Laser Skin Resurfacing

Laser resurfacing is a technique for smoothing fine wrinkles in the skin. This method results in less bleeding, bruising and post-operative discomfort than other resurfacing techniques. Facial skin tends to loosen and sag with time. Fine lines appear near the eyes, on and around the lips, and even across the cheeks. Creases deepen around the mouth and between the eyebrows. Different things can accelerate lines and wrinkling, cigarette smoke, stress, sun exposure, poor nutrition, pollution and alcohol can all spell disaster for your skin.

The laser can be applied to the skin in short pulses to remove irregular contours, discolored areas, tattoos, or blood vessels. The laser uses a beam of light to vaporize the outer layers of damaged skin at precisely controlled levels of penetration. All skin surfacing techniques have the same goal, i.e. to remove damaged and wrinkled skin which allows new skin layers to be exposed. The old skin layers are "vaporized" by the laser revealing the new skin which, after healing, results in a tighter, smoother, and younger looking skin surface.

The CO2 laser is used for sun damaged, aging, wrinkled or scarred skin. The depth of the laser is more predictable than that of chemical peels or dermabrasion since the laser strength and exposure time to the skin can be precisely controlled.

Anyone who has an irregular area of skin, whether due to contour, wrinkles, color, blood vessels, or scars, may be a good candidate for a laser treatment. The ideal patient is fair and healthy with non-oily skin. Patients with darker tones such as olive, brown or black skin, may have an increased risk of skin pigmentation changes regardless of the skin resurfacing technique used.

Laser treatment is not a substitute for a face-lift or surgery for baggy eyelids. Laser treatments do firm up the skin and increase skin tone, but they are not capable of eliminating skin that has lost its elasticity. Once the skin truly sags instead of simply wrinkling, surgery is required to correct the undesirable cosmetic appearance. Laser resurfacing does not show a good result in the neck area.

For the most part, lasers are very safe. However, as with any medical procedure there are risks and benefits. Scarring, pain , lack of permanent results, delayed healing up to several months, and other risks are uncommon, but possible.

Laser resurfacing is associated with minimal discomfort unless an extensive treatment is planned. This technique is most commonly performed under general anesthesia where you will sleep through the entire procedure. The procedural time is directly related to the amount of damaged skin being removed.

The initial post-operative redness fades in a few weeks to light pink, which is easily camouflaged with cosmetics and usually disappears completely in one to three months. Some swelling may occur, particularly around the eyes. It is important to use a sunscreen with minimum SPF 15 protection against UVA and UVB rays, and to avoid sun exposure for several months as this can cause changes in pigmentation. Some patients may experience transient spots of hyper-or hypopigmentation (coloration or discoloration). These conditions often resolve themselves in four weeks.

Counter Indications to CO2 Laser Resurfacing:

1. Oral isotretinoin for acne (recently).
2. Burns, chemical peeling and scleroderma (loss of appendages).
3. Neck and hands (scarce of appendages).
4. Patients with unrealistic expectations.
5. Smokers (delayed healing).
6. Red "Lipliner" tattoo.

Pre-Treatment:

Interrupt the use of retinoic acid, glycolic acid and hidroquinone at least 4 weeks prior to the resurfacing procedure. Retinoic acid or glycolic acid may be used following laser resurfacing as a skin maintenance program.

All patients will have to take Acyclovir. It is advisable to begin Acyclovir 24 to 48 hours prior to the procedure at a dose of 400mg three times a day and continue until re-epithelization (healing) is complete (10 days).

Post-Operative Care:

1. I use semi occlusive dressings after the resurfacing the face. The use of specific semi-occlusive dressings have revolutionized the post operative wound care following resurfacing procedures. A moist environment will allow more rapid healing to occur compared with dry desiccated wounds, with a reduced risk of scarring and infection. Another major advantage is the minimal post operative pain experienced by patients when these semi-occlusive dressings are used, compared with areas that are left open to the air. The dressings are changed when necessary, usually requiring a change after 48 hours, as the exudate will lift them. Once the exudate is cleaned and dried, a fresh dressing is applied which then sticks fairly readily to nonmobile areas, such as the forehead, cheeks, and periocular areas. Mobile areas such as the perioral region may require more frequent changes. When dressings are changed, the area is first cleaned thoroughly with aqueous cream and tap water until all the exudate has been completely removed. The area is then dried, thus allowing the dressing to adhere more firmly to the underlying area. Once re-epithelization is complete, the dressings can be soaked in baby oil leaving an intact re-epithelialized surface. In other cases we prefer not to use any dressings, but instead instruct the patients to use topical occlusive ointments.
2. Remember to continue Oral Acyclovir until healing is complete (usually for 10 days). A dose of 400 mg three times a day is used.
3. To prevent secondary bacterial infection, a broad-spectrum antibiotic medication (e.g., chephalosporin) is routinely prescribed. It is given intravenously during the procedure and continued orally afterwards until healing is complete. An alternative antibiotic medication such as ciproxen may be necessary.
4. Post-operative swelling may occur with an extensive resurfacing procedure. This may be minimized especially around the eyes if oral prednisolone, 100mg daily, is prescribed for 3 days.
5. Analgesic medication (e.g., acetaminophen) should be taken half an hour prior to dressing changes.
6. Sleeping tablets are recommended in all individuals.
7. Dressings should be change when necessary to avoid desiccation of the skin. This should be continued until full healing has occurred, which may take up to 14 days.

Once healing has occurred, several measures are recommended:

1. Sun Protection: While erythema is present, post-inflammatory pigmentation may occur with or without sunlight. Ultraviolet "A" light will certainly promote pigmentation for the ensuing 3 months following resurfacing.
2. Moisturizers: The skin generally will be dry for several weeks after resurfacing. A non-perfumed moisturizer is recommended.
3. Cleansers: Use non-perfumed, nonocclusive cleansers. The area should be washed thoroughly with an oil-free cleanser.
4. Make-up: It is preferable to employ the services of a make-up artist for optimal results.
5. Reducing the redness: Topical steroids (e.g., hydrocortisone 1% cream) will help reduce erythema and may be used for several weeks after laser resurfacing.
6. Pigmentation: Post-inflammatory pigmentation is common following laser resurfacing and may occur in the absence of sun exposure. The use of 4% to 5% hydroquinone with retinoic or glycolic acid post-operatively, however, will reverse post-inflammatory pigmentation within 2 to 4 weeks. In our experience, pigmentation has not been permanent in any of the cases to date.

Complications can occur with laser resurfacing, but should be minimized with proper post-operative care.

Complications

1. Herpes Simplex: Commonly is activated by laser resurfacing, spreads readily and may scar. To avoid this complication, Acyclovir, should be used routinely.
2. Bacterial Infection: To avoid this complication, all patients are given oral antibiotic agents prophylactically and dressings are changed frequently.
3. Fungal Infection: Treatment with Burow's solution (alumunium subacetate) compresses and oral ketoconazole, 400 mg daily, will rapidly eliminate the organism and will not lead to scarring.
4. Contact Dermatitis: The use of post-operative antibiotic ointment and even petrolatum frequently leads to contact dermatitis.
5. Pigmentary Change: Temporary hyperpigmentation occurs commonly (10% of individuals) especially in-patients with darker skin. Patients should be warned that this is likely to occur but will resolve with the use of 4% to 5% hydroquinone with 0.1% retinoic acid or 15% glycolic acid post-operatively.
6. Scarring: On rare occasions scarring can be permanent. Sometimes additional treatment in the form of surgery may be necessary after laser treatment.

Before	After

Before	After

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