Filling Up the Valleys

September 2019 | Volume 18 | Issue 9 | Features | 957 | Copyright © September 2019

James M. Swinehart MD

Denver, CO

Abstract
Man has tried and sought to erase wrinkles and scars for millennia. Sadly, however, the most effective and permanent techniques have fallen into disuse and neglect due to lack of training in universities, lack of awareness on the part of both physicians and patients, and heavy mass marketing of injectable fillers. Dermal grafting is a standard, time honored method for permanent correction of deep facial defects. Our goal as dermatologists is to generate the best results for our patients, and also to develop our personal skills and talents to the utmost.

Man has tried and sought to erase wrinkles and scars for millennia. Sadly, however, the most effective and permanent techniques have fallen into disuse and neglect due to lack of training in universities, lack of awareness on the part of both physicians and patients, and heavy mass marketing of injectable fillers. Dermal grafting is a standard, time honored method for permanent correction of deep facial defects. Our goal as dermatologists is to generate the best results for our patients, and also to develop our personal skills and talents to the utmost. 

Before you can sand down the mountains, you must fill up the valleys (depressed scars, facial irregularities, and deep wrinkles). Disadvantages and drawbacks of methods in common use include:

1) Hyaluronic acid fillers: These are temporary, expensive,and the results usually vanish within months.

2) Semi-permanent or permanent manufactured (artificial)fillers: These must be placed too deeply to effectivelyefface scars or wrinkles, may migrate with time, and maycause granulomas.

3) Punch excision or scar excision: The scar or suture marksfrom this procedure can often look worse than the originaldefect. Dehiscence is a potential disaster, especially giventhe fine sutures usually placed on the face.

4) Punch Grafting: The loss of a graft or failure of the graft totake can create a deep obvious hole.

The best methods for filling deep defects include:

1) The "CROSS" technique, in which 70% to 100% trichloroacetic acid (TCA) is applied via toothpick to pitted scars or "large pores" on the nose. This is often quite effective, but care must be takento place the TCA only into the pore and not the surroundingtissue.

2) Punch elevation, often used with tumescent anesthesia, is farmore effective with much less risk of failure of the procedure.With this technique, deep rigid scars between 1mm and 4mmin diameter are scored on the surface with a 2.0mm to 4.0mmpunch, varying in 0.25mm increments. A 5/0 or 6/0 Vicrylsuture is inserted on one side of the scoring, carried throughthe center of the unremoved skin, and out the other side, andtied very loosely so as not to squeeze the punched tissue or toforce it down deeper toward the dermis. The suture is used toelevate the bottom of the scar upwards until it is flush with theadjacent skin. With punch elevation, it is important not to excisethe graft but rather to leave it in place, attempting to elevate itvery slightly with a suture. Each graft is then covered with steristrips with Mastisol followed by the application of MupirocinOintment, Telfa Pad, and Hypafix.

3) Lipoinjection, properly performed, can be quite effective forlarge depressed areas such as tear troughs, areas of lipoatrophy, or cellulite dimples. It is quite technique sensitive and may need to be repeated. The fat is extracted via syringe after insertion oftumescent anesthesia and may be centrifuged. However, thematerial is free, and most patients can spare some extra!

4) Dermal grafting. The advantages are the material isautologous; it is permanent and will not migrate; the materialis free; it is non-allergenic; the operators' dermatologic surgicalskills can be utilized with minimal risk of cysts, and permanentcorrection of deep defects, if care is taken during dissection ofthe grafts.

Surgical Procedures 

During the preoperative visit, consent is obtained, and photos are taken with lab work drawn. Prescriptions are given for pre-op antibiotics, pain medication, and possibly a Medrol DosePak. At this time, consider a test spot both for dermabrasion and chemical peeling. 

Patient Selection: The techniques are effective for deep wrinkles, nasolabial or perioral folds, and broad soft acne scars pliable enough to be elevated via grafting. Rigid or pitted scars or "large pores" are best treated via punch elevation. 

Surgical Procedure: The patient is NPO after midnight and is given oral anesthesia with Diazepam, Meclizine, and Oxycodone or Hydrocodone orally. Because of the use of oral medications, an IV line must be inserted to keep open, with vital sign monitoring via pulse oximetry, and monitoring of blood pressure and heart rate. 

Nerve blocks are then performed of the supraorbital, supratrochlear, lateral zygomaticotemporal, temporal, mental, paranasal, and lateral mandibular nerves. Tumescent anesthesia is then performed with 0.1% Xylocaine with Epinephrine 1 1,000,000 with or without added sodium bicarbonate. 

An excision is then performed behind one or both ears, depending on the amount of material that needs to be removed. A very deep ellipse is performed down to the fascia encompassing deep fat and dermis. After closure of the defect, the epidermis, sebaceous glands, and hair follicles are carefully dissected free under magnification leaving a large ellipse of deep dermis and fibrous fat.

Dissection is then performed under magnification, cutting the dermis/fat tissue into strips or small grafts, depending upon the type of defect to be filled. These are placed into a petri dish filled with iced normal saline.