Effects of aging on the human face

As the human face ages, tissues descend; the skin thins and dries; pores enlarge; lentigines, keratosis, telangiectasias, and rhytides appear; and volume is lost. Surgery is performed to lift the soft tissues of the face, neck, and forehead to restore a natural and more youthful appearance. Resurfacing by laser, peels, or dermabrasion creates healthier and younger looking skin. Lost skin volume is replaced with fillers, volumizers, and implants. Face-lift surgery is the historical bedrock of surgical facial rejuvenation. Skin resurfacing is the tried-and-true method to rejuvenate aging skin. Total facial rejuvenation involves a many-pronged approach to the issues encountered in aging faces. Simultaneous use of these approaches shortens the time involved for both the patient and the surgeon and leads to a quicker realization of the final desired result. The technology exists today to successfully offer surgery, laser resurfacing, and volumizing concurrently.

Simultaneous surgery and resurfacing

It has long been the dictum that face-lift surgery and skin resurfacing should not be performed simultaneously for fear that undermining the skin and injuring its surface at the same time would lead to a high rate of skin necrosis. Performing face-lift and skin resurfacing at different times increases the cost to the patient because it involves 2 anesthesias, 2 facility charges, double the personnel, 2 downtimes, extra time away from work, and so on. Traditionally, resurfacing was only performed for areas of the face not involved with direct skin elevation, such as the perioral region.

There are many reports of simultaneous face-lift and laser resurfacing. Most of the studies used ablative technology to resurface the skin. The techniques used over the skin flaps involved greatly decreasing the energy, angling the beam as in feathering, and reducing the number of passes. These techniques were all performed to decrease the risk of skin necrosis. These altered techniques led to the conclusion that simultaneous treatment was not only effective but also had no greater risk associated with it.

Nevertheless, full ablative resurfacing over most of the face extends the full recovery after surgery by several weeks until skin color returns to normal. The relatively recent development of fractional carbon-dioxide (CO ₂ ) laser resurfacing has the added advantage of rapid return of normal skin color after the procedure. Thus, in most cases, the recovery period to normal appearance becomes equivalent and simultaneous for both procedures.

Simultaneous surgery and resurfacing

It has long been the dictum that face-lift surgery and skin resurfacing should not be performed simultaneously for fear that undermining the skin and injuring its surface at the same time would lead to a high rate of skin necrosis. Performing face-lift and skin resurfacing at different times increases the cost to the patient because it involves 2 anesthesias, 2 facility charges, double the personnel, 2 downtimes, extra time away from work, and so on. Traditionally, resurfacing was only performed for areas of the face not involved with direct skin elevation, such as the perioral region.

There are many reports of simultaneous face-lift and laser resurfacing. Most of the studies used ablative technology to resurface the skin. The techniques used over the skin flaps involved greatly decreasing the energy, angling the beam as in feathering, and reducing the number of passes. These techniques were all performed to decrease the risk of skin necrosis. These altered techniques led to the conclusion that simultaneous treatment was not only effective but also had no greater risk associated with it.

Nevertheless, full ablative resurfacing over most of the face extends the full recovery after surgery by several weeks until skin color returns to normal. The relatively recent development of fractional carbon-dioxide (CO ₂ ) laser resurfacing has the added advantage of rapid return of normal skin color after the procedure. Thus, in most cases, the recovery period to normal appearance becomes equivalent and simultaneous for both procedures.

Rationale for CO ₂ laser resurfacing

The use of high-energy pulsed CO ₂ lasers for facial ablative resurfacing dates back to the 1990s. It soon became accepted that 50% to 90% improvement of facial rhytides and acne scars was attainable. However, 3 issues lent caution to their use:

• 1.
  

  There was an attendant posttreatment redness to pinkness of the treated skin that persisted from several weeks to months.

  
  
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  Skin types no darker than Fitzpatrick skin type III could be treated without the threat of considerable risk.

  
  
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  Complications, although manageable and somewhat avoidable, were formidable, including scarring, infection, ectropion, and delayed hypopigmentation. It was also cautioned that one should never perform skin resurfacing and face-lift simultaneously. It was rightly feared that skin necrosis was a real risk.

Fractional CO ₂ lasers were developed to allow the persistence of nontreated skin between the columns of laser light laid down by the device used. These areas of nontreated skin permit rapid reepithelialization in 1 to 2 days. This attribute reduces risk of infection, prolonged erythema, and scarring. Another advantage of fractional CO ₂ lasers is the ability to reach the depths of the dermis where the collagen fibers are located. As age progresses, the skin loses volume, collagen fibers stretch out and disappear, and rhytides appear. As the deep wounds heal, new collagen fibers are formed as is elastic fibrin restoring volume to the tissue. In addition, the remaining fibers shrink causing the skin to tighten over time.

Efficacy of CO ₂ resurfacing

In the last few years, reports in the literature have begun attesting the efficacy of fractional laser resurfacing. Studies have demonstrated significant improvement in photoaging, reduction of rhytidosis, diminution of pore size, and improved skin laxity. Biopsy results have also demonstrated neocollagenesis and fibrosis at 3 months.

Ortiz and colleagues followed up 10 patients for 2 years, 6 with acne scars and 4 with photodamage. The investigators reported maintenance of improvement in 83% and 67% of patients with acne scars and photodamage, respectively. Recurrence of photodamage may well be due to the patient’s lifestyle.

Protection from solar radiation is necessary for all individuals, not just patients undergoing laser resurfacing. People who lead a very active outdoor lifestyle, golfers, boaters, hikers, and so on, have greater sun exposure and may not be consistently diligent in reapplying sun protection throughout the day, which inevitably leads to continued photoaging.

Complications with CO ₂ laser resurfacing

The incidence of complications from fractional laser resurfacing is lesser than that from fully ablative procedures. Ablative resurfacing has an infection rate of 0.5% to 4.5% for bacterial pathogens, whereas fractional resurfacing is reported at 0.1%. Viral infections have reduced from 2% to 7% to 0.3% to 2%. Postlaser acne eruptions are also fewer.

Scarring is a complication that can be related to technique. Using too much energy, overtreating previously resurfaced skin, and stacking pulses can all lead to scarring. The skin is more sensitive to contact and allergic dermatitis soon after reepithelialization. Significant dermatitis outbreaks and infections can lead to hypertrophic scars. Areas that are prone to scarring include the infraorbital skin, which can lead to ectropion along the mandible and the neck.

Postinflammatory hyperpigmentation (PIH) varies with different skin types and laser settings and is reported from as low as 0% to 32%. PIH is by far the most common problem after laser resurfacing, whether fully ablative or fractional. PIH resolves spontaneously, but its improvement may be accelerated with the use of 4% hydroquinone or other lightening agents.

Delayed hypopigmentation, the absence of melanocytes, is a permanent and problematic occurrence after traditional CO ₂ laser resurfacing. Hypopigmentation is delayed by 6 to 12 months posttreatment. Caution should be exercised when treating a patient who previously underwent dermabrasion or a phenol peel. Delayed hypopigmentation occurs in 8% to 57% of patients. This spread may be because of the inclusion of pseudohypopigmentation as true absence of pigment. Pseudohypopigmentation is observed after the treatment of severely photodamaged skin with actinic bronzing and many lentigines. The newly rejuvenated skin appears as having lost pigment compared with adjacent nontreated areas. The author has not observed this phenomenon in fractional laser resurfacing up to this publication.

Types of CO ₂ lasers

The many fractional CO ₂ lasers available today vary in pulse energy delivered to the skin and, accordingly, treatment depth. These lasers include Lumenis UltraPulse Encore (Active FX and Deep FX, Lumenis, Inc, Palo Alto, CA, USA), Fraxel re:pair (Solta Medical, Inc, Hayward, CA, USA), Matrix (Matrix Lasers, Coventry, England), OMNIFIT (Alma Lasers, Buffalo Grove, IL, USA), and Affirm (Cynosure Inc., Westford, MA, USA), among others. The varying parameters of pulse energy make it difficult to compare their efficacy. In 2010, Dover presented a comparison of 4 devices and reported no appreciable differences. The author’s experience has solely been with Lumenis CO ₂ lasers for more than 17 years.

Outcomes of laser techniques combined with face-lift

Given the understanding that the face ages in many different ways, techniques have been developed to address these varying problems ranging from surgical rejuvenation to skin resurfacing to volume restoration. Each modality has its own costs, risks, discomforts, and downtimes. Combining modalities reduces time and cost investments for both the patient and the surgeon. It has been reported that patients’ perception of results shifts in that they see the outcome as younger in years with combined procedures rather than with single treatments. With the advent of fractional laser resurfacing, the problems associated with concurrent treatment, such as increased infection, skin necrosis, and delayed healing, are all but eliminated.

Earlier studies attributed the incidence of skin loss when skin resurfacing is done simultaneously with face-lifts to deep chemical peels ; hence the watchword, “never do harm to the surface of undermined skin.” Early studies of simultaneous CO ₂ laser resurfacing and face-lift surgery advocated against the practice because of concerns of flap necrosis.

Koch and Perkins performed a meta-analysis on 9 studies involving 453 patients who underwent simultaneous face-lift and laser resurfacing. Complications were minimal:

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  A rate of anterior flap necrosis of 0.2% occurred in 1 patient.

  
  
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  Four patients, 0.9%, had minimal posterior flap necrosis on nonlasered skin.

  
  
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  Six patients, 1.3%, had superficial infections (3 bacterial, 2 herpetic, 1 fungal).

  
  
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  Two patients had hypertrophic scarring in nonelevated skin.

  
  
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  One patient had necrosis at the corner of the mouth.

  
  
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  There was an incident of scleral show that resolved.

The complication could be ascribed to the combined therapy only if the patient was a smoker and had anterior skin necrosis.

In 2009, Struck reported a series of 10 patients undergoing face-lift and concurrent CO ₂ fractional laser resurfacing using the Fraxel Re:Pair laser. He used an extended supraplatysmal skin elevation all the way to the nasolabial folds. Twenty percent of the flap surface area was ablated. All the patients healed without problems, leading the investigator to conclude that this combination of treatment is safe.

The single most important factor in flap survival, particularly with the dual modalities discussed here, is blood supply. In fully ablative CO ₂ resurfacing, the upper reticular dermis is the end point of treatment. This treatment depth produces some thermal injury to the dermal blood supply. When a standard skin flap elevation with superficial musculoaponeurotic system (SMAS) imbrication or plication is performed, total ablation of the flap increases the risk of flap blood supply compromise. Koch and Perkins describe their technique as a modified deep plane face-lift. Maintenance of the dermal blood supply is paramount for flap survival. Most reports describe using some variation of a deep plane lift or short skin flap, elevation of the skin-SMAS flap, and lightly resurfacing the skin flaps in some manner with the ablative laser.

Fractional laser resurfacing, by virtue of its tissue-sparing ability, allows an almost risk-free ability to simultaneously perform face-lift and laser resurfacing.

Indications for fractional laser resurfacing

The usual problems targeted for improvement with fractional resurfacing using both deep and superficial beams and Total FX are:

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  Skin with mild to moderate rhytidosis

  
  
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  Mild to moderate acne scars

  
  
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  Lentigines

  
  
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  Loss of skin volume

  
  
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  Skin laxity

  
  
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  Large pores

  
  
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  Uneven tone and color.

Other treatable conditions include:

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  Actinic keratosis

  
  
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  Seborrheic keratosis

  
  
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  Bowen disease

  
  
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  Sebaceous hyperplasia

  
  
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  Cheilitis

  
  
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  Rhinophyma

  
  
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  Xanthelasma

  
  
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  Melasma

  
  
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  Traumatic scars

  
  
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  Others.

Severe rhytidosis and acne scars require total ablation resurfacing.

Contraindications to fractional laser resurfacing

Contraindications to laser resurfacing include active infections, such as viral; bacterial, including active acne; and fungal. The use of isotretinoin within 6 to 12 months would necessitate delaying the procedure until that period has passed. The length of delay after the use of isotretinoin is not agreed on.

Further, caution should be exercised in patients with

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  Connective tissue disorders

  
  
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  A history of keloid or hypertrophic scar formation

  
  
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  Irradiated skin

  
  
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  Vitiligo

  
  
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  Psoriasis

  
  
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  Other skin diseases.