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Less invasive procedures for facial rejuvenation are becoming more and more popular as prospective patients seek out treatment options that offer the best-possible results with the least amount of downtime and risk including anesthetic risk.  One such option is Laser SmartLifting™, which utilizes the Smartlipo laser for laser lipolysis and skin tightening through tissue coagulation during the preliminary stages of facial rejuvenation procedures

How is Smartlifting™ Performed?

Power by Cynosure’s Smartlipo or Smartlipo MPX, the basic technique applies the laser subcutaneously prior to traditional facial flap elevation in established facial rejuvenation proceures such as rhytidectomy or forehead rhytidectomy and neck lifts. Initially in our studies short pulses with high peak power of a 1064nm Nd:YAG system, FDA-approved for subcutaneous use, was utilized to irradiate subcutaneous tissue through a 600-micron optical fiber with a 1- mm diameter stainless steel micro-cannula of variable length connected to the tip of the fiber.  At the distal end of the cannula is a section of optical fiber 2 mm in length which interacts with the facial and neck soft tissue. A trans-illumination effect from a He:Ne laser source in the beam path shows precisely where the laser is working. For most facial and neck anatomical regions, a 6W-12, 100μs pulsed laser at 40 Hz and 150 mJ is appropriate. Recently the Smartlipo MPX has been utilized and both the 1320nm and multiplexed 1064nm/1320nm wavelengths have been used. We have also investigated the use of a 980nm continuous wave laser for laser flap elevation. Power, laser-action, time or both can be decreased for small or superficial areas. Laser dissection involves thermal and photo-mechanical effects. (See Diagram) The Nd:YAG laser’s hemostatic properties allow for the coagulation of small blood vessels in the subcutaneous plane with preservation of the dermal plexus of vessels. Skin tightening through tissue coagulation also occurs concurrently with the tissue separation. There are usually three portals for the laser introduction including the temporal, adjacent to the lobule and posterior auricular. The laser aids in tissue separation while tightening skin and tissue. The addition of the laser resulted in less bleeding than seen with traditional flap elevation techniques such as scissor vertical spreading techniques.. Operating time for flap elevation decreased by more than 50%, according to a retrospective review of over 130 patients our preliminary study. Many patients also experienced less post-operative bruising and some were able to return to work in as little as three days. The procedure is based on the disruption of soft tissues usually in the plane between the subcutaneous plane and the superficial muscular aponeurotic system (SMAS) or superficial fascial layers. Flap separation is also possible in typically difficult-to-reach areas such as the nasal labial folds and the corner of the mouth when completing full rhytidectomy. SmartLifting™ also facilitates tissue separation complicated by scar tissue and fibrosis during secondary rhytiudectomy  

Why Use Lasers for Skin Flap Elevation?

Early in 2008 we were consulted by a patient who had interest in a minimally invasive approach to her facial and neck concerns .  She was aware of the Smartlipo laser and had a specific interest in slimming her neck which had quite a bit of pre-platysmal and sub-plastysmal fat with concurrent laxity.  When we examined her further we recommended a minimally invasive approach to tighten her mid and lower face in addition to her neck rejuvenation.  We also had significant interest in evaluating how the laser would interact with her significant acne scarring.  After fully disclosing the nature of the laser’s use for these problems she was scheduled for a minimally invasive “Smartlipo” lift.

Is There Facial Lifting in Smartlifting™?

Up until early 2007, most of the procedures completed in our office and in other offices around the country were completed by utilizing the laser for laser lipolysis and the concurrent tightening of the facial soft tissues that follows laser lipolyis.  This is the “Smartlipo” procedure or laser lipolysis itself.  Over the past years we were also streamlining our approach to the SMAS in our Mini-Lift procedure and began implementing the Quill-SRS sutures for a vertically oriented SMAS plication which we found to be very helpful in correcting significant neck laxity as well as improving volume in the malar and submalar regions. 

Smartlifting™: The LaserSmartLift™ & UltraMiniLift™

 We utlilize a modified Klein’s solution to hydro-dissect and vasoconstrict the flap. The Smartlipo laser is then used to separate the skin and dermis from the SMAS by creating multiple “microdissection tunnels.”  After the skin is noted to be mostly loosened from the SMAS the incisions are done and the flap is easily dissected with minimal bleeding. We have elevated the flap in as little as 2 minutes in several patients and the average time is 4-5 minutes. After the flap is adequated elevated and mobilized the Quill-SRS sutures are used to elevate the jowl and upper neck.  Occaisionally a small purse-string neck plication is done at the level of the manbidular angle.  This original technique has evolved into the LaserSmartLift™ which is a mini-lift version with variable length incisions past the retroauricular sulcus.  Several patients have recently been treated with an an even less invasive approach we termed the UltraMiniLift™.  The incision for the UltraMiniLift™ extends from the temporal hair tuft to the mid tragus level.  Laser Smartlifting is then completed and the Quill sutures are placed. This procedure works well in younger patient with early jowling who are interested in a minimally invasive surgical approach for correction. The improved hemostasis facilitated by Smartlifting™ the flap allows the surgeon to address the SMAS through such a small incision.

Smartlifting™: The Results

After completing the first Smartlifting™ procedure early in 2007 it was not the post operative result that got our attention.  After Smartlifting™ the facial flaps we were pleasantly surprised to encounter almost no bleeding on either side. The first patient also had significant dermal fibrosis from her extensive acne scarring.  After the initial procedure we elected to utilize Smartlifting™ in all of our facial rejuvenation procedures including forehead rhytidectomy and it continues to be significantly useful for all the procedures we perform.  We have utilized it for festoons and malar crescents as well as residual fullness after blepharoplasty procedures.  Before and After views are in the photo gallery

Smartlifting™: Complications

Smarlifting™ has been utilized in over 130 procedures since early 2007.  These include face, neck and forehead procedures as well as concurrent use in sub-platysmal fat ablation and muscle ablation during endoscopic forehead procedures.  There have been few complications in our earliest patients all treated with the Smartlipo 6 and 18 W systems.  We are developing newer protocols to maximize the enhanced coagulation properties inherent with the laser while minimizing the potential for collateral thermal damage to the neural and cutaneous anatomy. 

Smartlifting™: Future Applications

Smartlifting™ utilizing the Cynosure Smartlipo and Smartlipo MPX lasers promises to be very useful for Facial Plastic Surgery procedures particularly facial, forehead and neck lifts.  The primary utility of this technique results from the significant hemostatic effect the laser has when used to microtunnel the surgical plane between the dermal-subcutaneous plane and the SMAS.  In addition to the substantial and beneficial hemostatic effects  of the laser the thermodynamic changes induced by the laser in the dermis also contributes to a significant tissue tightening that is not possible in traditional face forehead and neck lift procedures.  The addition of state of the art self retaining sutures for jowl and neck correction to the increased hemostasis and tissue tightening effects of the laser constitutes the technical triad we have dubbed “Smartlifting™”. We and our patients have been very pleased with the natural results obtained from a procedure requiring just over an hour to complete and under only mild sedation

Presented at the American Academy of Facial Plastic & Reconstructive Surgery Annual Meeting:
September 18, 2008 Chicago, Illinois