Aesth. Plast. Surg. 24:1–10, 2000 DOI: 10.1007/s002669910001

© 2000 Springer-Verlag New York Inc.

Simultaneous Facelift and Carbon Dioxide Laser Resurfacing: A Safe Technique? Ian T. Jackson, M.D., Reha Yavuzer, M.D., and Barbara Beal, R.N. Southfield, Michigan, USA

Abstract. A modified facelifting technique with simultaneous carbon dioxide laser resurfacing makes for improved quality of the overlying skin, which enhances the effect of repositioning of the deep facial structures. Concerns have been expressed with regard to complications which may occur when this approach to facelifting is used. This paper presents guidelines which, if observed, allow this procedure to be performed safely in terms of laser skin injury. Over 100 patients have been treated using this combined technique, frequently with the addition of further ancillary procedures. Patient follow-up ranged from 1 to 36 months and showed none of the feared complications to have occurred. This combined approach has improved the results achieved previously by either technique used on its own. In addition, it saves time for both patient and surgeon, and apart from redness, the postoperative recovery period is similar. This technique requires patient education and a postoperative team effort by surgeon, nurse, and aesthetician. Experience has shown that this is a safe procedure which can produce good results with the proper pre- and postoperative management.

underlying structures. In fact, total understanding of this has not yet been achieved. It seems, however, that if these problems are to be dealt with in a logical fashion, it is necessary to reposition the displaced deep structures, in addition to rearranging and tightening the overlying facial skin. We now have a weapon to change the structure of the skin to give a more youthful appearance, both clinically and histologically. It seems logical, if possible, that these procedures should be combined; this is certainly desirable for both patient and surgeon. Although aggressive management of the deep facial structures is commonplace, there has been resistance to employing the CO2 laser simultaneously to rejuvenate the skin [1]. A solution which has been adopted is either to modify the facelift or to decrease the power of the laser but thus reduces its affect on the skin. It should, however, be possible to provide the patient the maximum benefit of these two techniques in a single stage with only moderate adjustment of the facelifting technique.

Key words: Facelift—CO2 laser—Facial rejuvenation

Materials and Methods Preoperative Patient Education

As has been pointed out more frequently recently, facial aging is a complex procedure involving the skin and the

Correspondence to Ian T. Jackson, M.D., Institute for Craniofacial and Reconstructive Surgery, 16001 West Nine Mile Road, Third Floor Fisher Center, Southfield, MI 48075, USA; E-mail: [email protected]

The preoperative visit is probably one of the most important aspects of the entire management. It should consist of two sessions. In addition to explaining the techniques of the standard facelifting procedure, the laser is discussed extensively, namely, its use during the procedure, the dressing technique, the immediate postoperative management, and the prolonged postoperative management. There is also an extensive interview by the nurse who will be treating the patient in the postoperative

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Fig. 1. (A) Skin flap elevated subcutaneously to the midcheek area. (B) The elevation is continued in the sub-SMAS layer to the nasolabial fold. (C) The full-face laser resurfacing using 350, 300, and 250 mJ, respectively, for each pass. The preauricular area and the neck were feathered. (D) After each pass the skin debris is removed with a moist sponge. (E,F) The face is dressed with Flexan, followed by a standard head wrap, followed by Spandage netting to keep the Flexan in place.

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Fig. 2. (A,B) Preoperative appearance of the patient. (C,D) Postoperative appearance at 1 month. (E,F) Postoperative appearance at 1 year.

phase, and there is always a short meeting with the aesthetician. Although the patients are reassured as much as possible, they are presented with the worst-case scenario. Written information is supplied and they are encouraged to ask questions. The requirement for antiherpes medication is emphasized and reassurance is given that this relates to facial herpes; this is an important piece of information.

also decreases the pigment production of the melanocytes. Antiviral therapy consists of valacylovir (Valtrex; Glaxo Wellcome, Inc., NC), 500 mg two times per day, 48 h prior to surgery; this continues for 5 postoperative days. Antibiotics are prescribed; our preference is cephalexin (Keflex; Dista Products Company, IN), 250 mg four times a day for 1 week, starting 1 day prior to surgery.

Preoperative Skin Care and Medications

Procedure

If possible, 6 weeks of skin preparation is recommended prior to surgery, supervised by the nurse. This involves the use of hydroquinone together with the standard products containing ␣-hydroxy or glycolic acids. This treatment increases skin metabolism and cell turnover; it

The operation is carried out under intravenous sedation, initially midzolam (Versed; Roche Laboratories, Nutley, NJ), followed by propofol (Diprivan; Zeneca Pharmaceuticals, Wilmington, DE); this allows an accurately controlled situation. The face is infiltrated with 0.5%

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Fig. 3. (A,B) Preoperative appearance. (C,D) Postoperative appearance at 1 week. (E,F) Postoperative appearance at 1 year.

xylocaine, 1:400,000 epinephrine with Wydase. Prior to facial infiltration, supraorbital, infraorbital, and infraalveolar nerve blocks are carried out, depending on the extent of the surgical procedure. The more effective the facial anesthesia, the less propofol is required; this is very important in outpatient surgery. Frequently upper and lower blepharoplasties are performed, in addition to brow lifting, rhinoplasty, and occasionally augmentation of the facial skeleton, but these are not discussed here. The incisions are relatively standard, transverse into the occipital hairline and preauricular, which may stop at the temporal hairline and have a horizontal extension or may go into the temporal hairline, depending on what is considered necessary for the individual patient. If there is to be a temporal lifting, this is carried out in the standard fashion, with sub- or supraperiosteal dissection over the

lateral orbital rim, the infraorbital rim, the malar area, and the zygomatic arch, as indicated. In the cheek, whether this is being done in continuity or alone, the skin is elevated to the midcheek area (Fig. 1A). An extensive dissection is then carried out on the neck, with wide exposure of the platysma. Following hemostasis, the SMAS is elevated extensively. It is incised up onto the zygoma and then continued medially (Fig. 1B). Inferiorly, this is continued under the platysma, which is extensively elevated; when indicated, a transverse incision is made low in the neck. The malar fat pad is then suspended with No. 4-0 PDS. The SMAS is anchored in the temporal area with No. 4-0 PDS, incised vertically in the preauricular area, and this portion of SMAS is transposed posteriorly and anchored to the occipital periosteum. The inferior SMAS and platysma are fixed posteriorly, again

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Fig. 4. (A,B) A patient requiring total facial rejuvenation. (C,D) Postoperative appearance at 1 year.

with No. 4-0 PDS. With the deep structures now in place, a transverse incision is frequently made under the temporal hairline and the temporal scalp is dissected superiorly and laterally and the excess scalp is removed. The preauricular skin and the postauricular flap are now pulled superiorly and posteriorly; these are sutured with No. 3-0 monofilament Prolene temporarily to the temporal scalp and occipital scalp, respectively. The lower part of the ear becomes covered by the flap and an incision can be made to reposition the scalp accurately in relation to the junction of the earlobe and the face. This having been done, the excess skin overlapping the temporal hairline is removed and sutured; and then the preauricular skin is removed and sutured. When this is done, there is little or no subcutaneous undermining present in the preauricular region. In the postauricular area, the No. 3-0 Prolene suture is now removed, an incision is made

down to the transverse incision on the temporal hairline, and this point is secured with a suture. Excess skin and scalp are removed anterior and posterior to this suture, and the posterior hairline is closed with a subcuticular No. 4-0 Monocryl suture, adjusting it so the hairline is always accurately positioned. As the subcuticular suture is placed, staples provide additional closure; this makes for a surgeon-controlled procedure and thus assures accuracy. At this point a suction drain is usually placed in the neck, postauricular excess skin is removed, and that area is sutured. The procedure is carried out bilaterally. In many cases, an incision is made in the submental area, being careful to avoid the submental crease, since this will result in a slight but uncorrectable witch’s chin deformity. When the skin is dissected, the medial edges of the platysma are plicated in one or two layers,

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Fig. 5. (A,B) Preoperative appearance. (C,D) Postoperative appearance at 10 months. Note the midface elevation and better mandibular definition, in addition to the improved skin texture.

sometimes with a transverse incision when indicated. The face is cleansed and dried and is ready for laser resurfacing.

pattern for the lids and a larger pattern for facial skin (Fig. 1D). Dressing

Laser Resurfacing With all appropriate laser precautions being taken for staff and patient, resurfacing is commenced. The laser is the UltraPulse CO2 Laser 500 Series (Coherent Medical Group, Palo Alto, CA) with the Computer Pattern Generator. Exactly the same setting is used for all areas of the face. The initial pass is at an energy level of 350 mJ at 100 W, followed by a second pass of 300 mJ at 60 W. Occasionally for the face, but not for the eyelids, a third pass of 250 mJ at 50 W per pulse may be used (Fig. 1C). The pulse density is 6 for all passes. The pattern is adjusted according to the areas to be treated, a smaller

This is an important part of the procedure because it must involve adequate dressing of the facelift and the lasered skin. We have solved this using Flexan (Dow Hickam Pharmaceutical, Inc., Sugarland, TX), which has been chosen as a result of experience with other ointments and dressings (Figs. 1E and F). When possible, it is stabilized by applying Mastisol to the nonlasered skin to provide adhesion for the Micropore tape, which keeps the Flexan in place. Our standard facelift dressing of sponges, Kerlix bandage, and Ace bandage is applied, and a Spandex bandage (Spandage; Medi-Tech International Corporation, Brooklyn, NY) is placed to provide further fixation

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Fig. 6. (A,B) Preoperative appearance. (C,D) Postoperative appearance at 3 years.

of the Flexan. Holes are cut for the mouth, nose, and eyes. Postoperative Management In an attempt to decrease swelling, oral steroids are given in the form of methylprednisolone (Medrol Dose Pack; The UpJohn Company, Kalamazoo, MI), together with Arnica, which is a homeopathic medication that seems to be effective for reduction of both swelling and hematoma; this is only a clinical impression and has not been proven scientifically. The dressing and drains are removed the following day, but the Flexan is left in place. The nurse now directs the dressing regimen and it is her decision as to when the Flexan should be removed; this is anywhere from 2 to 3 days. The face is then cleaned with Cetaphil cleanser

(Galderma Laboratories, Inc., Fort Worth, TX) and Aquaphor (Beiersdorf, Inc., Norwalk, CT), a petroleumbased ointment, which is placed on the resurfaced skin. This soothes the skin and prevents pain which can result when laser skin is exposed to the air. The patient is instructed to cleanse the face four times a day with a clean washcloth and Cetaphil, and the Aquaphor is again applied liberally. On the 14th day, 1% hydrocortisone cream (Gentle Soothing Cream SPF 14; Biomedic, Phoenix, AZ) is used together with a camouflage cream to conceal the redness. The aesthetician may be called for advice at this point. After 2 weeks, sunscreen is advised and should be continued for 6 months. It is at this point that the aesthetician takes charge of the patient to institute a skin care regimen and to provide advice on makeup.

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Fig. 7. (A,B) Preoperative appearance. (C,D) Postoperative appearance at 2 years.

Results Over a period of 5 years, more than 100 patients have been treated with simultaneous facelifting and carbon dioxide laser resurfacing. There was obviously some variation in techniques of pre-, intra-, and postoperative management. However, the personnel remained constant: the same surgeon, the same nurse, and the same aesthetician. The follow-up ranged from 1 to 36 months (Figs. 2–9). The expected transient swelling, redness, and numbness in the preauricular area and sometimes in the ears were frequent, but apart from one patient who had a small superficial postauricular slough unrelated to the resurfaced area, there was excellent skin flap survival. The patients had a longer postoperative recovery period, with occasional small hematomas that resolved spontane-

ously. One patient had temporary weakness of the frontal branch of the facial nerve, and another of the marginal mandibular branch. These resolved at 3 and 4 weeks, respectively. Discussion In our practice, the move toward full-face laser resurfacing with simultaneous facelifting was a gradual one. There was an initial reluctance because of the occasional pessimistic presentation at a national meeting, particularly showing gross swelling that took an unacceptably long time to settle. Eventually, after having looked at patients on the operating table who had had a facelift and laser resurfacing around the eyes and around the mouth, it seemed as though there was only a very small area

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Fig. 8. (A,B) Preoperative appearance. (C,D) Postoperative appearance at 9 months.

of the face left for laser treatment. In addition to this, the limited SMAS management of Baker [13] seemed to give good results. Therefore, our initial attempts at resurfacing were a combination of his limited elevation of SMAS together with skin tightening. It then progressed rather rapidly to a deep plane procedure medially without lifting the skin in that area since it seemed that this would cause minimal disturbance of the facial skin blood supply. In addition, by the time the preauricular skin is removed there is virtually no undermined area remaining. Again, caution was used initially, leaving an unlasered preauricular strip about 2 to 2.5 cm in width, however, with time this has also been treated with the laser. This more aggressive approach has not caused any increased problems related to the resurfacing procedure. The next concern was how the patient would accept

the postoperative problems of laser resurfacing. We have found that along with careful preoperative preparation and providing the patient with the security of a team approach, this has not been as much of a problem as we had anticipated. There is no doubt that the postoperative period is a difficult one, but with a dedicated and enthusiastic staff, this can be managed satisfactorily. The patients greatly appreciate having the total procedure in a single operation. They are then involved as soon as possible in a skin care program. This approach, as long as it is safe—and we have proved this to be the case—is logical. The deep tissues are repositioned correctly, and the facial skin is tightened and then rejuvenated by the laser resurfacing procedure. It allows the carefully selected patient to have the ideal treatment in the shortest period of time.

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Fig. 9. (A,B) Preoperative to combined facelift and laser resurfacing. (C,D) Postoperative appearance at 1 year.

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