Key points
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With upper facial cosmetic surgery, the skin must be youthful appearing to give an overall esthetic appearance.
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Resurfacing has been an established treatment option for years with chemical peels and fully ablative laser treatments being the most common treatment options.
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In the appropriately selected patient, fractionated laser results are favorable and predictable for upper facial rejuvenation with limited sequelae and complications.
Video content accompanies this article at http://www.oralmaxsurgeryatlas.theclinics.com .
Introduction
Aesthetic treatment of the upper face has been a cosmetic concern since early Egyptian times. Potential changes seen in the upper facial aging are thinning or the epidermis, loss of elastic fibers and subcutaneous fat, weakening of underlying muscles, bone resorption, ptosis, and skin changes that are produced from intrinsic (chronologic) and extrinsic factors (photoaging). Specific changes to the skin are seen as photodamage: roughness, altered texture, discoloration, acral lentigines, mottled hyperpigmentation, decreased epidermal thickness, basophilic degeneration of dermis, decrease in collagen, decrease in dermal vessels, and epithelial atypia ( Box 1 ). Upper facial rejuvenation brings with it some of the most rewarding and dramatic results for appropriately selected patients. However, in today’s hyperkinetic society, many patients are demanding minimal downtime with appreciated results that compare with more traditional surgical procedures. When exploring the possibilities for skin resurfacing procedures of the upper face, there are many options a patient can be presented; each has its indications and limitations. The options range from superficial skin topical treatments with retinoids, α-hydroxy acids, and antioxidants to more ablative procedures of dermabrasion, chemical peels, and laser resurfacing.
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Intrinsic Aging Factors
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Epidermis thins
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Dermis and bones shrink
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Fine wrinkles
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Pigmented spots, lentigenes
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Dry skin
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Muscles weaken
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Loss of elastic fibers
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Fat on face decreases, psuedofat herniation
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Extrinsic Aging Factors
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Epidermis thickens
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Dermis thins
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Coarse wrinkles, deep wrinkles, furrows
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Mottled, uneven, roughened skin
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Skin growths
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Epithelial atypia
All cosmetic lasers work by absorption of laser light to a certain selective chromophor (blood, melanin, water, etc). The gold standard for facial skin resurfacing is the carbon dioxide (CO 2 ; 10,600 nm) laser. This modality can give predictably satisfying results but comes with greater risks and complications. Pain, swelling, infections, prolonged recovery, hyperpigmentation or hypopigmentation, and scarring must be discussed and understood in detail. To minimize these sequelae/complications, initially nonablative technologies were explored. Rejuvenation technology of near infrared 1319 to 1320 nm, intense pulsed light, 532 nm potassium titanyl phosphate, and 585 to 595 nm pulsed dye lasers were explored, but gave minimal skin tightening affects. This shortcoming led to the exploration of nonablative fractional photothermolysis. Fractional photothermolysis is a concept of creating microscopic thermal wounds into the skin that allows for more rapid healing. The first commercial nonablative fractional photothermolysis 1550 nm was cleared by the US Food and Drug Administration for the treatment of periorbital rhytids, pigmented lesions, melasma, skin resurfacing, acne scars, and surgical scars. Patients had little to no downtime and tolerated the procedures well, most of the time needing between 4 and 6 treatments. There are many devices that are available currently.
The evolution of nonablative fractional photothermolysis lasers to ablative lasers occurred to try to obtain results more resembling traditional fully ablative resurfacing. There are many wavelengths that can be used, but CO 2 and Er:YAG (2940 nm) lasers are the 2 most commonly used currently. Er:YAG lasers have a 25-fold greater affinity for water when compared with CO 2 lasers. This allows the Er:YAG laser to ablate tissue well but does not produce significant lateral thermal heating, which results in less ultimate tissue tightening. The goal of this treatment is to reduce facial rhytids, skin irregularities, lentigines, keratoses, benign and precancerous lesions, reduction/removal of dyschromias or uneven pigmentations, and acne scars/scarring ( Box 2 ). This treatment can have minimal to moderate downtime (0–7 days typically), may require a form of topical, local, or intravenous anesthesia, and may require multiple treatments to gain the best ultimate results. This controlled skin ablation and thermal coagulation leads to improved skin texture and reduction of fine lines as well as dermal tightening and shrinkage for wrinkle reduction. Histologic evidence of neocollagenesis is noted at 1 month, continued collagen maturation until 4 to 6 months, and may continue to evolve over 1 year to see the final tightening effect.
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Reduce rhytids.
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Reduce skin irregularities.
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Reduce lentigines, keratosis, and benign precancerous lesions.
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Reduce dyschromias or uneven pigmentations.
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Reduce acne scarring or scars.
The ablative fractionated lasers work much the same as the traditional lasers, but the beam is split by a lens into several microbeams. Instead of ablating all the skin tissue, partial ablation is performed creating columns (microthermal zones) while leaving a percent of the skin intact. The microcolumn healing process occurs through delivery of the degenerated necrotic tissue outward to the epidermis, known as microscopic epidermal necrotic debris, which is unique to fractional thermolysis. The skin healing process from the pilosebaceous unit, serving as the progenitors from their base up the hair shaft and then out laterally is also known as epiboly . This type of ablation allows for fewer overall complications, especially quicker recovery, less erythema, and decreased risk of pigmentation changes or scarring with high patient satisfaction ( Box 3 ). Depending on the parameters used, multiple treatments many be indicated to gain the ultimate desired results. Each laser system has its own protocol for treatment. The fractionated laser pulse usually can be selected to a variable scanning size and shape to assist in treating different topographic areas of the face. The parameters may also allow the operator to select how the pattern is delivered to the skin ( Videos 1–3 ). These computer pattern generated (linear lines, zig zag lines, random, etc) injuries spread the heat in the tissue and may help with comfort. Specific settings of the laser beam may include output power (Watts) that determine the depth of penetration; percent of coverage, determined by the distance between each column in the treated region; and the length of time the laser beam column stays in contact with the surrounding tissues (dwell time), this determines the amount of collateral tissue injury. The zone of surrounding residual thermal damage is more important in neocollagenesis than the depth of ablation. But, there is some thought that ablative fractionated lasers may be superior to traditional resurfacing devices for skin tightening in that they can penetrate deeper into the dermis with lower risks of adverse events. The current fractionated laser the author uses also allows for a pulsed emission that consists of a rapid ablation of the epidermis and the first layers of the derma, whereas the second part of the pulse has low peak power allowing for targeted heating of the deeper areas of the skin. Although these are individual settings, they all interplay with each other and are dependent on the condition(s) being treated and the patient’s desires, resulting in a variety of results. As the parameters are escalated to obtain more dramatic results, the length of recovery and risks increase proportionately.
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Fewer overall complications
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Quicker recovery
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Less erythema
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Decreased risk of pigmentation changes or scarring
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High patient satisfaction
Before any ablative skin resurfacing procedure is performed, a standard thorough workup is indicated. Contraindications to laser skin resurfacing may include history of hypertrophic scarring/keloid formation, systemic isotretinoin within 1 year, previous recent medium to aggressive resurfacing procedure, recent open flap procedures within 6 months, immunocompromised patients, autoimmune and collagen vascular diseases, severe herpetic outbreaks, and pregnancy/current lactation. Diseases such as vitiligo and psoriasis, which have koebnerizing features, are considered relative contraindications ( Box 4 ). Once the patient is deemed an appropriate candidate, each practitioner will have their own specific algorithm from skin preparation to postoperative care. Depending on the patient’s skin classification (Fitzpatrick, Glogau, Baumann, etc) the practitioner may recommend certain topical products. There are too many products to discuss in detail in this article, but may include a cleaner, toner, topical retinoid/tazarotene, bleaching agents (hydroquinone/kojic acid/azelaic acid), and sun blocks. Antioxidants such as vitamins E and C are common agents to combat oxygen radicals and appeal to the public as wholesome, natural substances. Microdermabrasion and light chemical peels may also help to prepare the skin for a more predictable resurfacing procedure. Some of these products may be stopped a few days before the procedure to decrease sensitivity of the procedure.
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History of hypertrophic scarring/keloid formation
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Systemic isotretinoin (within 6–12 months)
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Recent medium to aggressive resurfacing procedure
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Recent open flap cosmetic procedure
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Severe herpetic outbreaks
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Collagen vascular diseases
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Pregnancy/current lactation
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Relative contraindications
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Vitiligo, psoriasis, koeberizing features
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Immunocompromised patients
Alternative options are discussed with the patient in detail. Medical microneedling is an entry-level skin resurfacing procedure. There are many proprietary devices that create small channels in the skin to standard or programmed depths. There is no thermal effect, but the microchannels can create new collagen and elastin stimulation, known also as collagen induction therapy. Certain products can be placed topically to help potentially aid in skin maturation and healing. Dermabrasion, although still practiced by some, has fallen out of mainstream favor for newer technologies mainly owing to it being technique sensitive and potentially hazardous with blood borne pathogens. Chemical peels remain a mainstay in skin resurfacing. Chemical peels come in a variety of types. Chemical peels have a mechanism of action that determine their effect and efficacy as well as different concentrations that also affect their performance. Concentration percentage is a common way to categorized peels and should be formulated by a reputable pharmacy. Trichloroacetic acid peels are common and can be applied to a level that gives predictable results. Depending on the patient’s desires, a light peel can be performed, having minimal downtime and risks. These peels can be performed in a series, 1 approximately every 2 weeks for 3 to 5 treatments. A medium peel can increase the results but brings with it more downtime and risks. A medium peel can also be incorporated with a pretreatment (eg, Jessners solution) to help produce enhanced results without the risks of multiple coats. Deep phenol peels can be performed by those with judicious experience. They must be performed in smaller regional units under cardiac monitoring.
Introduction
Aesthetic treatment of the upper face has been a cosmetic concern since early Egyptian times. Potential changes seen in the upper facial aging are thinning or the epidermis, loss of elastic fibers and subcutaneous fat, weakening of underlying muscles, bone resorption, ptosis, and skin changes that are produced from intrinsic (chronologic) and extrinsic factors (photoaging). Specific changes to the skin are seen as photodamage: roughness, altered texture, discoloration, acral lentigines, mottled hyperpigmentation, decreased epidermal thickness, basophilic degeneration of dermis, decrease in collagen, decrease in dermal vessels, and epithelial atypia ( Box 1 ). Upper facial rejuvenation brings with it some of the most rewarding and dramatic results for appropriately selected patients. However, in today’s hyperkinetic society, many patients are demanding minimal downtime with appreciated results that compare with more traditional surgical procedures. When exploring the possibilities for skin resurfacing procedures of the upper face, there are many options a patient can be presented; each has its indications and limitations. The options range from superficial skin topical treatments with retinoids, α-hydroxy acids, and antioxidants to more ablative procedures of dermabrasion, chemical peels, and laser resurfacing.
