Section 4 Plastic and Reconstructive Problems

Fiber Laser in Aging Face and Neck

preserved thermal confinement within the total en- ergy usage parameters suggested. The local anes- thetic mixture that the author favors for the submentum and neck includes 0.25% lidocaine, 0.125% Bupivacaine hydrochloride, 1:400,000 epinephrine, and hyaluronidase 1 to 2 IU per mL (eg, Hylenex recombinant). Initially, approximately 2.0 mL of this local anesthetic mixture is used to provide anesthesia to the percutaneous entry site as well as a field block that includes the tissue for debulking and contouring. A 1.6-mm multihole infiltration cannula (Tulip Medical Products, San Diego, CA, USA) is then used to deliver the local anesthetic to the LANC treatment area. As in the lower face, the thermally confined mi- cropulsed 1444-nm Nd:YAG interstitial fiber laser energy delivery occurs via a 600- m m silica multi- mode fiber with the fiber used either free (bare) or assembled with a disposable or nondisposable cannula. Prior studies have demonstrated general safety guidelines for energy delivery during LANC when using the micropulsed 1444-nm Nd:YAG interstitial fiber laser and minimal volume local anesthesia (dry technique)—typical parameters include power 8.0 to 10.0 W, pulse energy 200 to 250 mJ, pulse duration 100 m s (fixed), pulse rate 40 Hz, and total energy delivered 750 to 2000 J. 7 The mean total energy delivery for LANC in a cohort of approximately 180 neck contouring patients was just over 950 J whereas mean local anesthesia infiltration and lipoaspiration volumes were approximately 12.5 mL each in this same group. 7 Table 4 outlines major LANC treatment steps and typical treatment parameters. Because the neck skin is thinner (than in the lower face) and the energy delivery parameters are higher (than in LAFC), it is even more important to keep the fiber continuously moving through the

of patients with PIE, the cause of persistent full- ness with palpable subcutaneous fullness in partial responders is not known but similar mechanisms may be inferred in both the lower face and neck. Persistent fullness 6 to 12 months after LANC treatment may be addressed through a touch-up percutaneous LANC procedure. LANC treatment begins with identification and marking of the treatment area. Although patient positioning does not affect the submentum and neck soft tissues as dramatically as in the lower face, marking for LANC is conventionally done with patients in an upright, seated position to most accurately ensure inclusion of the desired tis- sue in the outlined treatment area. Depending on body habitus, the treatment zone may extend laterally well into the central and toward the poste- rior aspect of level I in the neck as well as inferiorly to or well beyond the thyroid prominence in the anterior neck. In most patients, the LANC percuta- neous entry point is conveniently placed at or just above the submental skin crease. Ensuring that the desired tissue is treated during LANC is accomplished via the following steps: (1) limiting exogenous water input with small amounts of local anesthetic used (eg, 12–24 mL); (2) using hyaluronidase to improve local anesthetic distribu- tion through the tissues; and (3) isolating and stabilizing the target tissue between the user’s thumb and forefinger during local anesthesia infil- tration, laser energy delivery, and lipoaspiration. Limiting exogenous water infiltration to approxi- mately 12 mL minimizes distortion of the anatomy during treatment, facilitates endpoint identifica- tion, and limits thermal confinement. The fatty tissue ablation efficiency of the micropulsed 1444-nm Nd:YAG interstitial fiber laser, however, enables an adequate local tissue effect with

Table 4 Major LANC treatment steps and typical treatment parameters

LANC Treatment Step Detailed Information Field block a

Include percutaneous access point and target tissue

Infiltrate target tissue a

12–24 (mean 12.5) mL each LAFC treatment area using Tulip 1.6-mm multihole infiltration cannula

Apply laser energy

1000 ( 1 ) J Typical laser parameters 8.0–10.0 W, 200–250 mJ, 40 Hz

Postcooling (thermal quenching)

Infiltrate 12-mL room temperature sterile saline (Tulip 1.6-mm multihole infiltration cannula) Mean 12.5 mL (Tulip 2.1-mm offset triple port aspiration cannula attached to 12 mL syringe prefilled with 1.0-mL saline)

Aspiration

Compression

Roll cotton and elastic compression garment

a Local anesthetic mixture contains 0.25% lidocaine, 0.125% Bupivacaine hydrochloride, 1:400,000 epinephrine, and 1 IU hyaluronidase per mL.