Background. Increasing demand exists for cosmetic correction of soft tissue contour defects. Treatments include simple tissue augmentation techniques or more complex surgeries with consequent relevant recuperation time for the patient. The search for new simple techniques to correct scars and age-related wrinkles and folds is therefore one of the main goals of cosmetic dermatologic surgery.
Objective. To improve the cosmetic outcome of patients suffering from soft tissue contour defects by the use of a novel surgical instrument and technique, subcutaneous dissection by wire scalpel.
Methods. Fifty-four patients were treated with the wire scalpel technique with no skin incisions to correct a total of 132 depressed cosmetic defects of the face. Forehead lines, glabellar, nasolabial and oral commissure folds, upper lip wrinkles, and acne scars were treated. A 2-month to 4-year follow-up allowed subjective and photographic evaluation of results.
Results. Good or satisfactory results were obtained in 79.7% and 16.6% of the cases, respectively. Minor complications did not change the overall positive outcome of the surgery.
Conclusion. Subcutaneous dissection by wire scalpel is a simple, safe, and effective method to improve the contour appearance of patients affected with scars or age-related contour defects.
THE HUMAN BODY is the picture of natural harmony, its complex anatomical contour being aesthetically perceived as an image of beauty. Therefore the goal of dermatological plastic surgery is not limited to the correction of functional disturbances: it must also help the patient to objectively evaluate and manage a body defect and thus achieve his or her aesthetic ideal, harmony, and peace of mind.
Recent increases in the aesthetic demand for beauty in human appearances makes the successful correction of facial contours and body proportions one of the main criteria for the efficiency of dermatological plastic surgery. At the same time, current approaches to the correction of scar deformities, soft tissue defects, wrinkles, and folds do not always meet the present-day high-demand tasks of aesthetics. Such surgeries often include a skin incision, with consequent bleeding, and require suturing as well as time for wound closure and scarring. Also, there is some risk of infection. Moreover, many patients affected with surface contour deformation of the skin appear to be much more concerned with the presence of a scar than with its size and shape.In such cases, dermatological plastic surgery may be less effective than expected.
In many patients, well-developed facial skin deformities, scars, wrinkles, and folds cannot be effectively treated by mere tissue augmentation via biologic or synthetic materials. Such cosmetic defects often need to be corrected by direct surgical removal of redundant skin (skin excisions or facelift); however, this surgical strategy cannot be universally applied despite its long standing cosmetic effect because it leaves scars and requires a long recuperation time. Laser resurfacing has recently emerged as a new method to treat scars and wrinkles, and to improve the texture of the skin; laser resurfacing, however, requires quite a long healing time and is not effective on deep, fixed folds of the face. An alternative correction can be achieved with the help of the subcutaneous needle dissection or subcision technique using a Dufaut or Nokor needle. This simple technique, however, has inherent limitations for many lesions and must be performed by an operator who is very experienced for it to be effective. The aim of our preliminary experience was to improve the cosmetic outcome of the surgical treatment of patients with facial contour defects of different etiologies by the subcutaneous soft tissue dissection technique. In order to eliminate or smooth wrinkles, folds, and scars we used a wire scalpel for subcutaneous dis- section of soft tissues without any skin incisions. The procedure was done as the sole intervention or during traditional cosmetic surgeries, with the aim of raising the base of the lesion in order to release it from its attachments to deeper planes.
A “wire scalpel” was specially designed and constructed for the purpose of this study [certificate no. 3223 of the Russian Patent Office (“Rospatent”), March 16, 1995]. The instru- ment allows subcutaneous soft tissues to be dissected with minor trauma through pinholes in the skin without skin incisions.
The scalpel is made of a firm and elastic wire (0.05–0.5 mm section) resistant to twisting. One end of the wire is fixed in a holder, the other is attached to a long (5–15 cm) tribeveled cutting trocar (Figure 1). The trocar is used to make entry and exit punctures in the skin in order to pull through the wire. In this way the wire is inserted so as to reach the subcutaneous fatty tissue. The trocar is then reinserted through the former exit site and the wire is again pulled through. By consecutive entries and exits of the trocar, the wire is placed in the desired hypodermal layer fol- lowing preoperative markings until the entire area within the contour line is completed. The depth of the subcutaneous level is controlled by the surgeon’s hand based on the ease of progression of the needle in the hypodermal fatty tissue (Figure 2). The strained wire is pushed to and fro by cautious sliding movements of both the holder and the trocar vigorous enough to dissect and split the tissue (Figures 3 and 4).
The area of the skin affected with scars, folds, or wrinkles to be treated is outlined with a dye. Antiseptic skin treatment is followed by infiltration anesthesia (lidocaine 0.5–1% with epinephrine 1:100,000; 25–30-gauge needle) at the subcutaneous level, and subsequent wire scalpel dissection of subcutaneous tissues underlying any individual lesion, forming a 4–6 mm thick cellulocutaneous flap. When choosing the depth of dissection in the hypodermal adipose tissue, anatomic features of each skin area must be taken into consideration as well as its blood supply patterns in order to avoid massive bleeding. Forehead, glabella, and nasolabial folds are skin depressions also caused by adhesions between the fibrosed dermis and the underlying muscles, with or without interposition of the superficial muscoloaponeurotic system (SMAS): subcutaneous dissection allows the release of the muscles and the SMAS. The detachment of the lesion from the deeper planes and subsequent wound-healing concur to elevate the lesion and smooth contours.
Hypodermal fatty tissues underlying nasolabial folds were dissected over an area 0.8–1.0 cm wider than the fold area at a depth of 5–7 mm depending on the skin and subcutaneous layer thickness. The wire was usually led from top to bottom as prompted by anatomic considerations concern- ing innervation and blood supply. Moreover, pulling the wire in this direction is less injurious to the underlying tissues. We have learned from our experience that mediolateral dissection is technically inconvenient.
Conversely, it was found to be methodologically simpler to dissect from the bottom to the top of the hypodermal tis- sues underlying folds and wrinkles in the glabellar region, in accordance with the direction of the neurovascular bundles outgoing from the inner canthus of the eye. Subcutaneous tissues of transverse forehead lines were dissected along their length, for technical considerations. This procedure included dissection of facial muscles directly attached to the skin. Labial tissues were dissected above and along the orbicularis oris muscle in order to respect underlying innervation and blood supply of the upper and lower lip. Depressed traumatic and wide acne scars were also treated by the same technique in the immediate hypodermal layer. Deep ice-pick scars are best treated by punch excision and dermal grafting and have not been treated.
Flaps in nasolabial, glabellar, and forehead areas are usually thicker than upper or lower labial ones, whose dissection is conducted in an upper plane. In most cases, three to four punctures have to be made through the skin and the underlying fatty tissue of the area to treat. Subcutaneous tissues of the upper lip covered with small wrinkles are dissected along its entire length through six pinholes.
All surgical procedures were easy to perform and took little time to complete (3–5 minutes for nasolabial folds, glabellar folds, and acne scars, 5–10 minutes for upper lips, wrinkles, and forehead lines). The resulting flaps were perfectly viable, and the skin punctures closed spontaneously, leaving no trace at the surface. Subcutaneous pockets formed by dissection frequently contained small amounts of blood which were immediately evacuated through the pinholes by injecting cold saline and applying external pressure and ice packs at the end of the procedure. In all patients, bleeding was eventually stopped by using a compressive bandage. Antibiotics have been prescribed only in selected cases.
This preliminary report deals with 54 patients treated with the wire scalpel subcutaneous dissection tech- nique to correct a total of 132 cosmetic depressed de- fects of the face. All patients (53 women and 1 man) were Caucasian between the ages of 24 and 62. Patients with a history of hypertrophic or keloid scarring or bleeding disorders were excluded from the study. All patients signed an informed consent. All patients exhibited type 2–3 (moderate to advanced) photodamage according to the Glogau classification12 and grade 3–4 skin folds according to the Adamian classification:13 grade 3 wrinkles are individual or multiple epidermal and partially dermal wrinkles with gross deformation of the skin not smoothing out to a quiet expression of the face; grade 4 wrinkles are individual or multiple wrinkles extending to all thicknesses of the skin, with gross deformation kept constant. In most cases the procedure is performed once and is repeated only on the specific request of the patient. Scars were all treated in one stage on an outpatient basis.
Table 1 details the distribution of surgeries by the location of the skin defect. The wire scalpel was most extensively used to correct the vertical wrinkles of the glabellar region and the nasolabial folds, due to the large size of these defects, which are associated with gross deformation of the epidermal and dermal layers. The follow-up period ranged from 2 months to 4 years (mean follow-up time 11 months). The results of the surgical treatments were categorized into good, satisfactory, and bad, as judged by subjective and photographic evaluations:
A “good” result was defined as a cosmetic effect that fully satisfied the surgeon and the patient. The treated scars, folds, and wrinkles were smoothed and the face contour was corrected. Photographic improvement was at least 50%.
A “satisfactory” result was defined as a cosmetic result that made the surgeon and the patient globally satisfied with the outcome of the surgery. The corrected wrinkles were almost inapparent and easy to disguise with make-up, and photographic improvement was clear. The surface contour was improved even though the overall appearance fell short of the patient’s expectation.
A “bad” result was defined as the lack of the expected cosmetic effect. The patients were utterly dissatisfied with the results of surgery, although they became eventually reconciled to the failure and consented to a new procedure.
Overall good and satisfactory results were documented in 43 (79.7%) and 9 patients (16.6%), respectively (Figures 5–8). We had only two bad results after the first treatment (3.7%): one patient was re-treated after 1 month for correction of nasolabial folds, another one was retreated after 1 year for correction of glabellar folds.
Side effects of the procedure included edema, bruising, and postoperative pain at the treatment site. These effects are to be expected as a consequence of trauma and generally resolve spontaneously in 7–14 days. Complications can include infection, hematoma, and keloid scarring. A careful history will help rule out patients at risk of keloids. We had no infection and only one case of hematoma under a nasolabial fold in the immediate postoperative period. It was identified in a patient who visited the clinic 4 days after surgery: an 8 ml hematoma was evacuated through a skin puncture.
The use of a wire scalpel for subcutaneous soft tissue dissection in the management of skin scars, folds, and wrinkles of the face and forehead is a simple, nontrau- matic, conservative, economical procedure that leaves no visible traces on the skin surface. Our preliminary experience showed satisfactory clinical efficacy with this method which allows cellulocutaneous flaps of any size and thickness to be obtained without skin in- cision. The method is technically simple and produces no postoperative cutaneous scar and/or skin injury, also allowing repeated procedures until a satisfactory level of correction is reached, thus creating the requi- sites for a long-standing cosmetic effect. Moreover, this procedure may be extensively used in addition to traditional rhytidectomy, skin resurfacing and tissue augmentation techniques.
A special feature of this technique is its good efficiency in those folds and wrinkles related to facial mimics (glabella and forehead lines) for its possible action over muscles. The subcutaneous dissection is also useful to release “cellulite” dimples and fibrous adhesions due to liposuction.
Potential long-term complications, like hypertrophic and keloid scarring or pigmentary changes, particularly in darker complexions, should be carefully evaluated before surgery in order to exclude all patients at risk. The proposed procedures are technically simple, minimally invasive, and do not require expensive equipment. They can be performed not only in specialized centers but also in outpatient departments. The use of the wire scalpel for subcutaneous dissection of soft tissues can be used to improve the quality of surgical rehabilitation of patients with scars and surface contour defects of soft tissues.
Marlen A. Sulamanidze, MD,Giovanni Salti, MD, Marcus Mascetti, MD, and Georgi M. Sulamanidze, MD
Center for Aesthetic Dermatology and Surgery, Russian Academy of Sciences Clinical Hospital, Moscow, Russia,
Florence Day Surgery Center, Florence, Italy, and Binder Institute of Aesthetic Surgery, Rome, Italy
1. Ellis DA, Mitchel MJ. Surgical treatment of acne scarring: non lin- ear scar revision. J Otolaryngol 1987;16:116–9.
2. Grishkevich VM, Filippova IV, Modazimov MM. Facial plastic correction by new methods of reconstructive surgery. In: Aktual’nie voprosy rekonstr. i vosstanovit. khirurgii (Current Problems of Re- constructive and Plastic Surgery) (in Russian). Moscow: A. Vish- nevski, 1989:218–9.
3. Muldashev ER. Theoretical and practical aspects of the develop- ment of ‘alloplast’ allografts for facial plastic surgery (in Russian). Sankt-Petersburg: A. Vishnevski, 1994:50.
4. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Derma- tol Surg 1995;21:543–9.
5. Sulamanidze MA, Britun YA, Savchenko SV. Subcutaneous dissec- tion and liquid-gel dermotension. Ann Plast Rekonstr Estet Khir (Rus) 1997;2:35–40.
6. Belousov AE, Kochish AY. Classification of the types of blood sup- ply of integumentary tissues from the standpoint of plastic surgery (in Russian). Vestn Khir Grek 1990;144:90–3.
7. Mole B. The naso labial fold: analysis and proposed techniques for correction (in French). Ann Chir Plast Esth 1990;35:191–200.
8. Mackay DR, Saggers GC, Kotwall N, et al. Stretching skin: under- mining is more important than intraoperative expansion. Plast Re- constr Surg 1990;86:722–8.
9. Snow SN, Stiff MA, Lambert DR. Scalpel sculpturing technique for graft revision and dermatologic surgery. J Dermatol Surg Oncol 1994;20:120–6.
10. Swinhehart JM. Dermal grafting. In: Klein AW, ed. Tissue Aug- mentation in Clinical Practice. New York: Marcel Dekker, 1998: 63–95.
11. Alt TH, Goodman GJ, Coleman WP III, et al. Ancillary techniques. In: Coleman WP III, Hanke CW, Alt TH, Asken S, eds. Cosmetic Surgery of the Skin. St. Louis: Mosby, 1997:125–8.
12. Glogau RG. Aesthetic and anatomic analysis of the aging skin. Semin Cutan Med Surg 1996;15:134–8.
13. Adamian AA, Magomadov RC. Planimetric plastics of soft tissues by various injections of polymeric materials (PhD dissertation) (in Rus- sian). Moscow: University of Moscow School of Medicine, 1997:38.