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Keywords:

  • rhytides;
  • CO2 laser;
  • aging skin;
  • laser treatment;
  • erythema

Summary

  1. Top of page
  2. Summary
  3. Background
  4. Patients and methods
  5. Results
  6. Comment
  7. Perioral Laser
  8. Periorbital and Full Face Laser
  9. Acknowledgments
  10. References

Background

There is currently a high demand for a concurrent system of skin rejuvenation accompanying rhtidectomy. CO2 laser treatment prior to surgical ablative reduction has produced promising results, but the adjunct service of laser treatment at the time of surgery has never been reviewed.

Objectives

Determine the effects of concurrent treatment of rhytides and evidence of aging in the skin with surgical correction followed by fractional CO2 laser application.

Methods

During study time from September 2008 to February 2009 treat patients who have underwent short flap rhytidectomy to the Lutronic eCO2 fractional laser using the patented “Controlled Chaos Technology.”

Results

Complications included 2.3% herpes simplex outbreak, 4% persistent erythema past 2 weeks, four cases of prolonged edema to 5 days, one case of impetigo, and no evidence of dyspigmentation. Patient satisfaction data demonstrated no refunds at 12 months.

Conclusions

Combination fractional laser resurfacing with short flap, high-Superficial muscular aponeurotic system rhytidectomy is a safe procedure with excellent patient satisfaction and clinical outcomes.


Background

  1. Top of page
  2. Summary
  3. Background
  4. Patients and methods
  5. Results
  6. Comment
  7. Perioral Laser
  8. Periorbital and Full Face Laser
  9. Acknowledgments
  10. References

The possibility of rejuvenation of the aging face creates an ever-increasing demand for facial cosmetic surgery as well as nonsurgical treatment applications. The trend toward synergistic activity in esthetic facial rejuvenation has typically been directed at the correction of dermal aging and comprised concurrent application of dermal fillers, Botulinum toxins (Botox®, Allergan, Irvine, CA, USA), and laser, light, or radiofrequency technologies. Skin resurfacing with the use of differing laser technologies is known to be a useful ancillary procedure for the enhancement of esthetic results in facial esthetic surgery. Rhytidectomy, however, is known to produce the most dramatic and lasting improvement, and it continues in evolution toward reducing the extent of dissection and shortening the incision length. In our center, this has resulted in a face-lift standardized to shorter periauricular incisions, skin flap width of 4–6 cm, and suspension of a laterally undermined Superficial muscular aponeurotic system (SMAS) layer or “Short Flap Rhytidectomy.” This procedure can often be combined with platysmalplasty, to improve neck tightening as well as liposuction to remove fat pockets in select patients.

The most common application of laser technology in ablative full-face skin resurfacing is for the correction of fine wrinkles. This esthetic approach is most frequently performed as an isolated procedure and occasionally, as an alternative to surgical correction of the signs of facial aging. The literature is replete with descriptions of the beneficial effects of carbon dioxide (CO2) and ErYAG lasers in full-face ablative resurfacing.[1-10] The literature discussion is primarily weighed toward the benefit and comparison of various laser therapies and systems. Conversely, there are studies that have combined rhytidectomy concurrently with fully ablative laser resurfacing,[11-15] but few studies have looked at the integration with fractional devices. Pitanguy has previously described the use of traditional ablative CO2 laser in conjunction with his ‘round facelift’ technique.[16] In his experience, there is limited associated morbidity with full laser ablation, and the final results were excellent. In 2007, Buis, et al.[17] described their experience with adjuvant treatment completed prior to face-lift. In their practice, synergistic treatment construct, four treatments at 1–2 week intervals are provided prior to face-lift surgery. They noted that fractional treatment is generally well-tolerated while describing the common occurrence of facial edema in these patients lasting 2–4 days. They agreed that fractional resurfacing is safe and effective and might be useful as adjunctive therapy with rhytidectomy. In our practice, we observed that many of our patients with advanced actinic damage achieved rejuvenating facial volume redistribution with the short flap rhytidectomy and a strikingly youthful appearance, but retained extensive perioral wrinkling, periorbital wrinkling, and photo damaged skin that contributed to a diminished overall facial rejuvenation. Our surgical suites are shaped in an ‘office setting’ where the patient has no general anesthesia, is given local anesthetic block and mild sedation only, and remains awake throughout the procedure. Ancillary procedures can be more challenging in this surgical setting. In pursuing esthetic rejuvenation of the aging face, there exists an artificial separation of noninvasive treatments, such as laser, light, or radiofrequency applications and esthetic surgical correction. Thorough and uniform rejuvenation of facial aging can be accomplished through the use of both approaches, although the challenge in many instances is how to integrate these nonoperative technologies into surgical facial rejuvenation.

Fractional ablative resurfacing holds the promise of aiding in the rejuvenation of the aging face while presenting fewer risks and less downtime than traditional ablative resurfacing.[18, 19] We hypothesized that the Lutronic eCO2® could be used concurrently at the time of rhytidectomy surgery, without increasing morbidity or impacting operative timeframe and at higher thermoablative settings to achieve results significant enough that additional laser treatment would be limited or unnecessary. We sought to provide a method for thorough rejuvenation at the time of surgery that would have minimal associated risk, minimal posttreatment care requirement, and that would be minimally disruptive to the surgical process. We also investigated the role of phasing laser treatments to achieve greater tightening, especially in the context of minimizing laser exposure to recently elevated skin flaps. We describe our synergistic use of fractional CO2 laser in resurfacing patients undergoing short flap rhytidectomy.

Patients and methods

  1. Top of page
  2. Summary
  3. Background
  4. Patients and methods
  5. Results
  6. Comment
  7. Perioral Laser
  8. Periorbital and Full Face Laser
  9. Acknowledgments
  10. References

One hundred and twenty-six patients who underwent short flap rhytidectomy are also treated with the Lutronic eCO2 (Seoul, South Korea) fractional laser using the patented ‘Controlled Chaos Technology’. The study period was from September 2008 to February 2009. Based on intake form information and photographs, Fitzpatrick skin types are documented. The study solely comprised patients with Fitzpatrick skin types I-IV. All patients undergoing rhytidectomy had some area of their face lasered, with patients having a history of photosensitivity or dyspigmentation with previous skin treatments excluded. Ten patients noted previous laser treatments on their intake forms.

Rhytidectomy

All procedures are performed by a single operator to maintain standardization. Standardized preoperative photographs are taken from each patient as well as postoperative photographs at 7–10 days and 6 weeks. Surgical markings are placed and maintained to help delineate skin flap elevated areas. These markings are revised if flap lengths exceeded the 4–6 cm usual boundary from the pre and postauricular incision markings. Each patient received local infiltration of the surgical area with 10 cc of 1% Marcaine with epinephrine (1:100 000) and 20 cc of .5% Lidocaine with epinephrine (1:100 000) into each facial side. Local infiltration extends out to the previously placed surgical markings. Patients are then prepped and draped using Cetaphil (Galderma, Alby-sur-Chéran, France) surgical prep. A periauricular facelift incision was made, extending from the temple tuft of hair passing along the pre and postauricular ear and extending just into the mastoid hairline. Skin flaps are then elevated over the cheek and neck maintaining flap lengths of 4–6 cm. The SMAS is identified and a vertical preauricular SMASectomy of the SMAS and upper platysma of 1.5 cm width was performed. The SMAS was undermined sharply to create a short SMAS flap. Hemostasis is achieved throughout with bipolar cautery. The posterosuperior flap corner is then rotated superiorly and imbricated to the temporal fascia layer using an absorbable 2-0-Ticron suture, superiorly securing the SMAS flap. A lateral SMAS and platysmal flap is then raised and elevated and secured to the mastoid fascia. Complete imbrication of the superior aspect of the flap is performed using absorbable 3-0-Vicryl suture. A second 2-0-Ticron is passed through the inferoposterior flap and imbricated to the fascia at vector along the angle of the mandible. Additional 3-0-Vicryl sutures are used to complete imbrication and closure of the flap along its entire length.

The skin flaps are then repositioned following equally precise vectors. The first fixation point is along a vector that connect the tragus to Darwin's' tubercle. This is secured with a single 4-0 nylon suture. The postauricular skin is secured to the retro auricular incision limb beginning point after accommodating the skin so that there is no tension or bunching whatsoever. Excess skin is then removed following the incision line allowing skin approximation without tension along the length of the facial flap. Closure is accomplished using 5-0-Vicryl at periodic subcutaneous points and a running 5-0-prolene anchored using periodic interrupted 5-0-Prolene suture. No drains are placed in female patients, and men receive a penrose drain for 23 h (Lift Photo Series Figs 1-5).

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Figure 1. Surgical markings and administration of local anesthesia.

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Figure 2. Identification and transposition of SMAS.

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Figure 3. Imbrication of SMAS flap to temporal fascia.

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Figure 4. Repositioned skin flaps.

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Figure 5. Eco2 Laser in use.

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Laser technique

After completion of one side of the lift, pretreatment for the laser consisted of topical anesthetic (Lidocaine 7%/Tetracaine 7%) applied during the rhytidectomy procedure approximately 1 h prior to laser application. The cream is applied to a region medial to the dissection, with sterile gauze covering this area during the second procedure side. Care is taken to minimize disruption of the surgical fields, and no cream is applied below the jaw line. We also monitored lidocaine dose amounts and subtracted injections in lighter weight patients to allow for the cream dose. When subtracted, about 5 mg of lidocaine were reduced from each side to minimize cream risk. We also performed select V1-V3 nerve blocks in 10 percent of patients who felt the cream was not adequate for pain control. These injections were carried out using 0.3 cc 2% lidocaine with 1:100 000 epinephrine with a 30G needle right on the V1-V3 foramens where the patient had pain.

All patients receiving eye treatments had tetracaine eye drops placed in each eye and a proper laser protective corneal shields placed. The shields undersurface is coated with lacrilube. For patients not having eye laser, external shields are placed on the eyes.

Fractional ablative photothermolysis treatment is carried out using the Lutronic Mosaic eCO2 laser of 10 600 nm with incorporated “Controlled Chaos Technology.” The potency of the laser application is calibrated according to the thickness of perioral, cheek, or periorbital rhytids, amount of skin damage and skin type. The fractional laser produces individual ablation columns rather than complete surface ablation. Ablation columns are produced in a pattern that is randomly generated by ‘Controlled Chaos Technology’ internal computer programming. These columns may be arrayed from 50 to 1000 per square centimeter based on the selected density and number of treatment passes. The eCO2 treatment parameters are standardized in our study at a Total Density of 100 spots/cm2 and Pulse Energy of 60–110 mJ (Table 1). Individual cosmetic units are resurfaced with energy delivered at one or two passes dependent on cosmetic unit, degree of photodamage, and Fitzpatrick skin score. Patients with deep rythids or extensive photo damage are treated at the more extensive settings. Pulse energy is lower on the eyelids and in areas of fine wrinkling only. An 8-mm to 12-mm scan square pattern is used at 30 W. Care is taken, however, to do very superficial lasering of the periphery, especially over the small amount of undermined skin that remained. This can be carried out on this platform using the “dynamic” mode, which allows for a more unstructured laser pattern.

Table 1. Average treatment parameters per facial esthetic unit
Treatment unitDensity MAC/cm2 Spot size 120 uPulse energy (mJ)MAC width (μm)MAC depth (μm)Pattern (mm2)
Perioral, Lip & Chin10080–110340–3701100–170012
Cheeks10080–100340–3601200–150012
Eyelid10060–80325–340900–12008
Forehead10060–80325–340900–120012

After the treatment, the skin is cleansed with saline gauze and petroleum jelly applied frequent application of petroleum jelly and cold compresses are the prescribed treatment in the first 48 h. The patient is seen at that time and the dressing is removed. Fluid accumulation is rare and may be drained with percutaneous aspiration. The skin surface is wiped gently with gauze and sterile water to remove dermal debris. Petroleum jelly is reapplied and this is continued for 7 days postoperatively. During the first 48 h, patients are encouraged to use ice, clean the skin with water, and apply the petrolatum jelly. Antibiotics are prescribed for bacterial prophylaxis in all patients who received a concurrent facelift and continued for 7 days. Viral prophylaxis (Herpes Simplex) is also prescribed in all patients using Acyclovir (800 mg per day), initiated 2 days before surgery and continued through the fifth posttreatment day.

All patients were brought back for a potential second laser treatment within 4 weeks of the initial procedure. The patients who received a full face laser were offered a second phase which would include the undermined flaps. Patients were allowed to choose if they wanted more phases based on their clinical outcome. The only exclusion criteria to phasing were healing from the primary phase with no evidence of erythema or pigmentary change. Subsequent phases were performed with acyclovir prophylaxis, topical cream application (7% lidocaine/7% tetracaine) and select nerve blocks of V1-V3. Patient charts were reviewed for refund and dissatisfaction data until 6 months after the final treatment phase. Photographs were obtained at 6 weeks post final laser phase.

Results

  1. Top of page
  2. Summary
  3. Background
  4. Patients and methods
  5. Results
  6. Comment
  7. Perioral Laser
  8. Periorbital and Full Face Laser
  9. Acknowledgments
  10. References

One hundred and nineteen Women and seven men with a mean age of 61.84 (Range 47–78, standard deviation 4.9) had concurrent face-lifting with fractional CO2 laser resurfacing using the Eco2 laser. Fitzpatrick 1–4 skin tones were only treated, with nine patients being Fitzpatrick 1, 65 Fitzpatrick 2, 42 Fitzpatrick 3, and 10 Fitzpatrick 4. Twelve separate laser treatment combinations were logged, with 30 patients receiving a full face laser, 75 patients, including a perioral treatment and 47 electing to have their eyes done. Fourteen patients outside the full face group had their foreheads treated, with nine of these patients getting their eyes and forehead treated at the same time.

Table 2 summarizes the phase data. We elected to let patients choose if they desired more phases, with no complication from the primary treatment being the main criteria. The average phase time is presented as well. Looking at phases and Fitzpatrick score, Fitzpatric 1 patients averaged 2.11 phases, Fitzpatrick 2 patients 1.58 phases, Fitzpatrick 3 patients 1.71 phases, and Fitzpatrick 4 patients 1.1 phases. An analysis (Table 3) was next performed looking at the total amount of energy delivered per Fitzpatrick score. For each Fitzpatrick group1–4, the average energy for each facial area lasered was multiplied by the average number of passes over that skin area, and then multiplied by the average number of phases for that subgroup.

Table 2. Summary of data summarizing patient data on phases
PhasesPatient numbersMedian time between phasesAverage time between phases (STD)Average fitz score
1 Phase68  2.55
2 Phases39812.7 (5.7)2.23
3 Phases175.645.6 (3.5)2.29
4 Phases2552.5
Table 3. Phase and total energy data per fitzpatrick score
Fitzpatrick scorePatient numbersAverage phasesTotal energy scores
  1. Total Energy = Average Phase × [(Eye Energy Average)(Average Number of Passes) + (Cheek Energy Average)(Average Number of Passes) + (Mouth Energy Average)(Average Number of Passes) + (Forehead Energy Average)(Average Number of Passes)].

Fitzpatrick 192.11989.24
Fitzpatrick 2651.58759.23
Fitzpatrick 3421.71834.46
Fitzpatrick 4101.10451.04

We experienced four cases (3%) of postoperative edema of the skin who underwent laser treatment. All cases resolved within 4–5 days and required no intervention other than the continued elevation and ice application. Regardless of preventive therapy with Acyclovir, three patients (2.3%) experienced Labial Herpes Simplex breakout and these are treated with a 7-day extension of Acyclovir 800 mg/q/day. There was complete resolution in these cases by the 10th postoperative day. Persistent erythema lasting beyond 2 weeks was encountered in five patients (4%), with resolution in all cases by the 4th week. Two of these patients went on to get subsequent phases. One patient developed forehead impetigo and was successfully treated with oral antibiotics with no subsequent scarring. No patient showed clinically obvious dyspigmentation by 6 weeks postlast laser phase photo evaluation.

Finally, patient dissatisfaction and refund data were reviewed for this cohort. Twelve months post final laser phase revealed no cases of refund requests in this study group.

Comment

  1. Top of page
  2. Summary
  3. Background
  4. Patients and methods
  5. Results
  6. Comment
  7. Perioral Laser
  8. Periorbital and Full Face Laser
  9. Acknowledgments
  10. References

Outpatient short flap rhytidectomy produces a significantly youthful appearance in many patients. There is, however, horizontal reorientation of facial rhytids that are not removed, as well as softening of nasolabial folds without improvement of perioral wrinkling. Perioral and periorbital wrinkling may become more apparent to the patient who has undergone rhytidectomy. Although laser resurfacing is accepted as safe for deep-plane face-lifts, there are consistent reports of preauricular skin loss with full-face laser ablation performed using standard face-lift techniques. Variables affecting outcomes include rhytidectomy technique, laser type and settings, postoperative care, and adverse events. We determined to evaluate these differences and define a protocol for care and carbon dioxide laser application for resurfacing when performed in combination with limited incision rhytidectomy. Ablative fractional thermolysis provides results that are as effective as traditional ablative approaches while avoiding the significant downtime and risks. The procedure results in minimal patient morbidity, no interference with lifestyle, and a low risk of complications, while providing a satisfying degree of rhytid reduction. The objective is to selectively confine thermal injury to the papillary and upper reticular dermis without any epidermal damage, leading to fibroblast activation and the synthesis of extracellular matrix material and new collagen.

Jackson et al.[20] reported techniques for full-face laser skin ablation combined with rhytidectomy and concluded that this saves time for both patient and surgeon. Apart from redness of the laser treated skin surface, the postoperative recovery period is similar. The most frequent complication of eCO2 laser treatment is persistent erythema. Fractional Laser resurfacing using the Lutronic eCO2 laser is a safe and efficient ancillary process that enhances surgical rejuvenation of the aging face. This allows the surgeon to provide skin rejuvenation to the perioral, facial, and periorbital rhytides that are not treated by rhytidectomy. The procedure can be performed in the same sitting as surgical correction and adds negligible risk of increased healing complications. Performed in conjunction with surgery, eCO2 treatment is well-tolerated and produces a more comprehensive facial rejuvenation than rhytidectomy alone. Understanding the relationship between the degree of dermal thermal injury and synthesis of new extracellular collagen matrix is fundamental to predicting the clinical efficacy and limitations of nonablative photorejuvenation. The esthetic units of the face must be considered and uniformly treated to obtain the more natural result.

With this particular device, we used a small spot sized handpiece (120 micron) and set the density uniformly at 100 spots/cm². This accounted for about 7–8% skin coverage per pass. We limited the number of passes to not more than two per treatment, and elected to offer patients phased treatments based on their own desired outcomes. Over 50% of patients elected to stay with only one phase, and there was clearly a trend to more phases in Fitzpatrick 1 patients compared to Fitzpatrick 4. Looking at the total energy data, although Fitzpatrick 4 patients received <50% of the total energy compared to the Fitzpatrick 1 group, nine out of 10 of these patients stayed with one phase and were satisfied with those results. The ability of fractional lasers to successfully treat darker skinned patients is a big step forward and can greatly augment facelift results. For lighter skinned individuals, there is great flexibility in increasing energy to achieve improved outcomes.

As for complications, we felt the routine use of acyclovir greatly reduced herpes simplex outbreaks. While three patients got this outbreak, it was generally limited and isolated to a single phase of treatment, of which we completed 205 phases. Persistent edema can be a consistent complication in patients getting lifts with lasers, but with this particular platform, we felt the incidence was low and resolved without intervention. Persistent erythema lasting beyond 2 weeks was encountered in five patients (4%), with resolution in all cases by the 4th week. No patient showed clinically obvious dyspigmentation. We also had no issues of flap necrosis from the transition zone blending using the dynamic mode. Of patients who had had some form of laser therapy prior, none had complications. The single case of impetigo on the forehead we feel came from poor postlaser care, but it resolved with no scarring.

The Lutronic eCO2 fractional laser has the flexibility to be used easily in the operative suite in either pulsed delivery mode or with a continuous delivery mode. This series demonstrates the safety of combining laser resurfacing with the SMAS technique face-lift with regard to adverse effects of prolonged edema or erythema, skin loss or dyspigmentation, and preauricular skin loss. Experience has shown that this is a safe procedure that will produce good results with the proper pre- and postoperative management. The technique requires patient education and a postoperative team effort by surgeon, nurse, and aesthetician. This procedure is demonstrated to be safe for use at the time of surgery without increasing complications or downtime and significantly improves the overall result of rhytidectomy.

Perioral Laser

  1. Top of page
  2. Summary
  3. Background
  4. Patients and methods
  5. Results
  6. Comment
  7. Perioral Laser
  8. Periorbital and Full Face Laser
  9. Acknowledgments
  10. References
Thumbnail image of

Patient A- Perioral: 61-year-old female patient treated with eCO2 laser combined with short flap face-lift. Fitzpatrick score: I/II. Tip size: 120 microns, energy level: 90mJ with 2 passes density 100 spots/cm2. 1st treatment results after 3 months

Periorbital and Full Face Laser

  1. Top of page
  2. Summary
  3. Background
  4. Patients and methods
  5. Results
  6. Comment
  7. Perioral Laser
  8. Periorbital and Full Face Laser
  9. Acknowledgments
  10. References
Thumbnail image of

Patient B-. Periorbital: 70-year-old female treated with eCO2 laser combined with short flap face-lift. Fitzpatrick I. Tip size: 120, energy level: 60, density: 100 spots/cm2 with 2 passes Perioral; Tip size: 120,80 mJ, 100 spots/cm2 with two passes. R/L Cheek; Tip size: 120, 80mJ, 100 spots/cm2 with two passes each. Nose/forehead; Tip size: 120, 80 mJ, 100 spots/cm2 with one pass

Acknowledgments

  1. Top of page
  2. Summary
  3. Background
  4. Patients and methods
  5. Results
  6. Comment
  7. Perioral Laser
  8. Periorbital and Full Face Laser
  9. Acknowledgments
  10. References

Bryan Wayne MD, Linda Schneider, Lifestyle Lift Corporation, Lutronic USA.

References

  1. Top of page
  2. Summary
  3. Background
  4. Patients and methods
  5. Results
  6. Comment
  7. Perioral Laser
  8. Periorbital and Full Face Laser
  9. Acknowledgments
  10. References