1. Oral Maxillofacial Surg Clin N Am 16 (2004) 215 – 230 Cosmetic ablative skin resurfacing Stephen W. Watson, MD, DDS*, Todd J. Sawisch, DDS Willow Bend Cosmetic Surgery Center, 5824 W. Plano Parkway, Suite 101, Plano, TX 75093, USA Cosmetic surgery has increased 225% over the in 625 AD, Paul of Aegina described the techniquepast 6 years, and advanced technology has been one used by Greeks and Romans of the seventh century toof the primary stimulants . Ablative skin resur- reduce facial wrinkles. A troche, or lozenge made offacing using CO2 and Erbium:YAG lasers is one of bruised-fish gelatin, ivory shavings, male frankin-those advanced technologies. One recent survey cense, and bitter weeds that grew among wheat wasreveals that ablative laser skin resurfacing accounts mixed with white wine and rubbed into the skin tofor approximately 1% of all cosmetic surgical proce- treat wrinkles. Alternatively, bruised fat figs, burneddures performed in the United States during 2002. powder of bitter wheat weeds, and the shells of squidHowever, when contrasted with the widespread in- were mixed with a small amount of honey and ap-troduction of laser technologies for rhytid reduction plied to the face. It is quite possible that the combinedin the early 1990s, culminating with a peak in 1998 effects of these abrasive materials and plant acids, the use of the CO2 and Erbium:YAG lasers has were the first recorded dermabrasion and chemicaldropped dramatically. Hence the technologic advan- peel techniques .ces in these two lasers have changed very little, if atall, since the development of superpulsed energy and Dermabrasioncomputer pattern generators. The drop in demand forlaser skin resurfacing is due in large part to the Dermabrasion is a term used to describe a proce-unwillingness of an informed public to undergo the dure that removes variable amounts of skin, particu-prolonged and involved recovery associated with larly the epidermis. In ancient times, Egyptians wereablative laser resurfacing coupled with the introduc- the first to use this procedure to remove blemishestion of nonablative technologies and intense pulsed and smooth the skin. Pumice and alabaster were usedlight. As a result, surgeons are returning in large as abrading tools. Modern advances in dermabrasionnumbers to more conventional resurfacing such as began in 1905 with the German physician Kromayertrichloroacetic acid peels and modified phenol peels . He was the first physician to formulate a method. Preoperative and postoperative protocols have of skin abrasion. In 1935, Janson reported the use of abeen altered somewhat, and more conservative sur- stiff-bristle brush to abrade tattoos  and the use of agical approaches that use lower fluences and fewer common sandpaper was introduced by Iverson inpasses are now generally used; however, ablative 1947 to remove a facial tattoo produced by gunlasers have changed little during the past 5 years. powder . The greatest advances in the technique are attributable to Abner Kurtin . He and a coworker developed and produced the instrumentsHistorical perspectives of today, including the modified power-driven instru- ments and refrigerants that aid dermabrasion. Descriptions of facial rejuvenation techniqueswere recorded as early as 1000 years ago. In Greece Chemical peel * Corresponding author. Chemical peeling of skin has been used since the E-mail address: firstname.lastname@example.org (S.W. Watson). time of ancient Rome. Over the intervening years,1042-3699/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.doi:10.1016/j.coms.2004.02.005
2. 216 S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230interest in peeling has waxed and waned. In the late Laser physics and tissue interaction1800s, chemical peeling had a resurgence and causticagents were used. In 1961 Baker and Gordon pio- LASER is an acronym for Light Amplification byneered chemical peeling with phenol . Since 1961 Stimulated Emission of Radiation. Atoms and elec-the general trend has been toward less aggressive trons are normally in their lowest energy or ‘‘resting’’types of peels, including trichloroacetic acid and, state. If the energy of a photon of light is absorbed bymore recently, alpha-hydroxy acids. The field of an electron, the electron is raised to an ‘‘excited’’chemical peel and facial rejuvenation continues to state. An excited electron returns to its resting stateevolve . by emitting a photon identical to the photon that was initially absorbed. If a photon is absorbed by anLaser resurfacing excited electron, this electron may emit two photons when returning to its resting state, a process called The initial role of laser for skin resurfacing in- stimulated emission . Repeating this stimulatedvolved the continuous wave CO2 laser in a defocused emission innumerable times generates a laser beammode. The idea was to gradually pull the laser hand [30,31].piece away from the skin, thus reducing the power All laser units consist of three basic elements: adensity and ideally sparing the deeper skin structures pumping system, a lasing medium, and an opticalfrom thermal damage. However, because of the tech- cavity. The pumping system supplies the power andnical sensitivity involved with this technology, ther- the lasing medium supplies the electrons needed formal relaxation times were often violated, resulting in stimulated emission of radiation. This medium can beprolonged healing times and scarring [10 – 19]. These gaseous (CO2), liquid, solid (Erbium:YAG), or com-unacceptable consequences of continuous wave lasers posed of free electrons. The optical cavity is a reso-led to the development of more reliable and effective nant cavity consisting of two parallel mirrors thattechnologies [20,21]. By delivering CO2 laser energy sustain the stimulated emission and allow for releasein short pulses (‘‘superpulsed mode’’), investiga- of the laser beam .tors were able to stay within the thermal relaxation Laser light has three important properties: it istime of the targeted tissues. This dramatically reduced monochromatic, coherent, and collimated. Mono-the incidence of the scarring and prolonged healing chromacity means that the light is of a single, discretetimes that occurred with continuous wave modalities wavelength, and this property determines the clinical[22 – 24]. specificity of the laser beam. A specific wavelength The Erbium:YAG laser was introduced next. This allows for selective absorption of the laser light bylaser emits a wavelength of 2940 nm, which is ab- specific chromophores of the skin (eg, melanin, hemo-sorbed by water 10 times more efficiently than with globin, or tattoo ink). Coherence means that the lightthe superpulsed CO2 laser [25 – 27]. The result is very waves are temporally and spatially related. Clinicalsuperficial absorption with the capacity to precisely predictability of the laser beam is a result of itsablate tissue by creating thermal injury by ablative coherence. Collimation means that the light wavesphotodecomposition. Nonthermal collateral damage are parallel. Consequently, the beam can be propa-is minimal, ranging from 0 to 30 mm. The reduced gated across long distances without spreading. Thishealing times and decreased postoperative erythema tight focusing gives the laser its clinical preciseness.after treatment with the Erbium:YAG appeared to As far as the skin is concerned, the laser is aestablish this technology as the treatment of choice ‘‘black box,’’ with clinical outcomes depending onlyfor mild to moderated rhytids, bridging the gap be- on the properties of the laser light entering the skintween CO2 resurfacing and chemical peels . and the presence of biologic targets of chromophoresHowever, with the increased absorption and short within the skin . Knowing the properties of thethermal relaxation times, heat generation is insuffi- laser (ie, wave length, pulse duration, energy fluence,cient to promote collagen shrinkage. Its primary use irradiance, and spot size) and how to alter themtoday is relegated to following the CO2 laser during allows the surgeon to predict and attain the desiredthe same surgical procedure in an effort to shorten clinical outcome. The specific wavelength of the laserhealing times and reduce erythema. light determines which chromophores in the skin will Computerized scanning also became available absorb the desired light energy. If more than one typewith the combination of high-energy, short-pulsed of chromophore is present, the absorption will belasers and allowed the surgeon to lay down various divided in relation to the relative absorption coeffi-patterns and to condense or expand these patterns on cients at that wavelength. Although some chromo-the skin to promote more even resurfacing . phores may shield deeper tissues by absorbing most
3. S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230 217of the laser energy, this chromophore shielding has thermolysis with the CO2 laser: (1) individual verylittle if any clinical consequence in skin resurfacing, high peak power (ultra) pulses of less than 1 milli-because the biologic target of both the CO2 laser second can achieve vaporization with less than(10,600-nm wavelength) and Erbium:YAG laser 0.1 mm of collateral thermal damage; or (2) a fo-(2940-nm wavelength) is the superficial intracellular cused, continuous wave laser beam can be sweptwater [30 – 34]. across the tissue with a dwell time at any one spot Heat dissipates from the site of laser absorption of less than 1 millisecond .mainly by heat diffusion, and large objects lose heat Energy fluence is important, because to achieve amuch more slowly than small objects. All objects clinical change in a target site, a certain amount ofhave a characteristic time—called the thermal relaxa- energy has to be absorbed by the target site. This istion time—that it takes to cool down to an ambient measured by the energy delivered per unit area (ie,temperature after having been heated. For most the energy fluence). As the energy fluence increases,chromophores in the skin, this time is determined the destructive force increases [38,39]. Energy flu-by the size of the object or lesion. If an object is ence is generally used when referring to pulsed lasersheated for longer than its thermal relaxation time, because it is easily calculated for each pulse.thermal diffusion occurs with heating of surroundingstructures (Table 1) [35,36]. If an object is heated fora period shorter than its thermal relaxation time, the Energy fluenceheat and resultant damage is confined to the targetobject alone. Therefore, proper pulse duration of the For selective photothermolysis, most pulsed laserslaser beam is essential for achieving the desired achieve clinical effects using energy fluences over aclinical effect and dramatically reducing the risk narrow range of 3 to 15 J/cm2. In laser skin resur-of scarring. facing, vaporization occurs when fluence raises the Currently available lasers used for skin resur- tissue temperature past the boiling point of waterfacing incorporate advancements based on Anderson (100°C) in less than the thermal relaxation time. Char-and Parish’s theory of selective photothermolysis. ring occurs when the fluence is not sufficient to evap-This theory states that selective heating is achieved orate the water, and pumping of further laser energyby preferential laser-light absorption and heat pro- into the charred tissue results in thermal radiation intoduction in the target chromophore when the pulse the surrounding tissue and increased scarring.duration is shorter than the target’s thermal relaxation Irradiance is the rate of energy delivery per unittime. The CO2 laser can be modified to take advan- area (ie, the intensity of energy delivery). The shortertage of selective photothermolysis [34,36,37]. To va- the pulse duration of a laser, the higher the irradianceporize water within biologic tissues, approximately must be to deliver sufficient energy for clinical effect.4.5 J/cm2 has to be deposited in the tissue [30 – 34]. High irradiance will achieve faster heating of anThe CO2 laser has a depth of penetration of 0.1 mm. object than low irradiance. Slow heating coagulatesThis thickness of tissue has a thermal relaxation time tissue, while fast heating may vaporize tissue [32 – 34,of approximately 1 msec. Therefore, the energy of 40 – 42].vaporization (4.5 J/cm2) should be deposited withinthe tissue in less than 5 milliseconds. ConventionalCO2 lasers deposit energy too slowly. However, there Irradianceare two methods available to achieve selective photo- Spot size determines whether or not the laser penetration is controlled sufficiently so that clean va- porization or ablation results and undesirable thermalTable 1 radiation or damage is avoided. A smaller spot hasThermal relaxation times higher power density, creating deeper ablation cra- Thermal relaxation ters; hence smaller spots can be used for cutting. ATarget time larger spot with sufficient power density to achieve100-mm port wine stain blood vessel 5 ms vaporization enables a more uniform vaporization of50-mm blood vessel 1 ms tissue and faster treatment time, but without the cra-50 mm of epidermis 1 ms tering or depth of penetration noted with the smaller7-mm erythrocyte 20 ms spot [33,39].1-mm melanosome 1 ms Finally, the beam quality or distribution of energy0.1-mm tattoo particle 10 ns across the diameter of the beam significantly impacts
4. 218 S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230the control of uniform tissue absorption and ablation. does not have the resiliency of normal elastic tissueThe TEM-00 mode beam (common with many CO2 [53,54,56].and low-power Erbium:YAG lasers) has a Gaussianshape and therefore uneven power densities along thebeam diameter. In larger diameters this can be con-trolled to some degree by pulsing the beam, but it still Patient selectionhas a higher density in the center. The lower densityalong the rim causes charring at the edges of the Dr. David Apfleberg has stated that laser ablation,ablation crater . By pulsing or stacking the in and of itself, is a simple procedure. However, hebeams, a flat top or non-Gaussian beam is approach- goes on to point out that it is the patient selection,able with the CO2 lasers . The higher-energy preparation, and postoperative management thatErbium:YAG lasers have a uniform (non-Gaussian) makes the skin rejuvenation process difficult .beam [43 – 45] that produces a uniform tissue ablation In this regard, patient selection is probably the mostand is particularly preferable for larger ablation areas difficult and certainly the most variable part of thesuch as those encountered in skin resurfacing. entire process. The single most important factor in patient selection is his/her chief complaint. Only after determining the patient’s chief complaint can the surgeon apply more objective criteria and subse-Skin aging quently guide the patient in selecting the appropriate technique or techniques to address the chief com- Aging of the skin has medical as well as cosmetic plaint. A patient’s selection should not be based onconsequences. Intrinsic aging generally results purely limitations of the surgeon’s technical acumen.from the passage of time, becoming visible around To decide if laser resurfacing will be a primary orage 35 and remaining subtle into more advanced secondary component of treatment, certain evaluationyears. These changes are most easily seen on areas criteria can be applied. The most commonly usedthat are not exposed to the sun [46 – 49]. Histologi- scales for evaluation are the Fitzpatrick Classificationcally, intrinsic effects are manifested by a thinning of of Sun-Reactive Skin Types (Table 2)  and thethe epidermis, hypocellularity of the dermis, and a Glogau Photo-aging Wrinkle Classification (Table 3).gradual decrease in number of blood vessels, type I Categories include: (1) absolute contraindications,collagen, and elastic tissue [49 – 52]. (2) extreme caution, and (3) relative contraindica- Extrinsic aging is primarily due to the effects of tions. Among patients considered as absolute contra-ultraviolet radiation. Sun exposure is the most im- indications are those who have had prior radiationportant factor, hence the terms photo-aging and exposure, who have had Accutane (isotretinoin) treat-photo-damage [47,48,53]. For the majority of the ments during the past 6 to 12 months, who have hadpopulation, sun exposure and ultraviolet damage deep phenol peels or burn scars, and who are de-occurs not in the pursuit of a tan but rather during pressed or disturbed [30,57,58]. Patients with priormultiple, brief exposures to the sun during normal radiation exposure, burn scars, and, in some cases,daily activities. Cumulative ultraviolet exposure can deep phenol peels have undergone permanent de-result in actinic keratosis, squamous cell carcinoma,basal cell carcinoma, and melanoma . Histolog-ically, ultraviolet alterations present as a thickened,basket-woven stratum corneum; a thinner or atrophic Table 2epidermis; generalized epidermal cellular atypia; ir- Fitzpatrick’s Classification of Sun-Reactive Skin Typesregular melanin dispersion; and abnormal-appearing Skinelastic fibers in the dermis [54,55]. type Color Reaction to first summer exposure Photo-damage accounts for more than 90% of the I White Always burn, never tanunwanted changes in skin appearance. Clinically, II White Usually burn, tan with difficultythese changes include fine to coarse wrinkling, laxity, III White Sometimes mild burn, tan averageleathery and coarse skin textures progressing to ir- IV Moderated Rarely burn, tan with easeregular pigmentation, dry scaling and roughness of brownthe skin surface along with telangiectasias and skin V Dark browna Very rarely burn, tan very easilysallowness. Solar elastosis results in the deposition of VI Black No burn, tan very easily aan abnormal, yellow elastotic material in the upper Asian, Indian, Oriental, Hispanic, or light Africandermis that replaces normal collagen and elastin and decent.
5. S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230 219Table 3Glogau Photo-aging Classification Type I Type II Type III Type IVCondition No wrinkles Wrinkles in motion Wrinkles at rest Only wrinklesPhoto-aging Early Early to moderate Advanced SeverePigmentation Mild changes Early senile lentigines visible Obvious dyschromia, Yellow-gray skin color telangiectasiaKeratoses None Palpable but not visible Visible Prior skin malignanciesWrinkles Minimal Parallel smile lines beginning Wrinkles when not Wrinkles throughout, no to appear moving normal skinPatient’s age 20 – 30 30 – 40 50 or older 60 – 70Makeup use Minimal or none Usually wears some foundation Always wears heavy Can’t wear makeup (‘‘cakes foundation and cracks’’)struction of fibroblasts and are not candidates for crow’s feet, lateral canthal lines) are relative contra-even light laser skin resurfacing [59,60]. Accutane, indications. Even though laser resurfacing may deac-on the other hand, retards re-epithelialization by centuate these lines, they will always recur. It isselective inhibition of collagenase and suppression important for patients in this group to understand thisof the pilosebaceous apparatus and can result in limitation before treatment.severe scarring after laser resurfacing [61,62]. Should such animation rhytids comprise the The patient groups in which extreme caution patient’s chief complaint, then other primary or ad-should be used include ethnic skins with Fitzpatrick junctive procedures should be considered. Primaryclassifications of 4 or 5. These individuals can still procedures such as laser-assisted endoscopic browliftsundergo laser skin resurfacing but must be made allow for denervation, debulking, and repositioning ofaware that they will have long-term, severe hyper- problem areas and can be performed simultaneouslypigmentation that may last for months . A second with laser skin resurfacing.type of patient in this classification includes those Consideration of volume enhancement shouldthat have deep acne scars along with high expectation also be entertained in this particular patient. Thisof resolution. Before becoming candidates, these may include endoscopic midface lifts for deep naso-patients must be warned that repeat treatments will labial folds, hyaluronic acid (Restylane) for perioralprobably be necessary and total resolution is unlikely. rhytids, and fat transfer for other deep rhytids. Relative contraindications include systemic dis- A widely used adjunctive technique is the injec-ease that may pose anesthetic or surgical risk (eg, tion of Botox (botulism-A toxin). These injectionsdiabetes, problematic hypertension, significant car- temporarily block nerve transmission to the affectingdiovascular or pulmonary disease, history of al- muscle groups, leading to subsequent atrophy andlergies). Also within this group are fair-skinned deaccentuation of the associated rhytids. Injectionsindividuals with a tendency to flush or blush easily should be performed 1 to 2 weeks before laser treat-(eg, Celtic skins). These individuals tend do develop ment to prevent activation of the muscles during 3 toscarring in tension areas, particularly along the man- 6 months of new collagen remodeling and reforma-dibular inferior border [57,58,64,65]. These patients tion that follow laser treatment. Botox injections mayare still candidates but care should be taken as to the also be repeated after laser resurfacing to achievedepth or number of passes used in laser resurfacing. more prolonged results. Each repeat injection resultsDark-skinned individuals (those with a Fitzpatrick in progressive muscular atrophy [66,68].classification of 6 or individuals with a history of Great care should be exercised in patients whohyperpigmentation after trauma) may also be consid- desire only regional resurfacing [7,30,57,58]. Theered relative candidates, but in the experience of perioral and periorbital regions are the two areas ofsome, complications with hyper- or hypopigmenta- photo-damage and wrinkling that respond most dra-tion have not occurred after laser scar revisions with matically to laser skin resurfacing, but if both areasthese patients. necessitate treatment, it is far better to laser resurface Patients whose primary concern is alleviation of the whole face. In general, full face resurfacing willrhytids associated with lines of expression caused by produce a better clinical result because treatment ofmuscle contraction (eg, forehead lines, glabelar lines, the full cheeks results in better tightening of nasola-
6. 220 S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230bial lines and lateral crow’s feet. The same can be resurfacing procedure is performed and to uncoversaid of the entire forehead and its effect on the any baseline irritant or allergic sensitivities .glabelar furrows and lateral temporal lines. In addi- These are all legitimate reasons to offer a preopera-tion, the even pigmentation and smoothing of the skin tive skin care program as long as one recognizes thisthat result from full-face resurfacing produces a more as a part of the art, not the fundamental science ofpleasing cosmetic appearance. Finally, it is much laser resurfacing.’’easier for the patient to deal with postoperative ery-thema occurring over the entire face rather than ery-thema located in regions or patches. Anesthesia The goal of anesthesia for laser skin resurfacing is basically the same as that for any surgical procedure:Preoperative preparation to ensure the safety and comfort of the patient and provide ease of operation for the surgeon. Laser The literature is replete with preoperative regi- resurfacing of the face and neck, whether performedmens purported to maximize the results of laser skin with the CO2 or Erbium:YAG, is a very painful pro-resurfacing. The protocols are largely extrapolated cedure. Either deep sedation with local anestheticfrom chemical peel and dermabrasion literature or the blocks and infiltration or general anesthesia is re-anecdotal experience of seasoned laser surgeons. quired [76,77]. Fortunately, there have been numer-Ratner and colleagues have reported that there are ous advances in anesthesiology that add efficacy andno controlled, randomized prospective studies to safety to the outpatient surgical setting [77 – 80].either confirm or repute the need for skin priming The newer sedative-hypnotic, propofol, is unlikebefore laser resurfacing. The Ratner study goes on to any agent currently available and offers definitivestate, ‘‘The application of priming principles to laser advantages over the more traditional drugs likeresurfacing is not necessarily warranted. It has not methohexital [79 – 82]. Newer inhalation agents likebeen shown that preoperative use of tretinoin signifi- sevoflurane and desflurane possess different phar-cantly enhances laser beam penetration or predict- macokinetic profiles from older agents like isofluraneability. Some suggest that pretreatment with tretinoin and halothane, and thus offer advantages in the officecontributes to prolonged erythema, which often per- setting [83,84]. Because airway maintenance andsists for months . Similarly there are no data to protection is paramount during anesthesia for facialsupport the utility of preoperative alpha-hydroxy surgery, the laryngeal mask airway is an alternativeacids. Topical hydroquinones affect the melanocytes method of airway maintenance that offers advantagesin the basal layer of the target skin. This is desirable over traditional techniques [85 – 87].for superficial chemical peels because this populationof melanocytes is implicated in postinflammatoryhyperpigmentation [70,71]. Because deeper chemical Procedurepeeling, dermabrasion, or the first pass of the CO2laser usually ablates the entire epidermis, the popu- Laser energy and techniqueslation of pretreated melanocytes is eliminated. Ke-ratinocytes and melanocytes migrate from the wound At present, almost all CO2 rapid-pulse systemsmargins and underlying adnexal structures during use computer pattern generators (CPGs). The impor-wound healing [72,73]. The adnexal structures are tant property of a CPG is not necessarily its patternnot expected to be accessible to topical hydroqui- design or its ease of operation but rather the consis-nones administered before the procedure, but this has tency of its pattern density (ie, the amount of over-not been confirmed. Thus only when melanocytes lap). Furthermore, the laser energy and power settingshave emerged from the adnexa to repopulate the skin are less important (with or without CPGs) than is thesurface would they be amenable to hydroquinone visible end point in determining the final result.therapy .’’ The appropriate energy and power settings depend Ratner continues, ‘‘Patients may already be on a on the depth of the pathologic condition (ie, the re-skin care program consisting of the aforementioned gion being treated) and the experience of the operatoragents. They may expect a pre-laser regimen and seek (ie, hand speed) and therefore are less importantthe sense of personal control over this care that may factors with CPGs .bestow. The physician can use such a regimen to To cleanly vaporize a volume of tissue, a CO2monitor patient compliance before a more aggressive laser must produce a fluence greater than 4.5 J/cm2,
7. S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230 221Table 4Depth of resurfacing techniquesNo. of Ablation Residual thermallaser passes depth (mm) damage (mm) Level of thermal damage Comparable treatment1 20 – 50 20 – 40 Epidermis/superficial Medium depth peel Papillary dermis2 20 – 50 80 – 150 Papillary dermis medium depth peel / dermabrasion3 20 – 50 120 – 150 Superficial reticular dermis Dermabrasionthe vaporization threshold of tissue. Lower-powered 3. Keep the feathered margins irregular.CO2 lasers are incapable of exceeding this fluence 4. The endpoint of treatment is when one of theand therefore coagulate the tissue, resulting in tem- following conditions are seen:peratures exceeding 600°C and creating extensive (a) The wrinkle or scar being treated is clini-(1 – 5 mm) zones of thermal damage, similar to those cal effacedproduced by electrocautery. Char-free tissue vapor- (b) A punctuate bleeding pattern is noted afterization occurs if the laser can deliver a fluence of Erbium:YAG laser4.5 J/cm2 within less than 1 millisecond. (c) No further skin tightening occurs. CPG pattern densities and their effect on ablationwere investigated by Kauvar and colleagues . This endpoint can usually be achieved with theDensity patterns corresponding to 10%, 35%, and CO2 laser in two passes over most of the face. Ad-60% overlap were studied. At a density of 10%, only ditional passes may be used around the mouth. Thepartial epidermal vaporization occurred after one authors use decreasing fluence and overlap with eachlaser pass. Islands of epidermis remained when the pass and never do more than three passes total (evendebris was wiped away. The CPG at 35% overlap though in the late 1990s it was common to performresulted in clean vaporization of the entire epidermis. five to six passes).One laser pass at a density of 60% overlap producedablation of the entire epidermis and superficial papil- Facial regionslary dermis, similar to a medium-depth chemical peel.Depths of residual thermal damage also increased It is helpful to consider the face as consisting ofwith increasing densities, but did not exceed 150 mm six cosmetic units: (1) the periocular region, (2) theafter three passes. These findings, and those from perioral region, (3) the cheeks, (4) the forehead,studies for repeat laser passes, have led to increased (5) the nose, and (6) the nonfacial region (ie, theunderstanding and predictability of resurfacing with neck and ears). Each of these regions requires athe CO2 computer pattern generator systems (Table 4) somewhat different laser technique.. The much shorter wavelengths of Erbium:YAG Periocular regionlasers are so highly absorbed by water that only mini- The periocular region is small and may be furthermal skin penetration (approximately 5 mm) is possible divided into two separate areas: the thinner infraor-. Therefore, the Erbium:YAG laser requires more bital skin and the thicker skin plus the crow’s feetpasses over the skin than do CO2 lasers (Table 5). area. In the infraocular region, the upper reticularHowever, the depth of thermal damage remains ap- dermis is thinner (0.2 mm) than in other facial re-proximately the same, regardless of the number of gions. Before performing laser resurfacing of thepasses . The endpoint closely resembles the punc- periocular region, local anesthetic eye drops aretuate, multiple point bleeding, similar to that seen placed into the eyes so that the sandblasted metalwith dermabrasion. plate (for protection of the cornea) may be inserted In summary, there are four general rules that apply painlessly. The eyelashes are displaced from thewith laser skin resurfacing: operating field by a moistened cotton swab to prevent them from becoming singed or removed. The entire 1. Avoid regional resurfacing. periocular unit is resurfaced evenly on the first laser 2. Always feather the peripheral areas by decreas- pass. Subsequent passes with either the CO2 or the ing the density of pulse applications, the pulse Erbium:YAG laser are determined by the clinical energy, or both. endpoint. A full-face laser skin resurfacing routinely
8. 222 S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230Table 5 endpoint for deeper resurfacing is difficult and ex-Erbium laser skin resurfacing protocol ceeding this endpoint virtually assures an un-Glogau type necessarily high rate of scarring. It is better to be Type I: Early aging 6-mm spot, 2 – 4 passes, conservative and re-treat 3 months later if necessary. If 600 – 800 mJ, 6 – 8Hz the rhytids extend onto the vermilion border of the lip, Type II: Moderate aging 6-mm spot, 2 – 6 passes, it is advisable to extend the resurfacing onto the 800 – 1000 mJ, 8 – 10 Hz mucosa to eliminate these creases. Lip mucosa heals Type III: Advanced 6-mm spot, 6 – 8 passes, especially well following laser resurfacing. photo-aging 1200 – 1400 mJ, 10 – 12 Hz Type IV: Severe 6-mm spot, 6 – 8 passes, photo-aging 1400 – 1700 mJ, 10 – 12 HzRegion and lesion Cheeks Eyelid 4-mm spot, two passes, Cheek skin is generally thicker than eyelid and 600 – 800 mJ, 4 – 8 Hz perioral skin. Greater laser energy or an increased (Consider for neck, hands), number of passes may be used to produce the desired repeat prn cosmetic improvement. Unlike the upper lip, the Perioral 4-mm spot, two passes, cheeks are more forgiving. The one exception is the 800 – 1200 mJ, 8 – 12 Hz mandibular margin because of the transition zone Acne scarring 4-mm spot, two passes at occurring at the inferior border of the mandible and 1000 mJ, then 1 – 3 passes also because of the extremes of movement and at 600 – 800 mJ Start at 6 – 8 Hz, increase prn stretching that occur there. This region should be Flat epidermal lesions 4-mm spot, two passes, treated more cautiously and is prone to scarring 800 – 1000 mJ, 4 – 8 Hz [64,65]. Small paular lesions 2-mm spot, one to three pulse bursts, 300 – 400 mJ Forehead In the forehead region, resurfacing is particularlyincludes resurfacing of the upper eyelids. In many indicated for removal of frown lines (horizontal andinstances, upper eyelid resurfacing produces signifi- vertical). This is the most effective and long lastingcant skin contraction that may mimic upper eyelid when combined with endoscopic forehead and brow-blepharoplasty. Some authors have noted vertical skin lifting, and simultaneous ablation of corrugator andshortening of 4 to 5 mm and up to 10 mm of short- frontalis muscle activity. Both endoscopic browliftening between the superior tarsal fold and the brow. and laser resurfacing may be performed during the same operation. Botox injections of the corrugator,Perioral region procerus, and frontalis muscles may also be used to Perioral rhytids are ideally suited for laser resur- enhance the result [66 – 68]. Laser skin resurfacing offacing. Frequently, these wrinkles are moderately the forehead should be carried into the fine vellusdeep throughout this region, but because of extreme hairs at the hairline. If this is not done, a zone ofmotion in this region, it is more prone to hypertrophic white skin, which cannot be concealed with makeup,scarring than any other area of the face. Consequently, will be conspicuous between the resurfaced area andprecise depth control is particularly important. The the hair.initial pass should cover the complete cosmetic unitevenly. Subsequent passes may be selective andconcentrate on flattening the shoulders of the rhytids. NoseThe required number of passes will depend on the The nose generally has a thick, sebaceous skindepth of the rhytids as well as the energy density se- with an excellent blood supply and is consequently alected. The desired endpoint can be readily achieved, forgiving region for laser skin resurfacing. Resur-but be aware that excessively deep treatment with the facing of the nose is usually indicated for rhinophymaCO2 laser will almost always result in scarring. The and acne scarring but is also resurfaced during totaltransition from papillary to reticular dermis appears face rejuvenation for blending purposes [91,92].(with the assistance of magnifying loupes) as a When performing an open structure rhinoplasty insmooth, fine, sponge-like appearance giving way to conjunction with facial skin rejuvenation, is it ad-a yellow, roughened, chamois-colored appearance. visable to laser resurface the nasal skin. Failure to doWith the Erbium:YAG laser, the end point will re- so can result in a very noticeable transition zone thatsemble that of dermabrasion. Discerning the absolute is troublesome to patients.
9. S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230 223Nonfacial regions exudative phase, closed dressings are also felt to Rules that apply to the face cannot be applied to increase growth factors, and decrease pain and ery-other regions of the body. It is generally considered thema. Hydrogels and silicone polymer films arehazardous to perform CO2 resurfacing of the neck or semitransparent, allowing some degree of inspectionhands because of the paucity of pilosebaceous units, of healing wounds and permit fluid absorption, whichthin skin, and high mobility. Hypertrophic scarring is useful for exudative wounds after laser resurfacingand alteration in pigmentation occurs readily. How- . Hydrogels are currently the most commonlyever, the decreased thermal radiation of the Erbium:- used biosynthetic semiocclusive dressings after laserYAG laser now permits skin resurfacing of these resurfacing. Foam composite dressings are opaqueareas without the scarring or pigmentary changes and more adherent but are useful nonetheless becauseseen with the CO2 laser. Nonetheless, results in non- of their ability to conform to the face and flex withfacial regions are not as substantial or dramatic as facial movements. These dressings have the disadvan-those seen on the face. tages of being difficult to keep in place, time-consum- ing to apply, and sometimes uncomfortable because of the accumulation of serous exudates under the dress-Postoperative care ing. In addition, they sometimes hide the wound surface, which makes it difficult to diagnose a wound After laser skin resurfacing, patients are left with a infection. In spite of these drawbacks, patients ap-partial thickness wound that heals by re-epitheliaza- pear to progress to a more cosmetically acceptabletion from cutaneous appendages, much like a burn point more quickly than when using the open tech-wound. Methods of care are essentially the same for nique .CO2 and Erbium:YAG lasers, although the duration ofcare may be dramatically less with the latter. In anycase, it should be remembered (as Dr. James Folton Complicationshas stressed) that ‘‘healing delayed is healing denied.’’ Following laser use, epithelial healing begins Herpes simplexwithin 12 hours. Keratin formation stops and hori-zontal migration and proliferation of epithelial cells It has been estimated that up to 90% of the Cau-begins [93,94]. The initial attachment of this new casian population in the United States has Herpesepidermis to the underlying dermis is weak and must simplex virus (Figs. 1 – 3), but only 10% manifest itsbe treated gently. The speed of healing and to some symptoms. Even if a patient has no prior history ofmeasure the quality of skin regeneration is propor- cold sores, Herpes simplex is commonly activated bytional to the pilosebaceous density and not the size ofthe wound [93,95,96]. Hence wounds on the face healmuch more quickly and aesthetically than those onthe chest and extremities. The most important concept to assist re-epitheli-zation is providing the proper substrate for epidermalmigration. Epidermis will only migrate over type I,IV, or V collagen, fibronectin, or laminin . It willnot migrate over dry crust, desiccated collagen, neu-trophils, or wound debris [97,98]. In addition, heal-ing is slowed by dryness, crust caustics, hemostaticagents, some antiseptics (0.5% chlorhexidine, 1%povidineiodine, 3% H2O2, gentian violet), radiationwithin 24 hours, lower than normal temperatures, in-fection, steroids (although topical 1% hydrocortisoneis acceptable), and significant vitamin deficiencies.Clearly, these conditions must be avoided. The use of bio-occlusive dressings has been shownto be beneficial during the first 2 to 5 days aftersurgery because they keep the skin clean of exudatesand permit re-epithelialization [97,99,100]. In addi-tion to promoting moist healing and preventing the Fig. 1. Patient before laser skin resurfacing and facelift.
10. 224 S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230 necessary. If on day 5 the patient suddenly develops malaise and fever, this should be considered Herpes simplex until proven otherwise, and appropriate mea- sures should be taken. Bacterial infection Resurfacing of the skin produces a large, open wound, yet bacterial infection (Fig. 4) is relatively uncommon. This scarcity of skin infections is felt to be due to colonization and competitive inhibition by the relatively innocuous normal skin flora, aided by the excellent blood supply to the head and neck, judicious wound care, patient selection, and prophy- lactic antibiotics. If a bacterial infection is suspected in the laser skin-resurfaced patient, appropriate swabs for culture and sensitivity should be obtained . Fungal infection Fig. 2. Herpes simplex infection 5 days postoperatively. The incidence of Candida infection (Fig. 5) in the laser skin-resurfaced patient was not uncommon before the introduction of semipermeable dressingslaser skin resurfacing . It occurs after laser skin when heavy occlusive ointments were used. It is moreresurfacing, spreads rapidly, and may lead to scarring. common in the perioral region, particularly in thoseIf an outbreak occurs, either the preoperative dose of patients with upper and lower dental prosthesis. Itacyclovir should be doubled daily until clinical im- presents either as a fine white film with a bleedingprovement is noted or acyclovir should be changed to under surface when wiped away or as widespreadValtrex or Famivir. This regimen should be continued pustules. The diagnosis is confirmed by microscopicand slowly tapered until complete re-epithelization examinations and cultures. Treatment consists ofhas occurred. Herpes simplex is difficult to recognizeon resurfaced skin, so a high index of suspicion is Fig. 3. Patient 2 months postoperatively. Fig. 4. Bacterial infection following laser skin resurfacing.
11. S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230 225 the whole face is therefore less likely to produce demarcation zones. Scarring The most unfortunate and damaging complication of laser resurfacing is scarring (Fig. 6). Incipient scarring is usually heralded by an area of persistent erythema, which subsequently becomes slightly thick- ened. If left untreated, this will inevitably progress to hypertrophic scarring. Scarring is most likely to occur in the presence of any of the following conditions: Fig. 5. Candida infection in perioral region. (1) laser use in the highly mobile areas of the perioral region and jaw line, (2) low energy densities, creatingtopical Nizoral cream and 100 mg of Diflucan orally a heat sink and subsequent thermal injury, (3) over-every morning for two successive days. lapping of laser pulses, (4) laser use too deeply be- cause of excess fluence or an increased number ofContact dermatitis passes, (5) postoperative infection (viral, bacterial, fungal), (6) crusting or desiccation of the wound, The frequent use of postoperative double and (7) isotretinoin therapy, (8) previous electrolysis ther-triple antibiotic ointments leads to contact dermatitis apy on the upper lip, or (9) deep chemical peels on theafter laser skin resurfacing and thus should be face [34,57 – 60,64,65,105].avoided . This also occurs in patients who areusing topical vitamin E ointments or oils . Be- Texture changescause it lacks the normal features of contact derma-titis, the diagnosis is difficult and a high index of Changes in skin texture inevitably occur with allsuspicion is necessary. If contact dermatitis is sus- laser skin resurfacing procedures. The degree ofpected, the patient should be questioned thoroughly change is primarily related to the depth of the laserabout any and all types of skin application regimens. skin resurfacing. The change is usually desirableThe treatment of contact dermatitis, after discontinu- because the skin appears smoother and more uniformation of the offending agent, consists of the admin- when the entire face is resurfaced. Deeper laser skinistration of oral nonsteroidal anti-inflammatory resurfacing procedures may lead to more profoundmedications or systemic steroids and an application textural changes with the skin becoming shiny andof the appropriate topical steroid cream. atrophic. Younger patients with large open pores may experience an increased opening of pores secondary to fibrosis at the pore margins. These patients shouldPigmentation changes therefore be informed that the pores will appear larger postoperatively. Temporary hyperpigmentation occurs commonlyafter laser skin resurfacing. This is especially true withdarker skin types (Fitzpatrick’s III – V). In addition topostoperative measures described previously, postop-erative hyperpigmentation can generally be resolvedwith the use of Kligman’s solution or with a 5%hydroquinone and 1.5% glycolic acid combination. Hypopigmentation is more likely to occur in fair-skinned individuals any may not become apparentuntil several months after laser skin resurfacing[63,105]. Although there are many theories to explainthis phenomenon, the exact cause is poorly under-stood. Many believe that hypopigmentation is causedby destruction of melanocytes or controlled fibrosiswith opacification of the epidermis. If hypopigmen- Fig. 6. Severe scarring in perioral region resulting from lowtation occurs, it is likely to be permanent. Resurfacing fluence continuous wave laser skin resurfacing.
12. 226 S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230Fig. 7. Patient preoperatively before laser skin resurfacingand facelift (but no blepharoplasties). Fig. 9. Patient before laser skin resurfacing and facelift.Fig. 8. Patient postoperatively with lateral ectropion onher right. Fig. 10. Patient 2 months postoperatively.
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