B. S. Biesman, MD
Vanderbilt University Medical Center, Nashville, TN, University of Tennessee Health Sciences Center, Memphis, TN, USA
Blepharoplasty of the upper and/or lower eyelids can restore a youthful appearance to the aging face. This is a minimally invasive procedure that can be accomplished with little bleeding and a small incision. Laser-assisted blepharoplasty was pioneered in 1980, with the technique simplified after the subsequent introduction of the pulsed carbon dioxide laser. Laser-assistance helps mitigate bleeding during blepharoplasty. In ideal circumstances, the laser can be used as a multipurpose device that simultaneously offers cutting, cautery and blunt dissection capabilities. However, there is little experimental evidence confirming the superiority of laser-assisted blepharoplasty over more traditional scalpel surgery. For some procedures coldsteel may be preferable, and some surgeons prefer to use a knife for initial incisions and then laser for its coagulative properties. Patient factors and physician skill should guide the selection of the ideal blepharoplasty technique.
Key Words: blepharoplasty, facial aging, laser
Over the past two decades, western society has placed increasing demands on physicians to perform procedures with greater speed and efficiency and shortened recovery times. Perhaps no discipline has been more affected by these demands than aesthetic surgery. Once considered a luxury available only to the extremely wealthy and long considered a “taboo” topic, aesthetic surgery has become a part of mainstream Western culture. Fashion magazines, the internet, and television shows feature aesthetic surgery topics that are so current that they discuss the use of products not yet approved for use by the US FDA. Cosmetic surgery has consequently become a part of mainstream Western culture.
Some of the earliest changes of facial aging are reflected in the periorbital region. These changes may include excess skin on the upper and/or lower eyelids (dermatochalasis), prominent upper or lower eyelid fat pads, and loosening of the lower eyelids due to laxity of the canthal tendons. It is thus not surprising that blepharoplasty is one of today’s most popular aesthetic surgical procedures.
To enhance efficiency, hasten a return to routine activities and reduce morbidity associated with a surgical procedure, efforts are typically made to minimize incision size, limit the amount of dissection, and shorten the operative time. Applying these concepts to blepharoplasty, the variable most amenable to change is duration of the operative procedure. Operative times may be shortened through operator skill and experience, and via use of a device to enhance intraoperative hemostasis.
Numerous devices permit soft tissue incisions to be made with little or no bleeding. Some examples include sapphire tips heated by an Nd:YAG laser, needle-tipped radiofrequency devices, fine-tipped monopolar cautery, CO2 laser-heated ultra-sharp diamond knife, and free beam CO2 laser. While hemostasis is important, when one is evaluating these devices the amount of thermal damage produced along the wound edges must also be considered, as excessive thermal effect will produce delayed wound healing, dehiscence, or even hypertrophic scarring.
Laser assisted blepharoplasty was first performed by Baker in 1980. He reported the results of his first 40 cases in 1984, concluding that this technique held promise.1 Despite Baker’s optimism, the prevailing opinion in the 1980s was that CO2 lasers produced too much thermal damage to be useful in cutaneous, much less aesthetic, surgical procedures.2
Interest in laser-assisted blepharoplasty was renewed in the early 1990s with the introduction of a high-energy pulsed CO2 laser. This device, known by the trade name UltraPulse® (Lumenis, Palo Alto, CA), produced a high frequency pulsed beam that made incisions with a smaller zone of thermal injury than was previously possible. This laser cut soft tissue with a pulsed beam whose frequency and energy could be independently varied to achieve the ideal blend of cutting and coagulation. Even when operated in “continuous wave” mode, this laser produced a pulsed beam with a frequency of 1000-3000 Hz. The UltraPulse® also produced a small (0.2mm) diameter beam that made it more useful for working in the periorbital region. When used properly, surgery could be performed quickly, intraoperative hemostasis and visualization of delicate anatomic structures was dramatically improved, and the zone of thermal injury surrounding the laser incisions was only about 115µm.3 Consequently, when these wounds healed they were usually indistinguishable in appearance from cold steel wounds. Similar devices subsequently produced by other manufacturers (e.g., Unipulse®‚ Nidek Incorporated, Fremont, CA, 0.2mm spot, peak power = 40W) yielded equally satisfactory results, leading to more widespread acceptance of laser incisional surgery as a viable technique in certain clinical settings. In an effort to further reduce the risk of complications, in 1998 Sciton (Palo Alto, CA) began adapting an Er:YAG laser to produce soft tissue incisions. Unfortunately the Er:YAG laser was unable to produce sufficient hemostasis to make it practical for use in soft tissue incisional surgery.
Proponents of laser incisional surgery find that soft tissue surgery may be performed more efficiently and, in some cases, more effectively with lasers than with standard techniques. There are several reasons for this. First, when used properly, the laser handpiece acts as three instruments: a cutting tool, a cautery, and a blunt dissection device. The intraoperative transfer of instruments and therefore total operating time is thus decreased. Second, intraoperative efficiency is increased further by the near absolute hemostasis that is often achieved when working in areas such as the periorbital region where most blood vessels have an internal diameter of 0.5mm or less. For this reason, the CO2 laser has found its greatest incisional applications in the periorbital region. Third, dissection with the CO2 laser in the eyelids and periorbital region allows surgery to be performed on delicate vascular structures such as the levator palpebrae superioris and the superior tarsal (Müller’s) muscle with a lower risk of tissue distortion, functional impairment, or hematoma formation. Consequently, the use of lasers allows certain incisional procedures such as blepharoptosis repair or correction of eyelid retraction to be performed with greater precision.
One of the most important questions is whether using lasers to perform incisional procedures benefits the surgeon, the patient, both, or neither. The literature is decidedly unclear in attempts to answer this question. Anecdotal reports and small unmasked studies offer conflicting conclusions as to the benefit of lasers in blepharoplasty, the aesthetic procedure performed most often with lasers rather than traditional instrumentation.4-7 Some authors report that the CO2 laser offers little advantage over the scalpel,8 while a recent survey comparing scalpel versus CO2 laser blepharoplasty indicated that the benefits of using a laser included quicker recovery time to usual activities (6.3 vs. 9.1 days), and shorter operating times (four eyelid blepharoplasty times of 58 vs. 94 minutes).9 Biesman and colleagues have performed the only prospective, multicenter, double-blind study to address this issue. Ophthalmic plastic surgeons who were experienced in both laser-assisted and traditional technique (at least 100 cases of each over the preceding 2 years) performed blepharoplasty procedures on 50 patients using laser on one side and cold steel on the other. The side treated with laser was randomly selected and the patients were blinded to the surgeon’s choice. Patients were examined 1, 2, and 4 weeks after surgery. Results were assessed by patient questionnaire and by evaluation of photographs by a skilled, masked observer. Two weeks after surgery there was no significant difference in the amount of swelling, discoloration, or wound appearance. The surgeons preferred performing surgery with the laser when possible due to the improved intraoperative hemostasis. This study did not evaluate surgical times.10
Despite these findings, after years of experience performing periorbital surgery with an array of incisional devices including cold steel, radiofrequency, monopolar cautery, long-pulsed Er:YAG laser and CO2 laser, I continue to prefer the CO2 laser when performing certain incisional procedures, especially for most cases of upper eyelid blepharoplasty, upper eyelid ptosis repair, and lower eyelid transconjunctival blepharoplasty. I have even found that the laser enables me to operate with a greater degree of safety on certain anticoagulated patients who require eyelid or orbital surgery but are unable to discontinue anticoagulation without significant risk of an untoward event.
I do not advocate the use of laser in all cases of periorbital surgery. Due to inconsistent results, I no longer use the laser to make the initial skin incision when performing upper blepharoplasty on patients with “tight” skin such as young patients, Asians, or patients with prominent epicanthal folds. I also prefer to make lower eyelid skin incisions with sharp instruments. However, once the initial incisions have been completed, I use the laser to complete the remainder of the dissection.
The CO2 laser produces a zone of irreversible thermal injury (coagulative necrosis) along the wound edge, an observation that has been correlated with the well recognized delay in the rate of laser wound healing, postoperative wound dehiscence, and unacceptable scarring. As long as these tissue effects are recognized and understood, postoperative problems can be avoided. For example, laser incisions should be made parallel to relaxed skin tension lines. This will allow wounds to be closed with the least amount of tension, thus reducing the risk of unacceptable scarring. Similarly, cutaneous laser incisions should be placed in areas such as the head and neck that have a rich blood supply. When closing cutaneous laser wounds, I believe that absorbable suture materials should be avoided as the coagulative necrosis produced by the laser, in conjunction with the inflammation stimulated by the suture material can produce wounds with an unacceptable appearance. I prefer nylon or polypropylene suture, and leave the sutures in place approximately 7 days as opposed to the 3-4 days I leave sutures after cold steel blepharoplasty. This gives the laser wounds an opportunity to heal more completely prior to suture removal.
When used appropriately and judiciously, lasers can play an important role in periorbital incisional surgery.