56 / 86
of patients with PIE, the cause of persistent full-
ness with palpable subcutaneous fullness in partial
responders is not known but similar mechanisms
may be inferred in both the lower face and neck.
Persistent fullness 6 to 12 months after LANC
treatment may be addressed through a touch-up
percutaneous LANC procedure.
LANC treatment begins with identification and
marking of the treatment area. Although patient
positioning does not affect the submentum and
neck soft tissues as dramatically as in the lower
face, marking for LANC is conventionally done
with patients in an upright, seated position to
most accurately ensure inclusion of the desired tis-
sue in the outlined treatment area. Depending on
body habitus, the treatment zone may extend
laterally well into the central and toward the poste-
rior aspect of level I in the neck as well as inferiorly
to or well beyond the thyroid prominence in the
anterior neck. In most patients, the LANC percuta-
neous entry point is conveniently placed at or just
above the submental skin crease.
Ensuring that the desired tissue is treated during
LANC is accomplished via the following steps: (1)
limiting exogenous water input with small amounts
of local anesthetic used (eg, 12–24 mL); (2) using
hyaluronidase to improve local anesthetic distribu-
tion through the tissues; and (3) isolating and
stabilizing the target tissue between the user’s
thumb and forefinger during local anesthesia infil-
tration, laser energy delivery, and lipoaspiration.
Limiting exogenous water infiltration to approxi-
mately 12 mL minimizes distortion of the anatomy
during treatment, facilitates endpoint identifica-
tion, and limits thermal confinement. The fatty
tissue ablation efficiency of the micropulsed
1444-nm Nd:YAG interstitial fiber laser, however,
enables an adequate local tissue effect with
preserved thermal confinement within the total en-
ergy usage parameters suggested. The local anes-
thetic mixture that the author favors for the
submentum and neck includes 0.25% lidocaine,
0.125% Bupivacaine hydrochloride, 1:400,000
epinephrine, and hyaluronidase 1 to 2 IU per mL
(eg, Hylenex recombinant). Initially, approximately
2.0 mL of this local anesthetic mixture is used to
provide anesthesia to the percutaneous entry site
as well as a field block that includes the tissue
for debulking and contouring. A 1.6-mm multihole
infiltration cannula (Tulip Medical Products, San
Diego, CA, USA) is then used to deliver the local
anesthetic to the LANC treatment area.
As in the lower face, the thermally confined mi-
cropulsed 1444-nm Nd:YAG interstitial fiber laser
energy delivery occurs via a 600-
m
m silica multi-
mode fiber with the fiber used either free (bare)
or assembled with a disposable or nondisposable
cannula. Prior studies have demonstrated general
safety guidelines for energy delivery during LANC
when using the micropulsed 1444-nm Nd:YAG
interstitial fiber laser and minimal volume local
anesthesia (dry technique)—typical parameters
include power 8.0 to 10.0 W, pulse energy 200 to
250 mJ, pulse duration 100
m
s (fixed), pulse rate
40 Hz, and total energy delivered 750 to 2000 J.
7
The mean total energy delivery for LANC in a
cohort of approximately 180 neck contouring
patients was just over 950 J whereas mean local
anesthesia infiltration and lipoaspiration volumes
were approximately 12.5 mL each in this same
group.
7
Table 4
outlines major LANC treatment
steps and typical treatment parameters.
Because the neck skin is thinner (than in the
lower face) and the energy delivery parameters
are higher (than in LAFC), it is even more important
to keep the fiber continuously moving through the
Table 4
Major LANC treatment steps and typical treatment parameters
LANC Treatment Step Detailed Information
Field block
a
Include percutaneous access point and target tissue
Infiltrate target tissue
a
12–24 (mean 12.5) mL each LAFC treatment area using Tulip 1.6-mm
multihole infiltration cannula
Apply laser energy
1000 (
1
) J
Typical laser parameters 8.0–10.0 W, 200–250 mJ, 40 Hz
Postcooling (thermal
quenching)
Infiltrate 12-mL room temperature sterile saline (Tulip 1.6-mm multihole
infiltration cannula)
Aspiration
Mean 12.5 mL (Tulip 2.1-mm offset triple port aspiration cannula attached
to 12 mL syringe prefilled with 1.0-mL saline)
Compression
Roll cotton and elastic compression garment
a
Local anesthetic mixture contains 0.25% lidocaine, 0.125% Bupivacaine hydrochloride, 1:400,000 epinephrine, and 1 IU
hyaluronidase per mL.
Fiber Laser in Aging Face and Neck