A New Addition to Face Lift Surgery: The Argon Gas Surgical Unit

In the continuing quest to improve the technique of performing face lift surgery, we have encountered a device that offers a number of improvements over current techniques. That device is the argon gas surgical unit. The improvements it offers include a reduction in the amount and risk of both intraoperative and postoperative blood loss, reduction in the amount and depth of tissue damage, a decrease in the amount of postoperative swelling, as well as a reduction in the amount of postoperative pain. These factors combine to make the procedure easier to perform.

There is extensive experience with use of the argon gas surgical unit for hemostasis during surgery on solid parenchymal organs, such as the liver, the kidneys, or the spleen.1-3,6,7 It has been particularly useful in trauma surgery for stopping bleeding from large open surfaces such as one encounters with hepatic or splenic injuries.2-5 The utility of the argon gas surgical unit in liver resections, in addition to being based on its ability to help control bleeding from the large planes of resection, is also based on the decrease in tissue necrosis one sees with the argon gas surgical unit when compared with conventional electrocoagulation, contributing to an improved postoperative course.8 In a series of patients undergoing major head and neck surgery, the argon gas surgical unit was found to reduce operative time by one-third and blood loss by one-half because of its remarkable effectiveness as coagulator.9

This paper describes our experience with the use of and the tissue effects of the argon gas surgical unit as compared with conventional electrosurgical units in 30 patients undergoing face lift surgery by one of the authors(Man).

Thirty consecutive patients undergoing facial rhytidectomy by one of the authors (Man) had their surgery performed utilizing an argon gas surgical unit(Valleylab Force GSU System, Valleylab, Inc., Boulder, Colo.) for both cutting and coagulation during the major portion of the surgery. The same surgical and anesthetic techniques were utilized on all patients. Skin incision was performed with a cold knife. Dissection of the flaps was achieved with a combination of blunt dissection and the argon gas surgical unit. Additionally, the argon gas surgical unit was used to cauterize blood vessels in the temporal and chin areas, as well as providing delicate cauterization of any oozing sites beneath the flaps. As the procedure progressed, a longer tip, which is an available accessory, was utilized so as to be able to reach beneath the flaps. The SMAS was elevated with conventional cold knife dissection. Settings on the argon gas surgical unit were 30 to 40 W for coagulation and 60 to 80 W for cutting. After dissection of one of the skin flaps, half the excess skin was excised with the argon gas surgical unit and half with conventional electrosurgical unit. The excised skin was then sent for histologic analysis to assess the depth of tissue damage caused by each technique. These results were compared by a t test for paired differences at a 0.5 level of significance. In addition, we assessed blood loss in this surgical group when compared with a retrospective control group who underwent the same surgical procedure by the same surgeon entirely with a conventional electrosurgical unit.

The argon gas surgical unit was first introduced in the late 1980s and gained popularity in trauma, hepatic, and oncologic surgery because of its remarkable effectiveness as a coagulator. Additionally, the argon gas surgical unit is a very safe tool in that its room-temperature gas beam will not ignite materials such as linen, surgical gauze, gloved hands, drapes, or fatty tissue, as a laser or conventional electrosurgical unit might. The argon gas surgical unit utilized in this study is a microprocessor-based radio-frequency(rf) electrosurgical generator. This system combines conventional electrocautery (monopolar and bipolar coagulation and monopolar cut) with the advanced argon technology (argon-enhanced coagulation and argonshrouded cut) in a single, full-capability electrosurgical unit. Argon is an inert gas that is relatively safe to inhale because it dissolves in the bloodstream and is cleared from the blood-stream in one respiratory cycle. Since argon is an inert gas, it is noncombustible and does not promote combustion. It is, however, easy to ionize, and it is this ionization of the argon gas by the electrosurgical spark that creates the glowing stream of argon seen when using argon-enhanced coagulation.

With conventional electrocautery, employing rf energy, there must be direct contact between the electrode tip and the tissue because air has low electrical conductivity. Argon-enhanced coagulation, in contrast, is based on a concept that uses a coaxial flow of argon gas, which is ionized by the rf energy being generated. This beam of ionized argon gas acts as an electrical bridge to conduct current between the electrode and the tissues, delivering the rf energy to the tissues and creating a noncontact form of coagulation. The stream of argon, a colorless, odorless, inert gas, not only conducts the current to the tissue and vessels but also effectively blows the blood away from the surface of the tissue, allowing both improved visualization and improved cauterization of the surface being coagulated. As a result, less rf energy is required.

There are several disadvantages to the conventional electrosurgical unit, which include tissue adhesion to the electrosurgical unit tip, significant charring of tissue, generation of significant quantities of smoke, and ineffective coagulation of bone and other high-impedance tissues. With argon-enhanced coagulation, the argon beam displaces oxygen and nitrogen, limiting oxidation of tissue and resulting in less combustion and therefore less carbonization (charring) of the tissue, less smoke and odor, and less tissue adhesion to the electrode tip than in standard electrosurgery. This combined with the lower power settings that can be employed with the argon gas surgical unit contributes to decreased tissue destruction and necrosis. The conduction of current by the argon beam allows for effective coagulation of even high-impedance tissues such as bone. When tissue is being cauterized with an argon gas surgical unit, the tissue temperature never exceeds 110?C because of a cooling effect from the argon gas and because no further conduction of rf energy occurs once eschar forms; in contrast, with conventional electrosurgical units, tissue temperature is approximately 270?C. This precise flow of energy allows the user to coagulate tissue in a more efficient and controlled manner. For larger oozing surfaces such as those one might encounter in a face lift or coronal lift, the electrode may be retracted partially and the entire wound surface can bepainted with the argon beam, giving excellent hemostasis with minimal tissue destruction.

With argon-shrouded cutting, the argon gas actually shrouds the electrode, which serves several purposes. Although it does not change the characteristics of the cut waveform, it does improve cutting by clearing smoke, water vapor, fluids, and blood away from the surgical site, improving both visibility and coagulation and allowing the use of lower power settings to achieve the same effect. Additionally, because the gas displaces oxygen at the electrode tip, there is reduced combustion, allowing the electrode tip to stay cooler and reducing eschar buildup.

On histologic examination of the skin specimens submitted, the mean distance from the cut margin to the end of cautery artifact at the level of epidermis was 0.27 mm with the argon gas surgical unit and 0.67 mm with the conventional electrosurgical unit. This difference was statistically significant at the 0.5 level of significance. This decreased depth of tissue damage was consistent, with all argon gas surgical unit margins demonstrating shorter distances than their matched electrosurgical unit counterparts(Fig. 1). Additionally, the standard deviation in the argon gas surgical unit group was much smaller than in the electrosurgical unit group (0.080 versus 0.272), implying that there is less variation when the argon gas surgical unit is used. Therefore, you obtain more consistent, more predictable results.

Fig. 1.

With regard to blood loss, as a whole there was a marked decrease in blood loss in the argon gas surgical unit group when compared with the electrosurgical unit group, although no patient in either group had hemodynamically significant blood loss, nor did any patient in either group require transfusion.

Something that is not apparent from these results is the clinically significant decrease in postoperative swelling in the patients in whom the argon gas surgical unit was employed. This decrease in swelling was a subjective finding and could not be made quantitatively. We attribute this decreased swelling to the decreased tissue damage with the argon gas surgical unit and to the fact that we are able to achieve hemostasis with less handling of the patients' tissues. This decrease in swelling contributes to improved wound healing and an overall improved postoperative course.

By using the argon gas surgical unit to paint the operative field, we are able to achieve a completely dry field rather easily. We havepainted over blood vessels and even some small nerves without any recognizable detrimental effect. This has contributed to a reduced occurrence of both hematomas and seromas and a reduction in the output of the drains we insert during surgery. Thus far we have not had to reexplore any patient in whom we employed the argon gas surgical unit because of either bleeding or a hematoma, whereas in the past, on rare occasions, reexplorations were necessary.

We have now begun using this device in other procedures where lower energy settings and decreased postoperative swelling are desirable, including blepharoplasty, breast reduction, and abdominoplasty. The argon gas surgical unit has been particularly useful in breast reduction and abdominoplasty, where the ability to achieve delicate tissue dissection with a combination of decrease in charring and tissue damage with excellent hemostasis has been especially advantageous. When doing blepharoplasties, we reduce our power setting to 15 to 20 W for coagulation and do not use cutting.

The reduction in bleeding also has contributed to reducing our operative time, in that we now expend less time achieving hemostasis. This reduced operative time is beneficial for a variety of reasons, including reduced anesthesia time and reduced time during which tissues are exposed to the desiccating effects of the operating room, among others.

Daniel Man, M.D.

Aesthetic Ambulatory Surgical Unit; 851 Meadows Road, Suite 222; Boca Raton, Fla. 33486