Fine lines and sun-damaged skin are common problems for patients who come to our Center. Skin resurfacing is a process of removing the outer layers of the facial skin and allowing new skin to form. Its purpose is to improve skin texture and to remove fine lines and wrinkles that form as a result of age and sun exposure. Both chemicals and lasers are used for this purpose
For quite some time, the use of lasers has replaced the older technique of chemical peel. There is no question that the old deep chemical peel produced by the use of phenol compounds was effective in reducing facial lines. Unfortunately, the price was rather steep with prolonged recovery, a relatively high risk of skin of lightning and the possibility of scarring. Patients are sometimes confused in thinking that the use of lasers provides for more effective elimination of lines. Actually, the advantage of lasers primarily involves the potential for greater safety rather than greater effectiveness. The problem is deciding which type of laser to use.
LASER SKIN RESURFACING
Laser resurfacing is used for the same purpose as was chemical peeling in the past. The results are similar. However, lasers have pretty much replaced chemical peeling for deeper resurfacing because it seems to offer added safety and faster recovery. Our experience with laser for skin resurfacing has been very encouraging. We are impressed with the control that this modality offers. We agree that healing time is shortened somewhat, compared to other methods.
The idea of using laser energy for skin resurfacing is not new but difficulties arose in attempting to create an even pattern of applying the laser energy to the skin. This obstacle was overcome by the development of computer-driven pattern generators.
Certainly the final answer is not yet in. However, we remain convinced that the CO2 laser offers the best combination of safety and effectiveness for skin resurfacing. As in every operation, there is a fine balance between the effectiveness and risk. There is no escaping the fact that if the surgeon is overly aggressive in applying laser energy to the skin, regardless of the type of laser, the risk of complications increases.
Dr. Howard Tobin and the staff at the Facial Plastic & Cosmetic Surgical Center continue to believe that a conservative approach is best. We do not believe that it is wise to attempt to eliminate all of the offending lines. We have also found that by adopting this conservative approach we can safely combine laser resurfacing with facelift surgery. By combining these two modalities, we can effectively take up the slack produced by aging and reduce the lines that have resulted from long-term skin damage with one operative session. This combination of facelifting and laser resurfacing has proven to be highly effective.
PRE TREATMENT IS IMPORTANT
Pretreatment options are important when considering skin laser resurfacing. The laser resurfacing vaporizes the outer most layers of skin, which are aged, sun damaged or irregularly pigmented, leaving the underlying skin cells to repopulate and resurface the area treated. This usually results in a much smoother complexion eliminating the pigmentary irregularities and achieving an improved final skin surface. Pretreatment with Retin A, other retinols or glycolic acid products have shown to be very useful in preparing patients for laser resurfacing. Our preference is for the glycolics.
These products stimulate the turnover of the cells deep within the skin that are continually dividing and replacing skin cells that are lost on the surface. By increasing the rate of turnover of these cells, many believe that subsequent healing time following laser resurfacing can be shortened with improved results. Skin preparation before laser treatment is usually suggested between two and six weeks because this seems to be the minimal time required to effectively stimulate increased activity of the skin.
BENEFITS OF RESURFACING
The process eliminates or reduces superficial and some deeper lines in the skin of the face, resulting in a fresher and more youthful appearance. At lower power settings, it can also be used in other areas such as the neck or hands. It can be helpful in reducing or removing freckles or pigmentation, although chemical treatments are usually tried first.
The very deep lines around the mouth are the most difficult to treat and sometimes a second treatment is indicated. Our policy is to offer this second treatment for only operating room and anesthesia fees.
As mentioned, laser resurfacing is often utilized as a compliment to surgery. It is not a substitute for the facelift operation as it does not correct facial laxity or sagging skin. It is excellent for treating fine lines on the cheek, beneath the eyes and around the mouth – the very lines that are difficult to correct with surgery. Although some patients will have resurfacing as an isolated procedure, often it is coupled with the facelift operation either as a staged procedure or as a combined adjunct, being utilized at the same time as the facelift operation.
After surgery, the skin that has been resurfaced will be raw, but will generally be healed in ten to fourteen days with deeper resurfacing, and even quicker with lighter treatments. The skin remains red for several weeks, and pink for a few months, although this can easily be covered with make up.
One major advantage noted with laser resurfacing, in comparison with the older technique of deep chemical peeling, is a decrease in the risk of skin lightening and scarring as reported in several clinical studies. While these risks are not eliminated, they seem to be less frequent. Another advantage is that the depth of treatment is more controllable.
As with all skin resurfacing, preoperative preparation and postoperative care are important.
MICRO-FRACTIONAL CO2 LASER RESURFACING
Combining the effectiveness of traditional carbon dioxide lasers — long thought to be the gold standard in wrinkle removal — with a new application technique, we can now achieve some of the benefits of traditional laser resurfacing with a marked decrease in recovery time and risk. However, it should be noted that several treatments are required for best results.
Laser resurfacing uses beams of light energy to bore tiny holes in the skin. This works to put the body’s natural collagen into a rapid regenerative mode. With traditional laser resurfacing, the entire surface of the skin is treated. Micro-fractional CO2 laser makes use of tiny dots which penetrate the skin and cause a disruption of the middle portion of the skin known as the dermis, sparing adjacent areas of the skin and offering maximum results with minimal recovery time. Through a combination of selective tissue evaporation and heating, the dermis remodels and tightens.
By combining state-of-the-art C02 technology and a computer scanner that increases time between adjacent pulses, the gold standard CO2 laser is delivered in micro-laser pulses in a manner like a “laser airbrush” effect. By creating thousands of tiny, microscopic laser wounds, spaced in an even pattern across the skin, but leaving areas of healthy, untreated skin between them, the lower collagen layer of the dermis is stimulated to renew and repair. The surface of the skin now contains only microscopic surface wounds, instead of one large, red burn.
Fractional CO2 resurfacing causes little downtime and redness because its micro-fractional laser pulses reduces skin injury. This makes the healing process much quicker and enables patients to get back to their normal life style sooner. Fractional CO2 laser resurfacing is primarily indicated for the fine lines that accompany aging or sun exposure but can also be helpful for deeper wrinkles, blemishes, areas of hyperpigmentation and acne scars.
Recovery is much faster than traditional resurfacing with patients ready for normal activity within a few days. While the procedure does provide some long lasting benefit, it does not provide the permanent change that is produced by traditional full laser treatment. It can be repeated if desired for additional benefit. Since it can be done under local anesthesia and requires much less recovery time, patients are much more prone to consider a second procedure.
Chemical peel, or chemosurgery as it is sometimes called, consists of the application of a chemical solution — usually an acid, to the skin of the face. While the older deep phenol chemical peel has almost entirely been replaced by laser resurfacing, lighter peels, called freshening peels are still commonly used.
One patient reported that she had large patches of dry scaly skin that were completely removed after the procedure. Others report that their makeup goes on much smoother after a freshening peel. In some cases, there may be improvement in the appearance of brown spots. Not everyone gets the same result, but most patients seem pleased with the procedure.
These peels require no anesthesia and allow for very prompt recovery. While there may be some scaling of the skin. The rawness associated with deeper treatment is not present. The skin may turn brown for a few days, but usually will return to normal color in a week or so. Occasionally hyperpigmentation will persist and require additional treatment.
These lighter peels are considered complexion peels. While they make the skin look brighter and fresher, they result in no permanent change, and therefore must be repeated to maintain the effect. Fine lines are certainly improved, but not permanently. Most patients will choose to have the peel repeated about every six months. Progressively stronger peels may be utilized to further enhance the effect. Freshening peels can be an attractive alternative for patients seeking better skin texture or for those not yet ready for a deeper treatment.
We feel that these light peels represent a cost effective alternative to such modalities as microdermabrasion, Fraxel treatment and many of the newer pulsed light and laser-like treatments.
As in all operations, there are risks associated with skin resurfacing. Fortunately, these are rare. Complications, which can occur, include changes in skin pigmentation and scarring, the latter being very unusual. Some patients will notice that their skin is a shade lighter after a peel. As would be expected, the change is more noticeable in dark skinned patients. As mentioned, skin lightening is felt to be less following laser resurfacing compared to the older, deep chemical peel. Rarely, the skin will appear darker after a peel due to activation of melanin producing cells. This darkening can be uneven, requiring make-up for cover. Often, pigmentation problems following a peel are the result of sun exposure and, in most cases, they can be successfully treated using various skin bleaching medications.
After resurfacing, it is important that patients avoid overexposure to the sun. The skin must be protected from burning or tanning, as these can lead to changes in pigmentation. With present-day sunscreens, this should not cause a great change in the patient’s lifestyle. Many patients will also choose to avail themselves of Alpha Hydroxy Acid treatment or Retin A® to further enhance the effect of the peel.
Some patients notice an apparent enlargement in their skin pores after deep resurfacing. This is probably not a true enlargement of the pores, but rather an apparent enlargement resulting from elimination of lines and fine wrinkles which previously tended to obscure the pores.
Skin resurfacing is a very useful adjunct to cosmetic surgery. Whether the entire face is being peeled, or just a problem area or two, the results can be very dramatic and highly gratifying.