Chir. plastica (Berl.) 2,239--246 (1974) �9 by Springer-Verlag 1974 Surgical Method ibr Removing Wrinkles* E d u a r d Schmid Department of Maxillofacial, Plastic and Reconstructive Surgery, Marienhospital Stuttgart (Chief Surgeons: Prof. Dr. Dr. Eduard Schmid, Dr. Dr. Werner Widmaier, Dr. Dr. Heinz Reichert) Received April 17, 1974 Summary. This is a report on a method for removing wrinkles, under devel- opment since 1957. The method involves direct subcutaneous undercutting of the wrinkled skin areas with a long, slender, stilette-like stable scalpel. To avoid hematoma formation, a pressure dressing is applied for 2 to 3 days, and then the skin is abraded. During healing, the skin becomes smooth. We explain this amazing change in appearance and structure of the skin to our patients with the illustration of "drum- skin". After removing the epidermis and mobilizing the dermis, there is probably new growth of cohesive collagenous fibers which, possibly supported by an elastic- fibre effect during their muturation time, i.e. including the period of epidermal regeneration, produces the wrinkle-free smoothness of the skin. The follow-up, varying from 6 weeks to 7 years, showed very satisfying results in all of our cases. Except for slight hematoma formation, with subsequent sub- cutaneous induration for several months, no postoperative or late complication oc- curred. In a few cases wrinkles reappeared only after many years, but always much fewer than before treatment. If stretching of the facial skin is indicated, we combine this with undercutting. Acne and pockmarked skin and similar scar areas can be treated successfully in the same way. The patient should be warned of the depigmentation of the regenerated skin zones. This may take place after any abrasion treatment and also after "chemical skin peeling". Fo r some years now the chemical t echnique of " s k i n pee l ing" [1, 2, 3] has been used to remove small skin folds which cannot be corrected by stretching. The technique requires skill, and changing the dressings is ve ry painful. I n 1957, for the first t ime in eases of this sort we used a t echnique which produced equal ly good, if not bet ter , results. We observed tha t wrinkled skin becomes complete ly smooth if i t is undercut , and at the same t ime abraded. I f the skin is only abraded, there are cer ta inly fewer ridges or papillae, but the wrinkles reappear . The wrinkles cannot disappear because the skin remains fused to the * Vortrag gehalten in Berlin, 1971. 240 E. Schmid Fig. 1 a--d. Sets of instruments and modes of applications subs t ra tum. However , if the skin is loosened from the subs t r a tum and abraded , we have found t h a t dur ing the healing process the surface contours become smooth and all wrinkles d isappear . We believe t h a t the exp lana t ion for this is t ha t the epidermis is r emoved and the dermis is undercut , which m a y cause a cont rac t ion in i ts in situ elast ic fibers. This is f ixed by newly formed collagen in the subsequent heal ing phase while, a t the same t ime, a new surface contour is p roduced to m a t c h the new s i tuat ion. I f the elast ic f ibers in an area of skin have been des t royed, the newly forming bundles of collagenous fibers might cont rac t during the heal ing phase and produce the same effect, wi thout elast ic fibers. Wrinkle- f ree re-epi the l ia l iza t ion of the surface can now t ake place over the dermis s tabi l ized by new collagen. Surgical Method for Removing Wrinkles 241 Fig, 2 a and b. 54-year-old woman (a) before, (b) 4 months after face-lifting and undermining of the skin on the lips, the chin, the bridge of the nose, the forehead, plus dermabrasion I n the first pa t i en t , a woman (Fig. 2a , b), whom we t r e a t e d in 1957 for a wr inkled uppe r l ip following face lifting, there was sl ight post- opera t ive h e m a t o m a fo rma t ion under the skin wi th subsequent deep f ibrous scarring. The s l ight ly disf iguring and u n t o w a r d subcu taneous swellings made the woman dissat isf ied and depressed a t first. This went on for some months unt i l the indura t ions had d i sappea red and the outcome was successful. To avo id the r isk of hema toma , we dec ided to use a two-phase t echn ique in the future. Operative Technique Dur ing a face-l if t procedure , or as a sepa ra te opera t ion , the wr ink led skin a t nose, g label la and o ther regions is undercu t be tween cor ium and subcutaneous fat . A compression dressing for 2 or 3 days is appl ied . A plas t ic p la te f ixed over the t ee th allows one to secure control lable , even pressure. On the second or in most cases on the th i rd day , the skin is a b r a d e d to the s t r a t u m spinosum unt i l the surface is b leeding even ly 242 E. Schmid Fig. 3 a--d. 70-year-old woman (a) and (c) before, (b) and (d) 2 years after operation. The same procedure as in case 2 was performed and a smooth surface is achieved. The wound surface is covered with Bepan then Gel. Healing is painless. The scab tha t forms is shed within 10 days. The demarcat ion lines between the zones to be t rea ted should be located in the anatomical border areas and discussed with the patients . For abrasion we use ca rborundum stones and d iamond rollers. The pa t i en t should be sedated. Except for the border areas, abrasion of the undercu t skin zones can be done completely painlessly. Surgical Method for Removing Wrinkles 243 c d Fig. 3 c and d Special Technical Considerations At first we were concerned that skin necrosis might occur. However, this worry appears to be unfounded if care is taken to remove any accumulated blood before placing the pressure dressing in position. The philtrum ridges should be left and undercutting of the philtrum groove retained. The degree of skin compression should be roughly the same as that used for full-thickness skin grafting. Despite all precautions, slight swelling and induration might occur, prolonging the convalescent period. The danger of subsequent bleeding is slight if the parameters are observed and if the scalpel cut is not deep but is always made parallel to the skin. The scalpel blade and the shaft should be long and slender enough to penetrate the skin like an injection needle without leaving a visible scar. On the other hand, the cutting edge and handle must be made so that the instrument cannot break or bend (Fig. 1 a-d). 18 Chir. plast ica (Berl.), Vol. 2 244 E. Schmid Fig. 4 a--d. 48-year old woman (a) and (b) 3 months after a limited undermining of the upper lip. Only the lower third was operated on; (c) and (d) 3 months after consequent complete undermining of the upper lip Indications Al though s t re tching the facial skin can of ten have ve ry beneficial effects, the d rawback is t h a t the skin of ten appears l imp and wrinkled a r o u n d the mou th and occasional ly in o ther zones of the face as well. Therefore , in s t re tching the facial skin surgically, grea t care has to be t a k e n to avo id produc t ing an unna tu ra l cont ras t in such regions; wi thou t th is p recau t ion the pa t ien t s mind is not a t rest. This p rob lem has now been overcome. A technique of th is sort can now restore a r e l a t ive ly a t t r a c t i ve and youthfu l appearance to the skin. Similar resul ts can usual ly be ach ieved in skin d a m a g e d b y act inic rays or d isf igured b y acne or smallpox. The abras ion reduces skin pigmen- ta t ion . B a k e r [2] also repor t s a " r e d u c t i o n in the melanosis of the ep ide rmis " in his paper " chemica l face peel ing and r h y t i d e c t o m y " of 1962. H e also Surgical Method for Removing Wrinkles 245 states: " the alteration in pigmentation and lightening of the treated skin zones which are liable to occur both with "chemical peeling" and abrading the skin (dermabrasion) should be pointed out to the patient ." Many patients with a highly pigmented skin are not concerned about lightening of the lip skin, and the abrasion can thus be confined to the mouth area. In patients with a lighter skin the difference is only slight and hence is also of little account. Results We have treated approximately 25 patients in the manner described above. The follow up, varying from 6 weeks to 7 years, showed very satisfying results in all of our cases. Except for slight hematoma formation, with subsequent subcutaneous induration for several months, no postoperative or late complication occurred. In a few cases wrinkles reappeared only after many years- -but always much fewer than before treatment (Fig. 3 and 4). References 1. Litton, C.: Chemical face lifting. Plast. reconstr. Surg. 29, 371 (1962) 2. Baker, T. J.: Chemical face peeling and rhytidectomy. Plast. reconstr. Surg. 29, 199 (1962) 3. Baker, T. J., Gordan, H. L., Seckinger, D. S.: A second look at chemical face peeling. Plast. reconstr. Surg. 87, 487 (1966) Prof. Dr. Dr. E. Schmid Fachabteilung fiir Gesichtsehirurgie, Plastische und Wiederherstellungsehirurgie Marienhospital Stuttgart-S D-7000 Stuttgart-S BSheimstr. 37 Federal Republic of Germany 18"