CO2 Laser Skin Resurfacing at the Maryland Plastic Surgery Center
Few medical advances have caught the public’s attention as has Laser Resurfacing. The prospect of a simple, reliable, “hi-tech” method to reverse the ravages of sun exposure and aging has an irresistible appeal, and hardly a day passes without hearing about some “new” method to rejuvenate the aging face.
In the early and mid 1980’s, surgeons working with the CO2 laser noted that it could be used to remove or shave successive layers of skin, and they applied this knowledge to treating precancerous lesions, blotches, scars and wrinkles. The development of the pulsed CO2 laser/computerized pattern generator made it possible to obtain a consistent and predictable result and led to the widespread acceptance of Laser Resurfacing by cosmetic surgeons and patients alike.
The Erbium laser has been publicized as a safer, faster healing alternative to traditional scanned or pulsed CO2 laser resurfacing. Microdermabrasion (“Parisian Peel”, “Power Peel”, etc.) for blotchiness and fine wrinkling is another technology that has received much publicity and uses fine alumina crystals in a sandblasting fashion. Coblation , which uses a controlled linear electrosurgical current to shave skin layers in a controlled fashion showed early promise, but ran into marketing difficulties in the late 1990s and is currently being reintroduced as a “new” treatment for wrinkles. “Laser Peels” which combine both a chemical peeling and superfical laser resurfacing with or without sanding with silicon carbide paper are popular in some areas, and combined CO2/Erbium resurfacing has been used in an attempt to improve results and healing time. “Non-Ablative” laser resurfacing has captured the public’s attention because of it’s promise of rapid, painless, and “permanent” skin rejuvenation without side effects.
To most people, all these different and competing techniques are very confusing, but they can be put into perspective if you remember these facts:
- All of these techniques injure the skin in a more or less controlled fashion.
- The regrowth of the skin from adnexal structures (such as hair follicles and skin glands) and remodeling of collagen remaining in the deeper skin layers after the injury is what actually causes the improvement in skin appearance.
- The results are less dependent on the method than on the skill and judgement of the surgeon and the healing response of the patient.
General Principles of Resurfacing
From experience, everyone knows that shallow scrapes heal faster than deep scrapes. Deep scrapes heal, but may turn reddish, then get lighter and may leave a textural change. Very deep scrapes may even scar as well. Scrape, burns, and cuts on the face heal better and faster than on other parts of the body. And of course, some people just heal better than others.
Similar to the injuries above, different techniques (such as chemical peeling, dermabrasion, or laser resurfacing techniques) are used to modify or remove skin in a controlled fashion, depending on what skin problem needs correction.
The more superficial the injury, the quicker the healing, and the less chance of any permanent detrimental or beneficial changes to the skin.
The deeper the injury, the slower the healing, and the more chance of any permanent detrimental or benefical changes to the skin.
In other words, the deeper the peel, abrasion or resurfacing, the more improvement, but, the greater the risk of complications such as discoloration and scarring. This is true for all of the techniques mentioned above-none are magic, and none are a panacea. When you hear of some “new” method that causes less discoloration, or less chance of scarring, or heals faster, etc., you can be certain that it’s because the skin injury is more superficial, and that the potential improvement will be less noticeable and less permanent. The goal is to get the desired improvement with the least risk, and that’s a matter for the patient and the surgeon to decide together.
Alpha-hydroxy Acids or “fruit acids”are weak organic acids derived from various foods, for example, Malic acid from apples, tartaric acid from grapes, lactic acid from milk, and perhaps the best-known, glycolic acid from sugar cane. AHA’s loosen the the bonds between epidermal cells, especially in the dead outer layer of skin, and stimulates ground substance deposition in the papillary dermis. AHA’s can be used regularly as a wash or lotion, or in higher concentrations as a very light or “lunchtime peel”, for the treatment of very fine facial lines, rough flaky skin, irregular pigmentation, blackheads, and mild acne.
Pro: AHA’s do not penetrate below the epidermis, so there’s little or no recovery time; It’s useful for all skin types; risk of scarring is near zero; it does not it increases the effects of other agents used on the skin, such as Retin-A or bleaching creams.
Con: AHA peels are superficial, and improvement is not permanent- peels must be repeated at regular intervals. May promote sun-sensitivity through its exfoliant effect.
Manual abrasion has been used since ancient times for tattoos, rhinophyma, and to improve the appearance of the skin, but it was not until the development of the high-speed hand dermabrader in the 1950’s that dermabrasion became popular. In dermabrasion, an abrasive wire or diamond wheel (right) is used by the surgeon to contour (“grind away”) successive layers of skin to the desired level. During the procedure, which is performed under local or general anesthesia, the preoperative contour of the skin must be maintained to allow the surgeon to judge the depth, and the skin must be altered from it’s normal semi-solid to a more solid consistency. This is usually done by freezing successive areas of the skin with a cryogen spray, abrading the area, then moving on to the adjacent area. Tumescent dermabrasion, in which large volumes of local anesthetic are injected to “puff up” the skin, followed by sanding with with sterilized sandpaper, has recently become popular, especially for upper lip wrinkle.
Simple in concept, Dermabrasion is technically very difficult, with a long “learning curve” for the surgeon. There are also certain areas that cannot be effectively dermabraded, for example, the eyelids. Currently dermabrasion is used mostly for acne scarring, often preceded by “pocket grafting” of the deeper scars. As with other resurfacing methods, complications can occur, including fever blister outbreaks, skin infections, milial cysts, and persistent redness. Scarring and loss of skin color from excessive penetration are relatively common in the hands of inexperienced operators. The risk of complications is directly related to the depth of the abrasion.
MicroDermabrasion has become a very popular procedure in recent years, and is widely performed in salons and spas, usually by an esthetician trained in the procedure. Aluminum oxide crystals or a diamond burr is used to lightly abrade the skin surface under mild vacuum. Dead epithelial cells and sebaceous plugs on clogged pores are removed, and collagen formation is stimulated by the mild, controlled injury. Immediately after treatment, the skin feels “polished” and very clean. Typically, 6 treatments performed 2 weeks apart are recommended, and a treatment or series of treatments may be repeated as the patient or practitioner desires.
The principal benefit of MicroDermabrasion is that there is no “downtime”, and the patient can return to normal activities immediately. Improvement is gradual over the course of treatments, and the elimination of clogged pores and dead skin cells enhances the effect of adjunctive topical skin treatments such as alpha-hydroxy acids, antioxidants, retinoids, etc.
Although microdermabrasion works at the level of the stratum corneum and doesn’t create a visible wound, a number of studies have demonstrated histologic changes after repeated treatments, including thickening of the epidermis and increased collagen and elastin deposition in the dermis, usally associated with some vasodilation and perivascular inflammation.
Long used as a cutting and vaporizing instrument, the CO2 laser has become the mainstay of contemporary skin resurfacing. Originally used to ablate tissue with a defocused beam, the CO2 laser was capable of shaving and contouring tissue, but with significant and often unacceptable thermal damage to the underlying tissue. The development of the pulsed CO2 laser with computerized pattern generator (CPG) and the FlashScanner in the mid 1990’s allowed a focused laser beam to be applied to the skin with enough energy to vaporize, but for a short enough time to minimize heat transfer to surrounding tissue (thermal relaxation time). These devices have made laser resurfacing technically simple, and they can be adjusted to produce predictable results compared to peels and dermabrasion.
Laser resurfacing utilizes the principle of Photothermal Ablation. Light energy is absorbed by the water in skin. This water heats up and flashes into steam, which expands and tears open the tissue. Collateral heat damage is kept to a minimum by keeping the time the laser beam dwells on the tissue under 1 millisecond, the thermal relaxation time of skin.
Advantages to Laser Resurfacing include versatility and predictability, not only for cosmetic resurfacing, but for sun-damaged skin, growths, acne scarring, precancerous conditions, and more. Resurfacing lasers can be preset to remove tissue precisely, bloodlessly, and to a predictable depth, with the added benefit of a “tightening” effect on collagen fibers related to collateral heating by the laser. Because of these advantages, laser resurfacing has to a large extent replaced deep chemical peeling and dermabrasion.
Disadvantages to Laser Resurfacing include the high cost of purchasing and maintaining the equipment, slightly longer healing times depending on the depth of the resurfacing, a tendency for somewhat more postoperative redness, and the increasing numbers of physicians with limited training and experience performing the procedure because of economic incentives and consumer demand, which may lead to an increased incidence of complications.
Recently, the Er:Yag or “Erbium” laser has been used for resurfacing. As with the CO2 laser, scanners can be used to facilitate rapid, even treatment of large areas. Because of its very strong water absorption, very thin layers of skin can be removed with even less thermal effect than with the CO2 laser. However, these same properties limit the depth to which Erbium laser energy can penetrate to the upper papillary dermis, thus limiting its effectiveness.
The Erbium laser has received much media attention, and has been advertised as being “safer” than the CO2 laser, with faster healing, and less chance of redness, scarring, and postoperative pigment changes, especially in dark skinned patients. These claims are true to the extent that the more superficial the resurfacing, the quicker the healing, and the less chance of any permanent detrimental or beneficial changes to the skin. Many experienced laser surgeons feel that the risks, expense, and healing time following Erbium laser resurfacing are not justified by the limited results.
Laser Resurfacing : the Procedure
Patient selection: As with any other resurfacing tecnique, patient selection is of the greatest importance. Skin types are classified as type I thru VI. A Type I patient has white skin that never tans and always burns; Type VI have black skin that never burns and tans very rapidly. Patients with Types I, II, and III skin are the best candidates for any resurfacing technique, including Laser Resurfacing. Patients with Type IV, V, and VI are likely to have lightening of the skin postoperatively, especially with deep resurfacing. Patients who are tanned are likely to have temporary or rarely permanent postoperative darkening of the skin.
Patient expectations must be discussed. The Ideal Patient is from 35-80 years old, with lighter skin and mild to moderate perioral (around the mouth and lips) and periorbital (around the eyes) wrinkling. Deep furrows will only be slightly improved, if at all. Sagging or jowling of skin are not treatable by any resurfacing technique. The patient must understand that:
As with any other resurfacing technique, Laser Resurfacing works best to freshen skin texture and reduce fine to moderate facial wrinkles. It does not erase them “permanently”. As aging proceeds, some wrinkles are bound to recur. The clock is turned back, not stopped!
Laser resurfacing will not improve jowls, puffy eyelids or eyelid bags, drooping eyebrows, eliminate deep cheek folds, forehead furrows, or decrease the size of skin pores. Laser resurfacing is often used to enhance results after appropriate procedures to correct these conditions.
Resurfacing deep enough to improve coarse wrinkles may cause some permanent lightening of the skin, especially in darker skinned patients. The skin may develop irregular pigmentation or become more sensitive to the sun, increasing the risk of premature aging and even skin cancer. If a patient is not willing to commit to aggressive sun protection or sun avoidance, he or she is not a candidate for any deep resurfacing procedure.
Laser Resurfacing is an operation with risks as well as benefits. Infection, scarring, and skin color changes may occur if the postoperative instructions are not followed carefully. The patient must commit to at least 7 days of intensive wound care, and possibly weeks of redness, skin sensitivity, and itching.
Preparation of the Skin regimens vary, and may include pretreatment with Retin-A, Renova, bleaching creams, or Alpha Hydroxy Acid preparations. Sun exposure should be avoided for at least 3 months. If there is a history of fever blistering, especially about the lips, an antiviral medication may be started immediately before surgery. Antibiotics may also be started preoperatively, especially in full-face laser resurfacing.
Technique: Patients may have a full face resurfacing, or may have certain facial cosmetic units, such as the upper lip, perioral area, eyelids and crow’s feet area, both cheeks, etc., treated individually. If a facial cosmetic unit is to be resurfaced, an anesthetic cream is applied to the area about 2 hours before, and local anesthetic is used just before the procedure. This can be easily performed in the office. If a full face resurfacing is planned, intravenous medications for sedation are used preoperatively, followed by local anesthetic, usually in a Surgicenter.
The laser is then scanned over the area to be treated. With the first pass, the epidermis, or outer layer of skin is removed, and wiped away with a gauze, exposing the pink papillary dermis. The second pass removes the papillary dermis and exposes the yellowish upper reticular dermis. At this stage the skin can actually be seen contracting and tightening. Additional passes can be made as needed, especially along the shoulders of the wrinkles, or for smoothing around acne scars.
Postoperative Care is directed toward keeping the raw, resurfaced skin moist, to allow for rapid regrowth of epidermis. Some surgeons use occlusive dressings, such as Silon, Vigilon, Flexan, 2d Skin, etc. which are applied over the treated areas. These dressings occlude the wound, keeping in moisture but allowing air to pass through; they are expensive, and by their nature, they tend to leak around the edges, and keep in germs as well as moisture. Other surgeons recommend occlusive creams or ointments, such as generic antibiotic ointment, Aquaphor, Catrix, Dermed, or even Crisco shortening. Frequent applications and frequent washings with warm tap water keep the wound and surrounding areas clean during the healing phase. Pain is mild to moderate postoperatively; severe pain may indicate infection. Some itching may occur, and may be treated with misting or oral medications such as Benadryl. The healing face should not be touched and crusting should not be picked off. Healing is complete in 7-10 days.
The skin remains very pink and sensitive, however, and patients should use a mild soap, a moisturizer, and cool compresses and misting for itching. A mild cortisone ointment may be prescribed. Makeup can be applied 2 weeks after the procedure. Sun exposure must be avoided for at least 3 months. The patient should not be discouraged if a few wrinkles recur as the swelling of the skin subsides.
Side effects and Complications may occur after laser resurfacing, as they may in association with almost any other human activity, and are similar to side effects and complications of other resurfacing techniques.
Side effects seen in many, if not most, patients include:
Postoperative redness, which is anticipated all patients, and usually resolves in weeks to months. The redness is often associated with intermittent itching. Deeper resurfacing will usually produce more and prolonged redness.
Contact Dermatitis, causing flaking and itching, to creams, ointments, and cosmetics is very common, and is related to the temporary thinning of the skin. Bland ointments such as Aquaphor or white petroleum jelly, non-sensitizing creams or lotions, including Catrix, DML, or even Crisco shortening, and mild soap such as Aquanil, Cetaphil, or Neutrogena may be used. In some cases, mild hydrocortisone cream may be prescribed.
Miliae are tiny white cysts which form from clogged skin pores during healing. They usually resolve spontaneously, or they may be treated with Retin-A, Alpha-hydroxy acid lotions, or simple lysis.
Postoperative Hyperpigmentation, or darkening of the skin, especially at the edges of the treated areas, is especially common in darker skinned patients. This usually appears after a few weeks, and resolve spontaneously after 3 or 4 months. Sun exposure can aggravate hyperpigmentation; treatment with Retin-A, Alpha-hydroxy acids, bleaching creams can be used to speed resolution.
Complications are much less common, and may include:
Herpes outbreaks, especially in patients with a history fever blisters. Usually this is a “reactivation” of a previous infection, similar to that seen after minor trauma or sun exposure. Rarely, a more extensive or disseminated infection similar to chickenpox can occur. Preoperative treatment with oral anti-herpes medication can minimize the chance the chance of an outbreak.
Infection with bacteria or fungus, especially in patients who fail to care for their wounds properly or who are using occlusive dressings. Infection prolongs healing and increases the risk of scarring. Preoperative treatment with oral antibiotics is used in high-risk patients or those undergoing full-face resurfacing.
Permanent postoperative hypopigmentation, or lightening of the skin, is relatively common following laser and other resurfacing proceedures especially in patients with darker or weathered skin and patients who have been previously been resurfaced or dermabraded. In some cases, the treated area appears relatively lighter in contrast to surrounding, untreated skin.
Scarring or skin atrophy, especially on the chin, upper lip, and cheekbones. Although scarring is often associated with excessively deep resurfacing, infection, or a history of keloid scarring, it may occur spontaneously in a very few patients.
Fortunately, the risk of complications is very low (under 5%), and is directly related to the depth and extent of the resurfacing.