Dr Niamtu

San Diego — A new method of facial rejuvenation has made a careful progression to its current, revolutionary state. The marrying of two techniques — facelift and CO₂ laser skin resurfacing — isn't uncommon. But doctors are beginning to realize the benefits of performing the procedures simultaneously. Dr. Joseph Niamtu III, D.M.D., of Drs. Niamtu, Alexander, Keeney, Harris, Metzger, Dymon & Associates Cosmetic Facial Surgery in Richmond, Va., says the two complement each other, and he explains why they no longer need be performed separately.

"One problem that has always existed is the fact that even the best facelift result does not address generalized skin wrinkling, "he says. "By the same token, an aggressive full-face CO₂ laser skin resurfacing can vastly improve wrinkles and tighten the skin, but rarely will produce lasting tightening of the jowls and never addresses excessive neck skin."

A successful technique for addressing ptotic skin, wrinkles and dyschromias all at once was slow to emerge. Dr. Niamtu says that early attempts that combined chemical peels and facelift led to necrosis on the facelift flap. The need for a safe, predictable means of treating damaged, aging skin in a single procedure was unfilled until the introduction of the CO₂ laser.

"The CO₂ laser has the ability to wipe away layers of skin damage in a very precise and predictable manner," he says. "By wounding the skin to the level of the reticular dermis, virtually all actinic dyschromias are removed and new collagen is formed in the dermis."

Obvious disadvantage Once the CO₂ laser was on the market, surgeons began to use it as a supplement to the facelift, but scheduled the laser resurfacing several months after. The obvious disadvantage of the process was that it required two procedures and two recoveries, Dr. Niamtu says. Slowly, surgeons became more confident with laser resurfacing during facelifts, and they began to laser the central oval of the face immediately after the procedure, while steering clear of the newly delicate tissue of the dissected lipocutaneous flaps. This produced better results, but still required the patient to return for additional lasering over the flaps.

Eventually, a number of surgeons discovered that laser resurfacing of the flaps at a lesser fluence immediately following the facelift actually did not adversely affect the flaps' viability.

Now, says Dr. Niamtu, "It is well recognized that hundreds of cosmetic facial surgeons have performed thousands of safe and effective facelifts with simultaneous CO₂ laser resurfacing. It is also recognized that without laser resurfacing some facelift flaps can lose viability and cause resultant necrosis, so some practitioners have refused to adapt concomitant laser skin resurfacing with facelift."

Not all skin types and facelifts are ideal for simultaneous laser resurfacing. Dr. Niamtu does not laser darker Fitzpatrick skin types. Technically, he explains, the facelift flap is an axial pattern flap, making it unique in its two extended and symmetrical skin flaps that share the same base as a pedicle. The nearly transparent skin flap survives because it's sustained by the subdermal arterial supply originating from the perforators in the pedicle area of the flap. The pedicle area of the flap has 11 pairs ofmusculocutaneous perforator arteries that emerge from three main trunks: the facial, the superficial temporal and the ophthalmic arteries. All have anastomoses involving all four carotid arteries. But the key to preserving the flap's vascularity is to not disturb the pedicle area, he warns.

"The blood supply is no different for the various planes of the face no matter which methods or planes are used, as long as the dissection does not pass beyond the limits of the pedicle area of the flap. The SMAS has little or nothing to do with facelift vascularity, as it is an avascular layer through which vessels pass from ... the masseteric facial plane to the subdermis."

He says that subcutaneous dissection that extends past the nasolabial fold jeopardizes the pedicle area, so he prefers to do a lateral SMASectomy when using concurrent CO₂ laser resurfacing. The SMASectomy, by using either long or short flaps, allows multivector lifting, and doesn't require extensive dissection medially toward the pedicle area.