CASE STUDY: SKIN RESURFACING AND FACE-LIFT IN THE SAME SURGICAL PROCEDURE: WHAT ARE THE ISSUES
ARISTIDES ARELLANO-H MD FRANCISCO ARELLANO-O MD ELIA FERNÁNDEZ DE LARA MD Department of Plastic and Reconstructive Surgery Department of Dermatology Department of Anesthesiology Dermatology and Aesthetic Surgery Clinic of Puebla (MEX)
73 cases have been done with this procedure since 2000, minimal complications have been observed. The facelift and skin resurfacing techniques are carried out during the same surgical procedure, in order to save time and improve the patient recovery. Perioral and orbital wrinkles, photo aging sings such as pigmentations and changes in skin color are treated with the skin Resurfacing technique. Many surgeons for neck and cheeks is performed as usually have mentioned the face-lift technique. By using these two techniques, a full-face rejuvenation is obtained with only one surgical procedure. The patient recovery is quicker and the result obtained is much better.
We start performing the facial rejuvenation with surgical procedure, SMAS plication and skin resurfacing in one surgical stage in 1997. However, it is needed between 6 to 8 weeks to recovery from the skin Resurfacing with CO2 laser. This procedure takes more recovery time and produces more edema, redness and patient discomfort. For that reason, we started in 2000 to perform the facial rejuvenation and the skin resurfacing with Erbium: Yag and CO2 Lasers (Derma K device). It is also carried out the Blepharoplasty in the upper eyelid and the tranconjunctival approach in the lower eyelid with the CO2 laser in the cut mode.
Once the patient is marked in the places to be corrected, the procedure is started making the endovenus anesthesia combined with the local anesthesia (tumescent technique). Some patients ask for general anesthesia, in those cases special laser endo tracheal cannulas are used to ensure a more safety procedure. When local anesthesia has been placed in the neck, cheeks and the forehead, the cutting of pre and post-auricular zone is started with the CO2 laser in the cut mode at a level of 6 Watts. The skin undermining is done using scissors, from the zygomatic arch to the nasolabial folds and the full neck. At the end, the hemostasia and the SMAS placations are done with 3-0 Nylon. The excess skin is removed and steaches are place in the area.
After finishing both sides of the face, the Blepharoplasty is performed. When skin excess is present in the upper eyelid, an incision with the CO2 laser in the cut mode is done. This allows removing the skin in a very easy way without bleeding, followed by the fat removal using also the laser at 6 Watts of energy. In the lower eyelid, the transconjunctival via is the technique we prefer for fat removal. The incision is made with the laser avoiding the presence of blood. The fat is taken out with fine forceps together with the laser. No skin is removed and the incision is closed with bringing near the borders, no suture is place. It is important to remember that all patients wear laser eye protectors to avoid eye damage. It is preferred to perform the lower eyelid by the transconjunctival approach because the orbicularis oculi muscle changes its fast fibers with the age, reducing the number of fibers and its size with the subsequent fibrous replacement. This changes in the musculature can produce round eye, change in the look expression, the sclera show, wrinkles, etc. With the transconjunctival approach the skin laxitude and wrinkles are corrected with the skin Resurfacing giving to the treated area a clear improvement. In all cases no skin excision was necessary.
If it is needed to perform an endoscopic forehead or a coronal approach, is possible to carry out the surgery and the skin resurfacing at the same time without complications. Laser Resurfacing is done at Rate 10, Fluence 14, Spot 3 of Erbium: Yag and Power 2 to 3 Watts and Pulse 050 of CO2, no scan was used at one step. The laser removes the skin layers by vaporization; therefore, it is important to know the amount of energy that is being transmitted to the skin surface in order to control the depth penetration and to avoid skin damage. Remember that Erbium: Yag laser carries out accurate ablation of superficial layers, opening the way for the CO2 laser to affect the deeper tissue layers below. Working with both laser technologies we have a full control of the temperature profile created in the tissue during skin rejuvenation procedures.
Skin Resurfacing carried out with the Erbium: Yag and CO2 lasers have been used in the forehead, the upper and lower eyelid, the internal and external Chantal of the eyes, the nose, the cheeks, the Perioral zone and the chin. In those zones sometimes we perform one or two passes. Permitting the treatment of fine and depth wrinkles, age spots, acne scars and photo aging.
However, in areas where the surgical procedure was performed we employ only the CO2 laser at 5 watts in one pass. The laser is normally applied in the areas describe before during the same procedure. The laser Fluence is increase or decrease depending on the wrinkles deepness, acne scars, skin sun damage, thickness, texture and color. In the first step, the laser is applied in the area to be treated. Once the first pass is finished, we lived the burn skin in place and perform the second step. Sometimes on the cross-feets or the Perioral area a third step is carried out.
As it was mentioned above, it is important to understand that the laser should be deeper in the central part of the face and lightly in the area were the surgical procedure was performed. In the cheeks were the SMAS plication and skin undermining was done. Employing the CO2 laser at 5 watts on the skin flap there is no different skin color; texture or border remains by the change of laser. With this method the redness and changes in color pigmentation disappear at the same time in both areas, taking only 2 or 3 weeks for patient with skin type 3, 4 and 5 to get the same skin color and texture.
When the procedure was done a Petrolatum cream with antibiotic is used two or three times a day. An occlusive bandage is used by 48 hrs helping to heal the skin more quickly. The cream application is used for 8 days, followed by a moisturizing cream with sun blackout 100% in all the face during the morning. At night we recommend a post laser cream mixed with sweet almonds, omega 6 acids, ceramid 934, silicone oils, aloe Vera and kojic acid helping to decrease the redness, dry skin discomfort and avoid de hyper pigmentation.
With this combined technique the result is highly satisfactory because a face-lifting procedure is carried out in the areas were skin laxity is more often such as cheeks and neck. The skin Resurfacing method is used in those places were the surgery was not performed.
76 YEARS OLD FEMALE PATIENT – FACE LIFT – UPPER BLEPHAROPLASTY WITH C02 LASER CUT MODE TRANSCONJUNCTIVAL IN THE LOWER EYELID AT 6 WATTS – RESURFACING CO2 – FOREHED, LOWER EYELID, CHIN AND NOSE, 2 PASES 7 WATTS WITH SCANN – CHEEKS 1 PASS CO2 AT 5 WATTS
We have seen that performing this procedure, the patient results are much better. If face lifting is carried out at the same surgical time with the skin resurfacing patients recovery takes less time and discomfort. In 20 days patient skin color is in the same tone. The skin looks much younger, smooth and facial rejuvenation is highly satisfactory. It is possible to perform different facial techniques at the same time such as fat graft, Gore-Tex implant, chin implant, endoscopic forehead, etc.
52 YEARS OLD FEMALE PATIENT – FACE LIFT – UPPER BLEPHAROPLASTY WITH C02 LASER CUT MODE TRANSCONJUNCTIVAL IN THE LOWER EYELID AT 6 WATTS – RESURFACING Erbium:Yag LASER + CO2 – FOREHED, LOWER EYELID
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