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    Combining lasers with more invasive aesthetic procedures requires caution


    Combining today's lasers and other energy sources with aesthetic surgical procedures may be a daunting proposition for many cosmetic surgeons, particularly for more "old-school," traditional professionals.

    Dr. Niamtu
    "In order to keep in step with the times and to better serve their patients, many physicians seek to incorporate lasers in their surgical procedures. However, many may find it difficult to embark on this endeavor, mostly because of the multitude of aesthetic devices on the market and/or inexperience with them and not knowing when to implement them," says Warren B. Seiler III, M.D., owner and medical director of Seiler Skin Cosmetic Laser Center, Birmingham, Ala.

    One of the quintessential combinations of lasers and plastic surgery is seen when an older individual with severe skin laxity requires major skin tightening (especially in the face and the neck). In the majority of cases, lasers alone will not tighten the skin sufficiently; these patients usually will need a more invasive face and/or neck lift surgery first, followed by CO2 and/or fractionated laser treatments to help improve the texture, fine lines and dyspigmentations on their skin.

    "The concomitant use of laser resurfacing with facelift, browlifts and blepharoplasty can be a controversial combination, and in my opinion, simultaneous laser and facelift should only be attempted by those surgeons with extensive experience with laser resurfacing and facelift surgery. This may sound obvious, but combining facelift and laser is simply not for the novice surgeon," says Joe Niamtu III, D.M.D., F.A.A.C.S. Dr. Niamtu is a board-certified oral and maxillofacial surgeon with a practice limited to cosmetic facial surgery in Richmond, Va.

    FACELIFTS FIRST When combining facelift and laser procedures, Dr. Niamtu typically performs the facelift first and does the laser work last. Although some surgeons only laser very small facelift flaps, Dr. Niamtu says he does not limit the extent of the flap dissection when performing simultaneous laser resurfacing.

    "Before I close the incision, I mark the extent of the flap undermining. I treat the central oval of the face normally and will perform up to three passes of high-fluence, high-density resurfacing. When I get to the junction of undermined flap, I maintain the laser fluence but decrease the density and perform a single non-debrided flap. Alternately, the surgeon can maintain the density but decrease the power," Dr. Niamtu says. "Some surgeons do not lower settings at all when switching from normal skin to undermined skin, but I don't personally recommend that."

    The timing of a laser procedure following surgery depends on the invasiveness of the surgery, he says. Larger surgeries will not only require longer healing times, but also the extended use of bandages and wraps.

    According to Dr. Niamtu, the use of post-facelift dressings can complicate laser healing from the abrasion of the dressing on the raw skin. As a result, he says he has moved from occlusive dressings on lasered skin to simply covering the area with a petrolatum-type dressing. This approach does not aggravate the lasered tissue, and there is no obstruction of the healing flap, as sometimes seen with traditional facelift dressings.

    "One thing that is very well known in the surgical and laser community is that you have to be careful with an aggressive laser peel on top of a full-face lift, which typically entails major dissection of tissues including the SMAS," Dr. Seiler says. "Here, there is some concern for either over-tightening the skin and/or damaging the blood supply, which can be microscopically damaged and compromised during the surgery."

    BROWLIFT FLAPS AND EYES When lasering over an endoscopic browlift flap, Dr. Niamtu says he makes no separate distinction, and since the flap is thick and subperiosteal, he typically uses traditional multipass, high-fluence and high-density settings.

    "However, I do change my settings when lasering over a subcutaneous browlift flap. I treat this flap as I would a facelift, as it is much thinner than the endoscopic brow flap. Again, I use the same fluence, but decrease the density and only use a single laser pass," Dr. Niamtu says.