Facial Contouring Surgery Combined with Skin Resurfacing

71

was used. This is a pulsed laser with 50% of erbium ions in YAG, with an energy that varies from 100 to 3,000 mJ. It has great absorption in water at a wave- length of 2.94 µm, while the CO

laser, with a wave- length of 10.5 µm, has smaller penetrability in water (Fig. 71.1). This means that the erbium-YAG laser causes less thermal damage in the skin; it does not burn like the CO

laser and postoperatively has one of its greatest advantages – the shortest time of erythe- ma. This physical property allows it to act in deeper layers of the skin hardened by time, smoothing its surface and returning its original texture with a brief recovery period. In the same way, this type of laser is used in combination with facial lifting when remov- ing the actinic and sun spots of the skin mainly in gerodermic skins that have suffered from the ageing process owing to the overexposure to solar radiation.

The procedure is accomplished under local anes- thesia with standby sedation. We use 5 mg midazolam (Dormonid) and 2 ml of fentanyl citrate (Fentanil).

We block the infraorbitary as well as the mandibular branches with 0.5% Xylocaine (lidocaine) with 1:160,000 adrenaline. We use the rest of the solution to infiltrate the whole area to be detached or submit- ted to the laser. The patient’s eyes are protected with ocular shells and the whole surgical nursing team should use protective glasses.

71.1 Introduction

Facial resurfacing with an erbium–YAG-laser has be- come a very common procedure in these last 9 years and a good alternative to chemical and mechanical peelings. The new generation of lasers called erbium–

YAG lasers, with their greater ablative and lower ther- mal action, has brought new progress in the treatment of wrinkles of the mouth and the eyes as well as of actinic and sun spots of the skin. In facial lifting the laser has also been shown to be a very versatile tool for finishing the surgery. In this chapter we try to show its indications, advantages, results and also its com- plications.

71.2 Method

A total of 126 patients were treated in the period from 1996 to 2004. The age group varied from 31 to 82 years and 88% of the patients were women. The main complaints they had were facial wrinkles around the mouth and the eyes, and actinic and sun spots of the skin. An erbium–YAG laser (Derma 30, ESC Med- ical Systems, Yokneam, Israel) with 3.0 J of energy

Facial Contouring Surgery Combined with Skin Resurfacing

Carlos Oscar Uebel

Fig. 71.1. The wavelength of light emit-

ted by an erbium–YAG laser is 3 times

smaller than that of a CO

laser and its

absorption in water is 10 times larger

than that of the CO

laser. This means

that erbium laser radiation is absorbed

more by the blood, does not coagulate

the blood vessels and does not produce

thermal damage in the deepest dermal

layers

The hand-piece applicator of the laser is of 3 mm diameter (Fig. 71.2) and it is connected to an articu-

late arm that allows mobility and comfort of the sur- geon. The application can be in a circular movement or forwards and backwards, depending on the indi- vidual case. For the correction of wrinkles and palpe- bral spots, we use an energy of 1,800 mJ at a frequency of ten pulses per second. The ablative process in this area is more delicate as the skin is much thinner. We recommend one or two blasts until bleeding from the dermis appears. In the lateral area, close to the “chick- en” feet, we can pass the bundle of light rays two to three times until the basal layer is reached. In the face, principally in the area of the cheeks and the zygomat- ic areas, we use an energy of 2,200 mJ, which allows more efficient removal of the actinic and sun spots of the skin. In facial lifting, we have been using an erbi- um laser almost routinely, because of its minimum thermal damage and since it is applied in one or two blasts, it allows us to detach the skin without causing trauma (Figs. 71.3, 71.4). The lips are an area where we can get outstanding results – we use an energy

Fig. 71.2. The hand-piece applicator is of 3 mm diameter and it is articulated in a mobile arm. The eyes of the patient should be protected with intraocular shells

Fig. 71.3. a , b Patient of 48 years with

cutaneous aging, actinic spots and

multiple facial wrinkles. c, d Three

days postoperatively. Two passes

of the erbium laser with an energy of

2,200 mJ, associated with minilifting

and blepharoplasty. Skin appearance

with a discreet erythema around

the zygomatic area. (Fig. 71.3 e,f

see next page)

Fig. 71.3. Continued. e, f Six months postoperatively showing skin of good texture and elasticity

Fig. 71.4. A 36-year-old patient with ageing skin and hyperchromic sun spots submitted to a minilifting and two passes of a 2,200 mJ erbium laser.One year postoperatively with a good skin resurfacing

Fig. 71.5. In the peribuccal and superior lip areas, we found one of the best indications for the use of an erbium laser. The con- trolled ablation, with an energy of 2,400–2,600 mJ, can remove

in layers the thick and hardened skin. The end point is when

bleeding begins

from 2,400 to 2,600 mJ depending on the thickness and the depth of the wrinkles. The prolabium is very susceptible to the ageing process, with multiple wrin- kles and thick dermal layers. The ablation in layers allows us greater control and we can apply several passes even before we reach the basal layer. The be- ginning of bleeding is the point where we should in- terrupt the procedure (Fig. 71.5), unlike for the CO

laser, which coagulates the blood and cauterizes the microvessels.

71.3

Erythema and Postoperative Care

At the end of the surgery we apply an ointment, pro- teolytic enzyme base (Fibrase, Iruxol), which should be applied daily for 5–7 days until the first crusts be- gin to fall off. We did not use the closed method, pre- ferring to maintain the open face and moistening it with creams and ointments. We did not recommend antibiotics but in some cases we indicate anti-inflam- matories of the type Propoxifeno. For patients who complain of pain or ardency we recommended the use of Tylex (paracetamol and codeine). After the crusts have fallen off, the patient starts to apply skin creams and sun block with a sun protection factor of 30 or 40. That is of great importance as the skin no longer has the superficial layers and this will increase hyperchromia owing to stimulation of the melano- blasts. We recommended the patient avoid exposure to the sun as well as exposure to fluorescent lamps and television screens.

The postoperative erythema can last for 3 weeks to 3 months. For patients with superficial laser treat- ment, the erythema tends to disappear more quickly (Fig. 71.6), while for patients with deeper ablation, with the intention of removing scars or more pro- nounced wrinkles, the erythema can last up to 2–

3 months. The unprotected skin will leave the deepest layers exposed and a longer time will be needed for reepithelialization. It is important that we inform the patients that the final result will not be apparent be- fore 3 months.

71.4 Results

Facial resurfacing with an erbium laser has shown surprising results. The quality of the skin, i.e., the elasticity and the softness, is improved in patients treated with this method. The ablation of the superfi- cial layers together with the actinic and sun spots of the skin and of the small wrinkles returns the skin to its youthful and original texture. In 90% of the cases we also perform minilifting, with a small scar, mini- mum detachment and skin excision, allowing a more effective and long-term result (Figs. 71.7–71.9). In these cases we recommended an operative program of maintenance of skin quality using moisturizing creams and sunblock for an indefinite time. Any of the advances that we can achieve with chemical, me- chanical or laser peeling are of little significance if we do not advise the patient to take care of the effects of time, of diet and of physical health. This concern is

Fig. 71.6. A 46-year-old patient submitted to minilifting with an erbium laser in the whole face using an energy of 2,200 mJ in two passes. After 3 weeks discreet erythema and a face with

edemas are still noted and after 8 months a quite natural result

with skin of good texture is seen

very important and we recommended frequent re- views with the surgeon or dermatologist. Some pa- tients do not accept the idea of the minilifting and they just want to have the skin spots removed to have a healthier appearance and at the same time they want to eliminate mainly the spots on the backs of their hands (Figs. 71.10, 71.11).

The area of the eyelids is very delicate and the ap- plication of the laser should be made with great care, protecting the ocular globe with intraocular opercu-

lum. The results are as significant in women as in men (Figs. 71.12, 71.13). Hyperchromia, which has the aspect of “hollow circles,” is difficult to treat once it reaches the whole thickness of the palpebral skin.

We can achieve an effectiveness of not more than 70%

(Fig. 71.14).

In the peribuccal and the superior lip areas we have obtained good results. This is where the skin is thick- er, with less elasticity and where larger number of ex- pression wrinkles can be found (Figs. 71.15–71.17).

Fig. 71.7. A 46-year-old patient with

precocious ageing submitted to facial

minilifting with an erbium laser. Four

months and 2 years postoperatively

showing good skin resurfacing

Fig. 71.8. A 62-year-old patient also submitted to minilifting with an erbium laser in the whole face. In the close-up, a good result

is observed around the mouth and lips

Fig. 71.9. A 71-years-old patient showing the result at 3.5 years with the same tech- nique: minilifting with an erbium laser in the whole face and peribuccal region

Fig. 71.10. A 75-year-old patient sub- mitted to erbium laser treatment in the face and in the back of the hands.

Result at 12 months

Fig. 71.11. A 68-year-old patient also

submitted to skin resurfacing with an

erbium laser. The good recovery of the

skin after 8 months can be seen

Fig. 71.12. A 47-year-old patient submitted to blepharoplasty. Postoperative result at 3 week

Fig. 71.13. A 38-year-old patient submitted to blepharoplasty with an erbium laser with 1,800 mJ. Result at 8 months

Fig. 71.14. A 54-year-old patient with inferior eyelid hyperchromia and “hollow circles.” Result at 3 months showing an improve- ment of 70%

Fig. 71.15. A 72-year-old patient with intense ageing in the

peribuccal area with deep wrinkles “crocodile”-type skin. We

used an energy of 2,600 mJ. Postoperative result at 3 months

with discreet erythema and at 2.5 years

Fig. 71.16. A 68-year-old patient submitted to minilifting with an erbium laser in the whole face (2,200 mJ) and three pass- es of 2,400 mJ around the mouth and lips. The results after

3 months and 3.5 years show the respective “close-up.” In a later postoperative stage, discreet hypochromia is observed

Fig. 71.17. A 53-year-old patient submitted to conventional lifting with eyelids. Erbium laser application in the whole face and

around the mouth. After 8 months we improved the “Cupid’s arch” with filers

71.5 Complications

The most common complication is hyperchromia in the order of 20% of the patients treated. The skin without its superficial layer is unprotected from UV radiation. It is not enough for the patient to protect himself/herself against the sun, protection must also be sought against radiation from fluorescent lamps and television screens. In these cases there is stimula- tion of melanoblasts and melanocytes and so there is an increase in melanin. A sun protection factor of 30–60 is indicated for effective protection. For treat- ment of hyperchromia we indicate pure 5% hydroqui- nonecream for 2 months (Fig. 71.18). Hypochromia is rare and appears in those cases where the ablation is deeper. It happens 12 months after application of the laser. Perforation lesions or burn scars are more re- lated to the thickness of the skin and to the attempt to eliminate wrinkles, stains and deeper actinic lesions by concentrating the bundle of light rays for a pro- longed time at these points. This can cause an ulcer- ated lesion that will undergo a second healing process without visible scars (Fig. 71.19). Herpetical lesions can occur on the lips in about 5% of the patients

(Fig. 71.20). The herpes simplex virus already exists in these patients and because of the decrease of the local immunity the signs become evident within 4–5 days postoperatively. We recommend the use of acyclovir (Zovirax) in a dosage of 800 mg/day for 5 days and in patients that have a history of herpes we recommended the use of prophylatic acyclovir, 6 days before the application of the laser in the same dosage of 800 mg/day.

71.6 Conclusion

The erbium laser’s use in facial resurfacing has shown very interesting results mainly in the areas of the eyes and of the mouth where we have difficulty with the action of chemical and mechanical peelings. Its versa- tility and its minimum thermal damage with short postoperative time of erythema allow it to be associ- ated in undermined areas in facial contouring sur- gery. The medium-tem and long-term results showed that the erbium laser is a device that can add value to the surgery and allows a better refinement of the facial contour.

Fig. 71.18. Patient submitted to conventional lifting and ap- plication of an erbium laser in the whole face. Hyperchromia occurs in the third month after surgery owing to exposure to

the sun. It was treated with 4% hydroquinone and the result

after 2 years is shown

Fig. 71.19. Ulcerated area in a patient submitted to minilifting with an erbium laser of 2,200 mJ. The con- centration of the energy of the laser in the attempt to eliminate an actinic lesion produced a superficial ulcer that reepithelialized after 45 days. One year postoperatively showing the complete recovery of the area

Fig. 71.20. Herpes simplex virus lesions in a patient’s peribuccal area submitted to erbium laser treatment. Involution of the pro-

cess after 45 days using of acyclovir

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