Practical Plastic Surgery

Major complications occur in 0.1–0.3% of patients and include:

•DVT or PE

•Cannula penetration of the abdominal or thoracic cavity 70 • Significant hemorrhage

•Hypovolemia due to inadequate resuscitation

•Fat emboli

Complications from the tumescent solution are rare but account for most of the deaths from liposuction. Most authors recommend overnight monitoring for patients undergoing large volume liposuction (greater than 5 liters of total aspirate). Complications include the following:

•Electrolyte abnormalities can occur in large volume liposuction due to massive fluid shifts and electrolyte losses. Intraoperative hypokalemia is common but usually corrects itself rapidly. Symptoms from electrolyte abnormalities are uncommon but should always be evaluated.

•Volume overload leading to pulmonary edema can occur in lengthy cases.

•Lidocaine toxicity is rare; some authors believe that a dose of up to 55 mg/kg is safe. Symptoms occur 8-14 hours after surgery and are typically neurologic: circumoral numbness, light-headedness and drowsiness followed by tremors and seizures. Cardiac and respiratory signs are late findings.

•Epinephrine toxicity has been reported. This stresses the importance of performing larger volume liposuction on patients with good cardiac function and reserve. Patients should always have basic cardiac monitoring with EKG leads during liposuction to detect any arrhythmias.

In light of these potential complications, the surgeon must be able to administer anticonvulsant medications and advanced cardiac life support.

Pearls and Pitfalls

In order to maximize the effect of the tumescent solution, at least 10 to 20 minutes should elapse prior to suctioning. This allows for the epinephrine-induced vasoconstriction and even distribution of the tumescence. In order to minimize intraoperative time, an area should be tumesced, and then one should move on to other areas or adjunct procedures rather than stopping while the tumescent takes effect. This can be difficult since it may involve turning the patient from side-to-side, or from the supine to the prone position multiple times. Nevertheless, the benefits of a nonbloody aspirate and shorter procedure time are worth this inconvenience.

Suggested Reading

1.De Souza Pinto EB, Erazo Indaburo P, da Costa Muniz A et al. Superficial liposuction: Body contouring. Clin Plast Surg 1996; 23(4):529.

2.Gasperoni C, Salgarello M. MALL liposuction: The natural evolution of subdermal superficial liposuction. Aesthetic Plast Surg 1994; 18:253.

3.Hughes IIIrd CE. Reduction of lipoplasty risks and mortality: An ASAPS survey. Aesthetic Surg J 2001; 21:120.

4.Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990; 16:248.

5.Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr Surg 1993; 92:1085.

6.Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: A new concept. Plast Reconstr Surg 1991; 86:1009.

7.Rohrich RJ, Smith PD, Marcantonio DR et al. The zones of adherence: Role in minimizing and preventing contour deformities in liposuction. Plast Reconstr Surg 2001; 107:1562.

8.Zocchi ML. Ultrasonic assisted lipoplasty. Technical refinements and clinical evaluations. Clin Plast Surg 1996; 23(4):575.

Table 71.1. Various chromophores and the range of light that they absorb

technology) supply a constant beam of laser light. These long exposure durations can result in nonselective tissue injury. These lasers also tend to have a limited peak power. Quasi-CW mode lasers (e.g., potassium-titanyl-phosphate [KTP], copper vapor, copper bromide, krypton and argon-pumped tunable dye [APTD]) break the CW beam into short segments. The pulsed laser devices emit very short pulses at very high peak powers with relatively long intervening time periods (0.1-1 second). These lasers can be either long-pulsed (e.g., pulsed dye laser) or very short-pulsed (e.g., quality-switched [QS] ruby, alexandrite, or neodymium: yttrium-aluminum-garnet [Nd:YAG]). Q represents a quality factor of energy storage in the lasing medium. This can be changed abruptly to produce a short, intense burst of light. The repetition rate for pulsed lasers is expressed in hertz.

Skin Cooling

Laser skin surgery requires precise control over placement, timing and temperature regulation (i.e., skin cooling) to prevent the amount of heat-induced skin injury. Skin cooling minimizes epidermal damage. This is especially important in the treatment of darkly pigmented skin which is at high risk for epidermal injury with visible or near infrared light at wavelengths of less than 1200 nm. There are three basic types of cooling methods: precooling, parallel cooling and postcooling, depending upon when in the process of laser exposure they are utilized. All cooling methods place a cold medium in contact with the skin surface, and the depth of cooling depends on contact time. The epidermis is cooled in tens of milliseconds, the papillary dermis in hundreds of milliseconds and the bulk of the dermis in seconds. Advantages of skin cooling are threefold: epidermal protection, ability to deliver higher fluences and anesthesia. Skin cooling methods range from ice packs and cooled aqueous gel to cold sapphire contact hand pieces and dynamic cooling devices.

Table 71.2. Thermal relaxation time (TRT) for common targets

Laser Resurfacing

Laser resurfacing (also termed laser peel, laser rejuvenation and laser surgery) removes wrinkles, discolorations, age spots and sun damaged skin. It can be performed with either ablative or nonablative laser systems (Table 71.3). Success of ablative lasers (e.g., CW CO2 laser) in treating dermatoheliosis, facial rhytides and atrophic scars has been well documented over the past decade. However, the unpredictable degree of thermal necrosis and scarring that can be seen has led to the development of nonablative, high-energy, pulsed systems for facial rejuvenation. Although these newer devices do not achieve as dramatic results, they do eliminate the high risk profile and extended healing time seen with the ablative systems.

Ablative Lasers

The CO2 laser emits light at 10,600 nm, in the far infrared portion of the spectrum. The chromophore for this wavelength is intracellular and extracellular water. It produces the most effective results in facial resurfacing. Epidermal ablation occurs after one pass at standard treatment parameters, but collagen shrinkage and remodeling require an additional one to two passes. These latter two factors are likely responsible for the long-term clinical improvements seen. Thermal desiccation with concomitant collagen shrinkage is believed to be the mechanism by which resurfacing works. When dermal temperatures rise beyond 55-62˚C, disruption of the interpeptide bonds within collagen’s triple helix shrinks the moiety to one-third of its normal length. This procedure usually produces a 50% improvement. This laser also provides excellent hemostasis. Newer ablative systems exist which minimize nonspecific thermal damage. These include high-energy, short duration CO2 laser and the erbium:YAG (Er:YAG) laser. Another less aggressive approach is to perform only a single pass with the CO2 laser. This method leads to only partial desiccation of the treated area, leaving an intact layer of skin to serve as a biologic wound dressing.

Short-pulse Er:YAG laser systems at a wavelength of 2940 nm were developed in the hopes of minimizing thermal injury and tissue necrosis. The Er:YAG laser penetrates less deeply into the dermis than the CO2 laser. This is due to its target chromophore, water. The Er:YAG laser is absorbed by water sixteen times more efficiently than the CO2 laser. Water makes up over 90% of the epidermis, and it is here where most of the energy of the Er:YAG laser is absorbed. As a result, there is less thermal damage. This explains its more modest clinical improvement as well as its less intense side effect profile. This laser provides very poor hemostasis. Combined,

sequential CO2-Er:YAG laser resurfacing combines both systems in an attempt to have the greatest clinical response with the minimum amount of tissue necrosis.

Indications

Indications for resurfacing with CO and Er:YAG lasers are photoaging (includ-

71ing dyschromias, facial rhytides, nonfacial rhytides (Er:YAG only) and facial solar lentigines), epidermal nevi, rhinophyma, atrophic acne scars, varicella or hypertrophic scars, adenoma sebaceum, sebaceous hyperplasia, seborrheic keratoses, syringomas, trichoepitheliomas and xanthelasma. Premalignant and malignant skin conditions that may be treated with these laser systems include actinic chelitis, actinic keratoses, Bowen’s disease, erythroplasia of Queyrat and superficial basal cell carcinoma.

Relative and Absolute Contraindications

Caution must be taken in patients who have a tendency towards keloid formation and those with a reduced number of adnexal structures. This absence or decrease of appendageal structures may prolong healing time and/or prevent complete reepithelialization. Diseases which koebnerize, such as psoriasis and lichen planus, are considered relative contraindications and patients should be well-informed prior to resurfacing. Atypical scarring after dermabrasion or chemical peeling has been associated with isotretinoin therapy. This has been reported even in cases where isotretinoin therapy was given over one year prior to resurfacing. Skin necrosis and scarring have been associated with resurfacing done in close temporal sequence to

face lifting or blepharoplasty. Resurfacing of the hands, neck and chest with a CO2 laser must be done with great caution due to the high potential for scarring.

Complications

Side effects and complications of laser skin resurfacing are common. Oozing, crusting, and edema occur in the days and weeks that follow the procedure. Infectious complications in this acute period include bacterial, viral and/or yeast infections. Erythema, pruritus and skin tightness can be seen weeks to months later. Eczema and allergic contact dermatitis, along with acneiform eruptions, milia and perioral dermatitis can all occur in this time period as well. Hyperpigmentation is most commonly seen in the first six months after the procedure, whereas hypopigmentation (perma-

nent, delayed) occurs between the sixth and twelfth month after laser resurfacing. Atrophic-, hypertrophicand keloidal-scarring tend to occur after the first month.2

Preoperative Considerations

The use of topical tretinoin, vitamins C and E and full-spectrum sunscreens have been used for preoperative regimens, although only the sunscreen appear to be of any proven benefit. All patients undergoing laser resurfacing receive prophylactic oral antivirals, antifungals and antibiotics with Gram-positive coverage to avoid secondary bacterial infection.

The CO2 laser is generally painful. Although local anesthesia may be sufficient in patients undergoing treatment of one or two cosmetic units, a combination of topical, local and systemic anesthesia is generally used for full face CO2 resurfacing. The Er:YAG laser is generally considered less painful than the CO2 laser. Nerve blocks with lidocaine (1-2%) with epinephrine (1:100,000) are appropriate for the central face. Sensory blockade of the lateral surfaces of the face tend to be more challenging (Table 71.4).

Intraoperative Technique

CO2 Laser

Both patient and physician must have eye protection. Regardless of the type of laser being used, the treatment protocol is standardized to use single-pulse vaporization with minimal overlap of the pulses. If more than one-pass is to be performed, the desiccated tissue debris is wiped away with moist gauze after the entire surface has been covered. This is performed to enhance the laser-tissue interaction of the second pass. Repeat treatment of any area should be done after a minimum six month waiting period to allow for adequate new collagen formation, remodeling of collagen and normalization of pigment.

Er:YAG Laser

The skin is first cleansed with an antiseptic and then rinsed with saline. It is imperative that the operative field be kept dry due to the Er:YAG laser’s high coefficient of absorption of water. In contrast to the CO2 laser, wiping between laser passes is not always necessary. Early pinpoint bleeding is an indication of penetration into the papillary dermis. Heavier bleeding indicates ablation to the level of the midpapillary to reticular dermis.

Postoperative Considerations

All patients undergoing an ablative laser procedure will have at least one week of significant morbidity until complete reepithelialization occurs. Head elevation and ice application can help reduce erythema and edema. Cool compresses can be applied to the treated area for the first week to remove the serous exudates and any residual necrotic debris. Either a thick healing ointment to the open skin surface or bio-occlusive dressings should be used during reepithelialization.

The burning sensation experienced during the immediate postresurfacing period can be treated with acetaminophen with or without codeine phosphate or hydrocodone. Antihistamines or mild topical steroids can be used for pruritus. A several day course of oral corticosteroids may be necessary to help reduce edema. Strict sun avoidance should be emphasized to reduce postinflammatory hyperpigmentation and all patients should be counseled to comply with this measure.

Nonablative Lasers

Nonablative lasers have largely replaced ablative laser systems because of their low risk profile and decreased recovery time. Pulsed dye laser (PDL), Nd:YAG laser, diode, erbium:glass laser and intense pulsed light (IPL) are all examples of nonablative systems. These systems emit light between 500-1540 nm. Absorption by superficial

water-containing tissue like the epidermis is relatively weak at these wavelengths. Cooling systems are used in conjunction with all nonablative lasers to ensure epidermal preservation. The epidermis is therefore not visibly disrupted. These systems work via their thermal effects on the dermis. The mechanism of action of nonablative

71lasers is thought to be through induction of collagen remodeling by creation of a dermal wound. Although not completely understood, fibroblast activation, collagen remodeling and subsequent increased pro-collagen III expression has been noted after use of these systems.

Nonablative rejuvenation is useful in the treatment of vascular markings including erythema and telangiectasias, pilosebaceous changes including pore size and skin smoothing, and pigmentary skin alterations including dyschromia, lentigines, mottled pigmentation and photoaging. Significant improvement of dermal and subcutaneous senescence including rhytides and lipodystrophy is more challenging with these devices. However, nonablative treatments can improve skin texture or surface irregularities. The more superficial wavelength systems are considered more effective in treating vascular, pigmentary and pilosebaceous irregularities, whereas the longer wavelengths may induce more dermal collagen and ground substance changes.

Practical Considerations

Multiple treatment sessions at 3 to 4 week intervals are necessary. Typically, 5 to 6 treatments are performed. Minimal erythema and edema are usually noted immediately after treatment and tend to resolve several hours soon thereafter. Patients are usually able to return to work the following day. Minimal anesthesia is required, and topical or local techniques are the mainstay of pain control.

Mild and limited pinpoint bleeding, transient erythema and edema, blistering, pinpoint scarring and post-inflammatory, transient hyperpigmentation are the most commonly reported adverse reactions. Purpura is characteristically seen with the PDL. The longer wavelength of the erbium:glass laser makes it the laser least absorbed by tissue melanin, providing an advantage when treating darker-skinned individuals.

Although their clinical efficacy does not yet meet that of the ablative laser systems, nonablative laser resurfacing has been shown to improve mild to moderate atrophic scars and rhytides with virtually no external wound. There is yet to be one in this class that stands out above the rest. As technological advances continue to refine these systems even more, nonablative lasers remain a popular choice for patients seeking noninvasive rejuvenation. Further trials and clinical experience are needed to help determine the overall efficacy of these systems in laser resurfacing.

Nonablative Radiofrequency Resurfacing

A new device has recently come to the facial rejuvenation market which appears to produce immediate collagen contraction with a single treatment. The nonablative device uses radiofrequency to produce an electric current which generates heat through resistance in the dermis. The epidermis is protected and preserved through a cooled electrode before and during the radiofrequency pulse via a cryogen-spray device. Intense, sustained, uniform heat is thought to cause shrinkage of collagen followed by a period of neocollagenesis and subsequent tissue remodeling.

Effects noted in early clinical trials report tissue tightening of the cheeks with improvement of the nasolabial fold, cheek contour, marionette lines and possibly the jaw line. Clinical changes appear approximately 4 to 6 months after the procedure. Benefits of this new system are believed to be gradual changes, no downtime and minimal

Ablative resurfacing is deceptively easy to perform, and one must refrain from being too invasive around thin skin areas such as the periorbital region and the jawline as this has been associated with a higher incidence of scarring after resurfacing. In general, the deeper the ablation, the better the results will be. The caveat is that the risk of scarring will be greater.

Once the top layer of skin is denuded, the patient needs very close monitoring and care. Even on broad-spectrum infectious coverage, any pustulation or blistering during the healing period must be aggressively evaluated and treated. Furthermore, areas of persistent erythema may indicate early fibrosis and may need to be immediately treated with intralesional therapy and possibly nonablative lasers.

Hypopigmentation, the most common side effect of laser resurfacing, may not appear until a year after the procedures and this risk must be reviewed in detail with the patient prior to the procedure. It may be that the lighter skin-toned patient may actually have a greater tendancy to develop hypopigmentation.

Nonablative remodeling is much safer and better tolerated by the patient. With nonablative lasers, the epidermis remains intact and many of the concerns regarding resurfacing are minimized or eliminated. However, the patient must still be informed of the rare potential of dyspigmentation or skin texture changes. Furthermore, there is great variability of improvement from patient to patient. Some respond favorably while many may experience only modest response, especially for the treatment of rhytides and skin tissue laxity.

Radiofrequency energy treatment of tissue laxity may be enhanced by the addition of laser energy. Radiofrequency application is usually painful depending on the amount of deposited energy. This may dissuade patients from undergoing this procedure and must be addressed in the preoperative discussion.

Suggested Reading

1.Alster TS, Lupton JR. Are all infrared lasers equally effective in skin rejuvenation. Semin Cutan Med Surg 2002; 21(4):274.

2.Fitzpatrick R, Geronemus R, Goldberg D et al. Multi-center study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med 2003; 33(4):232.

3.Fitzpatrick RE, Goldman MP. Carbon dioxide resurfacing of the face. In: Fitzpatrick RE, Goldman, MP, eds. Cosmetic Laser Surgery. St. Louis: Mosby, 2000.

4.Fitzpatrick RE, Goldman MP. Use of the Erbium:YAG laser in skin resurfacing. In: Fitzpatrick RE, Goldman MP, eds. Cosmetic Laser Surgery. St. Louis: Mosby, 2000.

5.Grema H, Greve B, Raulin C. Facial rhytides—subsurfacing or resurfacing? A review. Lasers Surg Med 2003; 32(5):405

6.Manuskiatti W, Fitzpatrick RE, Goldman MP. Long-term effectiveness and side effects of carbon dioxide laser resurfacing for photoaged facial skin. J Am Acad Dermatol 1999; 40(3):401.

7.Papadavid E, Katsambas A. Lasers for facial rejuvenation: A review. Int J Dermatol 2003; 42(6):480.

8.Tanzi EL, Alster TS. Side effects and complications of variable-pulsed erbium: yttrium-aluminum-garnet laser skin resurfacing: Extended experience with 50 patients. Plast Reconstr Surg 2003; 111(4):1524.

Table 72.1. Classification of chemical peel rejuvenation methods

Superficial Wounding

•Very light: to depth of s. corneum or s. granulosum depth

–Low potency formulations of glycolic acid or other α-hydroxy acids

Medium-Depth Wounding

•Through the papillary dermis to the upper reticular dermis

–Combination peels, single or multiple frost

•Solid CO2 + 35% TCA (most potent combination)

•Jessner’s + 35% TCA (most popular combination)

•70% glycolic acid + 35% TCA

–35-50% TCA, unoccluded, single frost (not recommended)

–88% full-strength phenol, unoccluded (rarely used)

–Pyruvic acid

Deep-Depth Wounding

•To the mid-reticular dermis

–Baker-Gordon formula, occluded or unoccluded

•3 ml 88% liquid phenol, USP

•2 ml tap water

•8 drops Septisol® liquid soap

•3 drops Croton oil

–> 50% TCA concentration

•Oral isotretinoin therapy in the preceding six months precludes use of medium-depth and deep peels because studies have shown that the medication impairs wound healing.

•Burn or radiation treated patients with a complete absence of intact pilosebaceous units on the fact should not undergo medium-depth or deep peels.

•Past or active herpes simplex infection should be treated appropriately prior to either medium-depth or deep peels.

•When contemplating deep peeling, caution should be taken in patients with a propensity towards hypertrophic or keloid scar formation.

•Deeper peels in patients with any condition which may impair the immune system such as human immunodeficiency virus should be done with great care.

•Absolute contraindications to chemical skin rejuvenation for all types of peels include but are not limited to: poor physician-patient relationship; unrealistic expectations; lack of psychological stability; poor general health and nutritional status; and active infection or open wounds.