A controlled evaluation of dermabrasion versus CO2 laser resurfacing for the treatment of perioral wrinkles

Ancillary Procedures to Facelift Surgery: What has Changed?

The facelift remains the gold standard for rejuvenating the aging face. Many surgical techniques exist in the surgeon's armamentarium that vary based on scar burden, extent of skin undermining, and manipulation of the superficial musculoaponeurotic system. Yet, existing strategies predominantly address the mobile face and have limited effect on fixed zones such as perioral, periorbita, and forehead. Multiple ancillary techniques have therefore been developed to address this therapeutic gap in facial rejuvenation. The most popular techniques today include dermabrasion, lasers, chemical peels, and radiofrequency devices. All have demonstrable safety and efficacy and are chosen based on the patient's unique anatomical presentation, comfort level, and tolerability of recovery time. Surgeons are ideally equipped with the tools and skills to offer all modalities and then tailor their treatment to the specific patient's anatomy. Herein, we review the most effective ancillary procedures of the facelift and describe an evolution of their use in our practice.

Level of Evidence 5

Carbon Dioxide Laser Rejuvenation of the Facial Skin

This article reviews the evaluation and techniques for facial skin rejuvenation using the fractionated carbon dioxide laser. It includes a detailed overview of laser skin rejuvenation and discusses the potential complications associated with this procedure. A review of clinical outcomes in the literature is also included.

An image-based mapping of significance and relevance of facial skin colour changes of females living in Thailand

Objective

There are methods to evaluate skin colour on defined areas over the face but no approach automatically and accurately evaluates skin colour variations on large facial areas, comparing subjects, treatments and/or time points. We propose such an image‐based approach to visualize quickly the outcome of clinical studies on colour variations.

Methods

Among 54 Asian women, one group applied a vehicle twice daily, during 28 days, and the other group an anti‐ageing emulsion, taking facial images at baseline and after treatment. Changes in L*a*b* values were studied on four pre‐selected facial regions. We also reconstructed average facial images from which the L*a*b* parameters were extracted for every pixel, computing relevance (ΔE) and significance data. Using colour gradients, we mapped these results onto the average facial images.

Results

After treatment, L*a*b* parameters show no statistically relevant colour changes in the vehicle group. In the ‘active’ group, skin was lighter at the upper cheek and, overall, redness decreased. Relevance and significance maps confirmed no visible colour changes in the vehicle group. In the ‘active’ group, the mapping approach revealed colour changes and their location. Skin became lighter below the eye, cheek and forehead. It was less red below the eyes, on the cheek, jawline and forehead, and generally more yellow.

Conclusion

Our image‐based mapping approach proves to be powerful. It enables us to identify precise facial regions of relevant and statistically significant colour changes after a topical treatment, regions that would have otherwise been undetected.

Simple In-House Fabrication of Microwells for Generating Uniform Hepatic Multicellular Cancer Aggregates and Discovering Novel Therapeutics

Three-dimensional (3D) cell culture models have become powerful tools because they better simulate the in vivo pathophysiological microenvironment than traditional two-dimensional (2D) monolayer cultures. Tumor cells cultured in a 3D system as multicellular cancer aggregates (MCAs) recapitulate several critical in vivo characteristics that enable the study of biological functions and drug discovery. The microwell, in particular, has emerged as a revolutionary technology in the generation of MCAs as it provides geometrically defined microstructures for culturing size-controlled MCAs amenable for various downstream functional assays. This paper presents a simple and economical microwell fabrication methodology that can be conveniently incorporated into a conventional laboratory setting and used for the discovery of therapeutic interventions for liver cancer. The microwells were 400-700 µm in diameter, and hepatic MCAs (Huh-7 cells) were cultured in them for up to 5 days, over which time they grew to 250-520 µm with good viability and shape. The integrability of the microwell fabrication with a high-throughput workflow was demonstrated using a standard 96-well plate for proof-of-concept drug screening. The IC50 of doxorubicin was determined to be 9.3 µM under 2D conditions and 42.8 µM under 3D conditions. The application of photothermal treatment was demonstrated by optimizing concanavalin A-FITC conjugated silica-carbon hollow spheres (SCHSs) at a concentration of 500:200 µg/mL after a 2 h incubation to best bind with MCAs. Based on this concentration, which was appropriate for further photothermal treatment, the relative cell viability was assessed through exposure to a 3 W/cm2 near-infrared laser for 20 min. The relative fluorescence intensity showed an eight-fold reduction in cell viability, confirming the feasibility of using photothermal treatment as a potential therapeutic intervention. The proposed microwell integration is envisioned to serve as a simple in-house technique for the generation of MCAs useful for discovering therapeutic modalities for liver cancer treatment.

Perioral Rejuvenation: A Prospective, Quantitative Dynamic Three-Dimensional Analysis of a Dual Modality Treatment

BACKGROUND

The perioral region is the most dynamic anatomic area of the face and subject to complex and dramatic changes during aging. Successful treatment for perioral rejuvenation has yet to be identified, and prior studies have reported only subjective outcomes.

OBJECTIVES

The purpose of this study was to utilize our validated dynamic 3-dimensional imaging technology to determine whether conservative neuromodulation combined with hyaluronic acid filler volumization can decrease perioral strain and increase volume with significant patient satisfaction.

METHODS

An IRB-approved prospective study of a dual modality treatment for perioral rhytids was performed on females with perioral aging who had not had prior facial treatment within the past year. Eighteen (18) units of Dysport were injected into the upper and lower orbicularis oris and 1 cc of Restylane Silk was injected in volume-depleted perioral regions in each patient. Each patient underwent imaging with digital image correlation (DIC) and completed the FACE-Q survey prior to injection and at 14 days and 90 days postinjection.

RESULTS

Thirty-two female patients were recruited. A significant reduction in perioral strain was observed at both day 14 and day 90. This was concomitant with a significant increase in perioral volume at day 14 that at 90 days was significantly retained in the marionette lines. Further, there was a significant improvement in patient satisfaction with overall facial appearance at day 14 that was maintained at 90 days.

CONCLUSIONS

Conservative neuromodulation and hyaluronic acid filler volumization of the perioral region produces a significant reduction in strain correlating with high patient satisfaction, even at 90 days. This dual modality treatment is effective in rejuvenating the perioral region, and its future optimization will provide greater therapeutic options for this anatomically complex area.

LEVEL OF EVIDENCE 4

Biomechanical properties of infantile hemangiomas: clinical stage and effect of age

BACKGROUND

Infantile hemangiomas (IHs) are benign vascular neoplasms with rapid capillary proliferation shortly after birth and slow involution with diminishing capillary proliferative activity, fibrosis, and fatty replacement over 7-10 years.

METHODS

Hemangiomas and contralateral control sites in 88 subjects were measured using a suction device, 6-mm probe and 200 mbar negative pressure. Mechanical properties were assessed vs. controls and effects of body site, depth, clinical stage, histology diagnosis, and time.

RESULTS

Biological elasticity, overall elasticity, net elasticity, total recovery, and elastic recovery were lower for IH vs. controls (P < 0.001). IH total deformation, elastic deformation, viscoelastic creep, and residual deformation were higher than controls (P < 0.001). Involuting IHs had lower viscoelasticity than proliferating and stable lesions (P < 0.001) and lower viscoelastic creep than stable IHs (P = 0.04). IH viscoelasticity was higher at 2.3 than 12.9, 23.7, and 61.0 months and at 4.9 and 8.1 than 61.0 months. IH elastic recovery varied by body site with larger differences vs. control for abdomen and leg. Elastic recovery differences from control were smaller at younger vs. older ages.

CONCLUSIONS

Measurement of biomechanical properties may be useful to characterize IH progression and treatment response in clinical settings.

WITHDRAWN: Interventions for photodamaged skin

This review has been withdrawn because a review author contravenes Cochrane's Commercial Sponsorship Policy. This policy ensures the independence of Cochrane reviews by making sure that there is no bias associated with commercial conflicts of interest in the conduct of Cochrane reviews. The author was employed by the biopharmaceutical company AstraZeneca and cannot say with certainty that the company did not produce or have any financial interest in the interventions in this review.

The editorial group responsible for this previously published document have withdrawn it from publication.

Photodamage: treatments and topicals for facial skin

This article provides an overview of current therapies for photodamaged facial skin and their efficacy, with particular focus on studies that use the objective, quantitative evaluation methods discussed in the previous article. The role of topically applied agents including prescription drugs and cosmetics is discussed. From this information, a schema for the relative effectiveness of therapeutic modalities in reducing perceived age is presented. This information assists the facial plastic surgeon in evaluating patient expectations and selecting the most effective program.

Intra- and inter-rater reliability of digital image analysis for skin color measurement

BACKGROUND

We determined the intra- and inter-rater reliability of data from digital image color analysis between an expert and novice analyst.

METHODS

Following training, the expert and novice independently analyzed 210 randomly ordered images. Both analysts used Adobe(®) Photoshop lasso or color sampler tools based on the type of image file. After color correction with Pictocolor(®) in camera software, they recorded L*a*b* (L*=light/dark; a*=red/green; b*=yellow/blue) color values for all skin sites. We computed intra-rater and inter-rater agreement within anatomical region, color value (L*, a*, b*), and technique (lasso, color sampler) using a series of one-way intra-class correlation coefficients (ICCs).

RESULTS

Results of ICCs for intra-rater agreement showed high levels of internal consistency reliability within each rater for the lasso technique (ICC ≥ 0.99) and somewhat lower, yet acceptable, level of agreement for the color sampler technique (ICC = 0.91 for expert, ICC = 0.81 for novice). Skin L*, skin b*, and labia L* values reached the highest level of agreement (ICC ≥ 0.92) and skin a*, labia b*, and vaginal wall b* were the lowest (ICC ≥ 0.64).

CONCLUSION

Data from novice analysts can achieve high levels of agreement with data from expert analysts with training and the use of a detailed, standard protocol.

Update on techniques for the quantitation of facial skin characteristics

The purpose of this article is to review the strategies and methods for quantifying treatment outcomes, perhaps defined by the consumer/patient as a "decrease in perceived age." The demand for the rejuvenation of facial skin is expected to increase as the population ages and seeks optimal outcomes from the array of available treatment modalities. This information will be of value to the plastic surgeon in collaborating with patients on evaluation and treatment strategies.

Use of lasers in acute management of surgical and traumatic incisions on the face

This article is a clinically practical review structured around the specific applications of laser technologies used in acute management of soft tissue injuries in surgical incisions and trauma. Surgical and traumatic incisions and injuries provide the clinician with the unique opportunity to follow the progression and maturation of the wound healing response from a very early stage. There has been a recent interest in early cosmetic optimization of surgical and traumatic wounds on the face using optical technologies. Early clinical results for acute laser intervention starting immediately after suture removal or the first several weeks after repair have been very promising.

EFFECT OF THERMAL DAMAGE ON COMPRESSIVE BEHAVIOR OF SKIN TISSUE

Biothermomechanics of skin tissue is highly interdisciplinary, involving bioheat transfer, burn damage, biomechanics and physiology. Characterization of the thermomechanical behavior of skin tissue is of great importance and can contribute to a variety of medical applications. However, few studies have attempted to address the influence of heat induced thermal damage on the mechanical properties of skin tissue. This paper presents the compressive behavior of pigskin at different thermal damage levels and discusses the possible mechanisms of thermal damage–dependent compressive behavior of skin. The results demonstrate that skin stiffness decreases with increasing thermal damage degree and there exists strain rate sensitivity at different damage levels, caused mainly by hydration changes.

Lasers and optical technologies in facial plastic surgery

Lasers and optical technologies play a significant role in aesthetic and reconstructive surgery. The unique ability of optical technologies to target specific structures and layers in tissues to effect chemical, mechanical, or thermal changes makes them a powerful tool in cutaneous rejuvenation, hair removal, fat removal, and treatment of vascular lesions such as port-wine stains, among many other procedures. With the development of adjunct techniques such as epidermal cooling, lasers and optical technologies have become more versatile and safe. The constant improvement of existing applications and the emergence of novel applications such as photodynamic therapy, nanoparticles, spectroscopy, and noninvasive imaging continue to revolutionize aesthetic medicine by offering a minimally invasive alternative to traditional surgery. In the future, therapies will be based on individualized, maximum, safe radiant exposure to deliver optimal dosimetry. Lasers and optical technologies are headed toward safer, easier, more quantifiable, and more individualized therapy.

Forensic sexual assault examination and genital injury: is skin color a source of health disparity?

PURPOSE

The study objectives were to (1) estimate the frequency, prevalence, type, and location of anogenital injury in black and white women after consensual sex and (2) investigate the role of skin color in the detection of injury during the forensic sexual assault examination.

METHODS

A cross-sectional descriptive design was used with 120 healthy volunteers who underwent a well-controlled forensic examination after consensual sexual intercourse.

RESULTS

Fifty-five percent of the sample had at least 1 anogenital injury after consensual intercourse; percentages significantly differed between white (68%) and black (43%) participants (P = .02). Race/ethnicity was a significant predictor of injury prevalence and frequency in the external genitalia but not in the internal genitalia or anus. However, skin color variables--lightness/darkness-, redness/greenness-, and yellowness/blueness-confounded the original relationship between race/ethnicity and injury occurrence and frequency in the external genitalia, and 1 skin color variable--redness/greenness--was significantly associated with injury occurrence and frequency in the internal genitalia.

CONCLUSIONS

Although differences exist in anogenital injury frequency and prevalence between black and white women, such differences can be more fully explained by variations in skin color rather than race/ethnicity. Clinical recommendations and criminal justice implications are discussed.

Dermabrasion for rhytids in the lateral canthal region

Dermabrasion of the periorbital region has been traditionally contraindicated due to the fear of complications. A method for safe dermabrasion of the lateral canthal region is described. Lateral canthal dermabrasion has the demonstrated advantages of being economical and relatively free of pigmentary problems. The results for 25 consecutive cases with a follow-up period of 12 to 16 months have shown good to excellent results in the majority of cases, with 4 cases requiring further revision. The technique is not intended to replace the gold standard, laserbrasion of the periocular region, and is not demonstrated to be safe for resurfacing of the lower lid region. However, the technique, rapid and easy once the learning curve is completed, was not associated with significant complications in the current series of patients.

Effect of dermal thickness, tissue composition, and body site on skin biomechanical properties

BACKGROUND/PURPOSE

Quantitative measurement of skin biomechanical properties has been used effectively in the investigation of physiological changes in tissue structure and function and to determine treatment efficacy. As the methods are applied to new questions, tissue characteristics that may influence the resultant biomechanical properties are important considerations in the research design. For certain applications, variables such as dermal thickness and subdermal tissue composition, as well as age and/or solar exposure, may influence the skin biomechanics.

METHODS

We determined the influence of dermal thickness, tissue composition, and age on the skin biomechanical properties at the shoulder, thigh, and calf among 30 healthy females. We compared two devices, the Biomechanical Tissue Characterization System and the Cutometer SEM 575 Skin Elasticity Meter , to determine the effect of tissue sampling size. Dermal thickness was measured with 20 MHz ultrasound (Dermascan C) and tissue composition was inferred from anthropomorphic data.

RESULTS

Skin thickness was significantly correlated with stiffness, energy absorption, and U(r)/U(f) for the shoulder. Body mass index (BMI) was significantly correlated with stiffness (negative correlation), energy absorption (positive), and skin thickness (negative) for the shoulder. Significant differences across body sites were observed. The calf was significantly different from the thigh and shoulders for all parameters (P<0.05, one-way anova). The calf had significantly lower laxity, laxity%, elastic deformation, energy absorption, elasticity, elasticity %, U(r), U(f), and U(r)/U(f) and significantly higher stiffness compared with the thighs and shoulders. sites. The thigh and shoulder sites were significantly different for all parameters except U(r)/U(f), elasticity %, laxity%, and stiffness. The dominant and non-dominant sides were significantly different. The dominant side (right for 90% of the subjects) had increased stiffness and decreased energy absorption (tissue softness, compliance) compared with the left side. A significant (P< or =0.02) negative relationship with age was seen for all biomechanical measures except stiffness at the shoulder. For the thigh and calf sites, significant negative correlations with age were found for elasticity %, U(r), and U(r)/U(f). Age and skin thickness were not correlated in this population. Skin thickness and age influenced the energy absorption at the shoulder site. The biological elasticity at the calf site could be predicted by age and BMI. The biological activity at the thigh site could be predicted by skin thickness and BMI.

CONCLUSIONS

Significant regional variations in biomechanical properties and dominant side effects were observed. The biomechanical properties were significantly influenced by age. Certain properties varied with dermal thickness and tissue composition. The parameters were well correlated between the two instruments. The Cutometer, with its smaller aperture, was found to be more sensitive to age relationships.

Interventions for photodamaged skin

BACKGROUND

Photodamage describes skin changes such as fine and coarse wrinkles, roughness, freckles and pigmentation changes that occur as a result of prolonged exposure to the sun. Many treatments are available to reverse the damage, but it is unclear which work and at what cost in terms of unwanted side effects.

OBJECTIVES

To assess the effects of topically applied treatments, tablet treatments, laser and surgical procedures for photodamaged skin.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, Issue 1 2002, MEDLINE (1966-June 2002), EMBASE (1974-June 2002), Health Periodicals (1976-June 2002). We checked references of articles and communicated with authors and the pharmaceutical industry.

SELECTION CRITERIA

Randomised controlled trials which compared drug or surgical interventions with no treatment, placebo or another drug, in adults with mild, moderate or severe photodamage of the face or forearms.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Thirty studies of variable quality were included. Eight trials showed that topical tretinoin cream, in concentrations of 0.02% or higher, was superior to placebo for participants with mild to severe photodamage on the face and forearms (although losses to follow-up were relatively high in most studies). For example, the relative risk of improvement for 0.05% tretinoin cream, compared to placebo (three studies), at 24 weeks, was 1.73 (95% confidence interval 1.39 to 2.14). This effect was not seen for 0.001% topical tretinoin (one study) or 0.01% (three studies). A dose-response relationship was evident for both effectiveness and skin irritation. One small within-patient study showed benefit from topical ascorbic acid compared with placebo. Tazarotene (0.01% to 0.1%) and isotretinoin (0.1%) both showed significant improvement over placebo for moderate photodamage (one study each). There is limited evidence (one trial), to show that the effectiveness of 0.05% tretinoin, is equivalent to the effects of 0.05% and 0.1% tazarotene. One small study showed greater improvement in upper lip wrinkles with CO2 laser technique compared to Baker's phenol chemical peel, at 6 months. Three small RCTs comparing CO2 laser with dermabrasion found no difference in wrinkle score at 4 to 6 months, suggesting that both methods are equally efficacious, but more erythema was reported with the laser. The effectiveness of other interventions such as hydroxy acids and natural polysaccharides was not clear.

AUTHORS' CONCLUSIONS

There is conclusive evidence that topical tretinoin improves the appearance of mild to moderate photodamage on the face and forearms, in the short term. However erythema, scaling/dryness, burning/stinging and irritation may be experienced initially. There is limited evidence that tazarotene and isotretinoin benefit patients with moderate photodamage on the face: both are associated with skin irritation and erythema. The effectiveness of other interventions remains uncertain.

Long-term results of ultrapulsed carbon dioxide laser resurfacing of the Mediterranean face

BACKGROUND

In Mediterranean countries, increased exposure to sunlight accelerates aging of the skin and the formation of wrinkles. The long-term follow-up results for the patients who underwent resurfacing with ultrapulsed carbon dioxide (CO(2)) laser are presented.

METHODS

All 47 patients who underwent ultrapulsed CO(2) laser between 1994 and 1996 were included in the study. The patients were photographed with their permission before the laser treatment, at postoperative month 6, and at year 5, with comparison of the results.

RESULTS

In this study, with its 5-year follow-up period, it was found that the ultrapulsed CO(2) laser achieved long-lasting and acceptable facial resurfacing.

CONCLUSIONS

The ultrapulsed CO(2) laser enables damage to the abnormal dermal region with high-energy transfer in a very short period. The recent development of high-energy pulsed CO(2) laser has generated much renewed enthusiasm for cutaneous resurfacing, especially over the long term.

Cutaneous oncologic and cosmetic surgery in geriatric patients

A wide array of surgical procedures is available to geriatric patients. These interventions can enhance the appearance of patients and facilitate the removal of skin cancers. Pre-existing medical conditions of geriatric patients must be considered comprehensively when selecting and performing cutaneous surgical procedures. Many older patients suffer from a variety of diseases and take a variety of medications and herbal supplements to ameliorate the consequences of such diseases. In general, skin surgery can be performed safely on even very old patients, provided precautions are followed. The biopsychosocial well-being and essence of patients must also be addressed when performing dermatologic surgery. If patients are treated holistically and comprehensively, their surgical experience can be enhanced and their health and appearance improved.

Can thermal lasers promote skin wound healing?

Lasers are now widely used for treating numerous cutaneous lesions, for scar revision (hypertrophic and keloid scars), for tissue welding, and for skin resurfacing and remodeling (wrinkle removal). In these procedures lasers are used to generate heat. The modulation of the effect (volatilization, coagulation, hyperthermia) of the laser is obtained by using different wavelengths and laser parameters. The heat source obtained by conversion of light into heat can be very superficial, yet intense, if the laser light is well absorbed (far-infrared:CO(2) or Erbium:Yttrium Aluminum Garnet [Er:YAG] lasers), or it can be much deeper and less intense if the laser light is less absorbed by the skin (visible or near-infrared). Lasers transfer energy, in the form of heat, to surrounding tissues and, regardless of the laser used, a 45-50 degrees C temperature gradient will be obtained in the surrounding skin. If a wound healing process exists, it is a result of live cells reacting to this low temperature increase. The generated supraphysiologic level of heat is able to induce a heat shock response (HSR), which can be defined as the temporary changes in cellular metabolism. These changes are rapid and transient, and are characterized by the production of a small family of proteins termed the heat shock proteins (HSP). Recent experimental studies have clearly demonstrated that HSP 70, which is over-expressed following laser irradiation, could play a role with a coordinated expression of other growth factors such as transforming growth factor (TGF)-beta. TGF-beta is known to be a key element in the inflammatory response and the fibrogenic process. In this process, the fibroblasts are the key cells since they produce collagen and extracellular matrix. In conclusion, the analysis of the literature, and the fundamental considerations concerning the healing process when using thermal lasers, are in favor of a modification of the growth factors synthesis after laser irradiation, induced by an HSR. An extensive review of the different techniques and several clinical studies confirm that thermal lasers could effectively promote skin wound healing, if they are used in a controlled manner.

Side effects and complications of variable-pulsed erbium:yttrium-aluminum-garnet laser skin resurfacing: extended experience with 50 patients

Recent advances in technology have provided laser surgeons with new options for cutaneous laser resurfacing. Despite its popularity, there is limited information on the short-term and long-term side effects and complications of variable-pulsed erbium:yttrium-aluminum-garnet (erbium:YAG) laser skin resurfacing. The purpose of this study was to prospectively evaluate postoperative wound healing, side effects, and complications of multiple-pass, variable-pulsed erbium:YAG laser skin resurfacing for facial photodamage, rhytides, and atrophic scarring. Fifty consecutive patients with facial photodamage, rhytides, or atrophic scarring were treated with a variable-pulsed erbium:YAG laser. Side effects and complications relating to postoperative healing, erythema, and pigmentary changes were tabulated. Patients were evaluated at postoperative days 3 through 7 and at 1, 3, 6, and 12 months after laser skin resurfacing. The average time for reepithelialization was 5.1 days. Prolonged erythema (>1 month) was observed in three patients (6 percent). Transient hyperpigmentation occurred in 20 patients (40 percent), with an average duration of 10.4 weeks. No cases of hypopigmentation or scarring were seen. In summary, a variable-pulsed erbium:YAG laser can safely be used for the treatment of facial photodamage, rhytides, and atrophic scarring. Although more postoperative erythema is seen after variable-pulsed erbium:YAG laser treatment than is usually produced with a short-pulsed erbium:YAG system, the side-effect profile and recovery period after variable-pulsed erbium:YAG laser skin resurfacing still are more favorable than after multiple-pass carbon dioxide laser skin resurfacing.

Lasers in oculoplastics

In the past year, there have been many important advances in laser application in not only oculoplastics but also related fields such as dermatology and plastic surgery. This review article highlights advances in laser assisted lacrimal surgery with the adjunctive use of mitomycin C and the treatment of capillary hemangiomata with a tunable dye laser. There also have been advances in laser skin resurfacing, such as the combination of carbon dioxide and erbium:yttrium-aluminum-garnet lasers to achieve improved results as well as the use of nonablative lasers. Lastly, physicians have achieved a greater understanding of the benefits and complications of combining laser resurfacing with other aesthetic procedures, such as lower blepharoplasty and facelifting.