Matthew Robert Hlavacek

Private Practice, Kansas City Surgical Arts, Liberty, Missouri and Truman Medical Center and St. Luke’s Hospital, Department of Surgery and Oral and Maxillofacial Surgery, Kansas City, Missouri, USA

Laser ablation of the mid-dermis and above to remove senescent changes.

Indications

1. Facial rhytidosis
2. Coarse skin texture
3. Mild skin laxity
4. Minor dyspigmentation
5. Acne scarring or facial scars
6. Dermatopathologic entities (rhinophyma, xanthelasma, or actinic keratosis)

Contraindications

1. Patients with poorly controlled comorbidities
2. Anticoagulated patients
3. Patients with collagen or vascular diseases
4. Isotretinoin use within the last 6 months
5. History of facial radiation
6. Dysmorphic patients with unrealistic expectations
7. Patients with malignant facial skin pathology
8. Caution in patients with preexisting eczema, rosacea, or atopic dermatitis
9. Caution in patients with a history of hypertrophic scarring or keloids
10. Caution in patients with darker Fitzpatrick skin types
11. Caution in patients with previous facial-lifting procedures (primarily lower blepharoplasty)

Anatomy

The epidermis is the most superficial layer of the skin and contains continuously regenerating squamous epithelial cells from its basal layer. It is limited at its deepest extent by the basement membrane. The epidermis also contains varying numbers of melanocytes, Langerhans cells, and Merkle cells depending on the location in the body. This layer produces the color and texture of the skin; however, it is devoid of collagen. Deep to the epidermis is the dermis, which is divided into the more superficial papillary layer and the deeper reticular layer. The main function of the dermis is to provide support both structurally and metabolically for the epidermis. The papillary layer is a minor part of the dermis that abuts the basement membrane and contains a concentrated vascular supply. The reticular layer forms the majority of the dermis and contains collagen and elastin fibers produced by fibroblasts, the main cell of the dermis.

Technique

1. Pretreatment conditioning with retinoic acid and hydroquinone is performed 4 weeks prior to the procedure.
2. Preoperative antiviral medication is initiated 24–48 hours preoperatively and for 2 weeks postoperatively. Single-dose intravenous preoperative antibiotics are administered prior to the procedure.
3. Ensure fire precautions are in place.
4. Intravenous conscious sedation or endotracheal general anesthesia may be employed depending on if adjunctive invasive procedures will be performed.
5. An equal mixture of 2% lidocaine with epinephrine and 0.5% marcaine without epinephrine is utilized to block the supratrochlear, infratrochlear, infraorbital, mental, and transverse facial-cervical plexus nerves.
6. Laser-resistant corneal shields with lacrilube are placed.
7. A laser setting is selected that is appropriate for the laser system and the patient Fitzpatrick skin type using a random pattern or fractionated setting.

8. Ensure that the face is dry. The face is lasered in subunits, protecting the follicles of the hairline and the brow with a tongue blade (Figure 38.2 [all figures cites appear in Case Report 38.1]). Start with the forehead, and laser caudally to the inferior border of the mandible in subunits. Care is taken to not overlap laser passes.

9. Withdraw the laser off of the skin, defocus, and angle at 45° to blend the laser over the inferior border of the mandible (Figure 38.3). Feathering of the thin cervical tissue may be performed with lighter laser settings.
10. A second pass is made with or without debridement, depending on the surgeon’s preference. (Figure 38.4). Problem areas may require additional passes with the laser. Make consideration to reduce the energy around the eyes and increase the energy around the mouth and deeper acne scars.
11. At the completion of the laser treatment, the face is covered with a thin layer of emollient (aquaphore) (Eucerin, Montreal, Quebec, Canada) (
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