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Mild to moderate post-treatment inflammatory
edema (PIE) is expected. Early on, PIE seems to
have blunted or limited the lower facial tissue con-
touring response; however, lower facial contour
improves over time as PIE gradually resolves and
the skin contracts. Early on (eg, weeks 2 through
6), weekly lymphatic massage sessions for the
LAFC treatment areas may help reduce PIE and
improve lower facial contour. Significant PIE
may be treated with staged escalating-dose
intralesional triamcinolone (eg, 10 mg/mL initially,
gradually moving to 40 mg/mL) beginning at
post-treatment month 1 or 2 and continuing
monthly as needed until final desired contour is
achieved or until no further tissue response.
Although this approach is successful in a majority
of patients with PIE, the origin of persistent lower
facial fullness with palpable subcutaneous fullness
in partial responders is not known.
Some of the adipocyte lipid content liberated
during laser lipolysis may be subject to reuptake
by adipocytes that remain at the periphery of the
treatment area. A significant increase in body
mass index after LAFC could also partially account
for a blunted tissue response. It seems more likely,
however, that the natural healing response to
adipose tissue ischemia and adipocyte necrosis
may stimulate a tissue regeneration response,
with adipose tissue remodeling involving adjacent
adipose-derived stem progenitor cells and forma-
tion of neoadipocytes—this phenomenon has
been carefully elucidated in animal models for
adipose tissue ischemia
4
and nonvascularized fat
grafting.
5
Persistent fullness 6 to 12 months after
LAFC may be addressed through a touch-up
percutaneous LAFC procedure.
LAFC treatment begins with identification and
marking of the desired treatment areas. In keep-
ing with anatomic studies of the jowl fat compart-
ment,
6
the desired area of tissue ablation for
contouring of the lower face and jawline may
include subcutaneous tissue fullness at, below,
and well above the caudal border of the mandible
(
Fig. 1
A). In many patients, the position of the
jowl changes substantially with supine or slight
Trendelenburg positioning; therefore, patient
marking for LAFC should be done with patients
in an upright, seated position to most accurately
ensure inclusion of the desired tissue in the out-
lined treatment areas. The LAFC percutaneous
entry point should be at least 1.5-cm posterior
to the posterior extent of the intended LAFC
treatment zone to ensure that an adequate tissue
seal is maintained between the entry point and
the treatment zone. If the entry point is placed
too close to the LAFC treatment zone, the lipoas-
piration step may be more difficult and inefficient
because air may easily be drawn into the aspira-
tion syringe.
Ensuring that the desired tissue is treated dur-
ing LAFC is accomplished via (1) minimizing any
positional tissue shift with slight reverse Trende-
lenburg patient positioning (eg, 20 ); (2) limiting
exogenous water input with small amounts of
local anesthetic used (eg, 3 mL); (3) using hyal-
uronidase to improve local anesthetic distribution
through the tissues; and (4) isolating and stabiliz-
ing the target tissue between the user’s thumb
Table 2
Management of thermal confinement and thermal diffusivity
Fiber Laser in Aging Face and Neck