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Simultaneous Rhytidectomy and Full-Face Carbon Dioxide Laser Resurfacing a Case Series and Meta-Analysis

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Simultaneous Rhytidectomy and Full-Face Carbon Dioxide Laser Resurfacing a Case Series and Meta-Analysis ORIGINAL ARTICLE Simultaneous Rhytidectomy and Full-Face Carbon Dioxide Laser Resurfacing A Case Series and Meta-analysis Brenton B. Koch, MD; Stephen W. Perkins, MD Background: The combination of facial rhytidectomy Selection: Referred sample patients were determined by and full-face carbon dioxide laser resurfacing would theo- the single operating surgeon who performed all proce- retically provide for superior aesthetic rejuvenation of the dures. For literature meta-analysis, only peer-reviewed face, but some reports have advised against this combi- studies of simultaneous rhytidectomy and full-face la- nation (particularly using chemical peel). However, sig- ser resurfacing from January 1997 through May 2000 were nificant differences exist between previous studies of com- included. bination therapy. Results: Among the 30 patients treated over our 26- Objective: To evaluate these differences and deter- month case series accession period, there was no evi- mine protocol for care and carbon dioxide laser settings dence of flap loss, skin slough, infection (viral or cellu- for resurfacing when done in combination with full- litic), or hypopigmentation. Settings for laser resurfacing face rhytidectomy. were determined. Of the 453 patients included in our meta-analysis, 1 (a smoker) sustained a 2-cm full- Design: (1) A case series of 30 patients treated in a pri- thickness flap necrosis, and 4 sustained varying degrees vate practice over 26 months with simultaneous rhyti- of skin slough in the postauricular area without full- dectomy and full-face laser resurfacing; (2) a meta- thickness necrosis. The complication rate did not differ analysis of 31⁄2 years of literature reporting the same from that of rhytidectomy alone. combination procedure (453 patients). Variables evalu- ated include rhytidectomy technique, laser type and set- Conclusion: Simultaneous rhytidectomy and full-face tings, postoperative care, complications, and outcome carbon dioxide laser resurfacing can safely provide a analyses. dual cosmetic benefit option for aesthetic rejuvenation of the face. Outcome Measures: Rate of postoperative complica- tions, premorbidity, previous surgery, concurrent pro- cedures, postoperative dressings, and follow-up status. Arch Facial Plast Surg. 2002;4:227-233 HE COMBINATION of rhytidec- METHODS tomy with simultaneous full- face laser resurfacing re- For the present case series, all patients treated mains a rarely used option in our practice with simultaneous rhytidec- for the dual cosmetic ben- tomy and full-face carbon dioxide laser resur- efit of rejuvenation of the face. This com- facing from February 1999 through April 2001 T were included. The indications, risks, tech- bination could treat skin laxity and infero- medial dermatochalasis as well as the signs niques, and alternatives of the planned proce- of surface aging such as fine rhytids, kera- dures were discussed with the patients preop- eratively. All patient questions were discussed toses, and lentigines of the facial skin. and answered, and documented informed con- sent was obtained prior to surgery. All proce- See also page 234 dures in this case series were performed at the Meridian Plastic Surgery Center in Indianapo- While this technique has been pre- lis, Ind, by the same primary operating surgeon viously documented,1-9 significant differ- (S.W.P.). Information evaluated in this case se- ences exist between these studies. The goal ries included postoperative complications, of this case series and meta-analysis is to premorbidity, previous surgery, concurrent pro- From Carithers and Koch cedures, postoperative dressings, and fol- Facial Plastic Surgery, illustrate these differences, evaluate the low-up status. Des Moines, Iowa (Dr Koch), safety of combining these techniques, and The meta-analysis included only peer- and Perkins Hamilton Facial discuss settings and variations in tech- reviewed articles published between January Plastic Surgery, Indianapolis, nique used on a large number of patients 1997 and May 2000 with outcomes regarding Ind (Dr Perkins). over 3 years. the practice of simultaneous rhytidectomy and (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 4, OCT-DEC 2002 WWW.ARCHFACIAL.COM 227 ©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/04/2021 The superior triangular portion of the SMAS was ad- vanced, and the redundant preauricular portion excised. This was suspended with buried 0 polyglactin 910 suture (Vicryl; Ethicon Inc, Somerville, NJ) at the level of the helical inser- tion and the postauricular mastoid fascia. Polydioxanone su- tures (3-0) were then used to reenforce the platysma-SMAS unit in the mastoid, infra-auricular, and preauricular areas. The skin was advanced in a more posterior vector with 4 to 6 cm of undermined skin in the preauricular region remaining. The skin from the neck was advanced to the posterior mastoid hairline. A single suspension in the high postauricular region was performed and the hair-bearing portions reapproximated with staples. The skin was sutured with running interlocking 5-0 plain catgut sutures. Just prior to the closure, a drain was placed in the neck portion of the wound on either side. Figure 1. Complete elevation of the subcutaneously undermined facial LASER RESURFACING TECHNIQUE skin flap. The face had been preoperatively washed with Septisol (San- full-face laser resurfacing. Outcomes included incidence of com- dent Co, Murfreesboro, Tenn). A Coherent UltraPulse 5000 plication and determination of safety of this procedure. The tech- laser (Coherent Inc, Palo Alto, Calif) was used for full-face la- niques for rhytidectomy as well as type of laser used and meth- ser resurfacing. The first laser pass on the face, except for the ods for delivery of laser energy varied from study to study, and upper and lower eyelids and preauricular area, was performed these differences were analyzed. at a fluence of 300 mJ, a power of 60 W, and a density of 6, with square pattern generator size 9. The surface char was re- RHYTIDECTOMY TECHNIQUE moved with wet and dry 4ϫ4-in gauze. The second pass on the full face included the first pass on the eyelids and preau- A modified deep-plane (biplanar) rhytidectomy was per- ricular area and was performed at a fluence of 250 mJ, a power formed.10 After submental, submandibular, and jowl liposuc- of 50 W, and a density of 5 (a rectangular pattern of size 6 was tion and anterior cervical platysma plication, the neck skin used on the eyelids) (Figure 2). The surface char was re- was undermined completely. The postauricular skin flap was moved. A second pass was made over the eyelids at a fluence then elevated in the immediate subcutaneous plane and con- of 200 mJ, a power of 40 W, and a density of 4. This setting nected with the neck skin elevation. Dissection in the tempo- was also used for feathering the jawline and for selected deep ral region was performed in the subgaleal supratemporalis fas- rhytids of perioral, glabellar, and forehead regions. A chamois cia plane to the lateral orbital rim. Dissection was continued color was often obtained with visible tightening with desicca- down near the upper border of the zygomatic arch in this tion of the skin. plane. A Silon TSR dressing (Bio-Med Sciences, Bethlehem, Pa) Subperiosteal release of the lateral orbital periosteum was was applied to the full face. An Aquaphor-coated (Beiersdorf performed. In the event of an inferior sideburn incision, a dis- Inc, Norwalk, Conn), nonadherent single-layer dressing was connected temporal incision and dissection was performed. Pre- applied over the periauricular areas and Combine-Abdominal auricular skin subcutaneous dissection was begun at the level padding (Hermitage Hospital Products Inc, Niantic, Conn) over- of the helical insertion in the subcutaneous plane and ex- laid and secured with a light compressive facial garment over- tended to the lateral orbital “crow’s feet” region. Subcutane- night (Figure 3). ous dissection was continued approximately 5 to 7 cm medi- All dressings and drains (except Silon) were removed in ally in the preauricular region connecting down to the elevated 12 to 24 hours. The Silon TSR remained in place until postop- neck and postauricular flap (Figure 1) to visualize all the way erative day 4, at which time the patient began water-soaked gauze down below the mandibular margin into the neck. cleaning and reapplication of an Aquaphor barrier 5 to 6 times An incision was then made in the superficial musculo- a day. Application of anti-inflammatory cream was started when aponeurotic system (SMAS) extending from the inferior bor- complete reepithelialization had occurred (usually 7 to 8 days). der of the zygomatic arch at the malar eminence diagonally down A skin care and make-up consultation was done on postopera- to the level of the earlobe and then continuing inferiorly 1 cm tive day 10, and the patient resumed normal activities, with rea- in front of the anterior border of the sternocleidomastoid. Dis- sonable discretion, at that time. section was carried out underneath the platysma muscle ap- proximately 3 to 4 cm. Just above the mandibular margin, dis- RESULTS section was continued superficial to the masseter muscle over the premasseteric fascia. CASE SERIES Dissection was then begun in the malar region just above the zygomatic buttress in the subcutaneous plane extending just A total of 27 women and 3 men, all nonsmokers (aged inferior to the orbicularis oculi muscle. This dissection re- 41-70 years), underwent simultaneous rhytidectomy and quired release of strong dermal attachments to the malar emi- full-face carbon dioxide laser resurfacing with the Co- nence. Elevation was then extended superficial to the level of the zygomaticus muscle into the midcheek region. This tech- herent UltraPulse 5000 laser with computer pattern gen- nique differs from the standard deep plane approach in that there erator from February 1999 to April 2001. Twenty-nine is a significant amount of skin elevated in addition to the SMAS of the 30 patients underwent other procedures simulta- creating 2 separate flaps for later biplane vector suspension.
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