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 Surgery 3 and the American Journal of Cosmetic Surgery.4
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.