Association between cutaneous occlusive vascular disease, cigarette smoking, and skin slough after rhytidectomy

This prospective study attempted to determine if nonreversible occlusive vascular changes in the skin contribute to skin slough after rhytidectomy. The dermal microvasculature from 83 consecutive rhytidectomies was evaluated for intimal proliferation and/or hyalin sclerosis. Occlusive vascular disease increased progressively with age in all patients, but smokers and ex-smokers had significantly greater involvement than nonsmokers at any given age (p = 0.03). Severe occlusive vascular disease and skin slough were associated (p = 0.02), and there was a strong trend toward an association between active smoking and skin slough (p = 0.06). Among smokers, there was a significant relationship between skin slough and failure to abstain from smoking postoperatively (p = 0.006). We conclude that with aging, nonreversible occlusive changes develop in the dermal microvasculature. These changes appear to be accelerated by cigarette smoking. Our data, however, show that these nonreversible occlusive vascular changes by themselves do not completely account for the occurrence of skin slough after rhytidectomy.     

Short-scar face lift with extended SMAS platysma dissection and lifting and limited skin undermining

In the past 8 years, short-scar cervicofacial rhytidectomy has been used with great success and a high level of patient satisfaction. The operation involves limited incisions in the sideburn and preauricular areas, extending just around the fold of the ear lobule. Extensive undermining of the superficial musculoaponeurotic system (SMAS)/platysma is performed, and lifting of the face and neck is performed mainly at this level. Skin undermining is kept to a minimum, eliminating the need for extended incisions to reduce dog-ears. The preservation of fibrous bands between the skin and the SMAS/platysma unit is an important factor in making such an operation practical and is the reason why the skin incisions can be kept short. Dissection of large areas of skin and separation of the skin from the underlying SMAS necessitate larger incisions. The operation is safe, speedy, less traumatic, and well tolerated among patients at high risk, such as smokers. The risks of complications are also reduced with this operation.     

Wound healing problems in smokers and nonsmokers after 132 abdominoplasties

To study the effects of smoking on wound healing, the authors retrospectively analyzed the records of 132 patients (121 women and 11 men) who had undergone abdominoplasty in the previous 5 years. All patients had received a full abdominoplasty, with large mobilization up to the ribs and a belly transposition. Patients were excluded from the study if they had arteriosclerosis, diabetes mellitus, or other systemic diseases, and if they had received a simple pannus resection without a belly transposition.The following study parameters were taken for analysis: age at the time of operation, body mass index, preoperative weight loss, amount of resection, and smoking habits indicated by the patients preoperatively. Smokers were interviewed by telephone postoperatively concerning their perioperative smoking habits. Wound healing problems were registered when medical intervention was necessary, such as débridement, treatment for infection, lavage after fat necrosis, or a secondary skin closure after skin slough. Hematoma and seroma were not considered to be wound healing problems and were registered separately.Among the 132 patients, 53.8 percent admitted to smoking and 46.2 percent reported being nonsmokers. No significant difference was seen between smokers and nonsmokers concerning age or body mass index. Smokers reported consuming, on average, 18.4 cigarettes per day. The rate of wound problems and wound dehiscence showed a statistical difference between smokers and nonsmokers (p < 0.01); 47.9 percent of the smokers showed wound healing problems before hospital discharge versus 14.8 percent of the nonsmokers. The patients had been asked to quit smoking 2 weeks before the operation through 2 weeks postoperatively. The retrospective telephone inquiry found that just 14.7 percent stopped smoking preoperatively and only 41.2 percent quit temporarily after the operation.Smokers should be informed about their possible higher risk of wound healing problems. Because it seems impossible to turn smokers into nonsmokers, the authors continue to perform abdominoplasties in smokers. During the operation, they try to mobilize and resect less tissue and to immobilize patients for the critical first 3 postoperative days to prevent them from smoking.     

Presuturing--a new technique for closing large skin defects: clinical and experimental studies

We have developed a new technique termed presuturing for aiding in the closure of large skin defects which may have otherwise required a skin graft or flap. This technique is based on biomechanical properties of skin (creep, stress relaxation) which allow skin to stretch beyond its inherent extensibility. Presuturing is performed under local anesthesia and consists of plicating intact skin over the area of planned excision the night prior to operation. Experimental studies in a pig model showed the decrease in force required to close a standard-sized wound to be 40.1 percent less than control (p less than 0.001). Fourteen patients who underwent wide excision of skin lesions had their wounds presutured. All but one wound could be closed primarily without undermining. Presuturing seems to be an easy and clinically useful technique in aiding the primary closure of large defects.     

Circumferential suction lipectomy of the trunk with anterior rectus fascia plication through a periumbilical incision: an alternative to conventional abdominoplasty

During the past decade, many combinations of operative techniques for abdominoplasty have evolved to suit the individual requirements of the patient. The purpose of this study was to present a safe alternative to conventional abdominoplasty for appropriate patients, namely, those with minimal skin laxity, moderate fatty tissue distribution, musculofascial diastases, and no concern for abdominal stretch marks. The procedure consists of circumferential ultrasound-assisted liposuction and direct abdominal wall plication through a periumbilical incision. Thirty-two patients were evaluated on overall patient satisfaction and complication rates, including seroma (five, 15.6 percent), major sensory loss (none), skin slough (none), skin burns (none), end hits (i.e., a small, partial-thickness, subdermal burn; one, 3 percent), and limited results (two, 6 percent). The patients expressed that avoidance of the abdominal scar and diminished recuperative time outweighed the benefit of tighter skin associated with conventional abdominoplasty. This technique may provide another avenue for appropriate contouring of the abdomen in properly selected patients.     

Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in "separation of parts" hernia repairs

Midline ventral hernia repair with bilateral sliding myofascial rectus abdominis flaps, or the "separation of parts" technique, has low hernia recurrence rates. However, this technique, as originally described, creates massively undermined skin and subcutaneous tissue flaps. These undermined skin flaps can suffer marginal skin loss, fat necrosis, and delayed wound healing. The authors propose that preserving the periumbilical rectus abdominis perforators to the abdominal skin flaps will decrease the prevalence of postoperative superficial wound complications. A retrospective review of 66 consecutive, large, midline hernia repairs using a separation of parts technique was undertaken to identify any correlation between the preservation of periumbilical rectus abdominis perforators to the skin flaps and the prevalence of postoperative wound complications. In 25 cases, the standard separation of parts technique was performed with wide undermining of the skin and subcutaneous tissues. In 41 cases, the modified separation of parts technique was performed with maintenance of the periumbilical rectus abdominis perforators to the abdominal skin flaps.Comparison of these two groups revealed no difference in age; sex; body mass index; initial hernia size on physical examination; prevalence of smoking, diabetes, or steroid use; or prevalence of a simultaneous intraabdominal procedure. A statistically significant difference was noted in postoperative wound complications between the two groups (p < 0.05). Of patients who underwent the standard separation of parts technique, five of 25 patients (20 percent) had wound complications as compared with one of 41 patients (2 percent) who underwent the modified separation of parts technique with perforator preservation. The postoperative hernia recurrence (7 percent and 8 percent, respectively) and hematoma (4 percent and 2 percent, respectively) rates were similar in both groups. A trend of increased wound complications was noted when separation of parts was combined with an intraabdominal procedure (18 percent versus 3 percent, p = 0.08). Interestingly, within this group, the modified separation of parts technique with preservation of the periumbilical rectus abdominis perforators demonstrated a trend of fewer wound complications as compared with the standard separation of parts technique (7 percent versus 31 percent, p = 0.15). The authors conclude that preservation of the periumbilical rectus abdominis perforators significantly reduces the prevalence of major postoperative superficial wound complications in separation of parts hernia repairs. Simultaneous intraabdominal procedures with separation of parts hernia repairs seem to increase the prevalence of wound complications. This increased prevalence of wound complications seems to be minimized when the modified separation of parts technique is performed.     

Suction lipectomy: complications and results by survey

In October of 1983, we sent a questionnaire on suction lipectomy to 2524 U.S. and Canadian members of the American Society of Plastic and Reconstructive Surgeons. Six-hundred and twelve plastic surgeons returned questionnaires (24.2 percent response rate). One-hundred and seven responding surgeons reported 1573 operations in which suction lipectomy with or without skin excision was used for 2685 procedures on various parts of the body. In the subset of 1249 operations in which suction lipectomy only was used to treat 2261 anatomic areas, surgeons reported greater than 80 percent good or excellent aesthetic results. The overall complication rate was 9.3 percent. The most frequent complications were persistent hypesthesia (2.6 percent), seroma (1.6 percent), and persistent edema (1.4 percent). Skin pigmentation, pain, hematoma, infection, and slough each occurred with an incidence of 1.0 percent or less. Based on the results of this survey, suction lipectomy is a valuable new modality for surgical improvement of body contour.     

Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to avoid a face lift for unsuitable candidates

Patients with submental fullness may not be candidates for a full or short-scar face lift because of medical contraindications, uncontrolled hypertension, a refractory nicotine habit, or anticoagulant medications, or patients may disqualify themselves because of cost, unavailable recovery time, or emotional resistance. Submental suction-assisted lipectomy has traditionally been reserved for younger patients. For older patients, suction-assisted lipectomy is typically used as an adjunct for face/neck lifts. This report describes experiences with suction-assisted lipectomy for older patients who were not face lift candidates, for the aforementioned reasons. The study goals were to better delineate the indications for submental suction-assisted lipectomy, as opposed to a face lift, and to obtain improved results with a less-invasive procedure. A 6-year study involving 132 patients (21 to 73 years of age), of whom 4.5 percent were men, was performed. Eighty-eight patients (67 percent), the primary focus of this study, were more than 40 years of age. Of those 88 patients, 24 patients (18 percent of the 132 patients in this series) were in their forties, 45 (34 percent) were in their fifties, 16 (12 percent) were in their sixties, and three (2.3 percent) were at least 70 years of age. The median follow-up time in this series was more than 1 year. The results were assessed with the five criteria for facial rejuvenation described by Ellenbogen and Karlin. All patients demonstrated improvement, with three to five of the Ellenbogen-Karlin neck rejuvenation criteria being met for each patient. All patients demonstrated an improved submandibular border, a more visible anterior sternocleidomastoid muscle border, and an improved neck angle (as determined with angle measurements). For many patients, all five of the Ellenbogen-Karlin criteria were met. A visible subhyoid depression and a visible thyroid cartilage bulge were the two criteria most often not met. A retrospective evaluation using Baker's preoperative classification of patient types for short-scar face lifts was performed. Results for patients more than 64 years of age (11 patients) were less satisfactory, often with redundant or crepe paper-like skin. Submental suction-assisted lipectomy, as opposed to a face lift, was observed to be a reasonable alternative for older patients who were unable or unwilling to undergo a face lift. Localized fullness in the midline was observed to be the best predictor of a good outcome (even better than age or skin tone). A crepe paper appearance of the skin preoperatively was the best predictor of failure. The surgical anatomical features, technique, advantages, disadvantages, and principles are discussed. Complications and their treatment are addressed. It is concluded that submental suction-assisted lipectomy alone, without platysmaplasty, can be helpful for patients with submental fullness who are unsuitable candidates for a face lift and who accept the limitations of liposuction without platysmaplasty. Suction-assisted lipectomy can sufficiently contract and smooth the skin envelope for selected patients, with less consideration for age than previously proposed.     

Endoscopic forehead lift: review of technique,cases, and complications

Endoscopy has provided a significant improvement in the surgical rejuvenation of the upper face. It offers a minimally invasive alternative that avoids many of the undesirable effects associated with the coronal approach. The standard minimal access forehead endoscopic procedure consists of a subperiosteal undermining through three small triangular prehairline incisions. To successfully elevate the eyebrows, it is essential to release the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the glabella. Until the periosteum reattaches itself, elevation is maintained by a temporary suspension suture between staples at the incision sites and 5 cm posterior to the hairline. The transverse closure of the triangular skin incisions achieves some additional elevation. The biplanar approach adds a partial subcutaneous undermining of the forehead to the endoscopic technique and allows plication of the frontalis muscle and excision of excess forehead skin. It is offered to patients with very ptotic eyebrows, deep transverse wrinkles, or a high forehead. The prehairline incision is a disadvantage but is tolerated quite well in older patients. The medical records of 393 consecutive patients who underwent endoscopic forehead lift from 1994 to 2000 were reviewed. Because seven patients had the endoscopic forehead lift repeated, the number of forehead endoscopies totaled 400. The complication rate was quite acceptable and did not markedly increase when a forehead lift was performed in combination with other facial procedures. The endoscopic forehead lift consistently attenuated the transverse forehead wrinkles, reduced the glabellar frown lines, and raised the eyebrows. It provided an appearance that was less tired and angry in addition to opening the area around the eyes. Long-term follow-up has shown that the endoscopic forehead lift produces lasting and predictable results.     

Tension decrease during skin stretching in undermined versus not undermined skin: an experimental study in piglets

In a controlled study using 15 piglets, the efficacy of skin stretching using a skin stretching device was tested by quantifying the tension decrease during skin stretching in undermined and not undermined wounds. The viability of the skin margins was examined in both situations. Thirty standardized wounds was created: around 15 wounds on one flank, the surrounding skin was undermined; whereas around the 15 wounds on the opposite flank, the surrounding skin was not undermined. The force required to close the 9 x 9 cm defect was measured at the beginning, after undermining, and after 30 minutes of skin stretching. Also examined was the wound healing after 1 day and 1 week. A tension decrease of 3.02 N (13.6 percent reduction of the total force that is required to close the wound at the beginning) was seen due to undermining the surrounding skin. Skin stretching for 30 minutes without undermining the skin showed a tension decrease of 6.10 N (26.5 percent). Therefore, the tension decrease due to skin stretching was twice as high in comparison with undermining the skin margins alone. This has been statistically proven to be significant (-d (difference) = 3.08, 95 percent confidence interval = 2.16; 4.00, p < 0.001). When the undermined skin of the wound was stretched for 30 minutes, we measured a total tension decrease of 7.60 N (34.1 percent). There was a statistically significant but small difference in total tension decrease as a result of undermining combined with skin stretching in comparison with skin stretching without undermining (-d = 1.51, 95 percent confidence interval = 0.77; 2.23, p < 0.001). Undermining the surrounding skin involved cutting musculocutaneous perforating vessels. Looking at the viability of the skin, seven wounds, all found in the undermined group, showed skin necrosis after 1 week. Excessive seroma formation was seen in all wounds around which the skin was undermined. In the not undermined wounds, there were no problems in wound healing. In conclusion, skin stretching for only 30 minutes using a skin stretching device significantly reduces wound closing tension. The additional advantage of skin stretching over that of undermining alone is clearly shown. Undermining the wound margins before skin stretching gives a small additional tension decrease but has well-known complications, such as skin-edge necrosis and seroma formation.     

Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction

Free pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction is often advocated as the procedure of choice for autogenous tissue breast reconstruction in high-risk patients, such as smokers. However, whether use of the free TRAM flap is a desirable option for breast reconstruction in smokers is still unclear. All patients undergoing breast reconstruction with free TRAM flaps at our institution between February of 1989 and May of 1998 were reviewed. Patients were classified as smokers, former smokers (patients who had stopped smoking at least 4 weeks before surgery), and nonsmokers. Flap and donor-site complications in the three groups were compared. Information on demographic characteristics, body mass index, and comorbid medical conditions was used to perform multivariate statistical analysis. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients (80.9 percent immediate; 23.3 percent bilateral). There were 478 nonsmokers, 150 former smokers, and 90 smokers. Flap complications occurred in 222 (23.7 percent) of 936 flaps. Smokers had a higher incidence of mastectomy flap necrosis than nonsmokers (18.9 percent versus 9.0 percent; p = 0.005). Smokers who underwent immediate reconstruction had a significantly higher incidence of mastectomy skin flap necrosis than did smokers who underwent delayed reconstruction (21.7 percent versus 0 percent; p = 0.039). Donor-site complications occurred in 106 (14.8 percent) of 718 patients. Donor-site complications were more common in smokers than in former smokers (25.6 percent versus 10.0 percent; p = 0.001) or nonsmokers (25.6 percent versus 14.2 percent; p = 0.007). Compared with nonsmokers, smokers had significantly higher rates of abdominal flap necrosis (4.4 percent versus 0.8 percent; p = 0.025) and hernia (6.7 percent versus 2.1 percent; p = 0.016). No significant difference in complication rates was noted between former smokers and nonsmokers. Among smokers, patients with a smoking history of greater than 10 pack-years had a significantly higher overall complication rate compared with patients with a smoking history of 10 or fewer pack-years (55.8 percent versus 23.8 percent; p = 0.049). In summary, free TRAM flap breast reconstruction in smokers was not associated with a significant increase in the rates of vessel thrombosis, flap loss, or fat necrosis compared with rates in nonsmokers. However, smokers were at significantly higher risk for mastectomy skin flap necrosis, abdominal flap necrosis, and hernia compared with nonsmokers. Patients with a smoking history of greater than 10 pack-years were at especially high risk for perioperative complications, suggesting that this should be considered a relative contraindication for free TRAM flap breast reconstruction. Smoking-related complications were significantly reduced when the reconstruction was delayed or when the patient stopped smoking at least 4 weeks before surgery.     

Using intense pulsed light for cosmetic purposes: our experience

The authors' experience using intense pulsed light for skin rejuvenation is summarized and analyzed with regard to its efficacy, safety, and complications. Rejuvenation using intense pulsed light was performed on 59 patients over a 6-month period (January of 2002 to July of 2002); these patients served as the study group. The areas treated were the face, neck, chest, hands, and legs. The parameters used during the procedure, patient satisfaction, and complications are described. Ninety-five percent of the patients included in the study had one or two sessions. Good to very good results were reported by 93.1 percent. Most patients had minor side effects and only three patients (5 percent) experienced complications (hyperpigmentation or scars). Intense pulsed light is an effective and safe method for skin rejuvenation. Its efficacy is mainly manifested by eliminating senile pigmentation and telangiectasias and a achieving a younger and fresher appearance of the skin. Although in the literature intense pulsed light skin rejuvenation is mainly reported for the face, the authors have obtained good results by using it for other areas of the body. The majority of the patients were satisfied. The authors conclude that intense pulsed light skin rejuvenation is a safe and effective method for facial and nonfacial rejuvenation.     

Immediate and long-term management of gunshot wounds to the lower face

The steadily increasing level of urban violence and attempted suicides in the recent past has resulted in large numbers of gunshot injuries to the face from small-caliber weapons. Our experience with 35 consecutive cases of civilian gunshot wounds involving primarily the lower face is presented. Initial management included securing of the airway, control of bleeding, and treatment of coexisting injuries. After clinical and radiologic evaluation and conservative debridement of all devitalized tissues, the mandibular fractures were reduced and stabilized appropriately. Large bony defects were treated by stabilization of the mandibular segments followed by secondary bone grafting. Intraoral soft tissues were then repaired with local mucosal flaps or tongue flaps when necessary. Finally, the soft tissues were repaired by primary closure or local flaps. Distant flaps were used only as a secondary procedure. Our results are presented, the differences between civilian and military injuries are discussed, and the principles of gunshot ballistics are described. We conclude that most of these wounds can be treated in a relatively conservative manner immediately after the injury with good functional and cosmetic results.     

The vertical mammaplasty: a reappraisal of the technique and its complications

Since 1989, superior pedicle vertical scar mammaplasty as described by Lejour has been used in the authors' department as the only technique for breast reduction. From 1991 through 1994, a series of 170 consecutive patients (330 breasts) underwent an operation. In these patients, minor complications were observed in 30 percent of the patients and major complications in 15 percent. Surgical revision for scar or volume corrections was necessary in 28 percent of the breasts, which seemed unacceptable. Therefore, the original technique was modified by decreasing the skin undermining and avoiding liposuction in the breast. Primary skin excision was performed in the submammary fold at the end of the operation if the skin could not be puckered adequately. This modified technique was used from 1996 through 1999 in 138 consecutive patients (227 breasts). In the second series, minor complications were observed in 15 percent of the patients and major complications in 5 percent. However, the technical modifications did not significantly change the rate of secondary scar and volume corrections, which were still necessary in 22 percent of the breasts. In large breasts, the addition of a horizontal scar at the end of the operation did not change the rate of secondary revision, which however compares favorably with the figures obtained with the inverted T, superior pedicle mammaplasty.     

Tobacco smoking and complications in elective microsurgery.

This study assesses the risk for complications in patients who chronically smoke but who have quit in the perioperative period of an elective free-tissue transfer as compared with patients who do not smoke. A retrospective review identified 104 free-tissue transfers in 93 smokers and 58 transfers in 51 nonsmokers. The demographics, wound etiology, and recipient sites were similar in the two populations. With the exception of a higher incidence of chronic obstructive pulmonary disease (COPD) among smokers, preexisting comorbid factors also were similar. Postoperative medical complications were comparable between populations. When comparing smokers with nonsmokers, we found that anastomotic patency and flap survival were not different (95 versus 94 percent, respectively), that delayed wound healing at the recipient site was different (35 versus 24 percent), and that smokers require an additional procedure to achieve final wound closure more frequently (27 versus 12 percent, p = 0.03). These findings suggest that cigarette smokers are at increased risk for complications, not at the site of the anastomosis in free-tissue transfer, but rather at the flap's interface with the wound or overlying skin graft.     

Combined erbium:YAG laser resurfacing and face lifting

Facial aging occurs secondary to gravity-induced tissue ptosis and photoaging. Combined face lifting and carbon dioxide laser resurfacing provides a comprehensive one-stage approach to facial rejuvenation but is condemned by many plastic surgeons due to the nonspecific thermal effects of the laser and risk of skin necrosis. Newer high-energy erbium:YAG lasers allow precise tissue ablation with minimal thermal effect. In this study, various facial rejuvenation techniques were combined with simultaneous erbium:YAG laser resurfacing to assess results and complications. A total of 257 patients from Florida, Melbourne, Australia, and Tel Aviv, Israel, underwent combined erbium:YAG laser resurfacing and surgical facial rejuvenation. Various face-lift methods were used, including endoscopic, deep plane, and subcutaneous. Simultaneous, full-facial laser resurfacing was performed using a variety of erbium:YAG lasers. It was found that combined laser resurfacing and face lifting was successful in greater than 95 percent of patients with minimal morbidity. Two patients (1 percent) (both heavy smokers) developed small areas of skin necrosis that healed with minor pigment changes. Five patients (2 percent) developed synechia that was treated with no residual effect. Two additional patients (1 percent) developed temporary ectropion. There were no other cases of scarring, infection, or cosmetically obvious hypopigmentation. Although larger studies are necessary, it seems that the lack of thermal injury from the erbium:YAG laser makes it possible to safely perform laser resurfacing with surgical facial rejuvenation in nonsmokers. However, the authors caution that familiarity with the nuances of erbium:YAG laser resurfacing be obtained before performing combined laser resurfacing and face lifting.     

Surgical treatment of the senile upper lip

Aesthetic changes in the aging upper lip constitute a troublesome problem for modern women. During the process of aging, the following alterations appear in the upper lip: (1) vertical wrinkles, (2) reduction in height of the vermilion border along with lengthening of the skin area of the lip, and (3) "disappearance" of the Cupid's bow. In 1993, Guerrissi and Sanchez described a surgical technique that allowed them to correct the effects of these senile changes in 19 patients. With the use of this surgical technique, a strip of skin on the vermilion border was deepithelialized. The remaining dermal flap was buried in the pocket, which was performed by undermining the superior third of the skin of the upper lip. The short-term results were satisfactory, although a slight reduction in height of the vermilion border and a decrease in the thickness of the lip were observed in five patients (26 percent) 4 years postoperatively. Beginning in 1994, the authors began using a new approach combining dermal flap reshaping with simultaneous lip augmentation using dermal-fat grafts, Gore-Tex (W. L. Gore and Associates, Flagstaff, Ariz.) or AlloDerm (LifeCell Corp., Branchburg, NJ.). No serious or definitive complications were observed. Scars on the vermilion border were not conspicuous. A peel was necessary at the same time for complete elimination of rhytids. With this method, both the patients and the surgeons were satisfied with the results.     

Stretching skin: undermining is more important than intraoperative expansion

The efficacy of intraoperative expansion in reducing the tension of wound closure was tested in young pigs. The young piglet as a model for studying human skin was characterized by finding a close similarity between the modulus of elasticity of young piglet skin and human abdominoplasty and mammaplasty skin (range 12.8 to 23.7 N/mm2 for piglet skin, 14.3 to 19 N/mm2 for human skin). The tension required to close a standardized wound was determined before undermining, after undermining, and finally after intraoperative expansion. These measurements were performed in 10 young pigs with an average weight of 11.5 kg. Undermining the wound edges resulted in a significant decrease in the force required to close the wounds (p less than 0.0001). Intraoperative expansion did not significantly decrease the tension. Previous work showing the importance of site and direction of pull on the tension for wound closure was confirmed in this study. Analysis of variance demonstrated that the tension required to close a standard wound is greater high on the pig's back than near the belly and near the shoulder as opposed to the hip for midflank wounds (p less than 0.0001). Increasing the extent of undermining from 62 to 136 cm2 significantly decreased the tension for wound closure (p less than 0.05). Further undermining did not result in a significant decrease in wound closure tension. In this model, intraoperative expansion offers no advantage over simple undermining. We suggest that the benefit reported by clinicians using intraoperative expansion may derive from an increase in the extent of undermining required to place expanders under the wound margins.     

Purse-string suture for nipple projection

A simple and useful technique for nipple projection is reported. A buried, subcutaneous, purse-string suture is placed through prick holes and, when tied, gives a nipple mound, without the need of skin incisions, flaps, or undermining. This procedure can be applied to inverted, missing, and/or ill-defined nipples.     

Combined rhytidectomy and full-face laser resurfacing

A series of patients undergoing a combined face lifting procedure with simultaneous laser resurfacing is described. Although resurfacing is accepted as safe for deep-plane face lifts and forehead lifts, there are reports of preauricular skin loss with a standard face lift. In this series, 26 consecutive cases are described. A superficial musculoaponeurotic system (SMAS) face lift technique was used. A skin flap was developed no more than 3.0 cm from the preauricular area, and most of that was excised. Full-face laser resurfacing was done with the SilkTouch laser. An 8-mm square pattern was used at 16 to 18 W. Three to four passes were done. Care was taken, however, to do very superficial lasering of the periphery, especially over the small amount of undermined skin that remained. There was no preauricular skin loss. This series demonstrates the safety of combining laser resurfacing with the SMAS technique face lift in regard to preauricular skin loss.