Jason N. Pozner

Postoperative care following carbon dioxide laser resurfacing : Avoiding pitfalls

&NA; Facial skin resurfacing using the carbon dioxide laser has become an increasingly popular procedure. Improvements in carbon dioxide laser technology have made the procedure simpler and more reliable. However, difficulties and problems in the postoperative period can lead to patient morbidity and physician anxiety. The authors have performed laser resurfacing in almost 2,000 patients in the last 4 years. Problems encountered and methods formulated to minimize postoperative complications are discussed.

Subperiosteal minimally invasive laser endoscopic rhytidectomy: the SMILE facelift.

Current concepts of total facial rejuvenation involve a comprehensive integrated approach to achieve a balanced youthful appearance. Recently introduced endoscopic-assisted techniques allow us to rejuvenate the face through small, remote incisions. Previously, we have considered only young patients with good skin turgor as candidates for minimally invasive procedures, but the advent of the resurfacing laser has allowed us to expand our indications for single stage minimal access rejuvenation. Full facial immediate laser resurfacing at the time of standard rhytidectomy has been avoided due to risk of flap necrosis. Subperiosteal minimally invasive endoscopic assisted techniques do not substantially interfere with facial blood supply. We can now perform endoscopic-assisted full facelifts combined with immediate laser resurfacing to reposition the tissues in a more youthful position and then tighten the skin envelope. Extended endoscopic-assisted subperiosteal forehead lift is performed through three to five scalp incisions; subperiosteal midface lift is performed through a crows foot or intraoral incision. Cervicoplasty, if needed, is performed through a small submental incision. Full face laser resurfacing is done using a Coherent Ultrapulse laser. To date we have performed eleven subperiosteal minimally invasive laser endoscopic (SMILE) rhytidectomies. There has been no evidence of flap necrosis with this technique. Postoperative recovery has been no different from patients treated only by full face resurfacing, except perhaps for the slight increase in early facial edema. We believe the SMILE facelift is a viable alternative to standard techniques. The limitations of this procedure still need to be elucidated.

Postoperative care following CO2 laser resurfacing: avoiding pitfalls.

Facial skin resurfacing using the carbon dioxide laser has become an increasingly popular procedure. Improvements in carbon dioxide laser technology have made the procedure simpler and more reliable. However, difficulties in the postoperative period can lead to patient morbidity and physician anxiety. Common problems such as prolonged erythema, hyperpigmentation, acne, milia, dermatitis, and infection can be controlled or avoided with proper postoperative care. Less common sequela such as hypertrophic scarring and prolonged healing are often a results of errors committed in the postoperative period. The authors have performed laser resurfacing in almost 2100 patients in the last 4 years. Changes in the postoperative regimen to include no pretreatment, use of semipermeable dressings, antiviral and antibacterial prophylaxis, and early treatment with sunscreens and bleaching agents have made for a smoother recovery with more predictable results.

Laser resurfacing as an adjunct to endoforehead lift, endofacelift, and biplanar facelift.

Laser resurfacing is a wonderful technological advance at improving the quality of aged skin. Physicians have been reluctant to perform full facial resurfacing at the time of rhytidectomy due to risk of flap slough. Newer endoscopic-assisted subperiosteal techniques allow hardy flaps without significant blood supply interruption. Since September 1995 we have performed 26 full facial resurfacings at the time of rhytidectomy or brow lift using the Coherent 5000C carbon dioxide laser. Standard settings and densities were used. Twelve patients underwent full endoscopic facelift; 5 patients, extended endoforehead lift; 8 patients, biplanar rhytidectomy; and 1 patient, standard rhytidectomy prior to immediate laser resurfacing. An additional 2 patients underwent endoscopic forehead lift and forehead resurfacing. There were three herpes infections, one in the endoscopic group, one in the biplanar group, and one in the standard rhytidectomy patient. There were 2 patients with minor skin slough in our early experience with the biplanar group. Full facial resurfacing at the time of rhytidectomy provides a one-stage rejuvenation of skin and deeper layers, and can be performed safely. However, only experienced laser practitioners should attempt resurfacing over undermined flaps.

Combined erbium:YAG laser resurfacing and face lifting.

Facial aging occurs secondary to gravity-induced tissue ptosis and photoaging. Combined face lifting and carbon dioxide laser resurfacing provides a comprehensive one-stage approach to facial rejuvenation but is condemned by many plastic surgeons due to the nonspecific thermal effects of the laser and risk of skin necrosis. Newer high-energy erbium:YAG lasers allow precise tissue ablation with minimal thermal effect. In this study, various facial rejuvenation techniques were combined with simultaneous erbium:YAG laser resurfacing to assess results and complications. A total of 257 patients from Florida, Melbourne, Australia, and Tel Aviv, Israel, underwent combined erbium:YAG laser resurfacing and surgical facial rejuvenation. Various face-lift methods were used, including endoscopic, deep plane, and subcutaneous. Simultaneous, full-facial laser resurfacing was performed using a variety of erbium:YAG lasers. It was found that combined laser resurfacing and face lifting was successful in greater than 95 percent of patients with minimal morbidity. Two patients (1 percent) (both heavy smokers) developed small areas of skin necrosis that healed with minor pigment changes. Five patients (2 percent) developed synechia that was treated with no residual effect. Two additional patients (1 percent) developed temporary ectropion. There were no other cases of scarring, infection, or cosmetically obvious hypopigmentation. Although larger studies are necessary, it seems that the lack of thermal injury from the erbium:YAG laser makes it possible to safely perform laser resurfacing with surgical facial rejuvenation in nonsmokers. However, the authors caution that familiarity with the nuances of erbium:YAG laser resurfacing be obtained before performing combined laser resurfacing and face lifting.

The RSVP Facelift: A Highly Vascular Flap Permitting Safe, Simultaneous, Comprehensive Facial Rejuvenation in One Operative Setting

Abstract. This study describes our effort to develop a reliably safe method for combining currently available treatment modalities in an effort to obtain comprehensive facial rejuvenation in one operative setting. Detailed evaluation of 101 available consecutive patients, their per- and postoperative photos and charts was undertaken. Five groups of patients were studied: (1) traditional facelift with wide subcutaneous undermining and SMAS plication. (2) Similar traditional facelift with regional laser resurfacing. (3) RSVP (rejuvenation with sparing of vascular perforators) facelift. Subcutaneous undermining stops 3 cm lateral to the nasolabial fold to preserve the rich angular/facial arterial supply and venous drainage, still permitting lateral SMASectomy or SMAS plication. Subcutaneous neck undermining is discontinuous, the posterior dissection being limited to that which is necessary for identification of the posterior edge of the platysma and its plication to the mastoid and SCM muscle. The anterior dissection is limited to that necessary for anterior platysmal repair leaving intact a vertical subcutaneous non-undermined zone 4–6 cm in width, preserving the submental perforating artery. If indicated, gentle liposuction with a fine cannula is performed through this area. (4) RSVP facelift and regional laser resurfacing. (5) RSVP facelift with total facial laser resurfacing. Mean follow-up was 13.6 months, minimum 6 months. There were no additional major complications associated with the addition of laser resurfacing or fat grafting to the RSVP group. The patients with laser resurfacing were pleased with their result, and estimated that their apparent age had been reduced by a mean of 10.4 years, compared with 6.6 years for the non-lased group. We conclude that the RSVP flap is a hardy, vascular flap permitting simultaneous laser resurfacing, fat grafting, and other adjunctive procedures without significant fear of flap loss.

Does Implant Insertion with a Funnel Decrease Capsular Contracture? A Preliminary Report

BACKGROUND Capsular contracture remains a common and dreaded complication of breast augmentation. The etiology of capsular contracture is believed to be multi-factorial, and its causes may include biofilm formation due to implant/pocket contamination with skin flora. It has been shown that insertion funnel use reduces skin contact and potential contamination by 27-fold in a cadaver model. After incorporating the funnel into our surgical protocols, we anecdotally believed we were experiencing fewer capsular contractures in our augmentation practices. OBJECTIVES The purpose of this study was to test the hypothesis that capsular contracture related reoperation rates decreased after insertion funnel adoption using data from multiple practices. METHODS At seven participating centers, we retrospectively reviewed the surgical records from March 2006 to December 2012 for female patients who had undergone primary breast augmentation with silicone gel implants. Group 1 consisted of consecutive augmentations done without the insertion funnel, and Group 2 consisted of consecutive augmentations done with the insertion funnel. The primary outcome variable was development of grade III or IV capsular contracture that led to reoperation within 12 months. RESULTS A total of 1177 breast augmentations met inclusion criteria for Group 1 and 1620 breast augmentations for Group 2. The rate of reoperation due to capsular contracture was higher without use of the insertion funnel (1.49%), compared to Group 2 with funnel use (0.68%), a 54% reduction (P = 0.004). CONCLUSIONS The insertion funnel group experienced a statistically significant reduction in the incidence of reoperations performed due to capsular contracture within 12 months of primary breast augmentation.

Endoscopic-assisted wire removal and neurolysis

Endoscopic-assisted surgery allows remote incision placement and provides an illuminated, magnified operative field. We have applied these principles to perform neurolysis of the zygomaticotemporal nerve and removal of a fixation wire under endoscopic control in a patient with pain and tenderness at the site of a previous zygomatic arch fracture. Endoscopic assistance aided dissection by placing the incision in a hidden, unscarred area.

Putting it all together: recommendations for pain management in nonsurgical facial rejuvenation.

Background: Nonsurgical procedures for facial rejuvenation vastly outnumber surgical procedures among board-certified plastic surgeons; interest in nonsurgical cosmetic procedures is rapidly growing for patients and physicians, with less down time, less scars, and potentially less cost. Nonsurgical procedures are often a gateway for patients into more invasive surgical procedures. Providing patients with a comfortable, pleasant experience increases the chance of referrals and return for future procedures, surgical and nonsurgical. Methods: In this review article, we describe basic principles for providing patients with a pleasant, minimal pain experience during nonsurgical facial rejuvenation procedures. The procedures are grouped into injectables, noninvasive devices, and minimally invasive devices, and basic guidelines for pain management are provided. Results: A review of each nonsurgical facial rejuvenation procedure is provided with typical patient perception of discomfort and methods to reduce or eliminate pain. This article covers the most popular procedures performed in many plastic surgery offices but is not inclusive of all devices and technologies available on the market. Conclusions: A wide range of nonsurgical options exist for rejuvenation, and there is nearly as much variety in pain associated with these procedures. As with any procedure that potentially may lead to pain or anxiety for a patient, it is important to assess patient’s pain tolerance preprocedurally to determine the level of intervention needed. Providing a relaxed, calm environment and satisfactory pain control helps to reduce anxiety and improve the overall perception of the procedure and provider.

Combination Therapy for Rejuvenation of the Outer Thigh and Buttock: A Review and Our Experience.

BACKGROUND Combination therapies are becoming more popular as a multifaceted approach to treating common aesthetic conditions. OBJECTIVE Often, the use of multiple techniques and modalities can lead to improved outcomes; however, there is a lack of current evidence on the use of combination therapies in the literature. METHODS AND MATERIALS With the recent expansion of minimally and noninvasive options for treatment of the outer thigh and buttock, it is important to understand how these techniques can be used together while avoiding increased risk. RESULTS AND CONCLUSIONS This review of current available therapeutic options for treatment of the outer thigh and buttock emphasizes current available literature and author experiences.