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arabic العربية

Rhinoplasty Bizrah: RELATED FACIAL SURGERY : Laser Resurfacing 2

March 27, 2017 by basharbizrah0

Vitamin C preparations: Most recently, vitamin C preparations are used for enhancing the response of collagen to the procedure. The home facial treatment formulated with 30% Vitamin C, when used weekly, will reverse and repair the environmental damage as it increases skin firmness, super hydrates the skin and improves uneven skin tone.

Topical Antibiotics: Topical antibiotics are recommended to suppress the inflammation caused by acne, rosacea, comedones, folliculitis, large pores or oily skin. Antibiotics reduce postoperative acne flare up and bacterial infection during the healing period.

Accutane (Isotretinoin): 10-20mg per day for six to eight weeks before the procedure, this is useful for patients with oily skin or active acne.

IMMEDIATE PREOPERATIVE PROPHYLACTIC TREATMENT:
On the day of the procedure, Ciprofloxan 500mgtwice a day as a coverage for Pseudomonas aeruginosa and an antiviral agent, Valacyclovir 500mg orally three times daily or Famvir (famiciclover) 250mg orally twice daily. These prophylactic treatments should continue for ten days following the procedure.

SURGICAL TECHNIQUE:
The author recommends the Shoenrock and Andrews procedure:
Planning diagram: During the preoperative evaluation, a planning diagram of the face is completed. The degree of the skin aging is noted for each facial zone and an estimated level of energy and number of passes appropriate for this degree of zonal aging are noted. Written diagrammatic notes are made as to the patient’s most significant concerns. (Figs. 18 – 19 & 20)

Surgical preparations: With the patient in the upright position, the face is marked to identify surgically relevant anatomic landmarks. For full-face laser treatment, the mandibular line and angle are marked. A demarcation of the extent of planned treatment is marked with a line that lies three cm inferior to the mandibular line. For patients with any visibility of rhytidectomy scars, these sites are highlighted with methylene blue. All deep rhytids, postacne scarring, or surgical scars that lie within the zones of planned treatment are highlighted with methylene blue markings. Because the injection of local anaesthesia leads to temporary effacement of deep rhytids in particular, these markings aid the surgeon in recalling these areas that require emphasis of treatment.

Additional surgical towels soaked with sterile water are draped about the hair-bearing scalp, lower neck and chest, only allowing exposure of the face and upper neck. The frontal and temporal hairline and eyebrows are generously moistened with water. A saline soaked 4×4 gauze is placed between the patient’s occluded teeth and lips. This aids to both protect the teeth, avert and stretch the lips. Either an anodized corneal protector is placed between the globe and eyelids or saline-soaked 4×4 gauze sponges folded into 2×2 squares are placed over closed eyelids for eye protection.

Anaesthesia: For full procedures, the face is anaesthetized with 0.5% lidocaine with

 

 

Fig. 18 – 20. Preoperative markings: deep rhytids, superficial rhytids, post acne scars and the inferior and posterior extent of the treatment.

1:200,000 epinephrine via nerve blocks of the supraorbital, supratrochlear, infraorbital, mental, zygomaticofacial and greater auricular nerves. Next, field blocks are completed by infiltration of 0.5% marcaine with 1:200,000 to each facial zone.

Principles of colour effect: The most significant improvements will occur when laser treatment leads intraoperatively to:

  1. A pink effect for submental and upper neck, preauricular, nose, malar eminence and mandibular angle.
  2. A grey effect for anterior mentum, prejowl, cheek (with exemptions as noted), preorbital and temporal regions.
  3. A grey or chamois effect for the forehead, upper lip, and lower lip regions between the vermillion border and mentolabial sulcus, or any focal areas in any facial region of postacne scarring, surgical scarring or class III or IV rhytids. Chamois effect is strictly avoided in patients of skin type IV, V and VI.

The challenge to the surgeon lies in determining the energy and density settings and the number of sequential passes and the respective settings for each pass that will reliably and safely achieve the desired colour effect (a reflection of depth of tissue penetration) for each of these regions. (Fig. 18 – 18)

Periorbital: Eye protection is achieved by corneal shield. Two passes may be used until the grey effect is achieved. Between each treatment pass, the desiccated skin is removed with a saline-soaked gauze. In each case, the laser delivery pattern orientation is rotated 450 between each application to avert any visible pattern on the skin during the healing process. In order to avoid overlapping and contraction, the laser pattern starts the eyelid margin and proceeds in the direction away from the eyelid margin.

Forehead: The forehead is treated with great care in order to protect the eyebrows and frontal temporal hairlines. Because the forehead skin is the second thickest of the face after the anterior mentum, two to four passes of treatment are typically used to achieve a desired result.

Nasal: A single pass is made along the alar margin and columella. In cases of acne rosacea or rhinophyma, additional passes are made, until the grey effect is achieved.

Cheeks: The first pass treats the cheeks and is extended to the tragal skin, earlobe and the non-hair bearing skin between the auricle and sideburn/temporal tuft. After the removal of the desiccated skin, an additional pass is made rotated by 450. This will usually lead to the desired grey effect for the cheeks.

Perioral: Usually two to three passes are adequate to achieve the grey effect. Additional passes are focused on the deep ryhtid lines until chamois effect has been obtained.

Upper neck: A single pass is used to treat the region from the inferior border of the mandible to a line drawn three cm inferiorly. An additional pass is made along the inferior-most aspect of this region using the triangular pattern at identical settings to create an intentional geometric irregularity, which is camouflaging the demarcation between treated and untreated areas (Blending Technique).

Critical Assessment: After each pass, once desiccated laser-treated skin has been removed, bright lighting is focused on the individually treated areas. The preoperative photographs and planning diagram are referenced and highlighted points of concern again examined carefully. Further additional treatment is made as needed to achieve the desired intraoperative endpoints mentioned earlier. When an incisional procedure has been performed (Rhytidectomy-forehead lift, blepharoplasty) the laser resurfacing is restricted to the skin elevated as musculocutanous flap. Skin that has undergone subdermal flap elevation should have no laser resurfacing.


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