Biomedical subjects
Publications and source records attributed to J N Pozner.
New resurfacing laser systems have been introduced that offer the ablative capacity of Er:YAG lasers with the ability to add controlled degrees of thermal effect to provide collagen tightening and hemostasis. This article discusses the current systems available and offers comparisons to short-pulse Er:YAG and carbon dioxide lasers. A histologic study and initial clinical results are presented and discussed.
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Laser resurfacing is a wonderful technological advance at improving the quality of aged skin. Physicians have been reluctant to perform full facial resurfacing at the time of rhytidectomy due to risk of flap slough. Newer endoscopic-assisted subperiosteal techniques allow hardy flaps without significant blood supply interruption. Since September 1995 we have performed 26 full facial resurfacings at the time of rhytidectomy or brow lift using the Coherent 5000C carbon dioxide laser. Standard settings and densities were used. Twelve patients underwent full endoscopic facelift; 5 patients, extended endoforehead lift; 8 patients, biplanar rhytidectomy; and 1 patient, standard rhytidectomy prior to immediate laser resurfacing. An additional 2 patients underwent endoscopic forehead lift and forehead resurfacing. There were three herpes infections, one in the endoscopic group, one in the biplanar group, and one in the standard rhytidectomy patient. There were 2 patients with minor skin slough in our early experience with the biplanar group. Full facial resurfacing at the time of rhytidectomy provides a one-stage rejuvenation of skin and deeper layers, and can be performed safely. However, only experienced laser practitioners should attempt resurfacing over undermined flaps.
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Facial skin resurfacing using the carbon dioxide laser has become an increasingly popular procedure. Improvements in carbon dioxide laser technology have made the procedure simpler and more reliable. However, difficulties in the postoperative period can lead to patient morbidity and physician anxiety. Common problems such as prolonged erythema, hyperpigmentation, acne, milia, dermatitis, and infection can be controlled or avoided with proper postoperative care. Less common sequela such as hypertrophic scarring and prolonged healing are often a results of errors committed in the postoperative period. The authors have performed laser resurfacing in almost 2100 patients in the last 4 years. Changes in the postoperative regimen to include no pretreatment, use of semipermeable dressings, antiviral and antibacterial prophylaxis, and early treatment with sunscreens and bleaching agents have made for a smoother recovery with more predictable results.
A 91-year-old man presented with a 9.0 x 7.0 cm exophytic mass on the dorsum of the right foot, surrounded by a scaling hyperkeratotic plaque-like lesion that had been present for many years. He had similar long-standing hyperkeratotic plaque-like lesions on both legs. Histopathologic examination of the exophytic mass revealed a well-differentiated squamous cell carcinoma surrounded by an eccrine syringofibroadenoma (ESFA). Histochemistry, immunohistochemistry and electron microscopy support this diagnosis. To our knowledge, this is the only reported case of ESFA being intimately associated with a malignant neoplasm.
Endoscopic-assisted surgery allows remote incision placement and provides an illuminated, magnified operative field. We have applied these principles to perform neurolysis of the zygomaticotemporal nerve and removal of a fixation wire under endoscopic control in a patient with pain and tenderness at the site of a previous zygomatic arch fracture. Endoscopic assistance aided dissection by placing the incision in a hidden, unscarred area.
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Adequate treatment of the deviated nose requires a detailed evaluation of the deformity present. A new method of component separation with internal cartilage splinting has been used with success to correct the severely deviated nose. The separation of the components allows detection and correction of all areas of cartilage deviation. The internal cartilage splinting allows long-term support and avoidance of mid-vault collapse.
Endoscopic techniques have revolutionized current surgical techniques and have now been introduced to plastic surgery. Advantages of endoscopic assistance include direct visualization, hidden scars, and decreased morbidity. We sought to implement endoscopic techniques to recontour the facial skeleton and avoid the disadvantages of open procedures. A standard video system and endoscopic instrumentation including a 4-mm 30-degree endoscope and a power bur were used. Cadaveric dissections were performed before clinical use. Using endoscopic assistance, the frontal bone of a 42-year-old Korean woman with bony deformities was visualized and sculpted using a power bur. An uneventful postoperative course ensued. This case illustrates the feasibility of using endoscopic techniques in forehead recontouring and sets the stage for further work in malar and mandible recontouring.
Current concepts of total facial rejuvenation involve a comprehensive integrated approach to achieve a balanced youthful appearance. Recently introduced endoscopic-assisted techniques allow us to rejuvenate the face through small, remote incisions. Previously, we have considered only young patients with good skin turgor as candidates for minimally invasive procedures, but the advent of the resurfacing laser has allowed us to expand our indications for single stage minimal access rejuvenation. Full facial immediate laser resurfacing at the time of standard rhytidectomy has been avoided due to risk of flap necrosis. Subperiosteal minimally invasive endoscopic assisted techniques do not substantially interfere with facial blood supply. We can now perform endoscopic-assisted full facelifts combined with immediate laser resurfacing to reposition the tissues in a more youthful position and then tighten the skin envelope. Extended endoscopic-assisted subperiosteal forehead lift is performed through three to five scalp incisions; subperiosteal midface lift is performed through a crow's foot or intraoral incision. Cervicoplasty, if needed, is performed through a small submental incision. Full face laser resurfacing is done using a Coherent Ultrapulse laser. To date we have performed eleven subperiosteal minimally invasive laser endoscopic (SMILE) rhytidectomies. There has been no evidence of flap necrosis with this technique. Postoperative recovery has been no different from patients treated only by full face resurfacing, except perhaps for the slight increase in early facial edema. We believe the SMILE facelift is a viable alternative to standard techniques. The limitations of this procedure still need to be elucidated.
This study describes our effort to develop a reliably safe method for combining currently available treatment modalities in an effort to obtain comprehensive facial rejuvenation in one operative setting. Detailed evaluation of 101 available consecutive patients, their per- and postoperative photos and charts was undertaken. Five groups of patients were studied: (1) traditional facelift with wide subcutaneous undermining and SMAS plication. (2) Similar traditional facelift with regional laser resurfacing. (3) RSVP (rejuvenation with sparing of vascular perforators) facelift. Subcutaneous undermining stops 3 cm lateral to the nasolabial fold to preserve the rich angular/facial arterial supply and venous drainage, still permitting lateral SMASectomy or SMAS plication. Subcutaneous neck undermining is discontinuous, the posterior dissection being limited to that which is necessary for identification of the posterior edge of the platysma and its plication to the mastoid and SCM muscle. The anterior dissection is limited to that necessary for anterior platysmal repair leaving intact a vertical subcutaneous non-undermined zone 4-6 cm in width, preserving the submental perforating artery. If indicated, gentle liposuction with a fine cannula is performed through this area. (4) RSVP facelift and regional laser resurfacing. (5) RSVP facelift with total facial laser resurfacing. Mean follow-up was 13.6 months, minimum 6 months. There were no additional major complications associated with the addition of laser resurfacing or fat grafting to the RSVP group. The patients with laser resurfacing were pleased with their result, and estimated that their apparent age had been reduced by a mean of 10.4 years, compared with 6.6 years for the non-lased group. We conclude that the RSVP flap is a hardy, vascular flap permitting simultaneous laser resurfacing, fat grafting, and other adjunctive procedures without significant fear of flap loss.