The greatest fear of using lasers subcutaneously in the face is that facial motor nerve injury will occur. With SmartLifting procedures, this is not a complication that occurs provided the laser and surgical guidelines are followed. We have seen several short-term, marginal mandibular neuropraxias in several patients, all of which resolved within weeks. There have been no permanent nerve injuries in any patient undergoing SmartLifting procedures. There is temporary interruption of cutaneous sensory nerves during the rhytidectomy, and the resolution of the temporary sensory deficits is identical to the resolution of non–laser-elevated rhytidectomies.
History of laser lipolysis and internal aesthetic fiber laser–assisted surgery
The history of laser lipolysis is brief and has been summarized well by DiBernardo, who notes that Apfelberg is credited for describing the laser-fat interaction in 1992, and that publications by Blugerman, Schavelzon and colleagues, and Goldman and colleagues followed in which each showed their own experience with lasers on adipose tissue. Badin and colleagues also highlighted the important tissue retraction that he noted with his technique of laser lipolysis. Ichikawa and colleagues published on the histologic evaluation of tissue treated with laser lipolysis, showing the destructive changes of heat-coagulated collagen fibers and degenerated fat cell membranes with dispersion of lipid after laser irradiation of human specimens. These histologic changes correlate with clinical changes seen by both physician and patient. Further, the hemostatic properties of the 1064-nm wavelength have been well documented and are discussed later. The thermal effect produced by the neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser (1064 nm) in the adipose tissue promotes better hemostasis, resulting in less surgical trauma and wound healing with fewer adverse sequelae. In addition to the histologic evidence, the clinical evaluation shows improved postoperative recovery, resulting in a more rapid return to daily activities with an excellent aesthetic result. The application of laser lipolysis to facial and neck rejuvenation, in conjunction with the advanced facial rejuvenation techniques of SmartLifting, were introduced by Gentile in 2007. The initial procedures were performed with the SmartLipo 1064-nm laser but, on introduction of the SmartLipo MPX, the 1064/1320-nm multiplexed laser was used. Although these lasers were introduced for the purpose of lipolysis, it became evident that, for the facial plastic surgeon, the lasers had significant hemostatic and tissue-tightening effects. External laser treatment of human skin does produce a remodeling of dermal collagen and elastin fibers as well as the stimulation of neocollagen. In other aesthetic devices, the epidermis and dermis presented itself as an obstruction to getting optical or electrical energy into the deeper dermal and subcutaneous layers. Internal aesthetic lasers bypass this obstruction and hence are better positioned to perform thermodermoplasty or shrink-wrapping of the facial and neck skin envelope. The use of internal aesthetic lasers is a new modality and the benefits of these innovative or technology-enabled techniques can be assessed by examining the factors listed in Table 1 regarding the potential benefits provided by introduction of a new technology-enabled technique. New technology should not only introduce another particular technique, it should be proved to offer the specific benefits that are detailed in Table 1 .
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