Marcaine

San Diego -- Perioral rejuvenation responds better to a combination of C[O.sub.2] laser and dermasanding than to laser alone, according to facial plastic surgeon John P. Fezza, M.D., Sarasota, Fla.

Dr. Fezza performed the combination procedure known as laserbrasion on more than 90 patients over three years and found that laserbrasion results in 95 percent wrinkle clearance in the perioral area as compared to 75 percent clearance with laser alone.

"This combination offers the benefit of tissue remodeling from the laser along with the sculpting, shaving and mechanical wounding of the dermasanding. The result is deeper penetration than laser alone without additional thermal damage," Dr. Fezza told attendees at the American Academy of Cosmetic Surgery (AACS) annual meeting.

"The technique is safe, effective and inexpensive with a greater clearance of wrinkles than laser alone," he adds.

Evaluation

When Dr. Fezza evaluates a patient for perioral rejuvenation he examines the oral cavity and the skin. Denture wear, volume deficiency, thinning of the lips and wrinkles from muscle overaction all factor into the extent of the reconditioning, he points out.

"If there are heavy wrinkles, I usually consider laser or laserbrasion," he tells Cosmetic Surgery Times.

Laser alone

By themselves, lasers can produce dramatic results in reducing facial wrinkles, and they work especially well around the cheek area. However, although C[O.sub.2] laser alone produces excellent perioral rejuvenation results for moderate wrinkles in a majority of patients, Dr. Fezza found that the results of laser alone were often disappointing to elderly patients.

"Many older patients have a disproportionate amount of perioral wrinkles compared to the rest of the face," Dr. Fezza explains.

Better modality

He suggests that the perioral area in elderly patients has deeper, more resilient wrinkles, because it is more affected by constant muscle movement of the orbicularis otis muscle and/or the more direct effects of smoking and direct sun exposure. This discrepancy prompted him to seek a safe modality to achieve better results to satisfy these patients.

He evaluated the effects of dermasanding, dermabrasion and chemical peels, as well as various combinations of these treatments and concluded that the combination C[O.sub.2] laser with dermasanding provided superior, safe and reproducible results.

"The other methods had disadvantages," Dr. Fezza says. "Dermabrasion can be bloody and can cause hypopigmentation, and deep chemical peels also have the disadvantage of potential hypopigmentation along with the possibility of perioperative cardiac arrhythmias," he says.

Laserbrasion technique

Dr. Fezza's five-step laserbrasion technique starts with tumescence and ends with postoperative Valtrex (Glaxo-Wellcome).

"First, I make the lips rigid and stretch the wrinkles with 20 cc of dilute local anesthesia comprising 10 cc of Marcaine 0.25 percent and 10 cc of sterile saline" Dr. Fezza says.

Step two entails an average of three to four passes with the C[O.sub.2] laser, which is followed by the third step of cleaning and evaluating the perioral region. Next he applies Frigiderm (Clarity Skincare, Inc.) to the lips to create a stiffer surface for dermasanding.

"This also limits blood splatter," he explains.

He follows the Frigiderm application with dermasanding using sterile 220 grade silicone carbide sandpaper.

"The endpoint of dermasanding in the perioral area is achieved with uniform bleeding points indicating the capillary loops of the reticular dermis," Dr. Fezza says.

Patients begin using Valtrex one day prior to surgery and continue for one week postoperatively. Aquaphor (Aquaphor) or CU3 are used postoperatively for 10 days. Patients are instructed to use Physician's Choice Progesterone Cream (Physician's Choice) progressively tapering the application postoperatively from weeks two through five.

Advantages

Dr. Fezza points out the advantages of this combination technique are that it is easy, effective, safe and cost effective. Furthermore, he adds, dermasanding has an additional advantage.

"Sanding removes some of the lasered tissue and allows me to go deeper than just using the laser alone without having to put excessive thermal energy into the skin," he says.

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