Skin Resurfacing in Combination with Facelift Surgery.

Rhytidectomy is a surgery of balance and judgment. The goal is to create a refreshed and natural look by lifting the midcheek and jowl tissues and by smoothing the neck bands and excess skin. Facial aging, however, is only partially explained by gravity and descent of facial and neck tissues. Fat compartments in the face atrophy, bone remodels, and the skin undergoes chronological and photoaging changes. Cutaneous photoaging is related to sun ultraviolet (UV)exposure. On a microscopic level, chronological aging includes disorganized collagen, thin epidermis, flat dermal– epidermal junction, decreased fibroblasts, and collagen.1 Photoaging includes increased or decreased thickness of the epidermis, accumulation of elastin fibrils below the dermal–epidermal junction (solar elastosis), increased vascularity, and hypercellular dermis.1 Patients will notice rhytids of the cheek, perioral region, and crow’s feet area with actinic changes and solar lentigines across the face. The rhytidectomy will address the aging changes due to gravity on facial tissues but will do little to improve skin texture, thickness, and pigmentation. In fact, the term rhytidectomy is a misnomer in that a facelift does not excise wrinkles. It only lifts and tightens sagging tissues. To address collagen loss, rhytids, and dyspigmentation, surgeons are incorporating resurfacing techniques including carbondioxide (CO2)/erbium ablative and fractional lasers, 35% trichloroacetic acid (TCA) chemical peel pretreatedwith Jessner’s solution, phenol 88% chemical peel, Baker’s solution chemical peel, and dermabrasion. Using multiple modalities for skin resurfacing for an individual patient to treat each area of the face andneck, separately yet blended, depending on the need for a certain depth of treatment is the key to the overall best result inmost cases. Technique andmodality selection are keys tomaximum single treatment results and therefore the greatest patient satisfaction. The mechanism of resurfacing techniques is to create dermal collagen reorganization and new collagen deposition.2 Thiswill be seen as brightening, smoothing, tightening, and plumping of the skin. The degree of tightening, however, will not replace the surgical tightening and lifting froma rhytidectomy.More recently, surgeons are approaching facial aging with a more comprehensive approach to addressing both gravity and collagen changes by a combination of rhytidectomywith resurfacing. Our preferred technique is the combination of rhytidectomy and CO2 fractionated laser resurfacing. Several considerations must be made to ensure that the laser treatments are performed safely and do not compromise the rhytidectomy flaps.