Wire scalpel for surgical correction of soft tissue contour defects by subcutaneous dissection.

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 "round block" purse-string suture: a simple method to close skin defects with minimal scarring.

We report the use of a subcuticular purse-string suture for closure of surgical skin defects, a simple maneuver that we have found to be very useful in closing difficult wounds and reducing scarring. The purse-string suture is performed with a large nonabsorbable suture that is passed intradermally and left in situ at least 4 weeks. This technique has been applied in 196 patients for a total of 221 sutures over a period of 2 years, being used to close skin defects from 2 x 2 to 8 x 11 cm in many areas of the body. All the patients showed, at closure, a large number of concentric redundant folds as well as considerable distortion of nearby structures; both improved impressively over a period of 2 to 3 weeks and became nearly normal at the time of suture removal (4 to 8.2 weeks, mean 5.7 weeks). The initially very limited and almost circular scar oriented itself along the skin tension lines over a period of a few weeks and, when matured, was always shorter than the original defect. In general, minimal scar widening occurred when we used larger sutures (more than 0-1) that were left longer (more than 6 weeks). Complications have been 23 cases of dehiscence (10.4 percent) in 23 patients (between the fifth and sixteenth days, mean 6.7 days); they were caused by the bad quality of the skin and by the use of too small sutures that cut through the dermis. The "round block" suture has many advantages: 1. It is a simple, inexpensive, and rapid technique for closing wounds by expanding the surrounding skin and often avoiding the use of skin grafts and/or local flaps. 2. It can minimize scarring; the final scars are shorter than the original defect and usually of very good quality. 3. It allows a very useful temporary closure that stretches the surrounding skin while waiting for the definitive histologic report. If this method is not chosen as a definitive closure, later repair with local flaps may be facilitated. 4. For the reasons expressed above, it never compromises the final result even in cases of dehiscence. The main disadvantage is the acceptability of the method on the part of patients, who need to be carefully prepared for both the gross initial distortion and the long time the suture has to be retained; nevertheless, patient satisfaction with the final results in generally very high, especially in large excisions of the face.

Use of a versatile axial dorsonasal musculocutaneous flap in repair of the nasal lobule.

We present our 17 years of experience in using a sliding axial musculocutaneous flap from the nasal dorsum in the repair of 53 nasal lobular defects (follow-up 3 to 212 months, mean 47.3 months). This flap is a modification of the classic Rintala flap but is based on a greater understanding of surgical anatomy, the biomechanical properties of skin, and physiology of flaps, all of which allow a more aesthetically satisfactory closure of very distal nasal lobular defects. After excising the tumor, two parallel incisions are made along the sides of the nasal dorsum, and flap is raised in the gliding plane deep to the fibromuscular layer of the nose and superficial to the cartilage and bone and then advanced over the defect, which can be as large as the entire nasal lobule. The flap is very reliable (no failure in our series) and easy to perform; furthermore, it is a fast, one-step reconstructive procedure that leaves the scars in areas of natural shadow. This flap makes use of a wide dorsal and glabellar undermining to recruit sufficient skin; it takes advantage of the mild tension exerted by the underlying nasal framework to lengthen the flap reliably without the need for an extra incision or Burow's triangles, as originally described by Rintala. Neither tip rotation nor glabella flattening has ever been found to be a real problem in our series because the flap elongates in a period of 2 to 6 weeks and tip always comes down, provided that the nasal framework is not modified. We believe that the axial musculocutaneous sliding flap has distinct advantages over other alternative local flaps in the repair of lobular nasal defects; moreover, although this simple operation cannot compete with the quality of the aesthetic results achieved by very skilled masters using frontal flaps, it is an easy, quick, one-step procedure that allows acceptable and reliable aesthetic results to be achieved by the majority of surgeons, and it does not harm the precious forehead donor site, which may become essential in case of the need for further reconstruction.

Iatrogenic nostril stenosis: aesthetic correction using a vestibular labial mucosa flap.

Nostril stenosis is an infrequent finding that often has an iatrogenic cause. It is a very difficult problem to resolve and usually requires several months of prosthetic support in order to counteract the recurrence of internal scarring and shrinking. We present a 4-year-old child with a monolateral iatrogenic nostril stenosis. A satisfactory and stable correction was obtained using a "piercing" flap taken from the labial vestibule. The use of a nasal stent (not placed immediately and worn only at night) was necessary for only 2 months. This technique has a number of advantages: the absence of external scars, little or no tendency to recurrence due to the absence of contraction provided by the well-vascularized flap tissue, and the ease and rapidity of the surgical procedure.