Laser skin resurfacing



Definition

Laser skin resurfacing involves the application of laser light to the skin in order to remove fine wrinkles and tighten the skin surface. It is most often used on the skin of the face.


Purpose

The purpose of laser skin resurfacing is to use the heat generated by extremely focused light to remove the upper to middle layers of the skin. This procedure eliminates superficial signs of aging and softens the appearance of other lesions such as scars. Upon healing, the surface of the skin has a younger appearance. Microscopic analysis of skin after laser resurfacing shows that the healed surface more closely resembles younger, healthier skin in many aspects.


Demographics

According to the American Society for Aesthetic Plastic Surgery, there were more than 72,000 laser skin resurfacing procedures performed in the United States in 2002. Almost all persons of sufficient age have one or more symptoms of aging or damaged skin that can be treated by this procedure, including fine lines in the skin, known as rhytides; discoloration of the skin; acne scarring; and surgical or other types of scars.


Description

A central component of the laser skin resurfacing technique is the laser device. Laser is an acronym for light amplification by stimulated emission of radiation. This device produces an intense beam of light of a specific, known wavelength. Laser light is produced by high-energy stimulation of different substances such as crystals, liquid dyes, and gases. For skin resurfacing, two types of lasers produce light that is well absorbed by the upper to middle layers of the skin: light produced from carbon dioxide gas (CO 2 ) and light produced from a crystal made of eribium, yttrium, aluminum, and garnet (Er:YAG). Combination lasers are also commercially available.

There are as yet no standard parameters for laser use in all skin resurfacing procedures. Settings are determined on a case-by-case basis by the laser surgeon who relies on his or her own experience.

Before the procedure begins, medication is often given to relax the patient and reduce pain. For small areas, local topical (surface-applied) anesthetics are often used to numb the area to be treated. Alternatively, for large areas, nerve block-type anesthesia is used. Some laser surgeons use conscious sedation (twilight anesthesia) alone or in combination with other techniques.

During the procedure, the patient lies on his or her back on the surgical table, eyes covered to protect them from the laser light. Laser passes are performed over the area being treated, utilizing computer control of the laser for precise results. In general, more passes are needed with Er:YAG lasers than carbon dioxide laser treatment.

Because areas of the body other than the face have relatively low numbers of the cells central to the healing process, laser skin resurfacing is not generally used anywhere but on the face, as elsewhere the healing process may be so slow as to result in scarring.

Diagnosis/Preparation

An initial consideration is to determine which laser would be best for any particular skin resurfacing procedure. Carbon dioxide lasers have been in use longer and have been shown to produce very good results. However, the healing times tend to be long and redness can persist for several months. In contrast, because the light produced by the Er:YAG laser is more efficiently absorbed by the skin, less light energy and shorter pass times can be used, which significantly shortens the healing time. Unfortunately, the results obtained with this laser have not been as consistently good as with a carbon dioxide laser. Patients should therefore discuss the two laser types and the condition of their skin with their doctor to determine which would be better for their particular situation.

Although controversial, some studies have reported abnormal scarring in patients previously treated with 13 cis-retinoic acid (Accutane), so many surgeons will require a six-month break from the medication before performing laser skin resurfacing.

Laser skin resurfacing does increase the chance of recurrent or initial herpes simplex virus infection (cold sores) during the healing process. Even with no patient history of the problem, it is important that anti-viral medicine is administered before, the morning of, and following laser skin resurfacing.


Aftercare

After the procedure, any treated areas are dressed for healing. Surgeons are divided on whether the wound should remain open or closed (covered) during the healing process. For example, surgeons that adopt a closed procedure can use a dressing that is primarily hydrogel held on a mesh support to cover the wound. This kind of dressing is changed daily while the epithelium (outer layer) is restored. Open wound care involves frequent soaks in salt water or dilute acetic acid, followed by application of ointment. Whatever wound treatment is used, it is important to keep the healing skin hydrated.

Full restoration of the epithelial layer occurs in seven to 10 days after treatment with a carbon dioxide laser and three to five days after treatment with a Er:YAG laser, although redness can persist for many weeks afterward.


Risks

Risks of this procedure include skin redness that persists beyond the initial healing period, swelling, burning sensations, or itching. These risks tend to be short term and lessen over time. More long-term problems can include scarring, increased or decreased pigmentation of the skin, and infection during healing. Finally, the formation of milia, bumps that form due to obstruction of the sweat glands, can occur, although this can be treated after healing with retinoic acid.


Normal results

Normal results of this procedure include reduction in the fine lines found in aging skin, improving skin texture, making skin coloration more consistent, and softening the appearance of scars. In a recent study, more than 93% of patients subjectively rated their results from the procedure either very good or excellent.


Morbidity and mortality rates

The morbidity and mortality rates for this cosmetic procedure are close to zero.


Alternatives

Surgical techniques such as facelifts or blepharoplasty (eyelid surgery) are often recommended when facial aging is beyond the restorative powers of a laser treatment and the most common alternative technique. Patients should also consider other skin resurfacing techniques such as dermabrasion or chemical peels, as these are more effective than laser resurfacing for certain skin conditions and certain skin types.


Resources

books

Roberts, Thomas L. III, and Jason N. Pozner. "Aesthetic Laser Surgery." In Plastic Surgery: Indications, Operations, and Outcomes, Volume 5, edited by Craig A. Vander Kolk, et al. St. Louis, MO: Mosby, 2000.


periodicals

Bisson, M. A., R. Grover, and A.O. Grobbelaar. "Long-term Results of Facial Rejuvenation by Carbon Dioxide Laser Resurfacing Using a Quantitative Method of Assessment." British Journal of Plastic Surgery 55 (2002): 652–656.


organizations

American Society for Aesthetic Plastic Surgery. 11081 Winners Circle, Los Alamitos, CA 90720. (800) 364-2147 or (562) 799-2356. http://www.surgery.org .

American Society of Plastic Surgeons. 444 E. Algonquin Rd., Arlington Heights, IL 60005. (800) 475-2784. http://www.plasticsurgery.org .


other

Tanzi, Elizabeth L. "Cutaneous Laser Resurfacing: Erbuim: YAG." eMedicine, January 10, 2002.


Michelle Johnson, MS, JD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


The procedure is performed by an experienced laser surgeon or a dermatological surgeon with special training in the use of the laser. It is performed in a special suite adapted for laser use, often located at the surgeon's offices.

QUESTIONS TO ASK THE DOCTOR


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