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
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.