In facial plastic surgery, there are multiple factors in facial aging. One which we have no control over and is arguably the most important is our genetic structure. This factor is provided to us by our birth parents and at this time is not changeable. Other factors that affect aging are (1) dietary-including alcohol/tobacco consumption, weight gain/loss, (2) environmental- UV exposure based on the geographic location in which we live and the use of sunscreens; Wind and its drying effects; average relative air humidity; air pollution levels, and (3) medical conditions diabetes, scleroderma/collagen vascular diseases, chronic stress, chronic fatigue, and hormonal effects.

SmartLook Lid Refreshing

Aging occurs in two primary ways that are especially noticeable in the facial areas, Gravitational and Soft Tissue Wasting (also called Deflation). These affect the skin and underlying supporting structures of the face and neck. Gravitational forces provide a continual downward traction force. The result is a lengthening of the deep SMAS network that attaches to the facial skeletal structure. The overlying skin is unable to resist such force. The skin is dynamic and a continually renewing organ of the body. It, therefore, grows to continually cover the underlying continually stretching SMAS. Deflation is relative to the effects of the aforementioned aging factor on all the soft tissue structures of the face. There is musculature atrophy. The SMAS loses tensile strength. The skin including the subcutaneous fat and dermis thins. The resulting lack of support for the epidermis creates new lines, wrinkles, and skin folds, all signs of aging.

To counteract the gravitational aging effect, numerous lifting techniques have been designed over the decades. Whether considered “deep, superficial, SMASectomy, plication, imbrication, ‘S’, ‘J’” or whatever, all have the same desire to result in lifting the supporting structures of the face and anchor them to the skeletal structures of the skull. The next step in almost all techniques involves the removal of an amount of extra skin that results from the effect of the lift procedure and then skin incision closure. The loose excessive skin surface area is reduced. Some deep folds are removed and heavy lines softened. Aged thinning skin, although less loose and better draped on the surface of the SMAS is still thin, poorly toned and allow in surface appearance. It appears dull and lacks the youthful glow created by the reflection of ambient light on tones skin. The fine crepe-like rhytids are primarily unchanged, because although stretched and redirected the skin is “dynamic” and will grow to its natural resting tone for its age. No significant new collagen stimulation occurs from surgical lifting.

Counteracting the wasting/deflation effects of aging has traditionally relied upon some topical or external forces being applied directly to the skin to stimulate collagen growth or by injection of “filler” substances. These are ever increasing in number as FDA approval occurs. The external forces for skin replenishment include; external beam lasers and IPL (intense pulse light), LED devices, and chemical solutions such as TCA, Jessener’s, Gordon-Baker, Retinoids, Glycolic, Lactic and other fruit acid peels. These skin replenishes all attempt to effect the actively growing primary source of skin renewal, the Dermis. The Dermis supplied by a vascular plexus is THE source of epidermal cushioning and support. Even dermabrasion is known to have a wounding effect that stimulates the dermal plexus to grow and by better oxygenation result in dermal growth stimulation. In more simple terms “the dermis is where the action is.” Unfortunately, every one of these techniques also requires a trans-epidermal crossing of the media. This means greatly less total energy/material delivery to the Dermis due to a dissipation of energy in the epidermis or failure of penetration of media. A worse problem is that too much epidermal absorption of energy can then cause it to be permanently damaged creating scar tissue and/or color change. What has been needed is a means of bypassing the epidermis safely and effectively to directly deliver media to the Dermis.

Now there has been for the first time, by Cynosure, the development of a safe and dependable system for the under the skin delivery of laser energy. The negative effects of through the skin laser delivery are eliminated. The full amount of energy is directed to the best location for skin replenishment and therefore, skin support is maximized. Two techniques were designed; one is a stand alone procedure for the face and neck skin. This is named ‘SmartLook’ Skin Refreshing. The second is an adjunct to face lifting techniques to create heretofore unobtainable safe full face skin rejuvenation without compromising skin viability that may cause tissue loss by damaging the dermal plexus. This is named the ‘SmartM.A.C.’ Couture Lift.

Numerous surgery techniques have been postulated in the advancement of facial rejuvenation. Deep plane, superficial plane, SMASectomy, SMAS plication/imbrication, FAME lift, long flap, short flap, “S” lift, “J” lift and the multiple trademarked facelifts on the market are all technical changes meant to achieve superior results. These have been techniquedriven advances. The use of Cynosure’s Smartlipo 1064nm laser to safely deliver under the skin thermal energy is a major technological advance that we believe has created the next generation of improvement in facial plastic surgery results. This manner of collagen synthesis stimulation and reorganization has not been achievable previously. The results of improved facial skin tone and elasticity combined with skin shrinkage we feel are truly revolutionary in our field.

All subjects treated have shown no negative effects on skin pigmentation. Treatments have been performed on multiple skin types including subjects of Caucasian, Black, Hispanic, Middle Eastern, Scandinavian, Eastern European, and Asian heritage. No hyper- or hypo-pigmentation has developed or any sign of keloid formation. In actuality, if the subjects had areas of melasma, actinic induced depigmentation, or rosacea there were was objective visible improvements in most all cases.

Bruising is generally mild in laser alone patients and reduced in lift/laser cases when compared to average facelift alone patients. The pain was reported as mild to none. Patients having surgical lifting concurrently had noticeably less utilization of pain medication than the usual face lift alone patient.

Observed changes in the skin are as follows. Pore size is reduced. The improved skin ambient light reflex results in a more youthful glowing complexion. Improved skin tone/elasticity provides a gentle lifting effect on the treatment zones whether surgical lifting was performed or not. Treatment zones can include all areas of the face and neck excluding the nose and upper eyelid skin. Skin improvement is evident as early as 2 weeks. The first 3 months post procedure are when the majority of skin changes are seen with mild further improvement noted up to 6 months. Improvement is then stable. Longevity of results will be affected by all the same aging factors that were present at the time of procedure as with any rejuvenation technique. No procedure stops the aging process.

With demand for maximum cosmetic results with minimally invasive procedures and rapid recovery time, this new application of a well-studied technology will have a central place in my practice of aesthetic plastic surgery.