PMID: 10946951

Issn Print: 0032-1052

Publication Date: 2000/08/01


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A Paradigm Shift for Plastic Surgeons: No Longer Focusing on Excising Skin Excess

Donald A. Hudson

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From the Department of Plastic and Reconstructive Surgery at Groote Schuur Hospital and the University of Cape Town. Received for publication December 30, 1999; revised February 28, 2000. Plastic surgery is undergoing another quiet revolution—not so much in new techniques and technology, although these are occurring, but in concepts and understanding of the effect these newer technologies are having on human tissue. For decades, plastic surgery, especially cosmetic surgery, was concerned essentially with dealing with “excess” tissue. Because the fundamental working tissue of the plastic surgeon was the skin, the focus of the specialty was developing methods of removing excess skin. In a sense, this is illustrated by the traditional subcutaneous rhytidectomy, in which skin undermining was extended further and further. No other method was considered to exist to deal with the excess.
However, the development of newer techniques (e.g., liposuction, endoscopic surgery) and the availability of botulinum toxin have led plastic surgeons to re-examine their methods of dealing with the “excess” and have questioned the dogma of focusing on the skin to achieve results. In fact, newer concepts regarding skin mechanics have evolved as a result of these techniques; they have demonstrated that surface changes may be effected by methods other than simple or sophisticated skin excision. Whereas these concepts have been alluded to in the plastic surgery literature, this editorial attempts to highlight these concepts and to provide a composite picture for reflection and consideration.
Concept 1: Skin Excess Is Treated by Excision (Old Concept) versus Skin Excess Can Be Dealt with by Redraping (New Concept)
Traditionally the focus of the discipline has been the skin. Excess skin is simply excised, albeit in a sophisticated way. For example, in the aging face, excess skin led to folds or jowls—this was dealt with by a subcutaneous rhytidectomy. Similarly, in an approach to reduction mammaplasty, the focus of the Wise keyhole or inverted-T pattern is on the skin; reduction and improved shape are obtained by tightening the skin envelope. The parenchyma is not considered in this approach.
In contrast, newer techniques do not just excise skin excess; rather, tissue is molded (see concept 2) and the skin is redraped over the sculpted parenchyma. In part, this paradigm shift has evolved from liposuction, where it is well established that skin retraction occurs if the tissue beneath it (i.e., the fat) is removed—no skin needs to be excised.
An extension of this concept is demonstrated by skin redraping, which is observed after undermining in a deep-tissue plane. In the endoscopic forehead lift, for example, little or no skin is excised, but rather the skin is redraped to achieve a more youthful appearance. It is important to be aware that there are limitations to the amount of skin that can be redraped; hence, this concept is applicable only where there is not a large amount of skin laxity. In the latter situation, redraping will be an inadequate form of treatment, and of course excision is the better option.
Clinically one is now required not only to carefully assess the quantity of excess skin but also to pay equal attention to its quality. It is this factor that determines the capacity to redrape. Simplistically it is determined by three major factors—age, genes, and anatomic site—and a host of minor factors including skin type, smoking habits, and body weight fluctuations.
Concept 2: Alteration to the Surface Anatomy Can Be Achieved by Molding and Repositioning the Parenchyma 1
It has now recognized that SMAS manipulation (or some method of deep-tissue manipulation) in rhytidectomy produces better and longer-lasting results.
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