Options in the management of the aging face. An otolaryngology-facial plastic and reconstructive surgeon's perspective.

Our objective is to keep the discussion relevant to internists and primary care providers. The presentation, evaluation, and management of the most common manifestations of the aging face are included. For organization and analytical purposes, the aging face is divided into thirds. Each procedure described addresses one segment of the aging face. Rejuvenation of the brow and eyelids, correction of facial rhytids (wrinkles), and resurfacing of fine-line wrinkles are all covered in this article.

Effects of thermal conducting media on the skin surface during laser irradiation.

OBJECTIVES: To investigate the effects of thermally conductive, optically transparent media placed on skin during treatment with the flashlamp excited dye laser (FEDL). The use of higher energy densities to treat persistent cutaneous vascular lesions may result in a decrease in the number of treatment sessions. However, increased fluences can cause complications of scarring, hyperpigmentation, infection, skin texture changes, or hypopigmentation. The thermally conductive media should assist in dissipating surface thermal energy and thereby protect the skin from the complications. STUDY DESIGN: This was a prospective laboratory study using an animal model. The results were verified in a prospective, pilot, human-use trial. METHODS: The threshold for acute skin damage and measurements of the thermal transients were made using a rabbit model. The threshold for purpura was noted with and without the use of a sapphire as a thermal conductor. The thermal transients were measured with small thermocouples placed subcutaneously. On a human subject, purpura intensities were photographed and measured using computer morphometrics after treatment with the FEDL and skin surface protection with air, glass, sapphire, and diamond as conductive media. RESULTS: With the interposition of the sapphire thermal conductor during the FEDL treatment, excessive temperature increases of the epidermis were prevented during the laser pulse compared with glass and controls. Both sapphire and diamond resulted in decreased purpuric intensities with the applications of equivalent fluences. Wound recovery time for the purpura was decreased by approximately half a day when any of the surface conductors were used. CONCLUSIONS: The decreased transient temperature and decrease in purpura seen with the use of sapphire and diamond protecting the epidermis during treatment with the FEDL should result in fewer untoward effects during treatment of vascular lesions and facilitate their management.

Comparison of wound healing using the CO2 laser at 10.6 microm and 9.55 microm.

OBJECTIVES/HYPOTHESIS: The wound healing characteristics of incisions made with the short pulsed CO2 laser tuned to 9.55 microm versus the traditional 10.6 microm were investigated. Previous studies have shown that at 9.55 microm, collagen is targeted more selectively than at 10.6 microm, which results in decreased acute thermal injury patterns. This study investigates the difference in wound healing over time between lasers and compares laser incisions with cold knife techniques. STUDY DESIGN: Randomized controlled trial using a porcine model. METHODS: Tissue from 10.6-microm and 9.55-microm incisions of 10 piglets was evaluated with histological analysis and tensiometry at 3, 7, 14, and 21 days postoperatively. A Bonferroni-Dunn corrected analysis of variance analysis at a 95% significance level was used to compare the effect of wavelength. RESULTS: The results demonstrate that although knife incisions are consistently stronger than laser incisions, the 9.55-microm CO2 laser incisions are no stronger than incisions made with the conventional 10.6-microm laser. Furthermore, histological analysis shows no difference in lateral thermal damage between lasers at 3, 7, 14, and 21 days postoperatively. The progression of collagen formation and inflammation does not differ over time. CONCLUSION: This study of wound healing using a porcine model demonstrates that the 9.55-microm CO2 laser does not demonstrate an improvement in wound healing over the traditional 10.6-microm CO2 laser. These results may be secondary to the common explosive vaporization mechanism produced by both lasers in the infrared spectrum.

Erythema after cutaneous laser resurfacing using a porcine model.

OBJECTIVES: To measure and compare postoperative erythema after laser cutaneous resurfacing using 2 carbon dioxide laser systems and varying postoperative treatment methods. DESIGN: Carbon dioxide laser systems are used as cutaneous resurfacing tools. The continuous-wave lasers have been associated with postoperative erythema, but the short-pulsed lasers reportedly result in less postoperative erythema because of shorter pulse durations. Although subjective evaluations of results have been published, a side-by-side comparison with digital photography has not been performed. Furthermore, postoperative treatment varies among physicians, and objective data about this treatment are scarce. SUBJECTS: To compare postoperative erythema, we created 240 resurfacing wounds on 8 piglets with continuous-wave and short-pulsed lasers, using the manufacturers' suggested settings. By using photography and computed color analysis, we measured the resultant erythema after 1, 3, and 5 laser passes at days 0, 1, 3, 5, 7, and 14. Tissue samples were obtained for histological analysis on days 0, 3, 7, and 14. INTERVENTION: We compared the resolution of erythema after postoperative treatment with petroleum jelly (Vaseline), a wound dressing (Vigilon), partially hydrogenated vegetable oil (Crisco), or a combination drug, bacitracin zinc-neomycin sulfate-polymyxin B sulfate on the wounds. RESULTS: The short-pulsed carbon dioxide laser resulted in an average of 22% less erythema compared with the continuous-wave laser (P<.001). No statistically significant difference in erythema was found among the postoperative treatment methods (P>.10). CONCLUSIONS: Compared with the continuous-wave laser, the short-pulsed carbon dioxide laser results in less postoperative erythema. However, the type of postoperative treatment has little, if any, beneficial effect for reducing erythema.

Interstitial Nd:YAG photocoagulation for vascular malformations and hemangiomas in childhood.

BACKGROUND: Vascular malformations and cavernous hemangiomas are common in childhood. Although cavernous hemangiomas may resolve spontaneously, aggressive intervention is required when their growth could damage vital adjacent structures, such as the orbit, nose, or tongue. OBJECTIVE: To evaluate the efficacy of interstitial Nd:YAG photocoagulation as an adjunct to intralesional and systemic corticosteroids for treatment of hemangiomas and vascular malformations that had failed to respond to other therapies. DESIGN: Prospective, nonrandomized trial. SETTING: Two referral practices of facial plastic and reconstructive surgery in tertiary care, academic medical centers. PATIENTS: Ten consecutive pediatric patients with either hemangioma or vascular malformation of the head and neck. INTERVENTION: Laser photocoagulation with an interstitial technique. The Nd:YAG fiber was introduced into the lesion via a 14-gauge angiocatheter needle, and the laser fiber was advanced as coagulation proceeded within the tissue. MAIN OUTCOME MEASURES: Decrease in the area of the target lesion, amount of energy applied, and number of treatments required to achieve reduction in size. RESULTS: Long-term follow-up demonstrated regression of the lesion in all 10 patients with good cosmetic results. The range of reduction in size was 20% to 98%. No reexpansion of the lesions was noted after a mean follow-up of 13 months. CONCLUSIONS: Interstitial photocoagulation of hemangiomas and vascular malformations is an effective treatment for carefully selected patients. When properly applied, this technique can achieve reduction in the size of these lesions without compromising cosmesis.

The long-term complications of percutaneous dilatational tracheostomy.

Percutaneous dilatational tracheostomy was adopted at our institution, because it was demonstrated to be more cost effective than standard open tracheostomy in critically ill patients. The objective of this study was to evaluate the long-term outcome and complication rate of percutaneous dilatational tracheostomy in critically ill patients. We performed a consecutive case study of all Level I trauma patients from August 1991 to May 1994 who underwent percutaneous dilatational tracheostomy. All patients were prospectively evaluated by a standard questionnaire a minimum of 1 year after the procedure. All symptomatic patients were offered fiberoptic laryngoscopy. Descriptive statistical methods and the Student's T test were used to analyze the data. Of 7054 consecutive trauma admissions, 237 tracheostomies were performed. A total of 143 tracheostomies (60%) were open, and 95 (40%) were percutaneous. Of the 95 patients, 20 were lost to follow-up, 12 died from causes unrelated to the procedure, 6 had severe traumatic brain injuries and were unable to participate, and 2 patients required conversion to an open procedure. This left a study group of 55 patients. At a minimum of 1 year follow-up, 40 patients (73%) were asymptomatic. Of the 15 (27%) symptomatic patients, two patients had acute airway compromise after decannulation secondary to subglottic stenosis. Both were recannulated and subsequently decannulated uneventfully. Six patients declined fiberoptic laryngoscopy, because their symptoms were minimal (minor voice changes in three and intermittent hoarseness in three). Nine patients underwent fiberoptic laryngoscopy, and all examinations were normal. The mean cost of standard open tracheostomy at our institution is $1134 (58%) more than the mean cost of percutaneous dilatational tracheostomy. Of the study group patients undergoing percutaneous dilatational tracheostomy, 27 per cent complained of symptoms a minimum of 1 year posttracheostomy. Of these patients, 60 per cent underwent fiberoptic laryngoscopy, and no subglottic lesions were identified. Our findings suggest that percutaneous dilatational tracheostomy is a safe, cost-effective alternative to standard tracheostomy in critically ill patients.

Auricular reconstruction with postauricular myocutaneous flap.

In the past reconstruction of large auricular defects more than 2 cm have been repaired with the use of local skin flaps from various sites in multiple stages. This entails longer hospitalization and a poorer aesthetic result. We developed a postauricular myocutaneous flap that has been used successfully in five patients. The cosmetic results are superior to previously described reconstructive techniques. This flap, which can be used in immediate one-stage reconstruction, is based on the auricular branch of the posterior auricular artery. This vessel supplies the auricularis posterior muscle, the skin over the mastoid, and the cranial surface of the auricle. This vessel was dissected and found to be anatomically consistent in five cadavers.

Cutaneous applications of lasers.

The cutaneous application of lasers today includes more selective and less damaging devices. Carbon dioxide, neodymium:yttrium-aluminum-garnet, potassium titanyl phosphate, argon, and yellow lasers are most prevalent in treating cutaneous lesions. Specific techniques in skin resurfacing, keloid excision, rhinophyma, actinic cheilitis ablation, and excision of superficial cutaneous tumors are discussed. Proper management of cutaneous vascular lesions is also presented.

Common skin lesions of the elderly.

The elderly patient can present with a variety of skin lesions of the head and neck. This article is designed to acquaint the otolaryngologist-head and neck surgeon with normal skin morphology and with the changes that occur with aging and sun exposure. Common benign and malignant skin lesions of the aging patient are discussed.

Considerations before rhinoplasty.

Patient evaluation and selection for aesthetic facial surgery and rhinoplasty in particular goes beyond assessment of anatomical indications. The selection of appropriate candidates involves an understanding of the patient's motivations for the procedure, expectations for the surgical outcome, and ego strength for tolerating the stress of operative intervention. The patient interview must be structured to give the surgeon ample information to determine the psychological and emotional stability of the candidate. Psychiatric consultation may be required if evidence is uncovered indicating psychiatric illness. Time spent informing the patient preoperatively will pay off great dividends in the postoperative period. If patient dissatisfaction does occur, validate and address the patient's concerns with a nondefensive posture.

Laser treatment of cutaneous vascular tumors and malformations.

Cutaneous vascular lesions are common in both children and adults. The vast majority of these lesions respond well to laser treatment. A select few lesions may require surgical intervention. In order to choose the optimal laser treatment for a given lesion, it is important to have a thorough understanding of the available technology. This understanding includes the characteristics of each laser wavelength, pulse duration, and possible associated epidermal cooling. Furthermore, it is important to understand the specific characteristics of each individual vascular lesion. Together, laser treatment of cutaneous vascular lesions of the head and neck region can be optimized.

Nonoperative techniques for scar management and revision.

Facial plastic surgeons are frequently called upon to manage facial scars, whether iatrogenic or traumatic. Numerous treatment modalities are available for scar management depending upon scar characteristics, age, and patient expectations. The focus of this article is to review commonly used nonsurgical methods of scar revision. These include topical applications (silicone, vitamin E, pressure dressing, herbal extracts), intralesional medication (steroids, antimitotics), soft tissue augmentation (collagen, fat), laser applications (585-nm flashlamp-pumped pulsed dye, CO(2)), cryotherapy, and make-up camouflage. Nonsurgical modalities can be used as prophylactic prevention of adverse scar formation, as definitive treatment, as intervening therapy until further surgical repair can be made, or as adjunctive treatment following surgical scar revision.

Laser safety features of eye shields.

BACKGROUND AND OBJECTIVE: A number of lasers are available for cutaneous periorbital surgery, yet not all eye shields are appropriate for all applications. We tested a variety of commercially available eye shields to assess their safety features. STUDY DESIGN/MATERIALS AND METHODS: Six commercially available eye protectors were studied. A focused laser was incident upon the shield, and the intensity and exposure duration required for visible damage to the shield were measured. We then measured the temperature on the underside of the eye shield during exposure from the laser. Time-dependent temperature measurements were made with a type-T thermocouple fixed to the eye shield with silicon grease. RESULTS: Thermal response curves and rates of warming for each of the six eye shields were generated. Plastic shields showed significant thermal damage with most of the lasers tested. The metallic shields warmed more slowly and to a lesser degree. CONCLUSION: Overall, the metallic eye shields had the most acceptable safety profile. Many of the plastic shields exhibited significant thermal damage, and therefore we discourage their use in periorbital laser surgery.

Collagen thermal damage and collagen synthesis after cutaneous laser resurfacing.

BACKGROUND AND OBJECTIVE: Objectively measure and compare postoperative collagen thermal damage and subsequent new collagen synthesis after cutaneous laser resurfacing using two carbon dioxide laser systems. STUDY DESIGN/MATERIALS AND METHODS: We created 240 resurfacing wounds on eight piglets with scanned and short-pulsed lasers using the manufacturer's suggested settings. The wounds varied with respect to the number of laser passes and postoperative survival times. Samples were harvested for histological analysis. RESULTS: The scanned laser resulted in an average of 52% more collagen thermal damage on the day of surgery (P < 0.0001) and an average of 78% more thermal damage 3 days postoperative (P < 0.0001) than the short-pulsed laser. The amount of new collagen synthesis correlated with the amount of thermal damage, with the scanned laser wounds showing 44% greater new collagen synthesis than the short-pulsed laser wounds on postoperative day 7 (P < 0.0001) and 48% greater new collagen synthesis on postoperative day 14 (P < 0.0001). CONCLUSION: Compared to the short-pulsed laser, the scanned laser results in a greater depth of collagen thermal damage with a correspondingly greater depth of new collagen synthesis after cutaneous resurfacing.