You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > COSMETIC SURGERY Facial Analysis for Skin ResurfacingArticle Last Updated: Aug 14, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota Michael Mercandetti is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Ophthalmology, American College of Surgeons, American Society for Laser Medicine and Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US, and Sarasota County Medical Society Coauthor(s): Adam J Cohen, MD, Assistant Professor, Department of Ophthalmology, Northwestern University Feinberg School of Medicine; Consulting Staff and Partner, Myers Wyse Center for the Eye; Edward W Chang, MD, DDS, Director of Facial Plastic Surgery Education, Assistant Professor of Otolaryngology-Head and Neck Surgery, Department of Otolaryngology-Head and Neck Surgery, Columbia University Medical Center Editors: Paul S Nassif, MD, Clinical Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Southern California at Los Angeles, University of California at Los Angeles School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Keith A LaFerriere, MD, Fellowship Director, Clinical Professor, Department of Surgery, Division of Otolaryngology, University of Missouri at Columbia; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: facial rhytidosis, facial wrinkles, facial analysis, preoperative analysis, preoperative laser resurfacing, nonablative laser resurfacing, ablative laser resurfacing, skin resurfacing, Fitzpatrick skin classification, types of rhytides INTRODUCTIONSection 2 of 11
  A comprehensive knowledge of laser systems, details and treatment parameters, appropriate patient selection, preoperative and postoperative care, and application of new technologies can produce aesthetic results that are satisfactory to both the patient and the surgeon. Before any intervention, a thorough facial analysis must be undertaken in order to promulgate an appropriate treatment plan. PREOPERATIVE HISTORYSection 3 of 11
With preoperative evaluations, surgeons seek to identify where potential contraindications to laser resurfacing may exist. As with any procedure, a detailed medical and dermatological history with emphasis on wound healing and scar formation is essential. In addition, obtaining a family history of abnormal wound healing, skin disorders, and ethnic background can facilitate an optimal outcome. If the patient has a history of collagen vascular diseases (eg, lupus, scleroderma, keloid formation) or immunologic abnormalities such as vitiligo, laser treatment may need to be avoided because these conditions can cause problems with healing and can be relative contraindications to laser resurfacing. The authors routinely request that patients complete a medical questionnaire and an aesthetic questionnaire to help identify prior or concomitant facial cosmetic treatments. ISOTRETINOIN AND RADIATIONSection 4 of 11
Ascertaining if the patient has used isotretinoin (Accutane) within 1 year before laser resurfacing is important. Some authors recommend discontinuation of isotretinoin for a minimum of 6 months before resurfacing with the erbium:yttrium-aluminum-garnet (Er:YAG) laser or the carbon dioxide laser. Others recommend waiting at least 1 year or longer. This concern stems from the effect isotretinoin has on the cells that repopulate the lasered skin surface. The epithelial cells of the adnexal structures are a regenerative source for the re-epithelialization of lasered skin. Isotretinoin and radiation exposure destroy these adnexal structures. Facial radiation has been used in the past for the treatment of acne and thyroid gland enlargement. TYPES OF RHYTIDESSection 5 of 11
Differentiation between static and dynamic wrinkles and the degree of rhytidosis must be ascertained and documented before laser resurfacing. Certain aesthetic scenarios require a combination of laser ablation and more invasive and traditional rejuvenative techniques to achieve adequate rhytide reduction. Face or midfacial lifting, forehead or brow elevation, and blepharoplasty may be coupled with resurfacing and tailored to the patient's needs. This combination of modalities may be performed together or in stages. Safety concerns do exist with traditional carbon dioxide laser resurfacing and full face lifting surgery. However, resurfacing can safely be performed in certain scenarios such as mini lifts. Rhytides exacerbated by active facial muscle contraction are more impervious to laser resurfacing than static lines are (see Image 1). Crow's feet and lateral smile lines around the eyes are deepened with smiling and can be treated with some success, as evidenced by reduction in wrinkle depth. Botulinum toxin treatment before resurfacing can lessen the mimetic-induced lines and provide a more pleasing aesthetic outcome. FITZPATRICK SKIN TYPE CLASSIFICATIONSection 6 of 11
Evaluation of facial skin pigmentation before laser resurfacing is paramount to successful results. Pigment can be inherited ethnically or acquired as in melasma or Addison disease. A higher degree of preablative pigmentation increases the risk of hyperpigmentation and hypopigmentation (see Image 2) after laser resurfacing. Hormonal changes during pregnancy can vary the amount of pigmentation, and performing resurfacing in women who are pregnant is contraindicated. Fitzpatrick devised a description of skin types known as the Fitzpatrick skin type classification. This classification denotes 6 different skin types, skin color, and reaction to sun exposure.
The higher the type and the degree of pigmentation, the greater the risk of postinflammatory hyperpigmentation. However, persons who have minimal pigmentation or light skin can develop prolonged postoperative erythema but are less likely to develop the pigmentary sequelae. Pretreatment regimens with bleaching agents commonly are employed; however, in 1999, West and Alster reported that these pretreatment regimens may not be necessary.1 However, the standard hydroquinone-based bleaching agents are not without concerns and are not available in all countries. CLASSIFICATION OF RHYTIDOSISSection 7 of 11
Glogau developed the traditional rhytide/photoaging classification scheme that is used most often today.
Fitzpatrick reported an alternative classification system that is useful in assessing the degree of perioral and periorbital rhytidosis:
Fitzpatrick also correlated these 3 classes with the following scoring system and degree of elastosis:
Mild elastosis is defined as fine textural changes with minimal skin lines. Moderate denotes a yellow discoloration of individual papules (papular elastosis). Severe describes marked confluent elastosis with thickened, multipapular, and yellowed skin.2 FUTURE TRENDSSection 8 of 11
The newer nonablative lasers, such as the frequency-modified neodymium:yttrium-aluminum-garnet (Nd:YAG), the broadband high-intensity pulsed light, and the flashlamp dye laser, have been reported to affect dermal collagen without resultant exfoliation. A noted benefit is the marked reduction in recuperative time, allowing patients to be treated and return to work within their lunch hour. Although none of the companies has reported equal efficacy with the carbon dioxide or Er:YAG lasers for the degree of rhytid reduction, these nonablative technologies have been shown to diminish rhytides to a variable degree. CONCLUSIONSection 9 of 11
Laser resurfacing, ablative and nonablative, is an adjunct in the antiaging treatment spectrum. These technologies can be used separately or in conjunction with other noninvasive and invasive treatments. Regardless of how these techniques are used, the recipient of them must be assessed carefully before treatment can begin. The physician must ascertain the patient's expectations and render a critical and honest judgment as to whether these technologies can deliver the expected results. If the answer is no, or if the expectations are unrealistic, treatment should be deferred and other modalities considered, if applicable. Careful pretreatment analysis is an indisputable necessity in the evaluation and treatment of facial rhytidosis. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Facial Analysis for Skin Resurfacing excerpt Article Last Updated: Aug 14, 2007 | |||||||||||||||||
