Facial Resurfacing With Coblation Technology

Abstract

Objective

To describe our experience with coblation technology for facial resurfacing

Methods

Retrospective chart review of all patients treated with coblation at our institution

Results

Twenty-four patients (22 female) underwent a total of 29 coblation procedures for aging face (n = 21) or acne scarring (n = 3). The perioral region was the most frequently treated aesthetic subunit (n = 14), followed by the lower eyelid (n = 7). Five patients underwent full-face coblation. Three patients underwent a second coblation procedure for aging face while a single patient with severe acne scarring underwent 3 procedures. Repeat coblation was delayed at least 5 months (mean, 9 months). Seventeen coblation procedures (59%) were performed concurrently with procedures including, but not limited to, injection treatment, rhinoplasty, blepharoplasty, or combined face/necklift; no adverse events occurred. Seven procedures, including a full-face coblation, were performed in the office under local anesthesia and oral sedation without any adverse events. Mean follow-up was 6 months (range, 1 week to 24 months). No complications were observed. All patients were satisfied with the results after their final coblation treatment.

Conclusions

Facial coblation is a safe and effective treatment modality for facial resurfacing.

Introduction

Coblation, or “cold ablation,” technology has been applied in a variety of surgical disciplines. This technology, originally created for the vaporization of cartilage during arthroscopic procedures,[1] relies on the creation of a plasma field created within an electrically conductive solution, or gel, between closely approximated electrodes. The resulting plasma field results in predictable de-epithelialization at temperatures significantly lower (< 90°C) than those seen with conventional electrosurgical devices. However, the most potent effect with regard to treatment of the aging face or deep acne scarring results from controlled injury to the superficial dermis, leading to new collagen formation, re-epithelialization, and subsequent facial rejuvenation.

Patients currently have myriad options for facial resurfacing including coblation, dermabrasion, chemical peels, and laser treatment.[2] Risks of resurfacing include pigmentation changes, permanent scarring, viral outbreaks, and infection. Chemical peels also have the attendant systemic risks, such as hepatotoxicity and cardiotoxicity, depending on the solution used. Virtually all methods of resurfacing have varying durations of postprocedure erythema, referred to in the lay press as “downtime.” Coblation offers several advantages as compared to other methods of resurfacing, such as lasers and chemical peels. Herein we describe our experience with the use of coblation technology for facial resurfacing.

Methods

A retrospective chart review from the Division of Facial Plastic and Reconstructive Surgery at Oregon Health & Science University was undertaken. All patients who underwent facial resurfacing with coblation between June 2003 and October 2005 were included. Informed consent was obtained from all patients. For procedures, the coblation instrument (Arthrocare; Sunnyvale, California) was used with a Visage handpiece and foot-pedal activator. The procedure has been described in detail previously.[3] In brief, saline was run through the handpiece line at a rate of 1 drop per second and the handpiece was drawn across the skin at a rate of 1 cm per second. A machine setting of 5–6 (150–175 V/msec) was used for all facial subunits, except on the lower lids where a setting of 4 (125 V/msec) was used.[4] A maximum of 3 passes was used regardless of the subunit treated. Postoperative dressing consisted of either antibiotic ointment (bacitracin) or a commercial polyethylene oxide hydrogel dressing (Vigilon, Bard Medical Division, C. R. Bard, Inc., Covington, Georgia). Patient satisfaction was measured subjectively with a simple “yes/no” answer in postoperative follow-up interviews.

Results

Between June 2003 and October 2005, 24 patients underwent a total of 29 procedures involving coblation. Three patients underwent a subsequent coblation treatment (1 each) for aging face while 1 patient underwent a total of 3 coblation treatments for deep acne scarring. The treatment population (Table 1) consisted of 22 female and 2 male patients with a mean age of 53 years (range, 20–76 years). The most frequent indication (n = 21) for coblation facial resurfacing was dissatisfaction with the aging face. The remaining patients sought coblation for deep acne scarring (n = 3). All patients were Fitzpatrick skin type I through III.

Table 1.

Demographic Data

Characteristic		Number	Percentage
Age (years):
	Average	53
	Range	20 – 76
Sex:
	Female	22	92%
	Male	2	8%
Indication:
	Aging face	21	88%
	Deep acne scarring	3	12%

Five patients underwent a single full-face coblation procedure (Table 2). Among 19 patients undergoing 24 limited coblation procedures, the perioral region was the most frequent aesthetic subunit treated alone (n = 14 [Figure 1]) or in combination with other aesthetic subunits (n = 3). The second most frequently addressed area was the lower lid (n = 7, [Figures 2 and 3; Table 2]).

Table 2.

Aesthetic Subunit(s) Addressed With Coblation Technology

Aesthetic Subunit	# of Procedures
Perioral	11
+ periorbital	1
+ lower lids	1
+ lower lids, lateral orbit	1
Full face	5
Lower lids	3
+ crow's feet	1
+ smile lines	1
Cheek	1
Forehead, cheek	1
Forehead, periorbital	1
Temple, nose, cheek, chin	1
Temple, nose, midface	1

Figure 1.

Representative pre- (A) and 4 months posttreatment frontal view (B) after single perioral coblation treatment. Diminution of deep rhytids and effacement of fine rhytids are demonstrated. Note: This patient also underwent Restylane injection (Medicis Aesthetics Inc.; Scottsdale, Arizona) concurrently with coblation.

Figure 2.

Representative pre- (A-C) and 3 months posttreatment (D-F) frontal and oblique views following single periorbital coblation treatment, resulting in resolution of fine rhytids and reduction in deep wrinkles.

Figure 3.

Representative pre- (A) and 4 months postcoblation (B) images of results seen after single periorbital coblation and upper lid blepharoplasty, resulting in reduction in deep rhytids.

Repeat coblation was performed in 4 patients. One patient underwent increasingly focused coblation for deep acne scarring (Figure 4) beginning with the entire face and continuing with 2 subsequent coblation treatments for residual deep scarring over the nose, cheeks, and temples. Among 3 patients treated twice for aging face, subsequent procedures focused on more problematic deep rhytids or on areas not addressed with the initial procedure. Repeat coblation was delayed a mean of 9 months from the initial procedure (range, 5–12 months).

Figure 4.

Representative pretreatment (A) and 7-month follow-up (B) results after 3 coblation treatments for deep acne scarring with decrease in depth of acne scarring and overall increase in smoothness of skin.

Twelve patients (50%) underwent coblation as the sole procedure. Among the remaining 12 patients, injection treatment (n = 10) was the most frequent concurrent procedure (Table 3). However, coblation was also performed concurrently with procedures including face/necklift, upper/lower lid blepharoplasty, and endoscopic browlift (n = 3), without any adverse events (Table 3).

Table 3.

Concurrent Procedure(s) Performed With Coblation Facial Resurfacing

Concurrent Procedures	# Patients
None	12
Injection treatment	10
Restylane	(4)
Botox	(3)
Other	(3)
Face/ necklift, upper/ lower lid blepharoplasty, endoscopic browlift	2
+ chin implant	1
Dermabrasion	1
Revision rhinoplasty with conchal cartilage	1
Septorhinoplasty	1
Upper lid blepharoplasty	1

Overall, 22 coblation procedures (76%) were performed in the operating room under general anesthesia. However, in 7 cases (24%), coblation was performed in the clinic with an oral sedative and topical anesthesia. These 7 procedures, including a single full-face coblation, were well tolerated and performed without complication.

Periprocedure antimicrobial treatment consisted of an antibiotic directed against skin flora for 7 days (usually cephalexin or clindamycin). Herpes prophylaxis was clearly documented for 3 procedures in patients with recent herpetic outbreak. Following 24 procedures (83%), treated areas were dressed with bacitracin ointment while 5 patients (17%) had a commercial polyethylene oxide hydrogel dressing (Vigilon) applied. No difference in cosmetic result with the use of ointment vs this commercial dressing preparation was observed. Mean follow-up was 6 months following coblation (range, 1 week to 24 months). No complications were reported relating to coblation. A single patient undergoing concurrent face/necklift experienced a postoperative abscess that responded well to drainage under local anesthesia and conservative wound care. Two patients reported the persistence of significantly reduced but residual deep rhytids. However, all patients were satisfied with the improvement in their facial appearance following coblation treatment.

Discussion

Mechanical facial resurfacing traces its origins from the early 20th century with the advent of dermabrasion, first described by Kronmayer in 1905. Contemporary techniques include the use of a wire brush or diamond fraise, with erythema variably persisting for 7–10 days. Chemical peels offer another resurfacing technique, with superficial, medium, and deep peel options. Depth of peel depends on concentration of solution and duration of contact with the skin, but erythema can be prolonged, systemic risks significant, and “downtime” considerable. Laser resurfacing presents yet another option, but can be unpredictable and erythema can last for weeks.[5]

Although scarring of the lower eyelids has been reported after coblation resurfacing, no patients experienced this complication in our experience. Bellaney[6] described lower eyelid scarring after 4 passes (2 each at a setting of 4 and 6). No pre- or postoperative antibiotics were used and no mention was made of postoperative dressing. Two of the patients in our study tolerated 3 passes on the lower eyelids at a setting of 4 without scarring. Both had their sites dressed with antibiotic ointment postoperatively, followed by the standard 7-day course of oral antibiotics.

Many methods of local wound care after facial resurfacing have been espoused. It is well established that moist wound environments enhance epithelial cell migration,[7] and occlusive-type dressings promote proliferation of fibroblasts.[8] Conversely, wound desiccation impairs this process. Several wound care dressings have been described for use after coblation treatment, including Flexzan (polyurethane; UDL Laboratories, Inc; Rockford, Illinois),[9] petrolatum,[10,11] and gold gauze containing epidermal growth factor (EGF).[3] In the present report, sites were covered with either bacitracin ointment until healed (n = 24) or Vigilon dressing for 7 days (n = 5). Results were equivalent cosmetically, and all patients were satisfied with their results, regardless of dressing choice. No subjective differences in postprocedure erythema were noted between the 2 groups, with erythema resolving between postoperative days 5–7 regardless of wound care regimen.

Routine antiviral use in the setting of facial resurfacing is controversial. Controlled injury to the dermis can reactivate herpes simplex virus, and this can manifest itself as pruritic erosions or painful vesicles. Recommended antiviral prophylaxis from the laser resurfacing literature includes acyclovir 400 mg 3 times daily or valacyclovir 250–500 mg twice daily, with an increase to zoster doses should outbreak occur while on a prophylaxis regimen.[5] In our experience, 3 patients were placed on antiviral medication (valacyclovir), all of whom had a previous history of cold sores. No viral outbreaks were reported.

The efficacy of coblation for darker-pigmented individuals is not known. The skin type for all patients in our study was Fitzpatrick class I-III. It is widely believed that patients with darker skin (ie, class IV-VI) respond less favorably to resurfacing procedures, with higher incidence of pigment change and scarring. Future investigation into this area with respect to coblation is warranted.

In our experience, coblation has proven to be low-maintenance and inexpensive compared with other resurfacing methods. Lasers can cost thousands of dollars (plus upkeep) and chemical peels may require laborious quality control of solutions. Coblation units are, by comparison, commonly used in other specialties and are likely already available in many hospitals. Individual handpieces cost a few hundred dollars but can be stored at home and reused by the individual patient. Our safety and patient satisfaction record in conjunction with these low-maintenance and low-cost qualities have made coblation our facial resurfacing method of choice.