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2026.10.26
Hyaluronic Acid Formulations to Prevent Re-adhesion After Subcision: How to Choose Between Non-Crosslinked and Low-Crosslinked Formulations?
As an Assistant Professor, Associate Ward Director, and Chief of Dermatopathology at the university hospital dermatology department, I deepened my expertise through academic presentations and paper publications both domestically and internationally. I have handled a wide range of treatments, from birthmark therapy in children to adult pigmentation concerns, utilizing various lasers and injection therapies, while also contributing to community healthcare. Through encountering numerous cases, I strongly felt the potential and necessity of aesthetic medicine, resolving to pursue further expertise. Building upon my solid dermatological knowledge and meticulous diagnostic skills, I value treatments that gently support each individual's skin while bringing out its inherent beauty.
Even if the indentation caused by subcision improves, over time you may feel like “it’s come back again.” This is due to re-adhesion that occurs during the wound healing process.
This is where the design of hyaluronic acid—which helps maintain the “lubricating layer” at the site of the wound—comes into play.
In this article, we will categorize subcutaneous hyaluronic acid into non-crosslinked and low-crosslinked types, and explain the approach for minimizing the risk of re-adhesion as much as possible—using technical terms but expressed in everyday language.
[Doctor’s Note]
To prevent re-adhesion after subcision, it is important to design a treatment plan that not only removes the adhesions but also takes into account postoperative tissue repair.
Hyaluronic acid is selected based on the characteristics of the formulation (such as non-crosslinked or low-crosslinked), the depth of the indentation, skin thickness, and the tensile force of the scar.
However, the effectiveness of hyaluronic acid in preventing re-adhesion varies depending on the formulation and the specific case, and it cannot completely prevent re-adhesion.
It is important to assess the condition of the indentation and develop a treatment plan tailored to each individual.
Background of Recurrent Adhesions Following Subsection
Subcision is a procedure designed to flatten a depression by loosening adhesions in the fibers pulling on it.
The postoperative period is the “wound healing phase,” lasting about 2 to 6 weeks, during which the tissue attempts to reattach. If the space collapses or there is significant friction during this time, the fibrous tissue may tighten again, causing the indentation to become more noticeable.
Using hyaluronic acid as a cushion in the space is one strategy for creating an “environment that isn’t too intrusive” during this time.
Since the effectiveness, duration, and degree of swelling vary from person to person, preoperative evaluation and follow-up are key.
Basics of Non-Crosslinked and Low-Crosslinked Materials
Definitions and Properties
Non-crosslinked hyaluronic acid is a free form of hyaluronic acid that lacks a network structure. It has excellent water-retention properties, spreads easily, and has relatively low elasticity (G’). While it is quickly absorbed by the body, it does not last very long.
Low-crosslinking refers to a design with a loose mesh structure. It retains its shape better than non-crosslinked materials and offers moderate cohesiveness, but its texture is primarily soft.
In simple terms, the physical properties described using technical terminology are a balance between “how easily a material spreads” and “how well it retains its shape.”
Role in Preventing Recurrent Adhesions
Non-crosslinked materials spread thinly across the surface and mid-layers, excelling at creating a “slip” effect. They reduce friction early on and aim to create an environment where adhesion is difficult.
Low cross-linking tends to function well as "thin struts that are resistant to collapse" in slightly deeper spaces, making it suitable for applications where the goal is to maintain the space over time.
Since neither method is a one-size-fits-all solution, we consider the characteristics of the indentation and the thickness of the skin when selecting and determining the appropriate combination of treatments.
Criteria for Selecting Subcision Hyaluronic Acid
Instead of focusing on which option is better or worse, it’s easier to make a decision if you organize your choices based on “what kind of indentation, lifestyle, and texture you want.”
- Thin Skin and Superficial Indentations: Non-crosslinked formulas tend to avoid light transmission (the Tyndall effect) and blend in well. However, they may wear off more quickly.
- Depth of the Dent / Strength of the Pull: Low-crosslinking makes it easier to maintain space even with a thin layer and helps bridge the period of re-adhesion; however, it may leave a slight sensation of contact in the short term.
- The Concept of Downtime: The non-crosslinked option is suitable for those whose bodies tend to swell temporarily due to hydration. While the low-crosslinked option typically causes only mild swelling, a sensation of tightness in certain areas may persist for a few days.
- Time Frame Design: Based on the estimated 2–8 weeks it takes to get past the peak of wound healing, develop a plan—for example, apply small amounts of non-crosslinked products at regular intervals, or use small amounts of low-crosslinked products to extend the treatment period (individual results may vary).
- Texture and Movement: It’s generally easy to follow the approach of prioritizing softness in areas where facial expressions are particularly dynamic, and giving slightly higher priority to shape retention during periods when it’s easier to rest.
People Who Are Easily Persuaded / People Who Want to Consider Things Carefully
People Who Are Prone to It
- For those who prioritize early "slip" and want to naturally refine the texture of the surface (leaning toward non-crosslinked).
- For those who experience strong deep traction and want to prioritize maintaining space during the wound healing phase (leaning toward low cross-linking).
- For those who want to monitor their progress in small increments while making minor adjustments (applicable to both non-crosslinked and low-crosslinked options, depending on the plan).
People who want to consider this carefully
- People who are prone to swelling or are concerned about prolonged bruising.
- People who are sensitive to short-term changes in texture (a strange sensation when touched).
- People who find it difficult to rest after surgery or to keep up with their medical appointments.
Risks and Limitations
Swelling, bruising, and tenderness may persist for several days. There have also been rare reports of a lump-like sensation, asymmetry between the left and right sides, excessive fluid accumulation, and inflammatory reactions.
In areas requiring special anatomical consideration, it is important to assess the risk of serious complications and select the appropriate access route.
The degree of effectiveness, duration, and downtime vary from person to person, and we cannot guarantee that re-adhesion will be completely prevented.
Frequently Asked Questions
Which lasts longer: non-crosslinked or low-crosslinked?
In general, lower cross-linking tends to make it easier to maintain shape, but there is variation depending on metabolism, the treatment site, and the amount used. The design process works backward from the question of “how to get through the wound healing phase.”
Can re-adhesion be completely prevented?
We cannot guarantee that it will be completely avoided. Hyaluronic acid helps create an environment that is less prone to breakage, and we will make minor adjustments based on evaluations and progress.
Is there any pain or downtime?
Pain is typically mild to moderate, and swelling and bruising generally last from a few days to about a week. Results may vary depending on individual constitution and the extent of the procedure.
Are the "Before & After" photos helpful?
Appearance varies depending on light, angle, and the number of days that have passed. It is important to view this only as a general trend and to evaluate the results based on your own skin condition.
Is it necessary to use them together?
While the use of multiple treatments at different stages is sometimes discussed, each combination must be evaluated on a case-by-case basis. We prioritize a systematic approach rather than unnecessarily increasing the number of treatments.
Summary
The key to preventing re-adhesion after subcision is “how to maintain space and glide until the peak of wound healing has passed.”
Uncrosslinked materials form a thin, spreading sliding layer, while low-crosslinked materials act as gentle supports, complementing each other.
Rather than choosing between two options, a more realistic approach is to determine the allocation based on the characteristics of the indentations, daily routines, and preferences regarding texture, and then make minor adjustments as needed based on how things progress.
If you're unsure, try evaluating the thickness of your skin and the strength of the traction, and then consider your priorities (durability, texture, and downtime). If you'd like to know whether this is right for you, please feel free to consult with us.
