COMPARISON OF SKIN-TISSUE TENSIONS USING THE COMPOSITE AND THE SUBCUTANEOUS RHYTIDECTOMY TECHNIQUES

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.