Journal of Plastic Surgery
Intraoperative Tissue Expansion in Rhytidectomy Revisited
By Daniel Man, M.D.
Since its introduction over a decade ago, the validity of tissue
expansion during rhytidectomy has continued to be a focus of some controversy.
Despite this relatively long history, there has been no formal study of
the improvement achieved with this technique. Yee et al. present an interesting
attempt to objectively evaluate the cosmetic improvement obtained with
the use of tissue expansion. The authors are to be commended for their
effort in objectively evaluating the utility of intraoperative tissue
expansion. Nevertheless, a number of points merit further discussion and
clarification.
An important factor affecting this study is that it was retrospective.
There is no discussion whatsoever as to how the decision was made as to
which patients did not. This raises the question of selection bias; i.e.,
were the patients who underwent intraoperative tissue expansion the more
difficult cases? In addition, the treatment group and the control group
were compared only with regard to gender, age, and additional ancillary
surgical procedures. Absent were important factors such as skin thickness,
sun damage, deep wrinkles, and smoking history. For this study to have
any validity, at a minimum the patients would have to have been randomized
as to who would have intraoperative tissue expansion and who would not.
An even better method would be to perform tissue expansion on one side
and use the contralateral side as the control. However, this is an unacceptable
option in reality because of ethical and legal considerations.
From a technical point of view, the Man face-lift expander was specifically
designed to be inflated with air, whereas the authors in their study use
saline. In my experience, using air as opposed to saline allows for the
rapid circumferential relaxation of the elevated skin, whereas saline
inflation often causes the expander to drift away from the midline of
the face-lift dissection and yield expansion in the wrong direction (i.e.,
laterally instead of medially).
After expansion, some caution must be exercised with regard to the amount
of tension applied to the skin closure because of concerns regarding the
blood supply to skin that has already been placed under tension. The authors
mention that, in the group of patients who had undergone tissue expansion,
they used minimal tension during skin closure. In this context, the phrase
minimal tension is in fact a technically variable term that can be ambiguously
interpreted. With the use of intraoperative tissue expansion in rhytidectomy,
and "optimal" amount of tension must be used. There is a learning
curve in understanding this optimal amount of tension necessary to achieve
a good, long-lasting result. The use of less than optimal tension will
lead to disappointing long-term results. This is illustrated by the fact
that the authors mentioned that they were somewhat surprised by the findings
of their study after 6 months, in that they thought that the expanded
group had a better appearance in the early postoperative period.
Intraoperative tissue expansion is not appropriate in every face lift;
rather, it is another tool in our surgical repertoire that can be of great
utility in some circumstances and skin types but actually counterproductive
in others. Patients with excessive loose skin, heavy jowls, excessive
wrinkling lateral to the corners of the mouth, and sun damage are particularly
good candidates for intraoperative tissue expansion. Conversely, in patients
with thin or scarred skin, this technique should be avoided. By using
this technique, I have been able to perform a number of procedures that
otherwise could not have been undertaken. The advantages of intraoperative
tissue expansion can be well illustrated by the case of a young female
patient who had undergone two previous face lifts. These previous procedures
resulted in scars that had migrated medially and were far in front of
the ears, causing significant cosmetic deformity. She had been repeatedly
denied additional surgery by her original surgeons. By incorporating intraoperative
tissue expansion, thus taking advantage of the viscoelastic properties
of the skin, I was able to develop enough additional flap surface area
to perform her surgery and return the scar to an acceptable aesthetic
location within the ears, without creating a "pulled look".
This result could not have been achieved without the use of intraoperative
tissue expansion. The utility of this technique in specific situations
can be further illustrated by reviewing the authors' photographs. Had
intraoperative tissue expansion been used, greater improvement in skin
draping could have been achieved and her overall result would most likely
have been significantly better.
Finally, the lack of any demonstrated benefit to intraoperative tissue
expansion in this study is overshadowed by the overall lackluster results.
It is disappointing that among 50 patients undergoing face lift, methodology
notwithstanding, the mean rating of improvement on a scale of 1 to 10
was approximately 5 (5.27 versus 5.07). Most of our patients expect, and
consistently receive, results that are well above average from our professional
services. Many would wonder whether having an improvement of only this
magnitude would justify having cosmetic surgery at all.
Daniel Man, M.D.
851 Meadows Road
Suite 222
Boca Raton, Fla 33486 info@drman.com
REFERENCES
1. Man, D. "Stretching and tissue expansion for rhytidectomy:
An improved approach." Plast. Reconstr. Surg. 84: 561, 1989.
2. Man, D. "Stretching and tissue expansion for face lift:Five
year experience. " In U.T. Hinderer (Ed.), Plastic Surgery, 1992,
Vol. 1. Amsterdam: Elsevier Science Publishers, 1992.
