Long-Term Results of Upper Lips Treated for Rhytides with Carbon Dioxide Laser

Transcription

1 Cosmetic Long-Term Results of Upper Lips Treated for Rhytides with Carbon Dioxide Laser Sjoerd J. Dijkema, M.D., and Berend van der Lei, M.D., Ph.D. Leeuwarden and Heerenveen, The Netherlands Background: Carbon dioxide laser resurfacing has been widely reported as an effective method for smoothing facial rhytides. However, limited series have been published describing the long-term results. This retrospective study was undertaken to assess the long-term aesthetic results of upper lips treated for rhytides with the Silk- Touch carbon dioxide laser (Sharplan Lasers, Inc., Warwick, R.I.). Methods: The results of 35 patients were reviewed and evaluated, including patient demographics, skin type, laser pass data, laser parameters, and longterm aesthetic results and complications. Aesthetic results were graded by independent reviewers using a standardized photographic rhytide scale, and all patient satisfaction rates were evaluated by means of a five-point visual analogue scale. Results: Rhytides were almost completely ablated at 3-month follow-up. A persistence of approximately 81 percent of the rhytide reduction was shown at a follow-up period of 2.1 to 6.3 years (average, 4.5 years). Most of the patients would undergo the procedure again and would recommend it to their friends. The only drawback and main long-term complication was the high rate of hypopigmentation (57.1 percent). Conclusions: This study clearly demonstrates that laser resurfacing with the SilkTouch carbon dioxide laser is a highly effective treatment of rhytides of the upper lip that will last for a long time, but there is a high rate of hypopigmentation. (Plast. Reconstr. Surg. 115: 1731, 2005.) Rhytides of the upper lip are one of the stigmatizing signs of aging in women. Therefore, many women seek advice about treatment. Until the 1990s, dermabrasion and chemical peeling were mainly used for treatment of rhytides. However, these methods are not so ideal for upper lips; the results, although reasonable, are very surgeon dependent or not always reproducible and predictable because of the lack of depth control, particularly for the removal of rhytide shoulders around the mouth. 1,2 The development of carbon dioxide resurfacing lasers has greatly improved the results of treatment of these rhytides, and carbon dioxide resurfacing is now equal or superior to the older treatment modalities for skin aging. Carbon dioxide lasers allow a more precise level of tissue ablation, leading to better, safer, and more predictable results. Several studies have reported excellent short-term results, with a mean follow-up varying from a couple of weeks until 1 year by using either a Coherent UltraPulse (Coherent, Palo Alto, Calif.) or a Sharplan SilkTouch carbon dioxide laser (Sharplan Lasers, Inc., Warwick, R.I.) for treatment of rhytides. 1 8 Only a small number of studies have reported a longer fol- From the Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, Medical Center Leeuwarden, and Private Clinic Heerenveen. Received for publication April 1, 2004; revised June 23, DOI: /01.PRS F9 1731

2 1732 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2005 low-up This study was undertaken to evaluate the long-term aesthetic results of upper lips treated for rhytides with the SilkTouch carbon dioxide laser. PATIENTS AND METHODS Patients Since 1997, we have performed more than 150 laser resurfacing procedures with the Sharplan SilkTouch carbon dioxide laser. Until 2001, 59 patients underwent laser resurfacing of the upper lip. All of these patients were recalled; 35 responded and were willing to participate in this retrospective study (response rate, 59.3 percent; 23.7 percent were unreachable and 17 percent were not willing to participate or did not show up). The records of these 35 patients were thoroughly reviewed. All patients were white women, with a mean age of 51.7 years at the time of the laser resurfacing (range, 36.6 to 70.0 years). Skin types II to III, as classified by Fitzpatrick, 13 were most common (Table I). Laser Resurfacing Procedure All patients were instructed to use hydroquinone 4% cream daily and retinoic acid 0.025% cream nightly for a period of 2 weeks before the laser resurfacing. Zovirax (acyclovir, Glaxo- SmithKline, Zeist, The Netherlands, three times daily, 400 mg) was used as antiviral prophylaxis (starting 2 days before and continuing for 5 days after laser resurfacing). All laser resurfacing procedures were performed under local anesthesia (lidocaine 1% with epinephrine 1:100,000) on an outpatient basis by one plastic surgeon (van der Lei). Energy parameters, including spot size and wattage, and the amount of passes were recorded. In most instances, two passes were delivered (first pass, 4 mm/12 W; second pass, 4.8 mm/13 W) on the entire lip surface and one additional pass on Characteristic TABLE I Patient Data (n 35) Value Age, years Mean 51.7 Range Sex All women Race All white Fitzpatrick skin type 11.4% type I, 57.2% type II, 31.4% type III Smoking history 14 smokers Follow-up period, years (average, 4.5) the rhytide shoulders (4 mm/12 W). Between passes, tissue debris was mechanically removed with moist sponges. At the end of the procedure, a thick layer of silver sulfadiazine was applied. The postoperative care consisted of silver sulfadiazine application four to six times daily until healing was completed after 7 to 14 days (open method). Patients were seen at 1 week, 2 weeks, 6 weeks, and 4 months after laser resurfacing and again recently for the purpose of this study evaluation. If indicated, additional follow-up was planned. Patient Evaluation All patients were interviewed by the first author (Dijkema) (questions are listed in Table II). Satisfaction rates were evaluated by means of a five-point visual analogue scale. All photographs taken before laser resurfacing, 12 weeks after laser resurfacing, and at the time of this evaluation were randomized and scored by three independent reviewers (two plastic surgeons and one layperson) by means of the wrinkle assessment scale of upper-lip lines developed by Lemperle et al. 14 (Table III). These rhytide scores were evaluated by means of the Wilcoxon signed rank tests. Differences were considered to be significant at a value of p TABLE II Patient Satisfaction Based on a Five-Point Visual Analogue Scale ( 2, 1, 0, 1, 2) Mean Score Question Asked (Range) Did you receive enough information prior to the treatment? 1.3 ( 1 2) Was it a painful experience? ( 2 means a lot of pain, 2 means no pain at all) 0.2 ( 2 2) Did you receive adequate follow-up? 1.3 (0 2) Are you satisfied with the result? 1.1 (0 2) Is the result according to your expectations? 0.9 ( 1 2) Was the final result worth the physical efforts? 1.0 ( 2 2) Did the result maintain? 0.9 ( 2 2) Is your satisfaction at this moment still the same as shortly after treatment? 0.7 ( 1 2) Did the treatment improve your wellbeing? 1.0 ( 2 2) Would you undergo the same treatment again (with your current experience?) 0.9 ( 2 2) Would you recommend this treatment to your best friend? 1.1 ( 1 2)

3 Vol. 115, No. 6 / TREATMENT FOR UPPER LIP RHYTIDES 1733 TABLE III Wrinkle Assessment Scale of Upper Lip Lines According to Lemperle et al. 14 Class Description 0 No wrinkles 1 Just perceptible wrinkle 2 Shallow wrinkle 3 Moderate deep wrinkle 4 Deep wrinkle, well-defined edges 5 Very deep wrinkle, redundant fold A clas- Lemperle, G., Holmes, R. E., Cohen, S. R., and Lemperle, S. M. sification of facial wrinkles. Plast. Reconstr. Surg. 108: 1735, RESULTS Rhytides Evaluation The mean rhytide score before laser resurfacing was 3.1. These rhytides were almost completely ablated after laser resurfacing, as evaluated at the 3-month follow-up (mean rhytide score, 0.5; an equivalent to 83.9 percent of theoretical maximum improvement, p 0.05). At the long-term follow-up, as evaluated in this study, the overall aesthetic result remained very good and stable (mean rhytide score, 1.0; 67.7 percent of theoretical maximum improvement, p 0.05) (Fig. 1). This represents a persistence of approximately 81 percent of the rhytide score reduction at 3 months after laser resurfacing. There was no significant difference in rhytide score between smokers and nonsmokers, and smoking did not have any detrimental effect on the long-term aesthetic results (p 0.9). The upper lip of a representative patient before and 5 years after laser resurfacing is shown in Figure 2. FIG. 1. Rhytide score preoperatively (T0), 12 weeks postoperatively (T1), and at long-term follow-up (mean, 4.5 years; T3). FIG. 2.(Above) Lip before laser resurfacing and (below) 5 years after laser resurfacing. Patient Satisfaction Most patients were very satisfied with the results of the laser resurfacing procedure (Table II). The treatment met their expectations. Most patients noticed a long-lasting aesthetic improvement of their upper lip. The majority of patients (83 percent) would undergo the procedure again, and most patients (74 percent) would recommend the procedure to a friend. Drawbacks and Long-Term Complications Hypopigmentation, ranging from hardly visible to severe, occurred in 20 patients (57.1 percent); 12 (34.3 percent) of them needed to camouflage their lip for social events (Table IV and Fig. 3). Five patients (14.3 percent) found this hypopigmentation inconvenient, and only one patient would not have undergone the laser resurfacing if she had known the severity of this side effect. Only one patient had a very small area of minor scarring; this was successfully treated with a Kenacort (triamcinolone; Bristol-Myers Squibb B.V., Woerden, The Netherlands) injection. None of the patients dem-

4 1734 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2005 TABLE IV Long-Term Drawback and Complications Complication No. of Patients % Hypopigmentation Scarring Erythema ( 3 mo) Hyperpigmentation 0 0 Dry skin onstrated hyperpigmentation. One patient noted dry skin after resurfacing. DISCUSSION This study evaluating the long-term aesthetic results of upper lips treated for rhytides with the SilkTouch carbon dioxide laser clearly demonstrates its benefits. Both objectively and subjectively, the results are very good; the rhytides remain hardly visible even after many years, and most patients are very satisfied with the result. Most of the patients would have undergone the procedure again and would advise friends to undergo this procedure. The only drawback, however, and main long-term complication, was the high rate of hypopigmentation. Thus far, only a limited amount of long-term results have been published concerning carbon dioxide laser resurfacing. Schwartz et al. retrospectively reviewed 211 patients at a mean follow-up of 1 year after laser resurfacing of facial areas (33 patients underwent laser resurfacing of the perioral region) and concluded that the overall result was good, with only the perioral region showing a higher recurrence rate of rhytides compared with other facial regions. It is understandable that there will be some relapse of rhytides of the upper lip, as we FIG. 3. Hypopigmentation (arrow indicates the transition border). also found, because the upper lip is an area in which muscles largely exert their wrinkling forces. Bisson et al. 10 prospectively reviewed 31 patients after resurfacing of the perioral region and reported a mean reduction in wrinkle depth of 87 percent at 2 years. Manuskiatti et al. 12 retrospectively reviewed 96 patients following resurfacing of the perioral region and observed a high rate of patient satisfaction and a significant persistence of improvement at a mean follow-up of 2 years. Weinstein 11 stated great results at 4 years after laser resurfacing of facial areas, including the upper lip, but comparative data were not reported. Our study, however, evaluated a clearly defined area: the upper lip clearly demonstrates comparative data at 3 months and after a mean follow-up of 4.5 years. Hypopigmentation is a late complication related to the depth of tissue injury during the laser resurfacing procedure. The deeper this injury, which is mainly caused by thermal damage rather than depth of tissue ablation, the more hypopigmentation that will occur, but also the more new collagen formation that will occur, resulting in longer lasting clinical improvement. We have both a high rate of hypopigmentation (almost 60 percent) and a high rate of long-lasting good aesthetic results, which are probably related to each other. Other studies report rates of hypopigmentation up to 24 percent only, 5,8,10,12 although it is unclear how this rate was determined: we have counted even minimal changes. Actually, there are two types of hypopigmentation. First, treated skin can be relatively light in contrast to the more darkly pigmented, photodamaged adjacent skin, but can have the same color of areas not exposed to sunlight. Second, treated skin can also be lighter than the areas not exposed to sunlight. The latter type of hypopigmentation induced by laser resurfacing probably results from a suppression of melanogenesis rather than destruction of area melanocytes. 15 Topical photochemotherapy may be a solution of this cause of hypopigmentation. Patient satisfaction after an aesthetic treatment may decrease over time, 16 because the patient will forget about their appearance before treatment. Nevertheless, in our study, most patients were still very satisfied with the results of the laser resurfacing despite more or less hypopigmentation. Most of the patients would have the procedure performed again for

5 Vol. 115, No. 6 / TREATMENT FOR UPPER LIP RHYTIDES 1735 aging skin of the upper lip and would recommend it to friends. CONCLUSIONS This study clearly demonstrates that laser resurfacing with the SilkTouch carbon dioxide laser is a highly effective treatment of rhytides of the upper lip that will last for a long time (more than 6 years). The only drawback is a high rate of hypopigmentation. Berend van der Lei, M.D., Ph.D. Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery Medical Center of Leeuwarden Henri Dunantweg AD Leeuwarden, The Netherlands b.van.der.lei@znb.nl ACKNOWLEDGMENT The authors are grateful to the medical photographers of the Medical Center Leeuwarden for their support. REFERENCES 1. Chernoff, W. G., Schoenrock, L. D., Cramer, H., and Wand, J. Cutaneous laser resurfacing. Int. J. Aesthetic Restor. Surg. 1: 57, Alster, T. S., and Garg, S. Treatment of facial rhytides with a high-energy pulsed carbon dioxide laser. Plast. Reconstr. Surg. 98: 791, Waldorf, H. A., Kauvar, A. N. B., and Geronemus, R. G. Skin resurfacing of fine to deep rhytides using a charfree carbon dioxide laser in 47 patients. Dermatol. Surg. 21: 940, Penoff, J. Laser skin resurfacing. Ann. Plast. Surg. 36: 392, Schwartz, R. J., Burns, A. J., Rohrich, R. J., Barton, F. E., and Byrd, H. S. Long-term assessment of CO 2 facial laser resurfacing: Aesthetic result and complications. Plast. Reconstr. Surg. 103: 592, Lask, G., Keller, G., Lowe, N., and Gormley, D. Laser skin resurfacing with the SilkTouch flashscanner for facial rhytides. Dermatol. Surg. 21: 1021, Fitzpatrick, R. E., Goldman, M. P., Satur, N. M., and Tope, W. D. Pulsed carbon dioxide laser resurfacing of photoaged facial skin. Arch. Dermatol. 132: 395, Bernstein, L. J., Kauvar, A. N. B., Grossman, M. C., and Geronemus, R. G. The short- and long-term side effects of carbon dioxide laser resurfacing. Dermatol. Surg. 23: 519, Trelles, M. A., Garcia, L., Rigau, J., Allones, I., and Velez, M. Pulsed and scanned carbon dioxide laser resurfacing 2 years after treatment: Comparison by means of scanning electron microscopy. Plast. Reconstr. Surg. 111: 2069, Bisson, M. A., Grover, R., and Grobbelaar, A. O. Longterm results of facial rejuvenation by carbon dioxide laser resurfacing using a quantitative method of assessment. Br. J. Plast. Surg. 55: 652, Weinstein, C. Carbon dioxide laser resurfacing: Longterm follow-up in 2123 patients. Clin. Plast. Surg. 24: 109, Manuskiatti, W., Fitzpatrick, R. E., and Goldman, M. P. Long-term effectiveness and side effects of carbon dioxide laser resurfacing for photoaged facial skin. J. Am. Acad. Dermatol. 40: 401, Fitzpatrick, T. B. The validity and practicality of sunreactive skin types I through VI. Arch. Dermatol. 124: 869, Lemperle, G., Holmes, R. E., Cohen, S. R., and Lemperle, S. M. A classification of facial wrinkles. Plast. Reconstr. Surg. 108: 1735, Grimes, P. E., Bhawan, J., Kim, J., Chiu, M., and Lask, G. Laser resurfacing-induced hypopigmentation: Histologic alterations and repigmentation with topical photochemotherapy. Dermatol. Surg. 27: 515, Batra, R. S., Jacob, C. I., Hobbs, L., Arndt, K. A., and Dover, J. S. A prospective survey of patient experiences after laser skin resurfacing: Results from 2 1/2 years of follow-up. Arch. Dermatol. 139: 1295, 2003.