By Joseph Niamtu III, DMD, FAACS
Facelift surgery and full-coverage, ablative, high-fluence, high-density, CO2 laser resurfacing (FCAHFHDCO2) are both extremely powerful procedures for facial rejuvenation in their own right. Facelift surgery serves to restore a youthful jawline and neck, while laser skin resurfacing rejuvenates the facial skin in its entirety. A facelift, while addressing skin quantity, does nothing for skin quality. A facelift makes a tighter face, but does little to address rhytids and nothing to address actinic damage.
Surgical facial procedures such as facelift, blepharoplasty, brow lift, and facial implants are like rebuilding a vintage car. This is the bodywork. Full-face laser skin resurfacing is like painting the car. Both are important to achieve the best “restoration” or rejuvenation.
Facelift surgery has been performed for almost a century, and laser skin resurfacing procedures have been popular for about 20 years. Both remain mainstays of comprehensive facial rejuvenation around the world. Both procedures have also undergone permutations to decrease recovery time—hence, short-scar facelifts and fractional lasers. Yes, there is now a smaller surgery that can be done on an awake patient with a faster recovery, but the final result cannot equal the comprehensive final result and longevity of traditional facelift or traditional “old school” (FCAHFHDCO2) CO2 laser resurfacing.
Objectives
Three main questions face cosmetic facial surgeons, and have for the past several decades:
1. Can traditional facelift and traditional CO2 (FCAHFHDCO2) be performed simultaneously?
2. Is this combination safe, in terms of flap viability and repeatable outcomes?
3. Is the simultaneous use of laser and facelift the standard of care, and is it defendable in a lawsuit if flap necrosis or other complications ensued?
Having opined as a defense expert on several facelift/laser malpractice suits, I can attest that there is no shortage of surgeons willing to testify that simultaneous laser and facelift have no business in the same operative report. This presents that sticky legal subject of what is more valid: the standard of care or the evidence-based literature. Some surgeons require separate operations—one for facelift, and a later operation for laser (or vice versa). This involves a duplication of surgery, anesthesia, finances, and, most importantly, recovery.
Aggressive CO2 laser recovery rivals ?2 weeks, which is similar to that of a comprehensive facelift. It is hard enough for patients to take 2 weeks off for a procedure, let alone to double this.
A facelift as a sole procedure is a relatively straightforward recovery. A facelift with other procedures such as brow, bleph, and facial implants up the recovery ante. Adding a laser to all of this really intensifies the recovery and postsurgical care. Some patients cannot tolerate this.
An additional relative advantage of the combined treatment is the fact that facelift patients are numb in the immediate postop period, so laser pain is diminished. This study seeks to quantify the risks and complications associated with combined facelift surgery and FCAHFHDCO2 laser resurfacing, including flap necrosis.
Methodology
This article spans 15 years of experience by a single surgeon performing 792 facelifts. Of these, 238 (30%) had simultaneous (FCAHFHDCO2) laser resurfacing. Thirty (12.6%) of the 238 patients were admitted cigarette smokers.
All facelifts were standard anterior and posterior approaches with platysmaplasty and SMASectomy. The average distance of circumferential dissection of the flaps was about 8 cm from the external auditory canal. Several cases had lower power fractional resurfacing performed on the anterior neck (one pass of 40 mJ (3.5 j/cm2) and a density of 2). This was only a few cases, and it is not statistically significant.
Figure 1. In all cases, the terminus of the ?undermined facelift flaps were marked to serve ?as a guide for laser density adjustment.
At the end of the case (the laser is always performed last), the demarcation of the undermined and nonundermined areas were marked (Figure 1).
In all cases, the Luminis Encore Ultrapulse laser was used in a fully ablative manner with a computer pattern generator set at 80 mJ (6.0 J/cm2) with a density of 6 and 600 Hz. In most cases, the central oval of the face was treated with two to three passes of laser, and the perioral region was treated with three to five passes at the same settings. The skin surfaces were not debrided between passes, as I have shown this to be a safe procedure in the past1 (Figure 2).
Figure 2. This patient is shown 24 hours after facelift/CO2 laser and four-quadrant blepharoplasty. The central oval of the face is treated with two to three passes of full-coverage, ablative, high-fluence, high-density, CO2 laser resurfacing, and the flaps are treated with a single pass at the some power but with a lower density.
At this point, the laser settings are decreased in density from D6 (30% overlap of laser beam) to D4 (20% overlap of laser beam). Although not all surgeons adjust power or density settings, I find it safe and predictable. Next, a single pass is made over the undermined anterior facial flap with the same power setting of 80 mJ but a reduced density of 4 (Figure 3). This pass is not debrided, either.
Figure 3. This patient is shown 14 days after facelift with simultaneous CO2 laser skin resurfacing.
The lasered area is then coated with Vaniply ointment (Pharmaceutical Specialties Inc, www.psico.com), and no facelift dressing is placed. The discontinuance of traditional facelift dressings was a gradual choice. As 30% of my facelifts had simultaneous laser resurfacing, the traditional bulky full facelift dressing was irritating the lasered skin. I began using smaller and smaller dressings until it became apparent that there was no detriment to eliminating the dressing totally. This has not increased my hematoma rate or produced any negative healing or recovery problems.2 This deletion is appreciated by me, my staff, and most of all, by my patients.
I have never used drains in any facelift, but several years ago I began using two 14-gauge IV catheters in the submental region that are removed the next morning. This has eliminated my post-facelift seroma drainage.2
The post-facelift/laser regimen consists of vinegar soaks (1 tsp/cup of water) every several hours, and Vaniply application continually. The face is washed BID with Vanicream cleanser. When the skin is re-epithelialized (usually by day 9 to 10), the Vaniply is discontinued ?and Vanicream moisturizer is used continuously until healed. I use the “Vani” products (Pharmaceutical Specialties Inc) exclusively as they do not contain dyes, lanolin, masking fragrance, fragrance, parabens, or formaldehyde, and have simplified my post-laser regimen. Re-epithelialization occurs at the same rate as full-face CO2 laser without facelift (Figure 3). Patients resume Retin-A and hydroquinone at about ?4 weeks or when tolerated.
Results
A total of 792 consecutive facelifts were performed within this 15-year period. Of these patients, 554 underwent ?facelift only (70%) while 238 patients underwent facelift with simultaneous laser resurfacing (30%). Out of the total group (N=792), nine of these patients experienced preauricular flap breakdown (1.14%), defined as a preauricular ?necrosis greater than 1 cm2. Six patients with flap breakdown did not undergo simultaneous laser resurfacing (1.08%), while three of these patients did (1.26%) (Table 1).
*Preauricular skin flap necrosis greater than 1cm2
Conclusion
This preliminary data shows that the incidence of wound breakdown is similar in the two groups, suggesting no increased complication rates when performing facelift with simultaneous CO2 laser resurfacing. Of further interest, 30 of the facelift/laser patients (12.6%) were cigarette smokers.
Figures 4 and 5 detail typical post facelift/laser treatments
Laser skin resurfacing is a safe procedure when combined with cervicolfacial rhytidectomy if performed by surgeons experienced with both modalities.
This data and results support my experience that simultaneous facelift and ablative CO2 skin resurfacing is a safe and effective procedure that enhances the total rejuvenation of the case.
Although this combination of procedures is safe, it does increase post-facelift recovery and patient home care, and this must be communicated to all patients ?preoperatively.
Author note: This article represents preliminary data from an ongoing 15-year study that I intend to submit for journal publication when all data is analyzed.
Joseph Niamtu III, DMD, FAACS, is a cosmetic facial surgeon in Midlothian, Va. He is the special guest editor of this issue of PSP. Niamtu can be reached at [email protected].
References
- Niamtu J. To debride or not to debride? That is the question. Rethinking char removal in ablative CO2 laser skin resurfacing. Dermatol Surg. 2008;34:1-12.
- Niamtu J. Facelift drains and dressings: to be or not to be? Dermatol Surg. 2012;38:793-796.
