Section 4 Plastic and Reconstructive Problems

Holcomb

delivery of laser energy at the subdermal level throughout the flap minimizes the risk of a skin flap complication. Laser flap predissection de- creases the subsequent physical effort and time required to complete the flap elevation with facelift scissors. With these treatment parameters, bleeding from some vascular perforators, both on the flap and the underlying tissue, requires bipolar cautery for hemostasis. Laser flap predissection should include subder- mal release of the zygomatic-cutaneous ligament as well as connecting the posterior cervicofacial dissection with the LAFC and LANC treatment areas. Fully coalescing the LAFC and LANC treatment areas with the posterior cervicofacial dissection enables greater posterior and vertical repositioning of the skin flaps but also requires more effective management of the skin flaps to harness the potential for improved outcomes. 7 Figs. 6 and 7 demonstrate how the LAFC and LANC techniques may be integrated into aging face surgery to enhance outcomes. Integration of the thermally confined, micropulsed 1444-nm Nd:YAG interstitial fiber laser into mini- mally invasive and surgical management of the aging face and neck provides numerous benefits and some additional treatment options that are helpful for optimization of the 3-D contours of the mid- and lower face and neck. Currently LAFC may be the best nonsurgical answer to the main limitation faced by soft tissue augmentation (ie, that it does not address adjacent areas of soft tissue fullness). As such, one-sided attempts to enhance the appearance of the face with soft tis- sue augmentation may result in exaggerated features and excess fullness in attempting to cam- ouflage descended fat in the mid- and lower face. Even subtle soft tissue debulking with LAFC improves the effective proportional enhancement of soft tissue augmentation. LANC is an effective stand-alone percutaneous procedure for mild to moderate submental and neck soft tissue excess and skin laxity. The LAFL approach expands the use of this Nd:YAG inter- stitial fiber laser beyond LAFC and LANC to predissection of surgical flaps and release of osseocutaneous anchoring ligaments while also raising the possibility for percutaneous (closed) treatment of the neck and the platysma. SUMMARY

surgery. The outline of the jowl may be readily evident with the patient in the upright, seated po- sition for preoperative marking; however, due to tissue laxity and the effect of gravity, the marked tissue slated for contouring and debulking may move both superiorly and posteriorly when a pa- tient is placed in the supine or Trendelenburg po- sition for facial surgery. 7 Ensuring adequate lower facial contouring may be accomplished by minimizing any positional tis- sue shift with a slight reverse Trendelenburg pa- tient positioning (eg, 20 ) and by isolating and stabilizing the target tissue between the user’s thumb and forefinger during local anesthesia infil- tration, laser energy delivery, and lipoaspiration. It may be, nonetheless, initially surprising to laser surgeons that the lower face LAFC procedure may involve contouring tissue a significant dis- tance above the caudal margin of the mandible in some patients (see Fig. 1 B). The central sub- mental and neck tissue is less affected by patient positioning but adequate contouring in this area also requires manual guiding of the laser fiber into the areas of tissue fullness. Although LANC enables a closed (percuta- neous) approach to the neck in some facelift patients, persistent submental fullness and/or significant skin laxity immediately after LANC are indications for converting the initially closed pro- cedure to an open procedure via a submental crease incision. Through this greater access, the effects of the LANC procedure may be assessed and any required surgical intervention (eg, midline imbrication platysmaplasty) may be performed. A recent study suggests that even though a con- verted open approach may be ideal, in many cases, surgical manipulation of the platysma may be required in only 20% of cases. 7 In cases of excess skin laxity, retrograde dissection at the lateral margins of the LANC treatment area, including subdermal release of the mandibular cutaneous ligament, may be performed via scissor dissection or laser fibrolysis. The laser may be used to initiate the posterior cervicofacial skin flap dissection via fibrolysis and shrinkage of fine skin ligaments as well as for subdermal release of the zygomatic-cutaneous ligament. Safety of the skin flaps certainly takes precedence over use of the laser for this purpose. With appropriate treatment settings, limits on total energy applied, and proper technique, this applica- tion does not require anything other than the normal local anesthetic injection technique. Typical param- eters that the author used for laser flap predissec- tion include power 5.4 W, pulse energy 180 mJ, pulse duration 100 m s (fixed), pulse rate 30 Hz, and total energy delivered 200 to 300 J. Even

REFERENCES

1. Holcomb JD, Turk J, Baek SJ, et al. Laser-assisted facial contouring using a thermally confined