Section 4 Plastic and Reconstructive Problems

surgery. The outline of the jowl may be readily

evident with the patient in the upright, seated po-

sition for preoperative marking; however, due to

tissue laxity and the effect of gravity, the marked

tissue slated for contouring and debulking may

move both superiorly and posteriorly when a pa-

tient is placed in the supine or Trendelenburg po-

sition for facial surgery.

Ensuring adequate lower facial contouring may

be accomplished by minimizing any positional tis-

sue shift with a slight reverse Trendelenburg pa-

tient positioning (eg, 20 ) and by isolating and

stabilizing the target tissue between the user’s

thumb and forefinger during local anesthesia infil-

tration, laser energy delivery, and lipoaspiration.

It may be, nonetheless, initially surprising to laser

surgeons that the lower face LAFC procedure

may involve contouring tissue a significant dis-

tance above the caudal margin of the mandible

in some patients (see

Fig. 1

B). The central sub-

mental and neck tissue is less affected by patient

positioning but adequate contouring in this area

also requires manual guiding of the laser fiber

into the areas of tissue fullness.

Although LANC enables a closed (percuta-

neous) approach to the neck in some facelift

patients, persistent submental fullness and/or

significant skin laxity immediately after LANC are

indications for converting the initially closed pro-

cedure to an open procedure via a submental

crease incision. Through this greater access, the

effects of the LANC procedure may be assessed

and any required surgical intervention (eg, midline

imbrication platysmaplasty) may be performed. A

recent study suggests that even though a con-

verted open approach may be ideal, in many

cases, surgical manipulation of the platysma may

be required in only 20% of cases.

In cases of

excess skin laxity, retrograde dissection at the

lateral margins of the LANC treatment area,

including subdermal release of the mandibular

cutaneous ligament, may be performed via scissor

dissection or laser fibrolysis.

The laser may be used to initiate the posterior

cervicofacial skin flap dissection via fibrolysis and

shrinkage of fine skin ligaments as well as for

subdermal release of the zygomatic-cutaneous

ligament. Safety of the skin flaps certainly takes

precedence over use of the laser for this purpose.

With appropriate treatment settings, limits on total

energy applied, and proper technique, this applica-

tion does not require anything other than the normal

local anesthetic injection technique. Typical param-

eters that the author used for laser flap predissec-

tion include power 5.4 W, pulse energy 180 mJ,

pulse duration 100

s (fixed), pulse rate 30 Hz,

and total energy delivered 200 to 300 J. Even

delivery of laser energy at the subdermal level

throughout the flap minimizes the risk of a skin

flap complication. Laser flap predissection de-

creases the subsequent physical effort and time

required to complete the flap elevation with facelift

scissors. With these treatment parameters,

bleeding from some vascular perforators, both on

the flap and the underlying tissue, requires bipolar

cautery for hemostasis.

Laser flap predissection should include subder-

mal release of the zygomatic-cutaneous ligament

as well as connecting the posterior cervicofacial

dissection with the LAFC and LANC treatment

areas. Fully coalescing the LAFC and LANC

treatment areas with the posterior cervicofacial

dissection enables greater posterior and vertical

repositioning of the skin flaps but also requires

more effective management of the skin flaps to

harness the potential for improved outcomes.

Figs. 6

and

demonstrate how the LAFC and

LANC techniques may be integrated into aging

face surgery to enhance outcomes.

SUMMARY

Integration of the thermally confined, micropulsed

1444-nm Nd:YAG interstitial fiber laser into mini-

mally invasive and surgical management of the

aging face and neck provides numerous benefits

and some additional treatment options that are

helpful for optimization of the 3-D contours of the

mid- and lower face and neck. Currently LAFC

may be the best nonsurgical answer to the main

limitation faced by soft tissue augmentation (ie,

that it does not address adjacent areas of soft

tissue fullness). As such, one-sided attempts to

enhance the appearance of the face with soft tis-

sue augmentation may result in exaggerated

features and excess fullness in attempting to cam-

ouflage descended fat in the mid- and lower face.

Even subtle soft tissue debulking with LAFC

improves the effective proportional enhancement

of soft tissue augmentation.

LANC is an effective stand-alone percutaneous

procedure for mild to moderate submental and

neck soft tissue excess and skin laxity. The LAFL

approach expands the use of this Nd:YAG inter-

stitial fiber laser beyond LAFC and LANC to

predissection of surgical flaps and release of

osseocutaneous anchoring ligaments while also

raising the possibility for percutaneous (closed)

treatment of the neck and the platysma.

REFERENCES

Holcomb JD, Turk J, Baek SJ, et al. Laser-assisted

facial contouring using a thermally confined

Holcomb