Laser Resurfacing of the Skin

Laser technology is revolutionising the field of facial surgery. Just a few years ago, lasers were rarely used by facial surgeons. Today, lasers are used for purposes ranging from resurfacing of the skin to tattoo removal. This overview will describe the technique of facial skin resurfacing using the Carbon Dioxide (CO2) and erbium lasers.

How does the Resurfacing Laser work?

This new generation of CO2 and erbium lasers takes advantage of extremely short bursts (or pulses) of the laser beam that are very powerful, yet are of such short duration that they do not harm the surrounding tissues. Therefore, the laser can very precisely and accurately vapourise only the tissue being treated, leaving the other tissues completely intact. The wrinkled or scarred upper layers of skin are thus removed, leaving behind a new, healthy, smoother layer of skin.

What conditions can be treated with the Resurfacing Laser?

The CO2 laser is most commonly used to remove lines and fine wrinkles from the face. Different patients may require treatment in different areas. In some patients, only the area around the eyes the crows feet and eyelids need to be treated. In others, the area around the mouth requires treatment, these deep lines and wrinkles around the mouth often cause lipstick to bleed from the lips on to the skin. In still others especially those having spent long periods in the sun the entire face may require resurfacing. Essentially any lines or wrinkles of the face that are objectionable, can be treated with the laser.

Facial skin laxity can also be treated using the CO2 laser. This tightening effect is particularly striking in the jowl area. The jowls can often be tightened enough to eliminate the need for a more invasive procedure, such as a cosmetic facelift. Other areas that can be improved include the nasolabial fold area and the eye area. Many patients notice that the laser treatment seems to give a more open look to their eyes.

Another condition that can be treated with the laser is acne scarring, or scarring that is a result of surgery or trauma. The CO2 laser offers tremendous advantages over other treatments such as dermabrasion and chemical peels. Erbium is a gentler laser and produces less post operative complications, however, their efficiency is variable compared to CO2 laser.

How does the Laser tighten the skin?

It is postulated that the laser directly affects the collagen located in the dermal layer of the skin. It is thought that the laser causes the collagen, which is shaped like a coil, to tighten up, much like a spring. As the coil shrinks, the skin shrinks aswell. This tightening effect is striking to see, as each pulse of the laser causes a very obvious dramatic contraction, or tightening of the skin.

How much of the face should be treated at one time?

In the vast majority of patients, the entire face is treated. Certainly in patients with very limited wrinkles or scars, individual segments of the face are treated. However, most patients find it easier to camouflage the light pink colouration of the skin if the entire face is pink, as opposed to just around the eyes or just around the mouth, for example. When the entire face is treated, the demarcation line between the treated and untreated areas is hidden just below the jaw line. With make up, only close inspection will reveal this line. Of course, when the face is completely healed, the treated and untreated areas blend together completely.

Who is a good candidate for resurfacing with the Laser?

The ideal candidate for laser resurfacing has a relatively fair complexion. In general, the lighter the complexion, the more predictable the results. However, those with darker skins can be treated very successfully aswell. Since Asians and Afro-Caribbeans sometimes have a tendency to experience either some darkening or lightening of the treated skin, proper skin care both before and after the procedure is essential. This virtually eliminates the chance of these pigmentation changes. In questionable cases, a small test patch behind one ear a few months prior to the actual resurfacing can help determine if the skin will react favourably to the laser.

Patients with a mild to moderate amount of skin laxity (jowling, for example) are excellent candidates for laser resurfacing. For those that feel that it is too early for a facelift, the laser is an excellent alternative. Of course, patients with large amounts of hanging skin will need to have the skin surgically removed with a procedure such as a facelift. However, many of these patients prefer not to have a procedure that involves cutting. In these situations, the laser is a perfect alternative.

Can the neck be treated with the Laser?

The facial skin has remarkable healing capabilities, which is why laser resurfacing of the skin is possible. The neck, however, does not have the same capabilities. Therefore, a much less aggressive 25%TCA peel is performed on the neck. This light chemical peel will soften superficial wrinkles, light brown spots and will help blend in the new, healthy resurfaced skin of the face with the skin of the neck and chest. Erbium laser can be used on the neck.

What can be done to prepare for Laser Resurfacing?

Prior to laser resurfacing, patients are placed on a pre-treatment regimen of Retin-A or glycolic acid, sunscreen, a moisturiser and a bleaching agent. Treatment with a bleaching agent is of particular importance to those patients with darker skin.

Despite the name bleaching agent, these agents do not turn the skin white. They can, however, help eliminate any unwanted brown spots or patches. The use of a bleaching agent prior to laser resurfacing helps to suppress the skin cells that produce melanin, the substance that gives the skin its pigmentation and causes brown spots. This melanin, if produced in excessive amounts after a peel or laser procedure, can lead to irregular darkening of the facial skin.

By applying these bleaching agents both before and after the resurfacing, melanin produced is suppressed and the brown discolouration is much less likely to occur. Again, these bleaching agents are particularly important in those patients with darker skin.

What type of anaesthesia is used?

The choice of anaesthesia depends on many factors, including the amount of work to be done and the preference of the patient and surgeon. If limited areas are being treated (for example, just the lines around the mouth), local anaesthetic is usually adequate.

If more extensive areas are being treated (for example, the entire face), local anaesthetic and a sedative given intravenously are used. General anaesthesia can also be used if the patient prefers.

What does the procedure itself involve?

Laser resurfacing is generally performed on an outpatient basis. An intravenous infusion is started if the full face is being treated and sedatives are administered. Following this, the local anaesthetic is injected in the areas being treated. Again, if only a limited area of the face is being treated, local anaesthetic alone can be used. Some surgeons may use a topical (cream) anaesthetic aswell.

The face is cleansed with saline solution or an antibacterial solution. Since the laser beam can be harmful to the eyes, precautions are taken: the surgeons and nurses wear protective eyewear and protective eyeshields are placed in the patients eyes, after eye drops are used to anaesthetise the eyes.

The surgeon carefully chooses the various settings on the laser, according to the needs of each patient. The amount of laser energy being delivered and the frequency at which the laser beam contacts the skin are important variables which the surgeon determines prior to treating each patient.

At this point, the procedure begins. The surgeon aims the laser with a handpiece and turns the laser on and off with a foot switch. With the tissues anaesthetised, the patient cannot feel a thing. The surgeon treats each area individually and can vary the depth of the treatment from area to area, depending on how deep the wrinkles or scars are. The surgeon may increase the power setting for the deeper wrinkles around the mouth and may decrease the setting for the delicate skin of the eyelids.

He may perform several passes with the laser over the deep wrinkles around the mouth, but may stop at one pass over the eyelids. He will use the laser to feather the border of treated and untreated areas, so that they blend together. After each pass, the surgeon carefully inspects the treated areas to determine if the treatment is adequate, or if another pass is needed.

He wipes away the wrinkled or scarred upper layers of skin that have been treated with the laser and inspects the colour and texture of the remaining deeper layers to determine how much deeper the treatment needs to go. If the inspection reveals that the depth is appropriate, he stops. If not, the area is carefully treated again, re-inspected and if necessary, treated again.

After the treatment is complete an ointment is placed over the skin. If a general anaesthetic is used, the patient will usually stay over night in hospital.

Can other procedures be done at the same time?

Most patients request that other procedures be performed in conjunction with laser resurfacing. Such procedures include facelifts, forehead lifts, eyelid surgery, lip augmentation, chemical peels of the neck and chest and liposuction. In general, combining facial rejuvenation surgical procedures results in a more harmonious appearance. Furthermore, by combining surgical procedures, the patient undergoes just one recovery period and a single anaesthetic. Finally, the overall cost is significantly reduced if the procedures are combined.

What is the recovery period like?

If sedation was given, a short time in the recovery room is required. With local anaesthesia alone, the patient is released when the procedure is completed. As the local anaesthetic wears off, most patients experience a burning or stinging sensation over the treated areas. This burning is described as mild to moderate by most patients. The burning is completely gone in a few days. Oral pain medication and ice compresses help to relieve the discomfort. Some patients experience itching of the face. Medications can be prescribed to help with the itching.

What does one look like after Laser Resurfacing?

Immediately after the procedure the face is pink to red. Over the next few days, a mild amount of swelling may occur. During the first several days, light crusting will form over parts of the treated skin. Vinegar and water soaks will help to remove these crusts. At 7-10 days after the procedure, the crusts are off, the raw areas are completely healed over and the skin is pink.

How does one care for the face at home?

If ointment is used as a dressing, frequent application of the ointment is imperative. The treated skin must be kept moist at all times. The risks of scarring or infection are increased if the areas are allowed to dry out. Vinegar and water soaks are begun the day after the procedure. These soaks are performed every few hours, throughout the day, for the next several days. The soaks help eliminate any crusting that may occur. After each soak, a layer of ointment is reapplied. Over the next few days, as the crusting diminishes, the soaks can be performed less often. Any swelling can be minimised by sleeping with the head elevated.

When is the skin back to normal?

The pinkish colouration which fades with time, usually persists for 6-8 weeks. In some cases it can persist for longer. Most patients report that they can literally see the pink fading day by day. After 7-10 days, when things are healed over, camouflage make up can be worn. With the make up, the pink colouration is completely hidden. In some darker skinned patients, light brown areas may necessitate the use of bleaching agents. In general, the skin is completely back to normal in 2?-3 months.

What complications are possible?

As with any surgical procedure, there are risks involved with laser resurfacing. Changes in the skins pigmentation are possible. Careful pre-operative planning and post-operative follow up virtually eliminates the risks of pigmentation changes. Scarring is extremely unlikely. Because it is possible to precisely judge the depth of resurfacing when using the CO2 laser, the risk of treating too deeply is minimised. Infection is unlikely, since oral antibiotics and anti-viral medications are routinely prescribed. Some patients, during the first few weeks after laser resurfacing, develop a type of mild dermatitis or rash over the treated areas. Generally, these conditions clear up on their own, however, topical or oral medications can be prescribed, if necessary.

If complications occur, can they be corrected?

Frequent visits to the surgeon are necessary in the first few weeks after the procedure, so that any impending problems can be noted early and treated promptly. Any suspicious areas must be treated with the appropriate antibiotics, medications, or ointments.

What is the right age to have Laser Resurfacing performed?

As with any elective, cosmetic surgical procedure, there really is no "right age". Young patients in their late teens or early twenties with acne scarring often request resurfacing. Some people begin to develop significant wrinkling, often in the crows feet area, while still in their twenties and request laser resurfacing. Likewise, many patients in their 70s and 80s request laser resurfacing. Older patients are excellent candidates for laser resurfacing, as long as they are in good health.

In Summary

The following conditions may be treated with the:

Resurfacing CO2 Laser

  • Facial wrinkles
  • Lip lines and crows feet
  • Early facial skin laxity, including jowling
  • Acne scarring
  • Traumatic and post-surgical scarring
  • Freckles, age spots, sun spots and other types of hyperpigmentation

Erbium Laser

Erbium Laser is used exactly the same as CO2, however due to the higher absorption compared to CO2, the output leads to more efficient energy absorption and decrease depths of residual thermal damage.

Post operatively, the erythema is less and the healing is faster, however, there is little intra-operative tightening of the skin. Therefore, Erbium Laser is a superior tool for resurfacing particularly in areas such as the neck and hands.