| FACIAL REJUVENATION | ARTICLE
■ Coagulation disorders or treatment with anticoagulants
■ Receiving acetylsalicylic acid during the 7 days preceding treatment
■ History of severe or anaphylactic allergic reactions ■ Previous formation of keloids or hypertrophic scars ■ Pregnancy or breastfeeding. Patients were photographed using the Visia system
(Canfield Scientific, Fairfield, New Jersey, USA). Clinical photos were taken with a Canon G9 camera and LiteDome Q39 diffuse strobe box
flash (Canfield
Scientific). Reproducible positioning of subjects for images at baseline and follow-up was controlled using the Canfield Mirror software, which overlays the baseline image on top of the new image, thereby enabling positioning adjustments.
Assessments The degree of ageing in the lower and middle thirds of the face were assessed using the Wrinkle Severity Rating Scale (WSRS) and the Global Aesthetic Improvement Scale (GAIS) in order to determine the efficacy of treatment17–19
. The assessments were performed by the investigator
and an external observer (blind) using the WSRS scored from 1 (absence of jowls and ptosis in the lower and middle thirds of the face) to 5 (presence of jowls and extreme sagging of the lower and middle third of the face), and the GAIS graded using 5 levels of satisfaction (worse, no change, moderate, much improved, very much improved). The degree of patient satisfaction at each check-up visit was recorded using a visual analogue scale (0–10) on which 0 indicated no satisfaction and 10 maximum satisfaction. Data were analysed using SAS version 9.2 (SAS
Institute, Inc. Cary, North Carolina, USA). A sample of 124 patients was established with a 95% confidence interval. Statistical significance was set at P < 0.005. Efficacy was evaluated using the WSRS and GAIS, and FisherÕs exact test was applied. Satisfaction with treatment was evaluated using the Wilcoxon test.
Procedure The procedure using the Aspire laser (SlimLipo, Palomar) was as follows: ■ Marking of the entry point. Middle third ® laterally to or within the nasolabial fold at the level of the labial commissure. Lower third ® 3 cm in front of the earlobe and 1 cm above the mandibular angle
■ Injection of a local anaesthetic skin wheal using 0.5Ð 1 cc of 1% lidocaine
■ Preparation of the field (neck and face) with sterilising solution and delimitation with sterile dressings
■ Perforation of the skin with an 18 G needle ■ Infiltration of the area with 2Ð 3 cc of anaesthetic solution (0.5% Lidocaine, 0.25% Marcaine with adrenaline 1 : 200 000, hyaluronidase at 4 IU/cc) with a 1.6 mm diameter needle (Multi-Hole Super Luer Lock, Hamilton Company, Nevada, USA)
■ Laser-assisted lipolysis at a depth of 3Ð 4 mm from the skin surface
■ Injection of 3 cc of saline solution at room temperature into the treatment area for cooling.
■ Aspiration with 5 cc syringes previously filled with 1 cc of saline solution to reduce negative pressure (one syringe per area to ensure symmetry). The procedure is performed using a two-port cannula (2 mm diameter)
■ Compression for a few minutes to ensure absence of bleeding
■ Deep laser sweep to improve the effect of skin retraction.
It is important to mark out a 10 mm Ôno lasing zoneÕ
around the entry point in order to prevent burning with the sweeping movements of the laser fibre. The position of the fibre is evaluated by touch and aiming the beam; after a number of sweeps, the area is lifted between the thumb and index finger of the other hand, enabling good overall control of the area. The tip should be moved continuously (3 cm/s) to prevent excessive power build-up at a single point, and maintained against the surrounding skin cover to prevent the formation of deep tunnels and possible subsequent deformity.
Table 3 Wrinkle Severity Rating Scale after 3 months: investigator versus observer WSRS
WSRS
Investigator at baseline
Absent Mild
Moderate Severe
Extreme 0
17 71 33 3
124 WSRS=Wrinkle Severity Rating Scale 4
92 28 0 0
124
WSRS
Investigator after Observer after 3 -month follow-up 3-month follow-up
5
87 30 2
0 124
100 80 60 40 20 0
Absent Mild Moderate
WSRS Investigator before
WSRS Investigator after 3-month follow-up
WSRS Blend after 3-month follow-up
Severe
Extreme
Figure 3 No significant differences were noted between the investigator and the blind observer (P=0.987). Most patients are left with mild defects (WSRS=Wrinkle Severity Rating Scale)
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