Wired for beauty
Inquisitive surgeon shares wire scalpel technique
for facial rejuvenation

Publish date: Sep 1, 2007 Featured in CosmeticSurgeryTimes.com
By: Brett S. Kotlus, MD, MS

Dr. Kotlus

How can I improve this? We all think this occasionally when evaluating a post-operative cosmetic patient. Many of us adjust our surgical techniques based on the results of patients who underwent the same procedure. Maybe we alter the direction of pull ever so slightly or use a different suture material the next time around. This feedback loop is useful as we strive to achieve the best possible surgical results.

DEEP LINES During my two-year fellowship in cosmetic surgery, I conferred with my preceptor, Dr. Robert Dryden, after every case, and we shared suggestions about how we could improve our techniques. In one of these discussions, we spoke about the persistence of "crow's feet," nasolabial creases and marionette lines seen in some patients after facelift surgery. Rhytidectomy can significantly improve folds, but is often less helpful when attacking creases. 1 Botulinum toxin and injectable fillers are effective for dynamic wrinkles and mild to moderate fixed creases, but their effects are generally less permanent than the facelift itself and do not always address more longstanding, deep creases. We began to use the wire scalpel in these areas, to undermine the creases and lyse their underlying subdermal attachments. For example, in the nasolabial transition area, multiple musculodermal attachments, including those of the orbicularis oris, the levator anguli oris, the levator labii superioris, the zygomaticus major and minor, and the modiolus muscles can contribute to a discrete, elongated depression known as the nasolabial crease. 2 We saw some benefit in wire scalpel rhytidolysis, but the creases had a tendency to re-form over a period of months. Going back to our feedback loop, we decided to add fat transfer to our procedure, and it made a difference. We have described this technique in Plastic and Reconstructive Surgery3 and the American Journal of Cosmetic Surgery.4

Subcutaneous release of a "marionette line" with the wire scalpel.

The wire scalpel is a surgical instrument that facilitates subcision.5 This is not a new concept, as subcision is commonly performed with needles for scar conditions6 and has also been described with Keith needles and affixed sutures.7 I use the version produced by Kolster Methods, Inc., but others are available from Coapt Systems, Inc. and Innovative Med Inc. The instrument consists of a length of #2-0 stranded metal wire attached to a straight needle at one or both ends. I have no financial interest in any of these products.

SUBCISION TECHNIQUE
Before performing wire scalpel subcision under sterile conditions, I outline each of the rhytids of interest with a marking pen, including up to a half-centimeter margin on either side, as the area to be undermined. I always obtain standard pre-operative digital photographs. For anesthesia, I use local amide infiltration, regional nerve blocks, tumescent solution or a combination of these. I pass the wire scalpel needle through the skin into the subcutaneous plane in a configuration that allows me to outline the crease. By guiding the needle in and out of the skin through the same holes, I am able to customize the dissection area. In the end, the wire resides in a loop in the subcutaneous plane with both free ends exiting the skin through a singular puncture site. Then, for the most satisfying portion of the procedure, I pull the free ends back and forth in a sawing motion as the wire completes its dissection. I can actually feel the release of subdermal attachments as they are transected.

When I treat the "crow's feet," which occur perpendicularly to the circular direction of the orbicularis oculus fibers, I limit the area of dissection to 3 cm lateral and 2.5 cm superior the lateral canthal angle. Remaining within this safe zone, I can be sure that there is minimal risk to the temporal branch of the facial nerve. Based on the configuration of the rhytids, I may dissect a single crease at a time or use a triangularly shaped outline that spans multiple creases at once. Due to the dynamic nature of these lines, I will offer perioperative botulinum toxin to my patients. The inhibition of muscular action may prevent reappearance of "crow's feet" as subcutaneous reorganization occurs after treatment.

(left) Pre-operative and (right) six-month post-operative photos of 56-year-old female after "crows feet" subcision with the wire scalpel plus fat transfer. (All photos credit: Brett Kotlus, M.D., M.S., and Robert Dryden, M.D.)

FAT TRANSFER After rhytidolysis with the wire scalpel, I apply firm manual pressure to the dissection site. I then inject autologous harvested fat with a blunt cannula through a puncture site to the pocket or tunnel that I created with the wire scalpel. Injection is halted when sufficient volume enhancement is reached or when the autograft begins to extrude from a puncture site. I aim for overcorrection as I predict volume loss from fat detumescence. When necessary, I will place a single interrupted suture at the most inferiorly located aperture to prevent fat loss. Fat autografts to other facial areas and areas surrounding the subcision sites are sometimes performed simultaneously. The volume enhancement afforded by fat transfer also tends to reduce shadowing in these facial regions by filling out the skin envelope and minimizing the folding that occurs over areas of adherence.
Other fillers can be used instead of fat, such as in the case of an extremely thin patient with scant donor tissue. Injectable hyaluronic acid, calcium hydroxylapatite or collagen are considered in these instances, and may prevent the reformation of attachments in a similar manner as fat injections.

As with any procedure, one should not be surprised by encountering unexpected obstacles. Once, I inadvertently separated the straight needle from the wire during the course of the procedure. In this case, the instrument can be "salvaged" by passing the needleless wire through the lumen of a medium- to large-bore hypodermic needle, then proceeding as usual. I have also learned to pay careful attention to the direction of pull when carrying out the to-and-fro motion of dissection in order to avoid unnecessary enlargement of the terminal puncture site, as occurred in one patient who later underwent successful revision for a dimple that had formed.

THE FUTURE In an age of barbed threads, injectable implants and radiofrequency wands, the "minimally invasive" nature of the wire scalpel places it in a popular category of aesthetic technologies. When performed alone or in conjunction with a facelift, patients often appreciate that you are adding "something extra" to the treatment plan that you have specifically tailored to their needs. There is a growing awareness that the cosmetic concerns associated with aging are multifactorial, thus warranting a multifaceted approach to these concerns. With these considerations in mind, I have found the wire scalpel to be a valuable tool in modern facial rejuvenation.

There are other imaginable uses for this subcision device. It may assist in rapid subcutaneous dissection for the creation of facelift flaps and skin flaps for use in facial reconstruction. I have also heard anecdotes of subcision for horizontal cervical creases and for improvement of irregularities after liposuction. I look forward to seeing how the creative minds in the world of cosmetic surgery will choose to implement the wire scalpel in coming years.

Dr. Kotlus recently completed fellowships in cosmetic surgery and oculofacial plastic and reconstructive surgery. He is a senior contributor for plasticized.com