Biomedical Engineering Reference
In-Depth Information
Newer and more versatile technologies like the modulated
(coagulative and ablative mode) Er:YAG lasers and improve-
ments in treatment protocols and postoperative care regimens
have improved clinical outcomes and increased the safety of
laser skin resurfacing. This added margin of safety has made it
appealing for cosmetic surgeons to begin exploring the poten-
tial benefi ts of simultaneously combining laser resurfacing
with other surgical rejuvenation techniques.
Laser skin resurfacing has been regularly, safely, and effec-
tively combined with nonablative laser treatments in the same
session. Pigmented lesions, tattoos, and periorbital hyperpig-
mentation can be treated safely and more effectively when a
Q-switched laser (i.e., ruby, alexandrite, or Nd:YAG) is used
following ablative laser resurfacing. A 100% improvement of
facial telangiectasiae has been reported in patients treated with
the pulsed dye laser (PDL) prior to ablative facial skin resur-
facing (33).
Moreover, in both of these clinical situations, combination
treatment achieves cosmetic results that are superior to those
attainable with either laser alone. By combining ablative laser
skin resurfacing with other problem-specifi c nonablative laser
technologies, cosmetic surgeons are now more effectively
addressing multiple cosmetic concerns for their patient in a
single-treatment session.
Facial aging involves both gravity-induced ptosis of soft tis-
sue elements and photodamage of the overlying skin. Simulta-
neous rhytidectomy and full-face laser resurfacing address
both of these components of facial aging and theoretically
should produce superior cosmetic outcome than can be
achieved with either treatment modality alone. Unfortunately,
early reports of skin necrosis (34-36), after simultaneous
undermining and chemical peeling, initially discouraged sur-
geons from exploring the benefi ts of this therapeutic
combination.
However, as rhytidectomy and laser resurfacing techniques
have improved, the combination of both of these techniques
has become increasingly more popular. Cosmetic surgeons
are now regularly combining laser resurfacing with transcon-
junctival blepharoplasty, endoscopic brow lifting, and endo-
scopic face-lifts (39,299-302). A meta-analysis by Koch et al. of
10 series (493 patients) in which simultaneous treatment with
rhytidectomy and full-face CO 2 laser resurfacing was per-
formed found the complication rates to be no greater than
those previously reported for rhytidectomy or CO 2 laser resur-
facing alone (37).
The precise depth of ablation and signifi cantly smaller zone
of thermal damage produced by the Er:YAG laser as compared
with the CO 2 laser are considerably advantageous when resur-
facing the skin of face-lift fl aps that may have compromised
vascular supply. Weinstein and colleagues reported excellent
results in 98% of their 257 patients who underwent combined
face-lifting and full-face Er:YAG laser skin resurfacing. Two of
their patients, who were heavy smokers, developed small areas
of skin necrosis that healed with residual pigmentary changes.
They observed no additional cases of scarring, infection, or
pigmentary alterations in their large series (38). In another
large series of 242 patients treated with combined face-lift and
full-face resurfacing with a short-pulsed Er:YAG laser, no fl ap
complications were observed (39). A later retrospective study
of 34 patients who underwent combination CO 2 or Er:YAG
laser skin resurfacing and surgical lifting, including S-lift rhyt-
idectomy, blepharoplasty, and brow lift, reported a side effect
profi le that was similar to that reported after laser skin resur-
facing alone (303).
Given their improved effi cacy, favorable side effect profi le,
and remarkable versatility, resurfacing lasers will no doubt
continue to have a place in the armamentarium of cosmetic
surgeons striving for a comprehensive approach to facial
rejuvenation.
New Resurfacing Laser Technologies
While ablative resurfacing in experienced hands has been
shown to be safe and effective, the postprocedure recovery time
and side effects of hypopigmentation are unacceptable to many
patients. To overcome some of the morbidity and complications
associated with ablative skin resurfacing, a new concept of skin
rejuvenation called fractional photothermolysis was developed
several years ago. In contrast to ablative skin resurfacing, which
produces homogeneous thermal damage at a particular depth
within the skin, fractional photothermolysis creates microscopic
columns of thermal damage or tissue ablation and specifi cally
spares the intervening tissue. A detailed review of the current
state-of-the-art practices for ablative and nonablative fractional
resurfacing is covered in detail in chapters 7 and 8, respectively.
acknowledgments
Portions of this chapter were updated from the chapter by
Alex Carcoma and Mitchel P. Goldman in Goldman MP, ed.
Cutaneous and Cosmetic Laser Surgery. St. Louis: Mosby, 2006.
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