Dallas - Full-face CO₂ laser resurfacing in conjunction with a facelift not only can be performed safely, but can achieve maximum efficient facial rejuvenation, according to cosmetic surgeon Joseph Niamtu, M.D., who specializes in oral maxillofacial and cosmetic facial surgery.

Dr. Niamtu

He said this is accomplished by understanding vascular anatomy, preserving critical flap perforators, and using caution when lasering.

Dr. Niamtu, who has worked with the combined procedures for more than five years, presented his experiences on 21 consecutive procedures along with a literature review at the annual meeting of the American Society for Laser Medicine and Surgery, held here.

Dr. Niamtu said the advent of laser technology led to a major paradigm shift in the cosmetic surgery field. Before 1990, chemical peeling and dermabrasion were accepted treatments for facial wrinkling. Although both had positive treatment results, both had significant limitations. Neither offered precise control or predictable penetration.

Mainstay technique was limited Rhytidectomy had its weaknesses, as well. Although it is the mainstay of facial rejuvenation for the past century, it failed to improve significant facial rhytides, especially in the area of the central oval of the face, Dr. Niamtu said. "Facelift alone cannot produce the required skin and collagen changes necessary for cutaneous rejuvenation."

So began an evolution of combining facelifts with other facial rejuvenation procedures.

"Early attempts to combine face peeling with facelifts were disappointing and fraught with complications," Dr. Niamtu said. The peel caused trauma to the thin facelift flap, leading to tissue necrosis with significant scarring.

Laser with facelift. Also endoscopic brow and forehead lift with four quadrant blepharoplasty. (Photos courtesy Dr. Joseph Niamtu)

When lasers entered the picture, cosmetic surgeons were hesitant to use them in conjunction with a facelift, having experiencing the failed combination of face peeling and facelifts. But because doctors could predict and control lateral tissue damage, lasers offered the ability to dramatically improve superficial and deep facial rhytides using ultra-pulsed laser technology.

"Surgeons took baby steps at lasering over facelift flaps," he said.

First laser treatments flawed The first laser resurfacing was limited to the periorbital or perioral areas. However, this presented unacceptable tissue demarcations; the central oval was treated up to - but not including - the facelift flap. (Roberts, TL. Aesth Plast Surg 1998).

As more cosmetic surgeons gained confidence in lasers and incorporated them into facial rejuvenation, different techniques evolved, most with favorable results. Some surgeons only resurfaced over deep plane flaps, and others resurfaced superficial flaps but with low fluence, low density settings, and defocused or angled beams.

"There were some reports of tissue necrosis, which further muddied the water of safe and effective treatment with combined laser resurfacing over facelift flaps," Dr. Niamtu said. "Most studies did not produce the horrific flap loss [that was] once feared," he said.

Dr. Niamtu said multiple studies have demonstrated that facelift flaps do receive an adequate blood supply if the pedicle and major perforators are preserved, thus supporting the idea of combined facial rejuvenation procedures.

One study (Whetzel TP, Mathes SJ. Plast Reconst Surg 1992) showed that all four carotid arteries and 11 pairs of perforation arteries supply the pedicle area in the central face, which nourishes the dermal plexus of the facelift flap. Dye injections showed the superficial musculoaponeurotic plane (SMAS) has little effect on the amount of vascularity reaching the dermal plexus.

The researchers concluded that blood supply is not increased by a thicker flap or by preservation of perforators in the lateral aspect of the face outside the pedicle area.

Simultaneous procedures safe Another study (Roberts, TL, Pozner JN, Ritter E. Aest Plast Surg 2000) found simultaneous rhytidectomy with lateral SMASectomy and lasering to be safe when the dissection is terminated 3 cm lateral to nasolabial folds to protect the vital vascular pedicle of the face. More aggressive dissection could jeopardize the critical perforators and decrease flap viability, especially with concomitant resurfacing, he said. The SMASectomy technique does not require extensive SMAS undermining, which assists in vascular preservation.

A third study (Koch BB, Perkins SW. Arch Facial Plast Surg 2002) found no greater incidence of tissue slough with concomitant facelift and laser resurfacing than with facelift alone. The incidence of flap necrosis with either technique fell in the range of 1 percent to 3 percent.