Comparison of skin-tissue tensions using the composite and the subcutaneous rhytidectomy techniques

Controversy as to benefits, risks, and long-term durability of the subcutaneous rhytidectomy as compared with the composite and the subcutaneous musculoaponeurotic system (SMAS) rhytidectomy procedures has persisted over the last several years. Conventional surgical wisdom holds that deep-tissue support would provide both immediate and long-term benefits in rhytidectomy patients. Recent investigations have shown that deep-tissue support using the SMAS technique decreases epidermis closure tension. This effect has potential implications on vascularity, healing, scar formation, duration of results, and tension-related trophic 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 rhytidectomy without SMAS intervention. Using this approach, variability between techniques could be more accurately compared. Dissection levels were made as identical as possible on both sides. Tensions were then measured from premarked, standard key points, evaluating (1) the amount of tension 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 excision possible at a given tension. The added resistance is most likely the result of the deep fibromuscular layer. Resistance could be overcome by placement of deep support sutures, and the effect of the fibromuscular layer (SMAS) is effectively neutralized through increased viscoelastic support. This effect potentially helps to protect the dermal plexuses from the effects of tension created using the composite technique. The tension necessary to advance the epidermis to closure therefore compares favorably to the subcutaneous rhytidectomy method.