Yong — MBBS (NUS), MRCS (Edinburgh), MSc Aesthetic Medicine (London), MSc Practical Dermatology (Cardiff), and holder of a surgical qualification — examines scars personally at Orchard Road, and will tell you plainly which of yours are tethered and which never were.
Subcision is subcutaneous incisionless surgery: a needle or blunt cannula is passed beneath a depressed scar to divide the fibrous band anchoring it to deeper tissue. The skin surface is left intact. Once the band is released, the mechanical downward pull is gone, and the controlled injury beneath the scar triggers new collagen formation in the released space. It was described by Orentreich and Orentreich in 1995 and remains the standard approach to tethered scars.
Two observations point to tethering. First, stretch the skin gently either side of the scar — a tethered scar stays pinned down while the surrounding skin flattens. Second, watch the scar during animation — a tethered scar deepens when you smile, because the band transmits the pull of movement beneath. Both are screening signs rather than a diagnosis; the depth and direction of any bands still need in-person examination.
Resurfacing acts on the surface of the skin, and some depressed scars are not surface problems — they are held down by fibrous bands anchored in deeper tissue. Those scars persist through any amount of surface treatment, because the cause sits below the depth at which resurfacing works. A plateau after initial improvement is the classic pattern: the surface scars responded, and the tethered ones remained. The useful next step is re-examination, not higher energy.
No — they do different jobs and are commonly combined. Subcision releases the tether holding a scar down; resurfacing remodels the surface texture. Neither substitutes for the other, and the sequence matters: release generally comes before resurfacing, so the surface work is performed on skin that is free to lie flat. Which scars need which method comes out of a scar-by-scar assessment.
Subcision is performed routinely in Fitzpatrick III to V skin, which covers most patients in Singapore. Because the work happens beneath the skin rather than at its surface, there is no ablative injury to the epidermis — but bruising and inflammation still need careful handling, since inflammation in darker skin types can leave post-inflammatory pigment. Technique, depth and aftercare are planned around that risk, and response is assessed individually.
Bruising and swelling in the treated area are expected, since the work involves dividing tissue beneath the skin, and recovery varies between individuals and areas. Specific aftercare is given for the region treated, including sun protection while any bruising settles, because ultraviolet exposure over inflamed skin encourages pigment. Tell your doctor about any medications or supplements that affect bleeding before the procedure is planned.
The band that has been divided can partially re-form as the release heals — the same fibrotic process that built it the first time. This is one reason subcision is planned as part of a staged protocol rather than a one-off gesture, and why the response of each scar is reviewed as the plan proceeds. Techniques that support the released space, and correct sequencing with other methods, are chosen with re-tethering in mind. Response varies and is assessed individually.
The area is anaesthetised before any work is done, so the procedure itself is generally well tolerated — most people describe pressure and movement rather than pain. Tenderness and bruising afterwards are common and settle as the area heals. Comfort measures and what to expect are discussed before treatment rather than assumed, because tolerance varies considerably between individuals.
Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatologic Surgery 1995;21(6):543–549. source
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