Combination Surgical Lifting with Ablative Laser Skin Resurfacing of Facial Skin: A Retrospective Analysis

Transcription

1 ORIGINAL ARTICLE Combination Surgical Lifting with Ablative Laser Skin Resurfacing of Facial Skin: A Retrospective Analysis TINA S. ALSTER, MD, n SEEMA N. DOSHI, MD, n AND STEVEN B. HOPPING, MD w n Washington Institute of Dermatologic Laser Surgery, Washington, DC; and w The Center for Cosmetic Surgery, Washington, DC BACKGROUND. Cutaneous aging is manifested by rhytides, dyschromias, and skin laxity. Ablative laser skin resurfacing can effectively improve many signs of skin aging; however, the photoaged patient with facial laxity often requires a surgical lifting procedure in order to obtain optimal results. Concerns with delayed or impaired wound healing has led to reluctance to perform both procedures simultaneously. OBJECTIVE. To report the clinical results and side effect profiles after concomitant surgical facial lifting procedures and ablative carbon dioxide or erbium:yag laser resurfacing in a series of patients. METHODS. A retrospective analysis and chart review was performed in 34 consecutive patients who underwent combination CO 2 or erbium:yag laser skin resurfacing and surgical lifting procedures, including S-lift rhytidectomy, blepharoplasty, and brow lift. Side effects and complication rates were tabulated. RESULTS. The side effect profile of the combined surgical-laser procedures was similar to that reported after a laser-only procedure. The most common side effect was transient hyperpigmentation which occurred in 20.6% of treated patients. None of the patients experienced delayed reepithelialization, skin necrosis, or prolonged healing times. CONCLUSIONS. Concurrent laser skin resurfacing and surgical lifting of facial skin maximizes aesthetic results without increased incidence of adverse effects. Patients benefit from the consolidation of anesthesia and convalescent times as well as enhanced global clinical outcomes. TINA S. ALSTER, MD, SEEMA N. DOSHI, MD, AND STEVEN B. HOPPING, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS. CUTANEOUS AGING, although multifactorial in etiology, is predominantly a consequence of cumulative sun exposure. All cutaneous components are affected, accounting for a wide variety of manifestations including rhytides, skin inelasticity, dyschromias, telangiectasias, and enlarged pores. Despite recent advancements in nonablative laser technology, ablative laser skin resurfacing with the carbon dioxide (CO 2 ) laser continues to provide the most dramatic clinical and histologic improvement in photodamaged facial skin. 1 Although the CO 2 laser has been shown to tighten tissue and improve dermatochalasis as a consequence of collagen contraction and remodeling, 2 it cannot fully address moderate to severe skin redundancy concerns. A comprehensive approach to facial rejuvenation in which surgical lifting is combined with laser skin resurfacing would be expected to provide optimal improvement of moderately to severely photoaged skin. Address correspondence and reprint requests to: Tina S. Alster, MD, Director, Washington Institute of Dermatologic Laser Surgery, 2311 M Street, NW, Suite 200, Washington, DC 20037, or talster@ skinlaser.com. Concomitant laser and surgical treatment could potentially yield results that are not achievable by either procedure alone and additionally would minimize patient expenditures, anesthetic exposure, and recovery time. There has been great reluctance to perform simultaneous laser resurfacing and surgical rhytidectomy owing to concerns over skin necrosis and flap viability. This tentativeness is based on earlier published literature using phenol peels as the resurfacing modality. 3,4 Subsequent studies using a high-energy pulsed CO 2 laser system support the safety and feasibility of performing both procedures at one time; however, this combined approach has never been popularized. 5,6 Combining laser skin resurfacing with other surgical procedures such as blepharoplasty or brow-lift, although not as controversial, is also not commonly employed, perhaps owing to similar concerns of compromised wound healing. The purpose of the study outlined herein was to report our favorable experience with concurrent CO 2 or erbium: yttrium-aluminum-garnet (Er:YAG) laser skin resurfacing and a variety of surgical lifting procedures including blepharoplasty, brow-lift, and S-lift rhytidectomy. r 2004 by the American Society for Dermatologic Surgery, Inc. Published by Blackwell Publishing, Inc. ISSN: /04/$15.00/0 Dermatol Surg 2004;30:

2 1192 ALSTER ET AL.: SURGICAL LIFTING WITH ABLATIVE LASER SKIN RESURFACING Dermatol Surg 30:9:September 2004 Materials and Methods Records of patients who underwent a variety of surgical lifting procedures (S-lift rhytidectomy, upper and/ or lower blepharoplasty, endoscopic brow-lift) and concomitant CO 2 or Er:YAG laser skin vaporization from June 1998 through April 2003 with at least 6 months postoperative follow-up were reviewed. Thirty-four patients (32 women and, 2 men, skin phototypes I III, mean age 50.2 years) with upper and/or lower eyelid dermatochalasis, facial dyspigmentation, rhytides, and jowling were included in the retrospective analysis of data. No patients were smokers or diabetics (Table 1). Intravenous anesthesia with propofol and versed was administered by a certified nurse anesthetist. All surgical lifting procedures were performed by a single surgeon (S.H.) using traditional surgical techniques. Rhytidectomy techniques included S-lift (short scar rhytidectomy) and traditional rhytidectomy with postauricular extension. In an attempt to maintain thick healthy flaps, all face-lift dissections were performed in the supra-smas plane and limited to within 4 to 6 cm of the periauricular area. Liposculpture of the entire face and neck was routinely performed but only after flap elevation to maximize flap viability. SMAS plication sutures of 2-0 sutures (Ethibond, Ethicon Inc., Somerville, NJ) were placed from the periosteum of the zygomatic arch to the extended SMAS platysma of the neck and jowl. A principally vertical lift was accomplished with superior flap rotation. The subcutaneous tissues were closed with 4 0 sutures (Vicryl, Ethicon Inc.), the skin with 5 0 sutures (Monocryl, Ethicon Inc.), and the scalp with stainless-steel surgical clips (Diamond Lock, Snowden Pencer, Tucker, GA). In three patients, minimal incision temporal lifts were also performed deep to the superficial layer of the temporalis fascia. The temporal flap was advanced to a more superior level on the deep temporalis fascia and secured with a 3 0 mattress suture (Vicryl, Ethicon Inc.). In cases with platysma banding at rest, platysmaplasty was performed via a submental incision before rhytidectomy. The platysma bands were sectioned at the level of the hyoid bone and then approximated with interrupted 3 0 Vicryl sutures to the Table 1. Patient Characteristics Procedure Number of Patients Ages (Years) Women/Men Skin Phototype (I/II/III) Blepharoplasty /2 2/14/2 S-Lift /0 1/14/1 Total (mean) 32/2 3/28/3 temporalis fascia and with titanium screws to the outer table. The incisions were closed with stainless-steel surgical clips. Upper lid blepharoplasties were performed with skin-muscle combined resections, limited medial fat reduction, and subcuticular closure with 6-0 Ethibond. Lower lid blepharoplasties were performed transconjunctivally with limited fat reduction or vaporization and without sutures. After the surgical procedures and before laser skin resurfacing, the adjacent neck skin was treated with 25% trichloroacetic acid solution, producing a uniform light cutaneous frost (application time 2 min). The skin was then rinsed thoroughly with iced water before another single operator (T.A.) performed the facial laser skin resurfacing procedure. In 29 patients, a high-energy pulsed CO 2 laser (Ultrapulse, Lumenis, Santa Clara, CA) was used to resurface the entire facial skin in a series of nonoverlapping laser scans (300 mj energy, 60 W power, and CPG density 5). In all patients undergoing S-lift rhytidectomy, one pass with the CO 2 laser was performed over the entire face with angling of the handpiece to reduce applied energy along the lateral cheeks and mandible. Depending on skin laxity and severity of rhytides, up to two additional passes were performed in the periocular area immediately following blepharoplasty. Partially desiccated tissue was left intact in all areas except where additional laser passes were necessary to vaporize residual rhytides (e.g., periocular and perioral regions). In these latter areas (n 5 12), partially desiccated tissue was thoroughly removed with saline-soaked gauze between laser passes. In 5 patients undergoing blepharoplasty, an Er:YAG laser was used to resurface photodamaged skin. Either two passes with a variable pulsed Er:YAG system (Contour, Sciton, Palo Alto, CA) calibrated to 90-mm ablation and a 50% spot overlap or six passes with a short-pulsed system (ConBio, Continuum Biomedical, Dublin, CA) at settings of 2 J, 8 Hz, and a 5-mm spot size were used to ablate the entire facial epidermis with nonoverlapping laser spots or scans to within 2 mm of the edge of the surgical incisions. Postoperative wound care was similar in all patients and included several daily dilute acetic acid compresses and liberal application of healing ointment (Aquaphor, Beirsdorf, Inc., Wilton, CT). Multiple in-office visits were performed in the first postoperative week for evaluation of the skin s response and to determine the presence of side effects. All patients received oral antibacterial and antiviral prophylaxis during the 10- day postoperative healing period. Sutures were removed on the fourth postoperative day after upper lid blepharoplasty and on the ninth postoperative day after S-lift rhytidectomy. All patients were evaluated on at least a monthly basis for 6 months or more.

3 Dermatol Surg 30:9:September 2004 ALSTER ET AL.: SURGICAL LIFTING WITH ABLATIVE LASER SKIN RESURFACING 1193 Table 2. Side Effects and Complications Laser Type Blepharoplasty n S-Lift w Hyperpigment / Duration (Mean) Infection Scar CO / 2 12 (4.6 months) 3 1 Er:YAG / 2 12 months 1 0 Total / 2 12 (4.3 months) 4 1 n Two patients had concomitant temple lift. w Three patients had concomitant brow-lift. Results Each of the 34 patients responded favorably to the concurrent surgical procedures with minimal complications (Table 2, Figs. 1 and 2). The average time for reepithelialization of skin was 7.8 days (range, 7 9 days). There were no differences in wound healing rates or complication profiles in CO 2 versus Er:YAG laser-treated patients or with different surgical procedures (e.g., blepharoplasty versus brow-/face-lift). All surgical incision sites were well approximated without evidence of wound dehiscence or flap necrosis in any patient. Eleven (32%) patients developed hyperpigmentation 3 to 4 weeks postoperatively, predominantly at the mandible. Resolution of hyperpigmentation was achieved with 30% glycolic acid peels and daily application of at least one of the following agents: 0.1% N-furfuryladenine (Kinerase, ICN Pharmaceuticals, Aurora, OH), kojic/lactic/ascorbic acid mix (KojiLac- C, Young Pharmaceuticals, Wethersfield, CT), or 4% hydroquinone cream (Lustra, Medicis, Scottsdale, AZ). Three (8%) patients developed cutaneous infections (Staphylococcus aureus, Enterococcus) confirmed by positive bacterial culture and all responded to appropriate systemic antibiotic treatment. No herpetic or fungal infections were encountered. One patient developed early hypertrophic periauricular scars 3 weeks postoperatively that resolved after one treatment with a 585-nm pulsed dye laser (Sclerolazr, Candela Laser Corp., Wayland, MA). Average duration of postoperative erythema was 6.8 weeks (range, 4 10 weeks). The extent of clinical improvement was not evaluated as part of this study. Discussion With a multitude of surgical options available for rejuvenation, it is possible to consider a treatment approach that involves several concomitant procedures to maximize clinical results. When surgical rhytidectomy combined with cutaneous resurfacing is contem- Figure 1. Preoperative view of patient (A). Three days (B) and 12 months (C) after CO 2 laser skin resurfacing and S-lift procedures. Figure 2. Preoperative view of patient (A). Five days (B) and 4 months (C) after CO 2 laser skin resurfacing and blepharoplasty.

4 1194 ALSTER ET AL.: SURGICAL LIFTING WITH ABLATIVE LASER SKIN RESURFACING Dermatol Surg 30:9:September 2004 plated, the presence of a thick, well-vascularized flap is crucial. And, although recent reports have helped to dispel the dogma that combination surgical excision and laser resurfacing procedures should not be attempted owing to presumed increased risk of complications, acceptance of such an approach has been slow. Fulton 6 reported his experience with 25 patients who underwent rhytidectomy, brow-lift, hair transplant, and/or rhinoplasty concomitant with CO 2 laser skin resurfacing. None of the patients experienced a prolonged convalescent period and the incidence and intensity of ecchymoses, edema, and erythema was the same as with face-lift alone. Although two patients, one of whom was a smoker, developed partial thickness flap necrosis, all patients demonstrated an excellent clinical response at the 1- year follow-up evaluation. Fulton performed the laser skin resurfacing procedure before the surgical lifts to prevent distortion of suture lines owing to shrinkage of collagen. This theorized complication did not occur in our patients, all of whom received laser skin vaporization after surgical closure, likely because of avoidance of laser skin treatment within 2 mm of the suture sites. Achaeur et al. 7 described 26 patients who underwent combined CO 2 laser resurfacing and rhytidectomy, 22 of whom also had concomitant blepharoplasty, endoscopic forehead lift, lip-lift, rhinoplasty, or canthopexy. 7 A sub-smas flap was created, limiting the undermining of the preauricular area to 3 cm, which was then lased with a defocused beam. No complications were noted in any patient and all exhibited excellent facial rejuvenation 1 year postoperatively. Another group used a short-pulsed Er:YAG laser, which produces less thermal injury to the dermis than does the CO 2 laser, 1,8 to resurface skin concomitantly with various types of face-lifts in 257 patients, including deep plane face-lifts (n 5 67), endoscopic subperiosteal forehead and midface-lifts (n 5 24), biplanar (subperiosteal midface and subcutaneous) face-lifts (n 5 33), and endoscopic brow-lifts (n 5 111). 9 Excellent (490%) scores were achieved in 70% of the patients. Two patients, both of whom continued to smoke during and after surgery, experienced skin sloughing, but no delay in reepithelialization was observed in any patient in undermined areas. In the only prior published report of simultaneous S-lift and laser skin resurfacing, Fulton et al. 10 reported on eight patients who exhibited excellent clinical results without any skin sloughing. 10 The fact that tissue undermining is limited to an area superficial to the SMAS in the S-lift procedure is a likely explanation for the lack of postoperative complications related to compromised flap vascularity when traditional surgical procedures are performed. Endoscopic brow-lifts, when combined with laser resurfacing, do not carry the same risk as described with rhytidectomy because a robust cutaneous flap is created and the forehead vasculature is preserved. 11 Similarly, upper and lower blepharoplasties, particularly those performed through a transconjunctival approach, theoretically are perfectly suited for combined laser skin resurfacing to best ameliorate static rhytides and actinic damage. Roberts and Ellis 12 reviewed 40 patients who were age- and gender-matched with brow ptosis and glabellar rhytides who had coronal forehead-plasty (n 5 26), CO 2 resurfacing (n 5 24), or combined endoscopic brow-lift and CO 2 resurfacing (n 5 30). Independent assessors determined a 95% reduction in rhytides in the combination group in 80% of patients evaluated, compared to 42% rhytides reduction in the laser-only group and 50% reduction in the forehead-plasty group. In a retrospective review of 196 CO 2 -laser-assisted blepharoplasty patients, 92 of whom also underwent brow-lift, rhytidectomy, or rhinoplasty, the laser was used as a cutting tool and also for periocular skin resurfacing immediately postblepharoplasty. 13 Postoperative sequelae were minimal and transient, including ectropion (4.1%) and scleral show (2.5%) that resolved in less than 3 months. Seven patients experienced prolonged erythema that resolved within 6 months. The results of our retrospective analysis are even more impressive than those outlined in the aforementioned studies, in that no wound healing difficulties or skin sloughing was observed. In addition, because of the transconjunctival approach to blepharoplasty and the limited undermining of facial skin using the S-lift procedure, the risk of vascular compromise, scar formation, and ectropion were drastically reduced. A single pass with a CO 2 laser or up to six passes with a short-pulsed Er:YAG system combined with feathering or attenuation of energy over the lateral aspects of the cheeks and mandible optimized the clinical effect whilst reducing the risk of prolonged healing and other untoward sequelae. Conclusions The side-effect profile and complication rates observed in our patients were similar and no more frequent than those that occur in patients undergoing ablative laser resurfacing alone. 14,15 There was no incidence of flap necrosis, delayed reepithelialization, compromised or delayed healing of surgical incisions, or ectropion. It is probable that decreasing the application of thermal energy by minimizing the number of passes delivered over undermined skin and limiting combination procedures to superficial surgical lifts account for the favorable clinical results obtained.

5 Dermatol Surg 30:9:September 2004 ALSTER ET AL.: SURGICAL LIFTING WITH ABLATIVE LASER SKIN RESURFACING 1195 When considering facial rejuvenation options, the best aesthetic outcome is achieved by evaluating the entire clinical picture. Surgical procedures, ranging from blepharoplasty to rhytidectomy, offer only a partial solution in many cases owing to their inability to ameliorate static rhytides. Direct thermal injury to collagen by laser skin resurfacing leads to collagen tightening and remodeling that better deals with static rhytides and cutaneous dyspigmentation. Ablative laser procedures, in effect, give patients a fresh, healthier epidermis to complement and augment their surgical lifts. References 1. Alster TS. Cutaneous resurfacing with CO 2 and erbium:yag lasers preoperative, intraoperative, and postoperative considerations. Plast Reconstr Surg 1999;103: Alster TS, Bellew SG. Improvement of dermatochalasis and periorbital rhytides with a high-energy pulsed CO 2 laser: a retrospective study. Dermatol Surg 2004;30:483 7; discussion Spira M, Gerow FJ, Hardy SB. Complications of chemical face peeling. Plast Reconstr Surg 1974;54: Litton C. Chemical face lifting. Plast Reconstr Surg 1962;29: Guyuron B. Discussion combined rhytidectomy and full-face laser resurfacing. Plast Reconstr Surg 2000;106: Fulton JE. Simultaneous face lifting and skin resurfacing. Plast Reconstr Surg 1998;102: Achaeur BM, Adair SR, VanderKam VM. Combined rhytidectomy and full-face laser resurfacing. Plast Reconstr Surg 2000;106: Alster TS, Lupton JR. Erbium:YAG cutaneous laser resurfacing. Dermatol Clin 2001;19: Weinstein C, Pozner J, Scheflan M. Combined erbium:yag laser resurfacing and face lifting. Plast Reconstr Surg 2001;107: Fulton JE, Saylan Z, Helton P, et al. The S-lift facelift featuring the U-suture and O-suture combined with skin resurfacing. Dermatol Surg 2001;27: Ramirez OM, Pozner JN. Laser resurfacing as an adjunct to endoforehead lift, endofacelift, and biplanar facelift. Ann Plast Surg 1997;38: Roberts TL, Ellis LB. In pursuit of optimal rejuvenation of the forehead: endoscopic brow lift with simultaneous carbon dioxide laser resurfacing. Plast Reconstr Surg 1998;101: Seckel BR, Kovanda CJ, Cetrulo C, et al. Laser blepharoplasty with transconjunctival orbicularis muscle/septum tightening and periocular skin resurfacing: a safe and advantageous technique. Plast Reconstr Surg 2000;106: Nanni CA, Alster TS. Complications of carbon dioxide laser resurfacing: an evaluation of 500 patients. Dermatol Surg 1998;24: Tanzi EL, Alster TS. Single-pass carbon dioxide versus multiplepass Er:YAG laser skin resurfacing: a comparison of postoperative wound healing and side-effect rates. Dermatol Surg 2003;29:80 4.