Wb. Gamble et al., COMPARISON OF SKIN-TISSUE TENSIONS USING THE COMPOSITE AND THE SUBCUTANEOUS RHYTIDECTOMY TECHNIQUES, Annals of plastic surgery, 35(5), 1995, pp. 447-453
Controversy as to benefits, risks, and long-term durability of the sub
cutaneous rhytidectomy as compared with the composite and the subcutan
eous musculoaponeurotic system (SMAS) rhytidectomy procedures has pers
isted over the last several years. Conventional surgical wisdom holds
that deep-tissue support would provide both immediate and long-term be
nefits in rhytidectomy patients. Recent investigations have shown that
deep-tissue support using the SMAS technique decreases epidermis clos
ure tension. This effect has potential implications on vascularity, he
aling, scar formation, duration of results, and tension-related trophi
c changes. Twelve fresh frozen cadavers were dissected. At random, one
side was treated with the composite technique as described by Hamra,
whereas the other was treated with a standard subcutaneous rhytidectom
y without SMAS intervention. Using this approach, variability between
techniques could be more accurately compared. Dissection levels were m
ade as identical as possible on both sides. Tensions were then measure
d from premarked, standard key points, evaluating (1) the amount of te
nsion required to move the point 2 cm; (2) with a pull of 1.00 kg, the
amount of skin that could then be excised; and (3) after securing the
composite 2.0 cm reference points using deep-tissue support sutures,
the amount of tension needed to advance the skin to closure. We found
that the composite method has a higher resistance to stretch than the
subcutaneous method, which translates into a lesser amount of skin exc
ision possible at a given tension. The added resistance is most likely
the result of the deep fibromuscular layer. Resistance could be overc
ome by placement of deep support sutures, and the effect of the fibrom
uscular layer (SMAS) is effectively neutralized through increased visc
oelastic support. This effect potentially helps to protect the dermal
plexuses from the effects of tension created using the composite techn
ique. The tension necessary to advance the epidermis to closure theref
ore compares favorably to the subcutaneous rhytidectomy method.