Laser and Cosmetic Surgery

Laser and Cosmetic Surgery

Histologic Effects of the High-Energy Pulsed C02 Laser on Photoaged Facial Skin

Objective.—There is a dearth of information about the histologic effects of pulsed laser resurfacing of photoaged skin. The histologic structural changes induced by carbon dioxide (C02) laser resurfacing were examined in a 3 part study.

Methods.—In part 1, two 3-mm areas on the right side of the face of each of 5 patients were treated with the UltraPulse C02 (Coherent) laser at 300 mJ before they underwent a facelift for severe photodamage. One site received 2 passes, and the other side received 4 passes. A similar treatment using 500 mJ was performed on the left side of the face. These test sites were examined histologically for the depth of injury. In part 2, 10 patients aged 51-85 years with photodamaged skin underwent laser resurfacing of the right preauricular area using 2 passes at 500 mJ. Fifteen days to 6 months later, after rhytidectomy, a skin section containing laser-resurfaced and untreated skin was removed and examined histologically. In part 3, the hypopigmentation effect was histologically examined after 3 months in 3 blacks aged 30, 60, and 62 years, after 2 passes at 500 mJ.

Laser and Cosmetic SurgeryResults.—In part 1, the depth of injury was found to be dose dependent. In part 2, the treated site was smoother, more uniform in texture and clarity, and firmer than the nonresurfaced site. Re-epithelialization occurred within 7-10 days, and normal color returned in 2-3 months. The epidermis regenerated, and large, uniform keratinocytes formed. The mel- anocytic density, quantity, and distribution returned to normal. The dermis had a more normal appearance. New collagen formed, and glycosaminoglycans diminished. In part 3, re-epithelialization occurred within 7-10 days. Although treated skin was lighter than untreated skin initially, normal color returned at 4 months. These older black individuals had a high degree of microscopic skin damage. The histotopic response to the laser treatment was similar to that observed in whites.

Conclusions.—Laser-resurfaced photoaged skin is histologically similar to photoaged skin treated with phenol chemical peeling in the short-term. Long-term effects have to be assessed. The hypopigmentation effects of laser resurfacing of black skin gradually resolve by 4 months.

► Histopathologic interpretation of laser-treated sites on chronically photodamaged skin showed correction of epidermal atypia, dysplasia, and atrophy. Keratinocyte polarity and melanocytic hyperplasia were corrected as well. Histopathologic findings were quite similar to those seen with phenol peeling, but the lack of extensive posttreatment hypopigmentation suggests that the laser will become the “gold standard” for the treatment of actinically damaged facial skin.

Are More Passes Better? Safety Versus Efficacy With the Pulsed C02 Laser

Objective.—Carbon dioxide lasers have recently been used for skin resurfacing. Because high-energy pulses with short exposure result in energy loss through vaporization of the skin, thermal conduction into deeper skin layers is limited. The number of passes required for maximum benefit that does not compromise safety was determined by measuring the depth of injury in a clinical setting.

Methods.—Immediately before surgical excision, 1-16 passes were made on multiple test panels of breast skin and 1-8 passes on eyelid skin using the Coherent Ultrapulse laser at 300 mJ, with a pattern density of 4, estimated to produce a 20% overlap of the impact spots. The excised skin was examined histologically.

Results.—The first pass penetrated the dermis and the papillary dermis. The next 2 or 3 passes penetrated slightly deeper. After 3 or 4 passes, depth of tissue destruction did not increase with up to 16 total passes. When up to 11 passes were used to treat severe perioral wrinkling, there was no scarring, but deeper wrinkles were not affected. When 3 patients with deep perioral wrinkling were treated with 4 passes on one side and 10 passes on the other, no difference in safety or efficacy was noted.

Conclusion.—Multiple passes with the C02 laser do not appear to improve cosmetic appearance or compromise safety.

► The authors present an interesting histopathologic examination of multiple passes using a pulsed C02 laser. Many laser surgeons believe a chamois color signals penetration of the laser into the upper reticular dermis, and suggest that this may be an end point for laser resurfacing. Burkhardt and Maw argue that this chamois color indicates dessication, not increasing depth. Using multiple passes (1-16) of a pulsed C02 laser on breasts and eyelid skin, the depth of injury did not increase after 3 passes. There were no cases of full-thickness injury (below adnexal structures), even on thin upper eyelid skin. They then treated upper lips with 4 passes on one side and
10 passes on the other, and found no significant difference in the clinical course or aesthetic end point. Based on this report, aggressive resurfacing with multiple passes does not appear to increase the depth of thermal injury or enhance the long-term clinical result.

Fire Hazards and C02 Laser Resurfacing

Objective.—Carbon dioxide laser resurfacing in the presence of supplemental oxygen can create a fire hazard. Risk factors for fire, including laser energy parameters, oxygen flow rate, and target distance, were defined.

Methods.—Twenty pulses from a Coherent Ultrapulse CD2 laser were delivered to an area approximately 1.5 X 1.5 cm located 5 cm proximal to the nares and 0.5 cm left or right of the midline of an anesthetized Yucatan minipig to which oxygen was delivered through a nasal cannula or nasopharyngeal tube. In the first experiment oxygen was delivered at 6 L/min, and a high laser setting (500 mJ, 50 W, 100 kHz, 5 density) was used. In the second experiment, the distance from the target area to the oxygen delivery point was varied from 5 to 2.5 to 0.5 cm, with an oxygen flow rate of 6 L/min. In the third experiment laser energy was varied from 500 mj to 300 mj. In the fourth experiment the oxygen flow rate was varied from 6 L/min to 1 L/min.

Results.—No combustion occurred when pulses were delivered to sites 0.5-5 cm from the oxygen source after a total of 400 computer pattern generator treatments were delivered.

Conclusion.—Although no risk factors for combustion could be identified in this study, precautions should be taken.

► Fire hazards associated with the use of the C02 laser are a serious concern. Fire production requires an ignition source, a combustible substance, and a supply of oxygen. These investigators used high-powered laser settings in close proximity to oxygen from both nasal cannulas and nasopharyngeal tubes and could not produce a fire. This suggests that the skin is not a combustible substance and that the fire hazard of C02 lasers is not significantly increased by concomitant use of oxygen. It should be stressed that there must be no combustible substance (e.g., gauze, hair) within the operative field for safe laser operation.

Iontophoresis for Anesthesia During Pulsed Dye Laser Treatment of Port-Wine Stains

Introduction.—Laser therapy of port-wine stains (PWS) is often painful, and currently available methods of anesthesia are not always successful. Iontophoresis of lidocaine has been employed recently in an attempt to reduce the pain associated with flashlamp pulsed dye laser (FPDL) therapy for PWS. A double-blind, placebo-controlled study compared iontophoresis of lidocaine 5% with epinephrine, or mepivacaine 2% with epinephrine, for their ability to reduce pain in this setting.

Methods.—Patients eligible for the study were older than 6 years and had facial PWS larger than 15 cm2. The average age of 39 patients enrolled in the study was 17.2 years. Thirteen were randomized to lidocaine 5% with epinephrine as anesthesia during FPDL and 13 to mepivacaine 2% with epinephrine. The remaining 13 patients served as controls and received preservative-free 0.9% NaCl with epinephrine. Iontophoresis, which consists of the introduction of ions of soluble salts into the tissues, employed a constant electric current applied at 3 mA for 15 minutes. The level of pain was graded by the patient on a visual analog scale from 0 to 10, comparing the treated area to an adjacent area which had no anesthesia.

Results.—All but 1 of the patients had received previous FPDL treatments. Thirteen had not received anesthesia, 13 had received topical anesthesia, and 12 had the procedure with general anesthesia. Both iontophoresis of lidocaine 5% with epinephrine and mepivacaine 2% with epinephrine reduced the pain of FPDL impulses, but the pain was reduced significantly more with the lidocaine. Men reported more pain than women. The efficacy of FPDL treatment of PWS was similar in all 3 groups.

Conclusion.—Iontophoresis of lidocaine for anesthesia during FPDL treatment of PWS is safe, reduces discomfort, and is not associated with visible distortion of tissue or risk of infection. However a special apparatus is needed, the time for anesthesia is longer, and iontophoresis cannot be used on broken skin or hyperkeratotic areas. The efficacy of the technique in infants and young children has yet to be determined.

► Iontophoresis of local anesthetics, most commonly lidocaine and epinephrine, may be a valuable option to reduce intraoperative pain in the treatment of port-wine nevi. The clinical response does not appear to be affected by iontophoresis treatment. This technique may be especially useful in the laser treatment of facial port-wine stains in young children.

Lesion Size Is a Factor for Determining the Rate of Port-Wine Stain Clearing Following Pulsed Dye Laser Treatment in Adults

Introduction.—For the treatment of port-wine stains in adults and children, the flashlamp-pumped pulsed dye laser (PDL) has been used extensively since 1987. The effectiveness of the PDL in the removal of port-wine stains in adults has focused on the percentage lightening of the lesions, not on total clearing. Many patients, however, are concerned about decrease in lesion size and complete removal of the stain. The percentage clearing of port-wine stain as a function of initial lesion size treatment was determined.

Methods.—The PDL with laser output ranging from 6.0 to 7.5  J/cm2 was used on 74 adults with truncal, extremity, and facial port-wine stains. The area of involvement after each treatment was compared with the area of involvement measured in the first treatment session. The rate of clearing index was calculated according to the following formula: Final decrease in lesion size divided by the number of treatments to attain the final percentage decrease in lesion size.

Results.—There was 25% to 90% lightening in all the port-wine stains. There was 25% clearing in 85.1% of patients, and 50% clearing in 36.5% of patients. However, 100% clearing was not achieved in any of the patients. There were 4 patients with port-wine stain greater than 100 cm2, and none of them achieved 50% clearing after a mean of 17.2 treatments. The rate of clearing index for face and neck lesions was greater than for facial lesions, indicating more rapid clearing of the neck component than the facial component. The rate of clearing index decreased as lesion size increased.

Laser and Cosmetic SurgeryConclusions.—Pulsed-dye treatment alone may not achieve complete clearing, particularly for adult patients with port-wine stains greater than 100 cm2.

► Although significant lightening of port-wine stains (PWS) can be achieved with the flash-lamp pulsed dye laser, most laser surgeons have come to realize that complete clearing is the exception rather than the rule. The response of PWS not involving the face and neck is variable. Port-wine stains of the central face improve more slowly than those of the neck, forehead, periorbital area, lateral cheek, and chin. In this study by Yohn et al., the rate of clearing of PWS in adults was inversely related to the size of the lesion, and complete clearing of facial lesions larger than 100 cm2 was extremely difficult to achieve. Interestingly, power settings above 7.5 J/cm2 were not used. In my experience, the use of power settings exceeding this cutoff are safe and will result in additional improvement.

Clinical and Histological Responses of Congenital Melanocytic Nevi After Single Treatment With Q-switched Lasers

Background.—Laser irradiation in the treatment of congenital melanocytic nevi is controversial. Lesions appear to recur after the treatment. Also, the effects of laser irradiation on cellular biological behavior and the potential mutagenic responses of nevomelanocytes receiving nonlethal doses are unclear. However, without treatment, the potential for malignant degeneration during a lifetime is increased. The effects of Q-switched lasers on congenital nevi were investigated.

Methods.—Five congenital nevi were divided into 3 equal parts and subjected to different treatments: Q-switched ruby laser at a 694-nm wavelength, Q-switched neodymium:yttrium-aluminum-garnet (YAG) laser at a 1,064-nm wavelength, and no irradiation. The lesions were excised and assessed by routine staining 3 days to 3 months after laser irradiation.

Findings.—On macroscopic and microscopic inspection, both laser treatments were found to affect superficial and deep portions of the congenital melanocytic nevi. However, the Q-switched neodymium:YAG laser did not destroy all nevomelanocytes, especially in the deeper, less pigmented parts of the lesions.

Conclusions.—Both the Q-switched ruby laser and the neodymium: YAG laser had an immediate visible effect on the surface of nevi. The Q-switched ruby laser is apparently more effective at removing nevomelanocytes than the Q-switched neodymium:YAG laser.

► The malignant transformation of giant congenital melanocytic nevi has led to the recommendation that many of these nevi be removed. The standard of care has been surgical excision and repair. Many authors have studied the effects and clinical responses of these nevi after treatment with various lasers. Most laser treatments described in the literature have been complicated by recurrence of the nevus following treatment, probably because of the inability of the laser to remove the residual deeper melanocytic component present in many of these lesions. The biological effects of laser irradiation on nevomelanocytes are unknown. Although lasers may have a very limited role in surgically-unresectable congenital melanocytic nevi, the standard of care remains surgical excision and repair.

Laser Treatment of Tattoos: A Prospective, Paired, Comparison Study of the Q-switched Nd:YAG (1064 nm). Frequency-doubled Q-switched Nd:YAG (532 nm), and Q-switched Ruby Lasers

Introduction.—The new short-pulsed laser therapies can remove tattoos with a low incidence of side effects. Professional tattoos, however, especially those with brightly colored inks, are more resistant to therapy. A prospective study was conducted to compare the effectiveness of Q-switched neodymium:yttrium-aluminurn-garnet (Nd:YAG) (1,064 nm), frequency-doubled Q-switchcd Nd:YAG (532 nm), and Q-switched ruby (694 nm) lasers in removing tattoo ink.

Methods.—Twenty previously untreated tattoos, either amateur or professional, were treated in 20 consecutive patients between August 1993 and February 1994. Each tattoo was divided into 3 parts and treated once with each of the lasers. Eight to 9 weeks later, 3 dermatologists compared photographs of the treated areas taken before and after laser therapy. Treated areas were graded for degree of lightening and for side effects (hypopigmentation, hyperpigmentation, atrophy, and hypertrophy). Patients were asked to rank their level of discomfort and overall healing.

Results.—Fourteen of the tattoos were professional and had been present for a mean of 17.8 years. The 6 amateur tattoos had been present for a mean of 16.5 years. Twelve tattoos were black and 8 were multicolored. The Q-switched ruby laser was considered to have produced the greatest lightening in 75% of evaluations. None of the evaluations found the Q-switched Nd:YAG (532 nm) to be most effective at lightening. The Q-switched ruby laser was most effective for both professional and amateur tattoos and for both black and multicolored tattoos. The Q-switched Nd:YAG (1,064 nm) was better at removing red ink than the 2 other lasers. Side effects were minimal with all 3 laser treatments, but hypopigmentation was more prominent with the Q-switched ruby laser than with the Q-switched Nd:YAG (1,064 nm) laser. Wound healing was similar with the 3 lasers. The Q-switched Nd:YAG (1,064 nm) laser was reported to be the most painful by 60% of patients.

Conclusion.—The Q-switched ruby laser was the most effective overall of the 3 tested lasers in lightening amateur and professional tattoos.

Various lasers have been used with varying degrees of success to treat both professional and amateur tattoos. Goyal et al. found the Q-switched ruby and the Q-switched Nd:YAG (1,064 nm) lasers to be superior to the Q-switched Nd:YAG (532 nm) laser. The Q-switched ruby laser appeared to induce the most significant lightening of the tattoos but was accompanied by a higher incidence of hypopigmentation and textural change.

Long Term Culture of Normal Skin to Test the Effipacy of a Hydroxy Acid-containing Cream

Background.—Low concentrations of topical alpha-hydroxy acids (AHAs) decrease the thickness of hyperkeratotic stratum corneum by reducing corneocyte cohesion at lower levels of the stratum corneum, increasing viable epidermal thickness, and subsequently thickening the epidermal and dermal compartments of treated skin. The efficacy of a cosmetic cream containing AHAs, beta-hydroxy acid, and vitamin A palmitate was investigated.

Methods.—An ex vivo technique using human skin was used to approximate in vivo metabolic conditions. Human skin was maintained by organ culture for 21 days. Creams were applied to the epidermal surface and compared with untreated skin. Epidermal and dermal changes were assessed histologically and immunohistochemically after 21 days. In addition, tritiated proline was added to the culture medium, and the newly synthesized collagen was assessed using Webster’s method.

Findings.—Skin treated with the AHA-containing cream showed a reduction in stratum corneum thickness and an increase in the malpighian layer compared to control samples. Treated skin showed a well-differentiated epidermis when exposed to an antibody against total cytokeratins. The elastic fiber network in the dermis was improved in the superficial and reticular dermis. Analysis of collagen synthesis by the Webster method showed an increase of 28.5% in the treated skin.

Conclusions.—The efficacy of an AHA formulation on normal human skin at the epidermal and dermal levels was demonstrated using an ex vivo method. There was an important reduction in the stratum corneum cell layers, consistent with previous research showing that topical AHA application decreases corneocyte cohesiveness at the lower, newly forming levels of stratum corneum.

► Even more interesting than this study might have been a test of the individual components of the cream in the same ex vivo system.

Obagi’s Modified Trichloroacetic Acid (TCA)-controlled Variable-depth Peel: A Study of Clinical Signs Correlating With Histological Findings

Background.—Trichloroacetic acid (TCA) has been increasingly used in chemosurgical superficial dermatologic peels. Obagi has developed a modified TCA solution designed to slow the procedure and has identified clinical signs that indicate the depth of solution penetration. At the 50:1 level, (papillary dermal peel), course wrinkling (“epidermal sliding”) is observed. A uniform solid white frosting appears at the 50:2 level (upper reticular dermal peel). At the 50:3 level (mid-to-deep dermal peel), all background pink disappears, and the skin appears grayish. The correlation of these clinical signs with histologic changes was investigated using sequential biopsy findings.

Methods.—Twenty patients underwent at least 4 weeks of skin preparation with intensive application of tretinoin 0.1%, hydroquinone, and lactic acid before undergoing the chemical peel with a solution of 41.7% TCA in a diluent containing 10% glycerin. The mechanisms of the shortterm signs were investigated in 4 patients with 3-mm punch biopsy specimens taken 5 minutes after the clinical sign appeared. The biopsy material was examined with light microscopy and with electron microscopy in 2 patients. The longer term correlation between histologic findings and clinical signs of the depth of peel was evaluated with punch biopsy specimens obtained at 48 hours and 6 weeks after the chemical peel in 4 patients. In the other 12 patients, the thickness of the new dermis was assessed, using punch biopsy material obtained before and 6 weeks after a chemical peel to a 50:2 level.

Results.—Histologic specimens of tissue at the short-term 50:1 level revealed only mild changes and a thinner stratum corneum. Electron microscopy revealed nuclear leaching of the epidermal cells, and chromatin concentration on the nuclear membranes. There was irregular cytoplasmic organelle coagulation and intercellular space edema. There was also shrinkage and nuclear leaching of mesenchymal cells in the papillary dermis. Specimens at the short-term 50:2 level had complete loss of the stratum corneum and near total loss of the stratum granulosum. Ultrastructural changes included more severe cytoplasmic organelle coagulation, intercellular swelling, and coagulative shrinkage of mesenchymal cells. The specimens at the short-term 50:3 level revealed condensed squamous epithelium with nuclei arranged in parallel. Coagulation extended to the deep vascular dermal plexus. Collagen fibers had interfibrillar granules and microvesicular swelling.

The dermal changes were progressive, as shown by the biopsy specimens at 48 hours and 6 weeks. By 6 weeks, the chemical peel at the 50:2 level resulted in a new layer of fibrillar collagen in a laminar pattern replacing the upper reticular dermis. After a 50:2-level peel, the new dermis accounted for an average of 33% of the full thickness of the dermis. The new dermal layer was almost the full thickness of the reticular layer in patients undergoing a 50:3-level peel.

Conclusions.—The validity of Obagi’s clinical signs was supported by the histologic and electron microscopic findings.

► Using a modified 41.7% TCA solution in a diluent containing 10% glycerin. Obagi has presented clinical signs that correlate with histopathologic findings of progressively deeper injury from penetration of the acid. The surgeon should become familiar with these subtle clinical signs of increasing depth of penetration so that the safety and efficacy of medium-depth chemical peels can be improved.

Are Patients Satisfied With Results From Residents Performing Aesthetic Surgery?

Objective.—Whether patients undergoing cosmetic surgery performed by senior residents in one of the University of Toronto’s teaching hospitals were satisfied with the results was assessed by questionnaire.

Methods.—Cosmetic surgery in the Academic Aesthetic Surgery Service (AASS) is performed at reduced cost by senior residents under the supervision of staff surgeons. For 6 months the resident attends 2 aesthetic clinics a week and has clinical responsibilities for patients. The level of operating room involvement of the attending surgeon depends on the level of training of the resident. The surgical fee is $250, the hospital fee is reduced by 50%, and the anesthesia fee is reduced by 25%. Patients are required to pay for any prosthetic devices, must attend 2 free postoperative visits, and must pay 2 weeks in advance. Patients ranged in age from 12 to 82 years; the majority were between 20 and 50. Most were female, white, and from Ontario.

Results.—A total of 131 (49.4%) patients returned questionnaires, 42 in the first survey (1988) and 112 in the second survey (1994). Overall, 81.9% said their results were excellent or good, whereas 4.5% said their results were poor. Surgery was rated excellent by 50.8% in the second survey and by 31.0% in the first. Overall, 74.2% scored their results between 8 and 10 on a scale of 1 to 10, and 15.6% scored their results below 7. When asked if they would do it again, 88.3% said yes in 1988 and 95.1% said yes in 1994. By procedure, 100% of patients having rhytidectomies, 92.3% having breast augmentations, 88.2% having rhinoplasties, and 88.0% having blepharoplasties said they would have the same procedure again. In 1988, 88.1% of respondents would recommend the clinic, and in 1994, 96.6% would. Referrals from other patients have increased.

Conclusion.—Patient satisfaction with outcome after aesthetic surgery was high and compares well with results of more experienced surgeons.

► In this study, patients were quite satisfied with their surgical outcomes at a large resident-staffed plastic surgical clinic offering aesthetic procedures at a reduced rate under the supervision of an attending physician. Complex surgical procedures, whether they be constructive or aesthetic, are best learned by doing the procedure under the supervision of an experienced surgeon. This paper suggests that, in the right setting, incorporation of expanded- surgical services into residency programs can provide good patient outcomes and enhance the . surgical experience of physicians in training.

Psychological Characteristics of Women Who Undergo Single and Multiple Cosmetic Surgeries

Background.—Most individuals with minor physical imperfections do not have plastic surgery, which leads to questions about why some individuals do undergo such surgery. There is some evidence, mainly from unverified clinical reports or inadequately controlled studies, that individuals requesting cosmetic surgery are more likely to have personality problems. It has also been suggested that personality disorders may be more pronounced in patients requesting multiple cosmetic surgeries. The psychological findings of patients with multiple vs. single cosmetic surgeries were compared.

Methods.—Three groups of women older than 30 years were studied: 20 who had had single facial cosmetic surgeries, 16 who had had multiple cosmetic surgeries, and 49 controls who were interested in their appearance but who had chosen not to have cosmetic surgery. The 3 groups were compared on 5 personality measurements previously linked to patients who had undergone cosmetic surgery: self-esteem, body image, separation-individuation, narcissism, and social anxiety.

Results.—Narcissism scores were higher and problems with separation- individuation were greater for patients who had had cosmetic surgery than for controls. The patients who had undergone cosmetic surgery had a more positive body image, but there were no differences in self-esteem or social anxiety. No significant differences were noted between the patients having single vs. multiple cosmetic surgeries.

Conclusions.—Women undergoing cosmetic surgery have more problems with separation-individuation and are more narcissistic than controls. However patients who have undergone cosmetic surgery also have a more positive body image. There may be important psychological issues underlying the desire to undergo cosmetic surgery, beyond just the wish to improve one’s appearance. Women who choose to undergo cosmetic surgery may be advised to seek counseling or psychotherapy, on the grounds that doing so will help them achieve the greatest benefit from their surgery.

► As expected, patients who have undergone cosmetic surgery were found to be more narcissistic and to have more problems with separation-individuation than control groups. There did not seem to be a significant difference between women who had undergone a single surgical procedure as com-pared with those who had multiple surgeries. Interestingly, there were no significant differences in seif-esteem or social anxiety. Furthermore, women who had undergone surgical procedures appeared to have a more positive body image. These considerations should be taken into account when dealing with the patient requesting cosmetic facial surgery. It is possible that subgroups requesting other cosmetic surgical procedures may exhibit significantly different personality characteristics.

Evaluation of Lip Augmentation With Gore-Tex Facial Implant

Objective.—Although many materials have been used for lip augmentation, the ideal filler has not been found. Gore-Tex expanded fibrillated polytetrafluoroethylene polymer has been used for vascular replacement and abdominal wall and chest wall repair. The effect of Gore-Tex SAM facial implant for lip augmentation was evaluated, and an objective measurement method was developed for assessing the results.

Methods.—Under local anesthesia, 3 Gore-Tex implant segments were inserted into separate tunnels in the muscle of each of 23 lips of 17 adult female patients, age 26-52. Pre- and postoperative (1, 3, and more than 6 months) images were captured by means of a computer imaging system. Measurements were analyzed statistically.
Results.—All 77 implanted segments were in place at the follow-up visit without showing their shapes on the lip surface. Complications included extrusion of 1 segment and mild lip stiffness lasting more than 6 months, each in 1 patient. Projection of the lip increased by an average of by 0.98 mm and the width of the exposed vermilion increased by an average of 1.94 mm after 6 months.

Conclusion.—The Gore-Tex implant does not give sufficient projection if a safe amount of material is used. Furthermore, it is very expensive.

► Using a computer imaging system to compare pre- and postoperative photos, the authors were able to demonstrate enhancement of lip projection of 0.98 mm and exposed vermilion width enhancement of 1.94 mm 6 months after insertion of 3 segments of a 1.8 mm Gore-Tex facial implant. Although the patients generally were pleased with their operative result, it is important that the surgeon performing this procedure understand the small gains in lip projection accomplished by insertion of Gore-Tex facial implants.

The Liposhaver in Facial Plastic Surgery

Introduction.—The various modifications of the original blunt liposuction cannulas have all retained the basic avulsion principle as the method of fat extraction. With soft-tissue shaving cannulas, fat removal is more precise and less traumatic. The results of the liposhaver in cosmetic facial surgery are reported for 19 patients who participated in a multicenter clinical trial of the device.

Methods.—A nonrandomized, nonblinded evaluation of the liposhaver was undertaken in patients having submental lipectomy, facelift with need for defatting beneath the facelift flap, or correction of deep nasolabial folds. The liposhaver was designed to cut fat preferentially, but to be less efficient at cutting adjacent muscle and other soft tissue. Within the blunt, outer cannula lies a recessed oscillating blade that precisely cuts and extracts tissue as it is gently suctioned through the side port of the cannula. Surgeons at 3 centers reported details of each procedure and evaluated outcome. Pre- and postoperative photographs were obtained.

Results.—The procedures were performed between August 1994 and April 1996. In all cases the liposhaver was used successfully, and patients achieved the desired contour and profile result without any dimpling or asymmetry. There were no facial nerve injuries and no hematomas developed in the immediate postoperative period. All surgeons felt that the liposhaver was a precise, minimally traumatic, and efficient method of lipectomy. Some relied on direct visualization to avoid cutting soft tissue other than fat, whereas other surgeons initially employed precise surgical technique and knowledge of anatomy without direct visualization.

Discussion.—The liposhaver offers several advantages compared with conventional liposuction. Fat is removed precisely in a minimally trau-matic manner, without potentially bruising back-and-forth motion. There is the potential, however, for injury to vital nerves or vessels in the head and neck area when the device is used in the power mode without direct visualization.

► The authors report their experience in nineteen patients undergoing cosmetic facial procedures using the liposhaver, a blunt cannula tip with an inner oscillating cutting blade. Although the clinical results they present are rather impressive, there is significant risk of injury to facial nerve branches, most specifically the marginal mandibular nerve, and the vasculature. Given the technical difficulties of operation and possibility of neurovascular damage, this technique offers little advantage over traditional tumescent liposuction.

Use of Preoperative Subcutaneous “Wetting Solution” and Epidural Block Anesthesia for Liposuction in the Office-based Surgical Suite

Background.—Klein described a “tumescent technique” with uniform saturation of subcutaneous fat using a “wetting solution” formula. This technique has been shown to decrease blood loss during liposuction and eliminate the need for general anesthesia in some patients. The authors have found that this infusate does not provide adequate anesthesia in many of their patients. They use a preoperative infusion of Klein’s epinephrine and lidocaine solution for control of blood loss and postoperative pain only. For anesthesia, an epidural block technique is used. They report their experience with 85 patients.

Patients.—The 85 consecutive patients had liposuction under epidural anesthesia after subcutaneous fat perfusion with Klein’s wetting solution. Chloroprocaine was used for the epidural block.

Results.—The epidural anesthesia enableLaser and Cosmetic Surgeryd the wetting solution to be injected efficiently and painlessly. Suction-assisted lipectomy was performed painlessly. There were no cases of allergic reaction to chloroprocaine or toxicity from the combination of lidocaine and chloroprocaine. There were no serious complications associated with the epidural anesthetic. The average length of stay in the recovery room was 48 minutes for all patients. Postoperatively, none of the patients reported that they would choose a general over an epidural block anesthetic for future surgery.

Discussion.—Chloroprocaine is rapidly metabolized and has the lowest systemic toxicity risk of any local anesthetic agent. The characteristics of chloroprocaine are well-suited for outpatient surgery and there are few adverse effects. Based on these results, the combination of preoperative perfusion of the subcutaneous space with lidocaine and epinephrine for control of blood loss and pain and epidural block with chloroprocaine is recommended for most outpatient lipoplasty procedures. The epidural block does not delay the start of the procedure or prolong recovery time.

► The authors state that for liposuction in the office setting, mild sedation and regional anesthesia obtained with a tumescent solution is often accompanied by inadequate anesthesia. They suggest that an epidural block be administered for patients undergoing the procedure. In my experience, adequate infiltration with the tumescent solution and mild conscious sedation are almost always capable of providing adequate operative anesthesia. The epidermal block may produce significant perioperative and postoperative complications and should be administered only by those physicians expertly trained in the technique as well as in advanced cardiac life support.

Noninvasive Mechanical Body Contouring: A Preliminary Clinical Outcome Study

Background.—L.P.G. Endermologie is a noninvasive means of shaping the body by the use of rollers and positive and negative pressures. Its effectiveness is probably attributable to sublethal damage to the subcutaneous fat by the rollers. The safety and efficacy of this technique in body contouring were evaluated.

Methods.—Twenty-two women aged 24-48 years were enrolled for L.P.G. Endermologie sessions. All women completed at least 7 of 14 planned sessions, and 6 completed all 14 sessions. Sessions were 45 minutes long and occurred once or twice a week. Patient tolerance determined the amount of negative pressure used, and the technician determined the amount of positive pressure applied. The only dietary suggestions given were that patients should drink 8-10 glasses of water each day and follow a low-fat diet. Weight and circumference at the waist, hips, thighs, knees, and calves were measured at baseline and at 7 and 14 weeks. The average overall circumference loss was calculated.

Findings.—After 7 sessions, the average weight loss in these 22 patients was 1.35 lb, and the average circumference loss was 0.5439 in. For the 6 patients who completed all 14 sessions, the average weight loss was 0.7 lb and the average circumference loss was 1.121 in. Thus, patients who completed all 14 sessions had twice the reduction in body circumference as those who quit after 7 sessions. Some patients gained a small amount of weight, and some patients lost weight; but regardless of weight gain or loss, 21 of 22 had a decrease in their body circumference.

Conclusions.—Regardless of weight loss or gain, all patients except 1 experienced a reduction in overall circumference and a positive effect on body contour with L.P.G. Endermologie. Results were pleasing, and were greater for patients who completed the entire 14 treatment sessions. The technique, however^ is technician dependent, because the technician applies the positive pressure during rolling of the skin and subcutaneous fat. In sum, L.P.G. Endermologie is a mildly effective method for shaping the body contour via the subcutaneous fat plane.

► L.P.G. Endermologie is a technique that has been widely used in Europe in the last decade. Its reported benefits include reduction of persistent cellulite and noninvasive body contouring. In this study, the average woman showed a reduction in mean body circumference index as well as weight loss during the period of observation. On the basis of the data presented, it seems that this technique may be mildly effective in improving the appearance. However, it is very technique-dependent and the authors included no data on patient satisfaction.