3. SERIES IN COSMETIC AND LASER THERAPY
Published in association with the Journal of Cosmetic and Laser Therapy
Already available
1. David Goldberg.
Fillers in Cosmetic Dermatology. ISBN: 1841845094
2. Philippe Deprez.
Textbook of Chemical Peels. ISBN: 1841844950
3. C William Hanke, Gerhard Sattler, Boris Sommer.
Textbook of Liposuction. ISBN 1841845329
Of related interest
1. Robert Baran, Howard I Maibach.
Textbook of Cosmetic Dermatology, 3rd edition. ISBN: 1841843113
2. Anthony Benedetto.
Botulinum Toxin in Clinical Dermatology. ISBN: 1842142445
3. Jean Carruthers, Alistair Carruthers.
Using Botulinum Toxins Cosmetically. ISBN: 1841842176
4. David Goldberg.
Ablative and Non-Ablative Facial Skin Rejuvenation. ISBN: 1841841757
5. David Goldberg.
Complications in Cutaneous Laser Surgery. ISBN: 1841842451
6. Nicholas J Lowe.
Textbook of Facial Rejuvenation. ISBN: 1841840955
7. Shirley Madhere.
Aesthetic Mesotherapy and Injection Lipolysis in Clinical Practice.ISBN: 1841845531
8.Avi Shai, Howard I Maibach, Robert Baran.
Handbook of Cosmetic Skin Care. ISBN: 1841841793
4. Clinical Procedures
in Laser Skin
Rejuvenation
Edited by
Paul J Carniol MD FACS
Cosmetic Laser and Plastic Surgery
Summit,NJ
USA
Neil S Sadick MD FAAD FAACS FACP FACPh
Sadick Aesthetic Surgery and Dermatology
NewYork,NY
USA
6. List of contributors vii
Note on outcomes x
1 Laser safety 1
William Beeson
2 Evaluation of the aging face 11
Philip J Miller
3 Carbon dioxide laser resurfacing,
Fractional resurfacing and YSGG resurfacing 17
Dee Anna Glaser,Natalie L Semchyshyn and Paul J Carniol
4 Erbium laser aesthetic skin rejuvenation 31
Richard D Gentile
5 Complications secondary to lasers
and light sources 45
Robert M Adrian
6 Nonablative technology for treatment
of aging skin 51
Amy Forman Taub
7 Lasers, light, and acne 69
Kavita Mariwalla and Thomas E Rohrer
8 Treatment of acne scarring 89
Murad Alam and Greg Goodman
9 Nonsurgical tightening 103
Edgar F Fincher
10 Laser treatment of pigmentation
associated with photoaging 111
David H Ciocon and Cameron K Rokhsar
11 Management of vascular lesions 125
Marcelo Hochman and Paul J Carniol
12 Laser treatment for unwanted hair 135
Marc R Avram
13 Non-invasive body rejuvenation
technologies 139
Monica Halem, Rita Patel, and Keyvan Nouri
14 Treatment of leg telangiectasia with
laser and pulsed light 157
Mitchel P Goldman
15 Photodynamic therapy 173
Papri Sarkar and Ranella J Hirsch
16 Adjunctive techniques I: the bioscience of
the use of botulinum toxins and fillers
for non-surgical facial rejuvenation 181
Kristin Egan and Corey S Maas
17 Adjunctive techniques II: clinical aspects
of the combined use of botulinum toxins
and fillers for non-surgical facial rejuvenation 191
Stephen Bosniak, Marian Cantisano-Zilkha,
Baljeet K Purewal and Ioannis P Glavas
18 Adjunctive techniques III:
complementary fat grafting 205
Robert A Glasgold, Mark J Glasgold
and Samuel M Lam
Index 219
Contents
7.
8. Robert M Adrian MD FACP
Center for Laser Surgery
Washington, DC
USA
Murad Alam MD
Departments of Dermatology,
Otolaryngology, and Surgery
Northwestern University
Chicago, IL
USA
Marc R Avram MD
Department of Dermatology
New York Presbyterian Hospital-Weill Medical
College at Cornell Medical Center
New York, NY
USA
William Beeson MD AAFPRS AACS
Beeson Aesthetic Surgery Institute
Carmel, IN
USA
Stephen Bosniak † MD
Marian Cantisano-Zilkha MD
Manhattan Eye, Ear and Throat Hospital
New York, NY
USA
Paul J Carniol MD
Cosmetic Laser and Plastic Surgery
Summit, NJ
USA
David H Ciocon MD
Department of Dermatology
Albert Einstein College of Medicine
New York, NY
USA
Kristin Egan MD
Department of Otolaryngology
UCSF
San Francisco, CA
USA
Edgar F Fincher MD PhD
The David Geffen School of Medicine at UCLA
and
Moy-Fincher Medical Group
Los Angeles, CA
USA
Richard D Gentile MD
Facical Plastic and Aesthetic Laser Center
Youngston, OH
USA
Dee Anna Glaser MD
Dermatology Department
St Louis University
St Louis,MO
USA
Mark J Glasgold MD
Department of Surgery
Robert Wood Johnson Medical School
University of Medicine and Dentistry of New Jersey
Piscataway, NJ
USA
Robert A Glasgold MD
Department of Surgery
Robert Wood Johnson Medical School
University of Medicine and Dentistry of New Jersey
Piscataway, NJ
USA
Contributors
9. Ioannis P Glavas MD
Oculoplastic Surgery
Manhattan Eye, Ear and Throat
New York, NY
USA
Mitchel P Goldman MD
LaJolla Spa
LaJolla, CA
USA
Greg Goodman MD
Department of Dermatology
Minash University
Melbourne
Australia
Monica Halem MD
Department of Dermatology
Miller School of Medicine
University of Miami
Miami, FL
USA
Ranella J Hirsch
Skin Care Doctors
Cambridge,MA
USA
Marcelo Hochman MD
The Facial Surgery Center
Charleston, SC
USA
Samuel M Lam MD
Willow Bend Wellness Center
Lam Facial Plastic Surgery Center and
Hair Restoration Institute
Plano,TX
USA
Corey S Maas MD
Department of Otolaryngology
UCSF
and
The Maas Clinic
San Francisco, CA
USA
Kavita Mariwalla MD
Department of Dermatology
Yale School of Medicine
New Haven, CT
USA
Philip J Miller MD FACS
Department of Otolaryngology
New York University School of Medicine and
The NatraLook ProcessTM and East Side Care
New York, NY
USA
Keyvan Nouri MD
Department of Dermatology
Miller School of Medicine
University of Miami
Miami, FL
USA
Rita Patel MD
Department of Dermatology
Miller School of Medicine
University of Miami
Miami, FL
USA
Baljeet K Purewal MD
Department of Opthalmology
Lutheran Medical Center
Brooklyn, NY
USA
Thomas E Rohrer MD
Department of Dermatology
Boston University School of Medicine
and
Skin Care Physicians of Chestnut Hill
Chestnut Hill, MA
USA
Cameron K Rokhsar MD FAAD FAACS
Department of Dermatology
Albert Einstein College of Medicine
New York, NY
USA
viii List of contributors
10. Neil S Sadick MD
Sadick Aesthetic Surgery and Dermatology
New York, NY
USA
Papri Sarkar MD
Department of Dermatology
Harvard Medical School
Boston, MA
USA
Natalie L Semchyshyn MD
Dermatology Department
St Louis University
St Louis,MO
USA
Amy Forman Taub MD
Advanced Dermatology
Northwesten University Department of Dermatology
Lincolnshire, IL
USA
List of contributors ix
11. Although every effort has been made to ensure that
information about techniques and equipment is pre-sented
accurately in this publication, the ultimate
responsibility rests with the practitioner physician.
Use of these techniques or items of equipment does
not guarantee outcomes or that they are the optimal
procedures available. Procedure results and potential
complications frequently vary between patients:
physicians must evaluate their patients individually
and make appropriate decisions about treatment
based on each analysis. Although it is not always nec-essary,
when a physician initiates any new therapy on a
patient the use of ‘test spots’ or other tests of limited
areas should be considered for patient response before
initiating the full treatment itself.
Neither the publishers, nor the editors, nor the
authors can be held responsible for errors or for any
consequences arising from the use of information con-tained
herein. For detailed instructions on the use of
any product or procedure discussed herein, please
consult the instructional material issued by the manu-facturer.
Some of the use of technology and proce-dures
described in this text may be ‘off label’ as
regards the FDA in the USA and may also not have EC
approval in Europe, and are described as such, to be
used at the discretion of the physician.
Note on outcomes
12. INTRODUCTION
Surgical lasers have opened a new vista for aesthetic
surgery. Laser skin resurfacing is commonplace, as is
laser treatment for vascular lesions, varicosities, and
laser hair removal. Laser blepharoplasty and facelifts,
as well as the employment of the laser in endoscopic
facial surgery, are becoming commonplace.With the
increasing varieties of lasers and the numerous wave-lengths
available, laser safety has become a more
complex issue.1 It is incumbent upon the surgeon to
consider the safety of not only his or her patient, but
also the entire operating room staff.
With the increasing trend for more and more proce-dures
to be performed in an ambulatory surgical setting,
we find that medical lasers are commonly being
employed in small clinics or office surgical settings. Not
only physicians, but podiatrists, dentists, and others use
lasers on a daily basis in their office clinical practices.The
requirements and principles for the safe use of lasers are
no less stringent in this setting than when the lasers are
employed in a large metropolitan hospital. Laser safety
standards apply equally in all of these settings.
When a physician utilizes a medical laser, they have a
medical, legal, and ethical responsibility to be aware of
the requirements for the safe use of lasers in healthcare
facilities.This means that the physician should be trained
in laser safety and be knowledgeable as to local and fed-eral
regulations, as well as the advisory standards and
professional recommendations for the use of lasers in
their applicable speciality.
CLASSIFICATION OF LASERS
Medical lasers are classified in the USA in accordance
with the Federal Laser Product Performance Standard,
which essentially classifies lasers based on the ability of
the laser beam to cause damage to ocular and cuta-neous
structures. The Food and Drug Administration
(FDA) Center For Devices and Radiologic Health
(CDRH) has the responsibility for implementing and
enforcing the Federal Laser Product Performance
Standard and Medical Device Amendment to the
Food, Drug, and Cosmetic Act.
In general, medical lasers are of class III-B or class
IV. Medical lasers can be divided into two broad cate-gories:
those in the visible and mid-infrared range
(roughly 400–1400 nm), in which the focal image on
the retina presents the primary ocular hazard; and
those in the ultraviolet and infrared regions, in which
the main ocular hazard is to the cornea and skin. In
general, class IV laser systems present a fire hazard in
addition to the ocular and cutaneous hazards associ-ated
with class III-B lasers.
A class I laser is considered to be incapable of pro-ducing
damaging levels of laser emission. Class II
applies only to visible laser emissions, which may be
viewed directly for time periods ≤ 0.25 s: the aversion
response time (aversion response is defined as move-ment
of the eyelid or head to avoid exposure to a nox-ious
stimulant or bright light). This is essentially the
blink reflex time. Only if one purposely overcomes
one’s natural aversion response to bright light can a
class II laser pose a substantial ocular hazard. Class III
lasers may be hazardous by direct exposure or expo-sure
to specific reflection. A subcategory of class III
(class III-A) consist primarily of lasers of 1–5 nW
power. These pose a moderate ocular problem under
specific conditions where most of the beam enters the
eye. The aiming beam or alignment beam for a laser
usually falls within this range, and can be hazardous
when viewed momentarily if the beam enters the eye.
For this reason, one must take particular caution when
1. Laser safety
William Beeson
13. using the alignment beam and be aware that ocular
damage can occur with misuse. Class III-B lasers
comprise those in the 5–500 mW output range. Even
momentary viewing of class III-B lasers is potentially
hazardous. Class IV lasers are those emitting > 500mW
(0.5 W) radiant power. Most surgical lasers fall within
this class, and pose a potential hazard for skin injury,
ocular injury, and fire hazards.
REGULATIONS
In addition to FDA enforcement, other rules and regu-lations
apply to the use of lasers in the medical setting.
In recent years, the Occupational Safety and Health
Administration (OSHA) has stressed the need for
employers to inform and educate workers on work-place
risks. This has been of particular importance
with regard to the use of lasers in the workplace.The
Department of Labor has developed guidelines for
Laser Safety Hazard Assessment, which pertain to the
use of medical lasers.2
Compliance with OSHA rules is an important com-ponent
of a laser safety program.
HAZARD CLASSIFICATION
There are no specific OSHA guidelines for assessing
the level of compliance of a facility providing laser
facelifts and laser blepharoplasty. However, the
American National Standards Institute (ANSI) stan-dard
‘Safe Use of Lasers in Health Care Facilities’ (Z-
136.3) is used as a benchmark. All assessments by the
OSHA are made under the ‘general duty clause’,
which states that there is a shared duty between the
employer and employee for establishing and maintain-ing
a safe working environment. The employer has a
duty to provide the proper safety equipment, appro-priate
education and training, and a work environment
free of known potential risks and hazards. The
employee has a duty to attend the training, use of
personal protective equipment, and follow safe work
practices at all times. OSHA compliance officers
respond to requests, complaints, and accidents
reported. Facilities must demonstrate that they have
established policies and procedures, identified proper
personal protective equipment, implemented a
program for education of all employees who might be
at risk for exposure to laser hazards, performed and
documented periodic safety audits, and assured ongo-ing
administrative control in program surveillance.3
In addition to governmental agencies such as the
FDA, OSHA, and state departments of health,
nongovernmental accrediting and review organiza-tions
also have guidelines and recommendations for
the laser safety in healthcare facilities. The ANSI is a
nonregulatory body that promulgates thousands of
safety standards in the USA.Working committees have
representation from industry, the military, regulatory
bodies, user groups, research and educational facili-ties,
and professional organizations. The ANSI also
participates in international standard work through
groups such as the International Organization for
Standardization (ISO).The main objective of the ANSI
is to establish and maintain benchmarks for national
safety through consensus documents.
ANSI Z-136.3 has become the expected laser safety
standard in healthcare. Although it is not regulatory, it
has taken on the impact of regulations through its wide
acceptance. It is used by the OSHA and many accredit-ing
organizations such as the Joint Commission
(previously the Joint Commission on Accreditation of
Healthcare Organizations, JCAHO) and the Accredita-tion
Association of Ambulatory Healthcare (AAAHC),
and it is exhibited as reference during litigations.The
standard provides a comprehensive guide for the
development of administrative and procedural control
measures that are necessary for maintaining a safe laser
environment and should be used as the cornerstone
for all clinical laser programs.
It is important to develop a risk management
process regarding the safe use of lasers, consisting of
written policies and procedures, as well as ongoing
evaluations of compliance, and demonstrating timely
and appropriate responses to incidents or accidents
that could occur.Typically, the person responsible for
the management of the laser safety–risk management
program will be the laser safety officer. The ANSI Z-
136.3 standard defines the laser safety officer as ‘an
individual with the training, self-study, and experience
to administer a laser safety program. This individual
(who is appointed by the administration) is authorized
and is responsible for monitoring and overseeing the
control of laser hazards. The laser safety officer shall
effect the knowledgeable evaluation and control of
2 Clinical procedures in laser skin rejuvenation
14. laser hazards by utilizing, when necessary, the appro-priate
clinical and technical support staff and other
resources.’4
The laser safety officer should be responsible for
verifying the classifications of the laser systems, hazard
analysis, ensuring appropriate control measures are in
effect, approving all policies and procedures, ensuring
that protective equipment is available, overseeing
instillation of equipment, ensuring that all staff are
properly trained, and maintaining medical surveillance
records. In private practice in small clinical settings,
the physician who owns and runs the practice or clinic
is very likely to serve as the laser safety officer.
All laser users must adhere to the following principles:
• Laser safety requirements are no less stringent in
private practice than in a hospital setting.
• The individual laser user must know all profes-sional
standards and regulations and be thoroughly
trained in laser safety.
• The user must ensure that the entire staff are
properly trained in the safe use of lasers.
• There must be an appointed laser safety officer.
• The user must establish and follow standard-based
policies and procedures.
It is important that safety audits be utilized in a routine
manner to be sure that laser safety programs are being
adhered to. ANSI standards require an audit at least
annually. A laser safety audit is an assessment of all
equipment, supplies, and documents involved in per-forming
laser treatments in a facility. It is supervised
by the laser safety officer and consists of four basic
components:
1. Inventory all equipment and develop a checklist.
2. Inspect every item on the checklist.
3. Document results.
4. Identify action items based on audit results.
In addition to the ANSI, voluntary healthcare accredit-ing
organizations such as the Joint Commission and the
AAAHC all have standards that apply to the use of
lasers in the medical environment, including the office
surgical setting.
Laser regulation at state and local government levels
has increased significantly in recent years. Regulations
vary from state to state.The current trend is for state
Laser safety 3
regulatory bodies, such as medical licensing boards
and departments of health, to address laser safety issues
by setting standards for credentialing and training.
Regulations will usually dictate the type of individual or
individuals who are qualified to perform laser treat-ments
and prescribe levels of training to document cur-rent
competency with each type of laser being used.
Almost all require personnel using lasers in healthcare
arenas to be cognizant of basic laser safety issues.
Some states allow only physicians to perform laser
surgery, while others allow physician assistants and
advanced practice nurses to perform laser treatments.
Some will allow nurses and other allied health person-nel
to perform laser treatments, but only with the direct
supervision of a trained physician. Still other states
permit the use of lasers by paramedical personnel
and ‘others’ in less supervised situations. However, the
current trend is for increased supervision and training.
While some states may not directly address laser
surgery, they do so indirectly by requiring accredita-tion
of ambulatory surgical or office surgical units. In
these cases, the medical licensing board has subrogated
authority to a national accrediting organization such as
the Joint Commission, the AAAHC, or the American
Association for Accreditation of Ambulatory Surgery
Facilities (AAAASF). Each of these organizations has
developed specific standards that can be applied to
laser use in the medical setting.
In 2005, the Joint Commission, currently in its sen-tinel
event program, adopted measures for its accredited
organizations to utilize in an attempt to reduce the likeli-hood
of patient injury from fire resulting from the use of
lasers in the operating room. Since the Joint Commission
accredits the vast majority of hospitals in the USA and
since all Joint Commission-accredited organizations
using medical lasers must adhere to these recommended
standards, one could argue from a legal standpoint that
these are de facto ‘community standards’. The legal
implications of not meeting the accepted ‘community
standards’ if a patient has an injury when being treated
with a medical laser are significant.
It is imperative that any person in a medical practice
who treats with a laser adhere to strict regulations
regarding scope of practice, licensing requirements, and
standardized procedures. It is also extremely important
for the physician’s malpractice insurance carrier to
determine who is covered under the physician’s policy. It
is essential to know if the person doing the laser
15. treatments is outside his or her scope of practice, as an
insurance company will not insure someone who is ille-gally
practicing outside the scope of his or her license,
etc. Health practitioners cannot ignore the importance
of this issue for overall success and safety.
At present, there are no national, state, or local cer-tifications
or licensing agencies to qualify the compe-tency
of surgeons, nurses, or technicians in the safe
use of lasers. There is no standardized or universally
accepted certification or training organization. It is,
therefore, important to consider the ANSI guidelines
as well as the recommendations of various professional
medical societies in this regard (Boxes 1.1 and 1.2).
Box 1.1 Recommendations for establishing laser program and
clinical setting
1. Check with medical licensing board in your state
regarding laser regulations
2. Develop laser safety protocols for your facility.
Document training for yourself and your staff
3. Consider formal laser safety officer training and
appoint a laser safety officer
4. Monitor changes in accreditation standards and ANSI
Z-136.3 guidelines
5. Check with your medical liability carrier. Obtain
delineation of coverage for yourself and your staff
regarding the use of lasers in your practice
Box 1.2 Information resources for laser safety guidelines
• American National Standards Institute (ANSI), 11
West 42nd Street, New York, NY 10 036
• Laser Institute of America, 12424 Research Parkway,
Suite 125, Orlando, FL 32826
• US Food and Drug Administration (FDA), Center for
Devices and Radiologic Health (CDRH), 9200
Corporate Boulevard, Rockville, MD 20850
• US Department of Labor, Occupational Safety and
Health Administration (OSHA), 200 Constitution
Avenue, NW,Washington, DC 20210
• Joint Commission (formerly JCAHO), 1 Renaissance
Boulevard, Oak Brook Terrace, IL 60181
• Accreditation Association of Ambulatory Healthcare
(AAAHC), 5250 Old Orchard Road, Suite 200,
Skokie, IL 60077
BIOLOGICAL HAZARDS OF LASERS
Laser hazards can essentially be divided into non-beam-
related hazards and beam-related hazards. The
latter are unique to lasers, and pose the need for
special attention and safety requirements when using
lasers in the medical setting.This relates to the optical
radiation hazard, which can result in damage to both
eyes and skin. Because the eye is considered to be most
vulnerable to laser light, the ocular hazards are consid-ered
of paramount importance. In most cases, the eye
has a natural protective mechanism that limits retinal
exposure to irritants.The blink reflex occurs at about
every 0.25 s and accounts for the aversion response
previously described. However, the intensity of some
laser beams can be so great that injury can occur
before the protective lid reflex. This usually happens
with lasers operating at 400–1400 nm. It is commonly
referred to as the ‘retinal hazard region’. Because of
acoustic effects and heat flow, significant tissue damage
can occur, leading to severe retinal impairment. For
this reason, it is not uncommon to lose all visual func-tion
when exposed to even minimal amounts of laser
energy when that energy is focused on critical areas of
the retina such as the fovea. Such visual loss is gener-ally
permanent, since the neural tissue of the retina has
minimal ability to replicate.
Injury to the cornea and the anterior segment of the
eye is possible from wavelengths in the ultraviolet and
in the infrared beyond 1400 nm.When injury occurs
to the cornea, it is usually superficial and involves the
corneal epithelium. Re-epithelization usually occurs
within 1–2 days, and total recovery of vision usually
results. However, deeper penetration can result in
corneal scaring and permanent loss of vision. Carbon
dioxide (CO
) laser wavelengths pose such a potential
2
risk. Excimer lasers operate in the ultraviolet range and
pose a potential hazard to the cornea. Ocular injury can
occur from direct penetration of a focused beam.
However, it is more likely that injury will occur due to
accidental ocular exposure to a reflected beam.
Protection from reflected laser beams can be difficult.
The most commonly employed surgical laser today is
the CO
2
laser. Since the CO
2
laser wavelength of
10.6μm is in the far-infrared region, it is invisible, and
so this potential hazard can go unnoticed. For this
4 Clinical procedures in laser skin rejuvenation
16. reason it is imperative that precautions be taken at all
times when using CO
2
lasers.This is also true of Ho:YAG
and Nd:YAG lasers.This is in contrast to KTP and argon
lasers, whose emissions are in the visible region.
Reflections most commonly occur from flat metallic
mirror-like surfaces such as nasal speculums or surgical
instruments. Black anodized or abraded–roughened
surfaces can reduce (but not totally eliminate) the
potential for beam reflection. Roughening a surface is
generally thought to be more effective than ebonizing
it, since the beam is diffused to a greater degree.5
Because of the potential for ocular injury secondary to
beam reflection, it is imperative that proper protec-tion
be afforded to the patient and all operating room
personnel at all times when lasers are in use.
Ordinary optic glass protects against all wavelengths
shorter than 300 nm and longer than 2700 nm.
Polycarbonate safety glasses with sideshields are
suitable for use with the CO
2
lasers if the power is
<100W.The glass should have an optical density of 4.
While polycarbonate glasses may be adequate, there
can be burn-through with higher-power lasers. Thus,
even when wearing protective eyewear, one should not
focus the laser beam directly on the shield for any
length of time. Laser safety glasses should always have
sideshields. The optical density rating should be listed
on the sidebar of the eyeglasses.
It is important to realize that many lasers radiate at
more than one wavelength. For this reason, eyewear of
appropriate optical density for a particular wavelength
could be completely inadequate at another wavelength
radiated by the same laser. This is particularly impor-tant
for lasers that are tunable over broad wavelength
bands.
When a patient is within a nominal hazard zone
(NHZ), patient eye protection is imperative.The NHZ
is a space within which the level of the direct,
reflected, or scattered radiation during normal opera-tion
exceeds the acceptable maximal permissible
exposure (MPE). Proper eye protection may range
from wet eye pads to laser-protective eyewear. In most
cases, corneal protectors provide the best protection.
Plastic corneal protectors have become popular.
However, in some cases, plastic shields can transfer
thermal energy to the cornea, with resultant injury.
This is especially true with darker-colored shields.6
CUTANEOUS INJURY
Laser safety 5
While ocular injury is the most devastating direct
beam laser injury, cutaneous hazards do exist.The skin
can be injured either through a photochemical mecha-nism
or by a thermal mechanism. First-, second-, and
third-degree burns can be induced by visible and
infrared laser beam exposure. Such injuries have been
noted to occur in < 1% of patients, with 10% of sur-geons
reporting unintentional burns to either patients
or operating room personnel.7,8 In most cases, moist
towels draped around the operative site and fire-resistant
surgical drapes will provide proper protection.
NON-BEAM-RELATED HAZARDS
In addition to direct laser beam hazards to the eye and
skin, there are non-beam laser hazards that need to be
considered. These include electrical hazards, laser-generated
airborne contaminants (laser plume), waste
disposal of contaminated laser-related materials
such as filters, and laser-generated electromagnetic
interference.
All medical lasers must operate in compliance with
the National Electric Code (NFPA-70) and with state
and local regulations. Electrical hazards can be related
to damaged electrical cords and cables, inadequate
grounding, and the use of conductive liquids in the
vicinity of the laser when it is in operation. These
problems can usually be minimized with an appropri-ate
laser maintenance program by qualified biomedical
engineers and adherence to appropriate laser safety
guidelines when operating electrical equipment in the
surgical environment.
Laser-generated airborne contaminants present a
significant problem. Studies have shown the presence
of gaseous compounds, bio-aerosols, dead and live
cellular materials, and viruses in the laser plume.The
laser plume can cause ocular and upper respiratory
tract irritation. The unpleasant odors of the laser
plume can cause discomfort to both the physician and
the patient.The laser plume can cause ocular irritation,
and may be even more of a problem for individuals
who wear soft contact lenses, as the particles can
permeate the lenses and cause prolonged irritation.
17. However, of greatest concern is the mutagenic and
carcinogenic potential of the compounds contained in
the plume.At a time when the threat from bloodborne
pathogens has led to enhanced awareness of the risks of
contact with blood and blood byproducts, the practice
of universal precautions has taken on a new meaning.
The use of a laser smoke evacuator is imperative. If the
evacuator is held 2 cm from the source of the laser
plume, aerosolization of the particles is minimal.The
suction created in the evacuator tubing is important.
This results in the creation of a vortex that removes
mutagenic debris and prevents aerosolization of the
carbonized particles. (The latter impregnate the tub-ing,
which should therefore be treated as a biohazard
when it comes to disposal.) In most cases, routine
operating room suction and suction tubing do not pro-vide
adequate evacuation of the laser plume.
While surgical masks may help reduce laser expo-sure,
their use alone is not adequate. At present, there
is no mask respirator on the market that excludes all
laser-generated plume particles, such as viruses, bacte-ria,
and other hazards. Surgical masks are not designed to
protect from plume contents. Rather, they are intended
to protect patients from the surgeon’s contaminated
nasal or oral droplets. Specialized surgical masks that fil-ter
out particles down to 0.3μm with high efficiency are
available and can help to decrease the inhalation of laser
plume particles. While some laser masks are of suffi-ciently
increased density to remove a higher proportion
of laser-generated particles, their use alone is not ade-quate.
9 As with smoke evacuator tubing, filters will be
impregnated with potentially dangerous materials, and
should therefore be treated as hazardous waste.
Lasers can create electromagnetic interference.
Electromagnetic radiation generated by lasers can
interfere with other sensitive electronic equipment
present in the facility, such as cardiac telemetry equip-ment.
This can also affect patients who have pacemak-ers.
The electromagnetic interference potential of a
laser system is normally described in the manufac-turer’s
labeling, or it can be determined by a biomed-ical
engineer with laser safety officer experience.
FIRE HAZARD
Operating room fires are rare – but when such blazes
do occur, they can be lethal. Potentially flammable
materials such as gauze, cotton, paper surgical drapes,
and plastic endotracheal tubes can be ignited in the
operating room by the laser, and the oxygen-enriched
environment can intensify fires.
Accidental fires are a well-known hazard associated
with laser treatment. It has been estimated that com-bustion
occurs in 0.4–0.57% of CO
2
laser airway pro-cedures.
10 Others have demonstrated that, in the
presence of oxygen concentrations of 21–25%,
polyvinyl chloride, red rubber, and silicone endotra-cheal
tubes can rapidly ignite when struck with CO
2
laser beam.The threshold for ignition is increased with
the addition of helium to the oxygen concentration.
This is due to the fact that helium has a higher thermal
density and acts as a heat sink, delaying combustion for
about 20 s. Laser fires have also resulted from the igni-tion
of polyvinyl chloride endotracheal tubes wrapped
in aluminum tape.11
In general, medical lasers are class III-B or IV lasers.
Class IV laser systems (emitting > 500 mW radiant
power) present a fire hazard in addition to the ocular
and cutaneous hazards associated with class III-B
lasers. Most surgical lasers fall within this class.
The basic elements of a fire are always present during
surgery.A misstep in procedure or a momentary lapse of
caution can quickly result in a catastrophe. Slow reaction
to the use of improper firefighting techniques and tools
can lead to damage, destruction, or death.
To reduce the threat of a laser fire, it is essential to
understand and to employ the principles of the ‘fire
triangle’. For a fire to start, three components must be
present: heat, fuel, and an oxidizer. The key to laser
safety in this regard is to control all three components.
‘Heat’ represents the flame or the spark. It is the
‘ignition’ for the fire.The nature of the heat source can
be extremely varied – often something that one would
not immediately think of, such as an overhead surgical
light, an electrocautery unit, a drill, or a fiberoptic
light left on a surgical drape.
A ‘fuel’ has to be present for the heat source to
ignite. Once again, the potential ‘fuel’ can be an item
that one would not likely consider, such as a petro-leum-
based ophthalmologic ointment. Fuels com-monly
encountered in surgery can be divided into five
categories: the patient, prepping agents, linens, oint-ments,
and equipment.
The key ‘oxidizer’ in the operating room is the
oxygen-rich environment. An oxidizer can be thought
6 Clinical procedures in laser skin rejuvenation
18. of in this context as something that facilitates ignition
and combustion. Decades ago, anesthesiologists recog-nized
the hazards of flammable anesthetic agents in the
operating room and eliminated them.Today, oxygen is
one of the key components to deal with in regards to
operating room fires. In the great majority of such
fires that have been reviewed, an oxygen-rich environ-ment
and ineffective management of this ‘oxidizer’
were the key factors in the mishap.
Preventing fires in the operating room is dependent
on disrupting the fire triangle, as all of its components
must be present for a fire to develop. One needs to
control the heat source, manage the fuels, and mini-mize
the oxygen concentration.
One of the most common errors is inadvertent
activation of the laser. Not infrequently, the surgeon
thinks that he or she is stepping on the cautery foot
pedal when they are actually stepping on the laser
pedal, which activates the dangling laser, whose beam
is directed on a flammable surgical drape (the ‘fuel’).
One of the most basic – but most effective – safety
measures is to eliminate the clutter of multiple foot ped-als
for the laser, cautery, liposuction unit, etc. Removing
all of the foot pedals and having only the foot pedal of the
equipment one is using in access range is extremely
important. ANSI standards dictate that there be a
laser-designated operator trained in the safe use of any
particular laser.The responsibility of the laser operator is
to release the laser from standby setting mode when the
surgeon requests its activation and to immediately place
the laser back on standby mode when the surgeon is fin-ished.
This markedly reduces the likelihood of inadver-tent
laser activation. It is essential that the laser operator
ensure that there is an appropriate ‘environment’ before
activating the laser.They should scan the room to ensure
that no flammable agents such as acetone or cleaning
agents are present, that all personnel are wearing appro-priate
eye protection, that the patient’s eyes are pro-tected,
and that the oxygen has been reduced to room air
levels before the laser, is activated.
Managing the potential ‘fuel’ source is important,
and requires delegation and advanced planning. Proper
prepping techniques are critical. If possible, the use of
alcohol-based prepping solutions should be avoided. It
is important that flammable prep solutions be
removed and not allowed to drip and ‘pool’ on the
drapes under the patient, enabling fumes to accumu-late
and possibly be ignited. It is also important to be
Laser safety 7
alert for potential fire risks on the patient, such as eye
mascara, perfume, and hairspray, of all which can be
flammable.
Minimizing the oxygen environment is extremely
important and must be done in concert with the anes-thesiologist.
This requires presurgical discussion regard-ing
how one plans to perform the procedure, the type of
anesthetic to be used, etc. In many cases, monitored
anesthesia care can be used. It may be possible to reduce
the oxygen concentration being delivered to room air
levels during the time the laser is being activated and to
return immediately to supplemented levels when the
laser is deactivated.This requires coordination between
the surgeon and the anesthesiologist and the ability of
the surgeon to immediately terminate the laser use if the
anesthesiologist notes a precipitous drop in FiO
2
on the
pulse oximeter. If a nasal cannula or a face mask is used
to deliver oxygen, one has to be sure that surgical drapes
are not tented, such that oxygen can pool under them. In
cases where higher levels of oxygen are required by the
patient, and alternating from supplemented oxygen to
room air is not possible, a helium and oxygen combina-tion
may serve to increase the safety margin when
oxygen has to be utilized. Helium acts as a heat sink.
It can delay combustion for up to 20 s. The oxygen
concentration should be maintained below 40%.
Recommendations regarding anesthesia are summarized
in Box 1.3.
Box 1.3 Recommendations regarding anesthesia
• Oxygen should be used at the lowest possible
concentration
• Oxygen (or other gases) should never be directed
toward the laser field
• Any mixture of nitrous oxygen and oxygen should be
treated as if it were pure oxygen
• Helium can be used to increase the ignition threshold
• Laryngeal airways (with spontaneous respiration) are
preferred over face masks; if a mask is used, an oxygen
analyzer can be utilized to ensure minimal leakage
• If an endotracheal tube is used, the cuff should be
filled with saline rather than air. The tube should be
wrapped in aluminum or copper tape
• Collared masks, nasal cannulas, or airway materials
should be avoided.
• Anesthetics that are administered either by inhalation
or topically should be nonflammable.
19. PREPARING FOR FIRES
It is imperative to develop a laser-fire protocol. Being
prepared for fire is an inexpensive insurance and will
minimize the cost in dollars, loss in time, emotional
shock, injury, and possibly death. Preparation involves
a number of steps. The most important is practicing
fire drills to teach all staff about their responsibility
during a laser fire. This should be done similarly to
what is done for medical codes and other routine
disaster drills.
It is surprising how many individuals do not know
how to select a proper fire extinguisher or how to use
one. Most fire extinguishers operate according to the
mnemonic ‘PASS’: Pull the activation pin, next Aim
the nozzle at the base of the fire, next Squeeze the
handle to release the extinguishing agent, and Sweep
the stream over the base of the fire.
There are three classes of fire extinguishers: A, B,
and C. Class C is used for electrical equipment.With
the demise of Halons as fire-extinguishing agents, CO
2
is the best all around fire extinguisher for the use in the
operating room. Halons (bromofluorohydrocarbons)
are damaging to the environment and are no longer
made or sold. However, if a Halon fire extinguisher is
available, it is the optimal one to use. Small CO
2
fire
extinguishers have five-pound charges and weigh
approximately 15 pounds. This is easily enough for
most people to handle and small enough to mount
unobtrusively on the wall in the operating room near
the door. CO
2
fire extinguishers are rated for use
against class B and class C fires in the operating room
setting, although they can be used effectively against
the kinds of class A fires that are likely to occur. CO
2
fire extinguishers emit a fog of CO
2
gas with liquid and
solid particles that rapidly vaporize to cool and smooth
the fire, while leaving no residue to contaminate the
patient. Dry powder fire extinguishers employ pri-marily
of ammonium sulfate, which is emitted in a
stream against the fire. The powder smothers, cools,
and to some extent disrupts the chemical reaction of
the fire. During use, the powder limits visibility and
covers everything in the surrounding area, which can
damage delicate equipment. The powder irritates the
mucous membranes and its long-term toxicity has
not clearly been determined. Using a powder fire
extinguisher in the operating room will make the
room and much of the equipment unusable for a
period of time. For these reasons, dry powder should
not be used as the first line of defense against operating
room fires. Pressurized-water fire extinguishers are
available, but are heavy and chiefly effective against
only class A fires.
If a laser fire should inadvertently occur, quick action
is imperative.Ventilation should be stopped and anes-thetic
gases discontinued.Then the tracheal tube, mask,
and nasal cannula should be removed.The fire should be
extinguished with normal saline.The patient should then
be mask-ventilated with 100% oxygen.The anesthesia
should be continued in order to facilitate injury assess-ment
to allow the patient to be stabilized. Iced saline
compresses should be applied to areas of burn.A flexible
nasal pharyngoscope or bronchoscope should be used to
survey the upper airway and laryngeal tissues to evaluate
the extent of injury. Foreign bodies and carbonized
debris should be removed. Copious irrigation with nor-mal
saline and Betadine soap can be used to remove car-bonized
debris from cutaneous burned areas. Xeroform
gauze and bacitracin ointment can be applied to areas of
minor cutaneous burns. If thermal injury has occurred in
the nasal airway, a light nasal packing with Xeroform
gauze can be used to stent the airway to treat thermal
damaged tissues.
Depending on the severity of injury, it may be
important to consider the use of intravenous steroids.
High-humidity environments should be provided and
oxygenation monitored. Patients may require ventila-tory
support for laryngeal edema as a potential prob-lem.
A chest X-ray should be considered in order to
obtain a baseline evaluation to monitor for ‘shock
lung’. Evaluation by other consultants such as a pul-monologist
or ophthalmologist should be considered
when appropriate. Systemic antibiotics such as
cephalosporins should be considered. In all but the
most minor cases, the patient should be observed
overnight.12
ENVIRONMENT OF CARE
Medical lasers should be used in the appropriate envi-ronment.
There should be proper electrical grounding
8 Clinical procedures in laser skin rejuvenation
20. to minimize potential electrical shock. There should
be proper ventilation and the room should be of suffi-cient
size to enable the use of smoke evacuators, laser
equipment, and additional personnel needed for
proper laser instrumentation. Treatment should be
performed in a controlled area, which should limit
entry by unauthorized personnel. Proper warning
signs should be displayed at the entry and within the
controlled area. Only those properly trained in laser
safety should be admitted to the controlled area. All
open portals and windows should be covered or
restricted in such a manner as to reduce the transmis-sion
of laser radiation to levels at or below the appro-priate
ocular MPE for any laser used in the treatment
area. It should be noted that normal window glass has
an optical density in excess of 5.0 and therefore
should be appropriate for CO
2
lasers at 10:600 μm.
Other lasers require the facility windows to have
additional coverings or filtering.
While it is important that the entryway to the laser
room or treatment area be secured, it is equally
important that emergency entry be permitted at all
times. For this reason, internal locks are not advisable.
If a laser, fire, or explosion should occur, an internally
locked door could prevent appropriate emergency
response. It is important to have proper safety equip-ment
within the treatment environment.This includes
proper eye protection for all staff, as well as the
patient, a fire blanket, and a fire extinguisher available.
Of equal importance is an appropriate laser plume
evacuation device. In most cases, standard surgical
wall suction does not suffice.
TRAINING
It is imperative that all personnel using medical lasers
be properly trained and that appropriate laser safety
protocol exist within each facility. Acceptable stan-dards
dictate that an individual designated as a laser
safety officer be in charge of developing criteria and
authorizing procedures involving the use of lasers
within the facility, and ensuring that adequate protec-tive
measures for control of laser hazards exist and that
there exist a mechanism for reporting accidents or
incidents involving the laser.
It is also important that accurate records be main-tained
for lasers, as well as laser-related injuries.
SUMMARY
Lasers can be employed in a variety of medical set-tings.
When used properly, lasers can provide dramatic
improvements in the quality of patient care. However,
as with any medical procedure, complications can and
do occur. Close adherence to standard accepted laser
safety protocols can dramatically reduce that risk and
improve the quality of patient care.
REFERENCES
1. Sliney DH,Trokel SL. Medical Lasers and Their Safe Use.
New York: Springer-Verlag, 1992.
2. ANSI Z-136.3-2004: American National Standard for
Safe Use of Lasers in Health Care Facilities –. New York:
American National Standards Institute, 2004.
3. Smalley P. Laser safety management; hazards, risks, and
control measures. In: Alster T, Apfelberg D, eds.
Cutaneous Laser Surgery. New York:Wiley-Liss, 1999.
4. ANSI Z-136.3:The Standard For the Safe Use of Lasers in
Health Care Facilities. New York: American National
Standards Institute, 2004.
5. Sliney DH. Laser safety. Lasers Surg Med 1985;16:215–25.
6. US Department of Labor, Title 29: Codes of the Federal
Regulations, Occupational Health and Safety.
7. ANSI Z-136.3-1996: American National Standard for
Safe Use of Lasers in Healthcare Facilities. New York:
American National Standards Institute.
8. Wood RL, Sliney DH, Basye RA. Laser reflections from
surgical instruments. Lasers Surg Med 1992;12:675–8.
9. Ries WR, Clymer MA, Reinisch L. Laser safety features
of eye shields. Lasers Surg Med 1996;18:309–15.
10. Olbricht SM, Stern RS, Tany SV, Noe JM, Arndt KA.
Complications of cutaneus laser surgery. A survey. Arch
Dermatol 1987;103:345–9.
11. Baggish MS. Complications associated with CO
2
laser
surgery in gynecology. Am J Obstet Gynecol 1981;
139:658.
12. Fretzin S, Beeson WH, Hanke CW. Ignition potential of
the 585nm pulse dye laser; Review of the Literature and
Safety Recommendations. Dermatol Surg 1996;22:
699–702.
Laser safety 9
21.
22. 2. Evaluation of the aging face
INTRODUCTION
In this chapter, we will explore the algorithm involved
in analyzing the aging face. But before we even begin
that journey, we must ask the question ‘What is an
aged face?’
While the answer may seemingly be self-apparent,
further contemplation reveals a complexity not first
appreciated. For starters, when is the face considered
‘aged’? Secondly, are all ‘aged features’ that we would
typically list a result of aging? And finally, do we have a
comprehensive and detailed understanding of the
pathophysiology of facial aging, which serves as the
foundation for our analysis?
WHAT IS AN AGED FACE
While the jury may still be out regarding when life
actually begins, one could argue that death begins at
the moment of conception! Life is nothing more than
the balance between anabolic activities and catabolic
activities. Throughout our life, the ratio of anabolic
and catabolic states simply switches. Somewhere along
that continuum, we begin to demonstrate findings on
the outside of our body, particularly the face, where
the catabolic process has increased its relative strength
compared with the anabolic process. From that move-ment
on, at different rates and in different ratios,
mixed with different environmental exposures, these
processes determine the resulting ‘aged appearance’ of
any one person.
What is considered an aged face in one society may
not in fact be so in another society.We are quite aware
of the tremendous respect and honor awarded to
seniors in the Asian community – and, sadly, not so
present in the Western world.Typical features that we
would readily find people wanting to correct in the
West may in fact be worn as a badge of honor in the
East. Nevertheless, those features are still a result of
the aging process, and identifying them is the purpose
of this chapter.
ARE ALL FEATURES OF AN AGED FACE
DUE TO THE AGING PROCESS?
As Fig. 2.1 demonstrates, a typical aged face will con-sist
of a myriad of features. However, further inspec-tion
reveals that these features can be divided into two
different categories. One category is chronological
aging alone.These are the features that are never seen
in youthful individuals, they occur as one ages, and
almost everyone who is aged has them. The second
Philip J Miller
Aged features
Chronological features:
Those features that
appear in nearly all aged
individuals, and are not
present in the young
Morphological features:
Those features that
appear in nearly all aged
individuals, but are also
present in some youthful
individuals
Fig. 2.1 The breakdown of aged features into
chronological and morphological features.
23. category, I would like to refer to as morphological fea-tures.
These are features that, although possessed by all
aged people, are present in some individuals even in
their youth. Examples of these two categories are
listed in Table 2.1. It is interesting to note that features
such as a nasojugal groove or a low-hanging upper lid
crease or even a deepened nasolabial groove are pre-sent
in some 6-year-olds. These individuals are cer-tainly
not chronologically aged, nor do they appear to
appear old. Nevertheless, they certainly possess some
of the very features that we readily admit to appearing
in the aged face.
PATHOPHYSIOLOGY OF AGING
A thorough analysis of the aging face begs us to ask us
how it got that way. My impression is that the current
pathophysiological model of facial aging is in its
infancy, and we will see a rapid, indeed exponential,
rise in our understanding of the pathophysiology of
facial aging over the next two decades. Prominent in
this model will be an ever-increasing role of facial vol-ume
depletion as contributing to – if not primarily
responsible for – the ultimate contour irregularities
and transformations that occur in the aged face. The
old model of loss of elasticity, and sagging due to grav-ity,
will be replaced by a more detailed and compre-hensive
understanding of the individual role of and
complex interaction among
• skin aging
• skeletal remodeling
• fat pad atrophy
• subdermal fat loss
• fat deposition
Furthermore, we will find that these processes
inevitably exerts their effects on two anatomical com-ponents
that are fixed: the muscle attachments to the
bone and the osseocutaneous ligaments.This complex
reaction of changes and exertions is subject to gravita-tional
forces, resulting in a more typical aged facial
appearance. Adding to that an increase in muscle tone
in order to maintain facial function, particularly in the
periorbital region, so that decreased visual fields
are eliminated by contracting the frontalis, gives the
characteristic superficial skin findings associated with
the aged face.
YOUTH VERSUS BEAUTY
Where do we begin the aging facial analysis? Do we
start from the surface and proceed sequentially with
our assessment layer after layer? Do we begin at the
scalp and then proceed inferiorly towards the neck?
Do we start at the nasal tip and work posteriorly?
Do we make a global assessment and then work to the
specific areas? Does it matter?
I believe that the analytical algorithm that one uses is
not nearly as important as the ‘ideal’ with which the
patient is being compared. Thus, the real question in
‘aging face analysis’ is not so much ‘Why do they look
old?’ as ‘with what are we comparing the patient’s
face?’Are we trying to restore the patient to their own
youthful appearance or to an idealized youthful appear-ance?
Do most patients wish to be ‘restored’ to a prior
12 Clinical procedures in laser skin rejuvenation
Table 2.1 Example of age-specific and non-age-specific features
Aged features Youthful features It depends!!!!
• Wrinkles, fine and coarse • Overall facial fullness/volume • Low lid crease
• Malar depressions • Prominent cheeks • Low brows
• Furrows • Plump lips • Thin lip
• Skin excess • Smooth, unblemished skin • Nasojugal groove
• Actinic changes • Maxillary teeth visible • Nasolabial folds
• Mandibular teeth showing
• Submental fat accumulation
24. age, or to look more refreshed and rejuvenated, but
still look their ‘age’. Is there not a component of their
desire, in fact, that struggles with the desire to improve
their appearance while maintaining their essential
features?
Here it is worthwhile to explore the concept of
‘ageless beauty’ – which is ultimately the goal of the
aging face surgery that we perform. ‘Aging face
surgery’ is really a poor term, because it is not really
youthfulness alone that we are attempting to achieve.
Age does not necessarily make one less or more attrac-tive
– although it does play a role. Therefore, beauty
and youth are not necessarily one and the same.Youth,
in my opinion, is not our goal as much as an ageless
appearance, not a particular time period in the
patient’s past. The best result is a face whereby you
cannot tell the patient’s age. One looks at the postop-erative
face (not compared with the preoperative face)
and cannot tell whether the patient is 25 or 40.They
possesses volume and fullness. Their face is ageless. It
should be kept in mind that youth is not necessarily
attractive. If we were capable of magically restoring
our patients to their most desirable youthful state,
would they be completely satisfied? Some patients
would be, but others would not. For these patients,
‘aging face procedures’ means not only correcting an
Evaluation of the aging face 13
aging face or features, but also aesthetic facial
features by which we are asked to alter their appear-ance
to make them more attractive.Therefore, ‘aging
face analysis’ may mean a collection of aged and not
necessarily aged features that the patient possesses to
make them more attractive and appear more youth-ful.
It should be kept in mind that we want to do that
without altering those characteristics that are essen-tial
to the person’s uniqueness – those essential fea-tures
that make us look undeniably who we are.These
features may consist of the slight slant of the palpe-bral
aperture, the position of the malar fat pad, the
dimple on the cheek, the cleft in the chin, or the full-ness
of the upper lid. Over the years, some of these
features have been routinely and erroneously thrown
in with the list of aging face features. Consequently,
we are quick to identify them as ‘aged’ and to eradi-cate
them or modify them in an effort to create an
idealized youthful appearance by removing all that is
considered aged.
Obviously, those features that are essential to one’s
uniqueness should not be tampered with.A wonderful
example of this is seen in my twins (Figure 2.2). My
son has a very prominent upper eyelid crease, whereas
my daughter has a much fuller upper eyelid crease
with a lower brow. While typically a lower brow and
upper eyelid fullness is deemed to be a classic sign of
an aging face, requiring intervention, I submit that this
particular feature in my daughter is her ‘essence’ and
should not be at all manipulated now or 40 years from
now.We have seen this as well in two classical exam-ples,
one being Mr Robert Redford and the second
Mr Burt Reynolds. Both of their periorbital proce-dures
resulted in what would be considered a youthful
appearance. But their results occurred at the expense
of removing their essential upper eyelid features.Those
essential features for decades had been their ‘brand’;
a masculine hooded upperlid with a low brow.
Therefore, it is important to recognize that in per-forming
aging face analysis, one needs to separate the
analysis performed on a patient’s features that most
likely were a result of the aging process and those that
were never present at all and would in fact make this
individual appear perhaps more attractive. For the sake
of this chapter, we will focus exclusively on those fea-tures
that are a result of the chronological process.
Fig. 2.2 Twins with very different upper eyelid formations.
The female’s upper lids are age-appropriate and beautiful,
but could be considered ‘aged’ if these very same features
presented themselves in a 40-year-old.
25. SKIN
Among the absolute hallmarks of an aging face are the
changes associated with the skin. The most common
changes associated with facial skin aging are those due
to photoaging (skin damage related to chronic sun
exposure). This results in dyspigmented, wrinkled,
inelastic skin, with associated redness and dryness.
Furthermore, mild to moderate facial wrinkling and
laxity with benign and malignant lesions round out the
skin changes that should be addressed through many of
the techniques presented in this book. See Tables 2.2
and 2.3, which show the Fitzpatrick and Glogau classi-fications
of skin types and wrinkles respectively.
VOLUME LOSS
It is easy to overlook this particular component of facial
aging. Since surgical procedures reposition and lift, it is
only natural, but incorrectly, assumed that the cause of
that descent is skin laxity and gravity. However, on fur-ther
examination, evaluation, and analysis, it is clear that
descent and laxity can result from volume loss. As illus-trated
in Figure 2.3(a), a fully inflated balloon appears
robust and lacks contour abnormalities. However, as
seen in Figure 2.3(b), a deflated balloon has the poten-tial
to not only descend, but also become deformed.The
difference between Figure 2.3(a) and 2.3(b) is nota gen-eral
laxity of the balloon’s tarp, but rather the volume
inside the balloon. Reinflating the balloon, as opposed
to repositioning the tarp, is responsible for eliminating
all of those identifiable features.
Likewise, many of the features that we will discuss
below are in part due to a loss of volume, and one
should train one’s eyes to appreciate that volume loss in
the following areas: the temporal fossa, the lateral
brow, and the malar eminence. Furthermore, volume
loss may be seen in the lips and perioral region. Finally,
it should be appreciated that overall loss of volume in
14 Clinical procedures in laser skin rejuvenation
Table 2.2 Fitzpatrick skin types
Type Color Reaction to UVA Reaction to sun
I Caucasian; blond or red hair, freckles, Very sensitive Always burns easily, never
fair skin, blue eyes tans; very fair skin tone
II Caucasian; blond or red hair, freckles, fair Very sensitive Usually burns easily, tans with
skin, blue or green eyes difficulty; fair skin tone
III Darker Caucasian, light Asian Sensitive Burns moderately, tans gradually;
fair to medium skin tone
IV Mediterranean,Asian, Hispanic Moderately sensitive Rarely burns, always tans well;
medium skin tone
V Middle Eastern, Latin, light-skinned Minimally sensitive Very rarely burns, tans very easily;
black, Indian olive or dark skin tone
VI Dark-skinned black Least sensitive Never burns, deeply pigmented;
very dark skin tone
Table 2.3 Glogau wrinkle scale
Skin type Age (years) Findings
1. no wrinkles Early 20s or 30s Early photoaging: early pigmentary changes, no keratoses, fine wrinkles
2. wrinkles in motion 30s to 40s Early to moderate photoaging: early senile lentigines, no visible keratoses,
smile wrinkles
3. wrinkles at rest 50 plus Advanced photoaging: dyschromia and telangiectasia, visible keratoses,
wrinkles at rest
4 only wrinkles 60 or 70s Severe photoaging: yellowish skin color, previous skin malignancy,
generalized wrinkling
26. a b
Fig. 2.3 Two identical balloons.The one in (a) is inflated and is rigid and wrinkle-free.The one in (b) is partially deflated, its
surface contains ripples, like wrinkles, and it is lax and subject to deformation from wind or gravity. Human skin is like the tarp
on these balloons. Fully inflated skin appears youthful and robust. Deflated skin sags and reveals wrinkles and furrows.
the subcutaneous tissue can make certain bony features
much more prominent along the infraorbital rim,
as well as the submandibular triangle, wherein the
submaxillary gland appears quite prominent.
CHIN POSITION
The next step in the facial analysis process is to assess
the location of the chin in relationship to the patient’s
lower lip as well as the surrounding tissue. One should
look for the appearance of jowling, chin ptosis, chin
retrusion, submental fat accumulation and severe
neck skin laxity. Following the path of the mandible
Evaluation of the aging face 15
posteriorly, the next assessment is the general protu-berance
and width of the angle of the mandible.
Atrophy and medial displacement of the angle of the
mandible or atrophy of the masseter muscle can in fact
contribute to a narrow and withdrawn facial contour.
The nasolabial lines are now assessed for their pres-ence
and degree, as well as for the contribution made
to these lines by ptotic skin and subcutaneous tissue
superior to them. In my experience, the presence of a
nasolabial fold is less due to ptosis of the malar fat pad
than to atrophy of the malar fat pad with resulting pto-sis
(see the balloon concept illustrated in Figure 2.3)
of the resulting subcutaneous tissue. Elevation of the
malar tissue superiorly and slightly posteriorly assesses
27. the degree of laxity, as well as the overall effect of
repositioning this tissue to efface the nasolabial line
and to reinflate the malar mound.
PERIORAL REGION
The lips are now evaluated for the prominence of the
white roll, the philtral ridge, and robust red lips.The
maxillary teeth should be visible and the mandibular
teeth hidden.White lip wrinkles are also assessed.
PERIORBITAL REGION
Finally, attention is then directed towards the peri-orbital
region. Signs of upper lid ptosis are identified
and documented. Lower lid laxity and position are
identified and documented. Brow position is similarly
considered. Unlike the current trend of repositioning
the brow cephalically, I find that a lower placed brow
in both women and men, in combination with a more
robust lateral brow fullness, provides a sophisticated
and ageless appearance. An overly elevated brow does
not convey youth. It conveys surprise.The absence and
presence of forehead, glabellar, and periorbital rhytids
are evaluated and documented. Lower lid pseudo-herniation
of fat is noted, as is the presence of an infra-orbital
hollow. The degree of nasojugal depression is
documented, and photographs taken at an earlier age
are reviewed to ascertain which of the facial features
were present in youth and which were subsequently
acquired with aging.
SUMMARY
Technical expertise, however important to obtaining
excellent and consistent results, is only part of the
equation. The wrong technique performed flawlessly
will typically reveal a result that is below par, while
the correctly chosen procedure performed just satis-factorily
typically results in acceptable if not extra-ordinary
results.We can only recommend the most
suitable procedure if we perform a thorough and accu-rate
analysis, and that analysis includes not only an
assessment of the patient’s facial features, but also
their desires, expectations and their notions on which
procedures they feel most comfortable with to get
there.Therefore, proper and thorough analysis is para-mount
for it will lead us to selecting the most appro-priate
treatment plan and consequent results for any
individual patient and thus predictable and consistent
outcomes.
Nevertheless, analysis cannot be learned in a vac-uum.
Analysis inevitably requires that we compare it
with an idealized version, and even then it requires us
to understand the pathophysiology by which we got to
that point, and then we must correlate those findings
with a suitable treatment.
PLAN
Knowledge in all of these domains and re-exploring all
of these disciplines are essential parts of our growth as
physicians.
16 Clinical procedures in laser skin rejuvenation
28. 3. Carbon Dioxide Laser Resurfacing, Fractionated
Resurfacing and YSGG Resurfacing
Dee Anna Glaser, Natalie L Semchyshyn and Paul J Carniol
INTRODUCTION
Although skin resurfacing has been performed for
centuries in the forms of chemical peels, sanding, and
dermabrasion, it was not until the 1990s that lasers
were safely and effectively used as a resurfacing tool.
Initially, carbon dioxide (CO
2
) lasers with a wave-length
of 10 600 nm (1006 μm) were used as a
destructive tool.Technology advanced quickly in the
1990s from continuous-wave CO
2
lasers to pulsed
CO
2
lasers to help minimize the thermal damage
produced by the older CO
2
lasers. Ultrashort pulse
technology emerged, as did computerized pattern
generator (CPG) scanning devices that allowed for a
more standardized delivery of the laser pulses.
Because of the prolonged healing required and the
risks associated with CO
2
lasers, the erbium : yttrium
aluminum garnet lasers (Er:YAG) lasers with
stronger water absorption (2940 nm) and less ther-mal
damage were developed. Er:YAG lasers proved
to be excellent ablative tools, with shorter healing
times, but did not provide the same tightening that
was achievable with CO
2
resurfacing. The next
advance came in the form of erbium lasers with
longer pulse widths that could provide more heating
and thermal damage in the skin. The short-pulsed
erbium lasers were combined with CO
2
lasers and
long-pulsed Er:YAG lasers to try to blend the bene-fits
of shorter healing times with more substantial
skin tightening.
Attempts to improve the laser resurfacing tech-nique
continue to be studied, with a concentrated
effort now looking at nonablative options to induce
dermal remodeling and fractionated skin resurfacing
to minimize the risks from skin ablation and to shorten
the healing times for patients. This chapter will focus
on ablative resurfacing, with an understanding that the
principles behind good patient selection and care will
remain paramount despite continued changes in the
lasers that might be developed.
INDICATIONS
The most common uses for laser skin resurfacing are
to treat wrinkles and acne scars of the face. Any epi-dermal
process should improve with laser resurfacing,
including lentigines, photoaging, actinic keratosis,
and seborrheic keratosis (Box 3.1). Some dermal
lesions, such a syringomas, trichoepitheliomas, and
angiofibromas, will improve with laser resurfacing,
but results will vary with the histologic depth of the
process. In our experience, there is a high recurrence
rate with dermal lesions. Actinically induced disease,
including actinic keratosis (AK) and actinic cheilitis,
can respond very well to laser resurfacing. Superficial
and nodular basal cell carcinomas have been success-fully
treated with the UltraPulse CO
2
laser. The cure
rates achieved by Fitzpatrick’s group was 97% in
primary lesions (mean follow-up 41.7 months).1 In
addition, the use of laser resurfacing may be used pro-phylactically
to reduce the risk for the development of
future AK and AK-related squamous cell carcinoma.2
Prevention of some basal cell carcinomas may be
achieved, although this has not been definitively
demonstrated.3
29. Box 3.1 Indications for laser skin resurfacing
• Photodamage
• Rhytids
• Acne scars
• Benign adenexal tumors
• Benign epidermal growths
• Rhinophyma
• Actinic cheilitis
• Actinic keratosis
• Basal cell carcinoma
• Scar revision
Despite the multiple uses, by far the prime use in
our office is for the improvement of facial photoaging,
rhytids, and acne scars.To date, ablative laser resurfac-ing
is the most efficacious technique we have to treat
perioral rhytids (Fig. 3.1).
PATIENT SELECTION
The key to successful laser resurfacing is proper
patient selection (Table 3.1). Potential candidates
need to have a realistic expectation of the outcome,
risks, and significant amount of time required to heal,
as well as the time to see the final results. The ‘ideal’
patient has fair skin with light eyes, has no history of
poor wound healing, and is comfortable with wearing
make-up during the postoperative healing period.The
history should specifically address issues that relate to
wound healing, such as immunodeficiency, collagen
vascular diseases, anemia, diet, scarring history,
keloid formation, recent isotretinoin usage, and past
radiation therapy to the area. The history should
include the patient’s general health, current or past
medications, and mental health issues. Diseases
known to koebnerize are also a relative contraindica-tion
– these include psoriasis, vitiligo, and lichen
planus. Diseases that reduce the number of adenexal
glands or alter their function are relative contraindi-cations
and need to be reviewed – these include colla-gen
vascular diseases such as systemic lupus
erythematosus and scleroderma. A history of herpes,
frequent bacterial infections, or frequent vaginal
candidiasis is not a contraindication, but should be
noted to better plan how to treat the patient during
the perioperative period.
Equally important is to ascertain the pigment
response of the patient (in terms of hyperpigmenta-tion
or hypopigmentation) to sun exposure or injuries.
In our experience, patients with Fitzpatrick skin type
IV are some of the most challenging to treat due to
their risks of postoperative dyschromias. Patients will
need to avoid sun exposure for several months after
the surgery, and the physician needs to document the
patient’s ability to do so along with their ability to use
broad-spectrum sunscreens daily. In the Midwest of
the USA, with four distinct seasons, it is preferable
to perform deep resurfacing procedures during the
winter months to minimize sun exposure. However, a
thorough review of a patient’s travel plans during the
3- to 4-month healing period then becomes impor-tant.
Although most patients recognize the risks of a
trip to a warm sunny destination, many may under-estimate
the risks with higher altitudes such as with
snow skiing.
18 Clinical procedures in laser skin rejuvenation
a
b
Fig. 3.1 Significant reduction in perioral rhytids
at 4 months.
30. PROCEDURE
Carbon dioxide laser resurfacing, fractionated resurfacing and YSGG resurfacing 19
Preoperative care
The preoperative care should begin at the time that the
patient decides to undergo laser skin resurfacing.
Photoprotection and prevention of tanned skin should
be maximized before surgery. Melanocyte stimulation
before the laser resurfacing may increase the risk of
postinflammatory hyperpigmentation after the proce-dure.
A sunscreen with a sun protection factor (SPF) of
30 or higher should be used daily, along with an ultra-violet
A (UVA) blocker such as zinc oxide, titanium
dioxide, or avobenzone.We advise patients to supple-ment
sunscreen use with physical measures such as
large sunglasses and hats.
The use of topical therapy before surgery is com-mon
– this might include topical tretinoin, hydro-quinone
and antioxidants. It is clear that the use of a
topical retinoid is quite valuable before skin resurfac-ing
with chemical peels through its action on the
stratum corneum and epidermis. The use of topical
tretinoin can increase the penetration of the peel, pro-vide
a more even peel and enhance healing.4,5 Due to
the high affinity for water with the CO
2
and Er:YAG
lasers, these lasers are very capable of evaporating the
epidermis without the use of tretinoin. There may be
other effects that could theoretically improve the laser
resurfacing process and healing. Retinoids regulate
gene transcription and affect activities such as cellular
differentiation and proliferation. They can induce
vascular changes of the skin and a reduction and
redistribution of epidermal melanin.6 Retinoids (at
least theoretically) can speed healing and perhaps
reduce pigmentary changes.Thus, it is our practice to
begin a topical retinoid at least 2 weeks prior to the
procedure – even earlier if possible.
Because of the relatively common development of
postinflammatory hyperpigmentation after laser resur-facing,
especially in the darker skin tones, many physi-cians
will pretreat with a bleaching agent such as
hydroquinone (HQ). HQ works by inhibiting the
enzyme tyrosinase, which is necessary for melanin
production within the epidermis. It can also inhibit the
formation of melanosomes. There is a clear role for
HQ products after laser resurfacing to treat hyperpig-mentations;
this will be discussed later in the chapter.
HQ may not have any clinical effect when used prior
to laser surgery, since the melanocytes that it is work-ing
on are all removed during the laser procedure. It is
certainly not unreasonable to initiate HQ in a 3–5%
cream for those patients at high risk for developing
hyperpigmentation after their procedure. Like the
topical retinoids, it can be irritating and should be dis-continued
if it is causing an irritant dermatitis. A rare
side-effect of HQ is exogenous ochronosis, but this
usually occurs only with prolonged use of higher con-centrations
and should not develop even in predis-posed
individuals within just a couple of weeks.7
There is no proven role for the use of topical anti-oxidants,
alpha-hydroxy acids, or beta-hydroxy acids,
but they are often in the skin care regimen of patients
and we do not discontinue their use prior to laser
resurfacing.
Tobacco smoking can delay wound healing, and
patients are strongly encouraged to stop tobacco
use.As an alternative, if the patient is unable or unwill-ing
to stop smoking at least 2 weeks prior to the
Table 3.1 Patient selection
Absolute contraindications Relative contraindications
Unrealistic expectations Tendency to keloid formation
Unable/unwilling to perform wound care Tendency to poor wound healing/scar
Isotretinoin therapy within prior 6–12 months History of radiation therapy in area
History of collagen vascular disease
History of vitiligo
Diseases that koebnerize (e.g., psoriasis)
Pregnancy/breastfeeding
Unable/unwilling to avoid sun exposure postoperatively
31. procedure, he or she is encouraged to switch to a
tobaccoless product such as a patch or gum.
The use of oral antiviral therapy is standard practice,
even if the patient does not have a history of herpes
simplex virus (HSV) infections.Typically, famciclovir
or valacyclovir is used in prophylactic doses such as
famciclovir 250 mg twice daily or valacyclovir 500 mg
twice daily. Doses need to be adjusted for renal dys-function.
The patient begins therapy the day before the
procedure and continues until re-epithelialization
is complete. It can be helpful to keep antiviral therapy
in the office to administer to the patient if he or she
forgot to initiate therapy before the procedure.
The use of prophylactic systemic antibiotics is of
questionable value prior to surgery and remains con-troversial.
8 A first-generation cephalosporin is typically
used by one of us (NLS), while no antibiotics are rou-tinely
used by the other (DAG). Interestingly, recent
animal studies have shown that CO
2
laser resurfacing
reduces microbial counts of most microorganisms on
lasered skin compared with skin treated using mechan-ical
abrasion.9 On the other hand, nasal mupricin is
routinely prescribed (by DAG) for healthcare workers
due to the current high rates of methicillin-resistant
Staphylcoccus aureus (MRSA) in hospitals and nursing
homes. Unfortunately, the incidence of MRSA in the
community is also increasing, and MRSA may be
encountered in non-healthcare workers.10,11 Surgeons
should monitor their local communities for recom-mendations
regarding community-acquired MRSA.
There have been no published studies on the use of
antifungal therapy prior to laser resurfacing, although
Candida infections can develop during the postopera-tive
period, especially when occlusive dressings are
used. It has been our practice, and that of others, to
treat women with a known history or frequent or
recurrent vaginal candidiasis with oral fluconazole
after the procedure, even when using open healing
techniques.9
Botulinum toxin is routinely administered to our
patients prior to laser resurfacing of the face. Placebo-controlled
studies have demonstrated improved results
when compared with laser resurfacing alone.12,13 Pre-operative
use of botulinum toxin type A can diminish
rhytids as well as textural, pigmentational and other
features of skin aging when used in conjunction with
laser resurfacing.13 Our preference is to treat at least 2
weeks prior to laser surgery and repeat at approxi-mately
3 months postoperatively.
Patients are given instruction sheets listing skincare
items they will need after the procedure along with
their prescriptions for postcare medications. These
will be discussed later in the chapter.
Laser resurfacing
Before coming into the office for their procedures,
patients are instructed to wash their face well. After
drying, they apply a topical anesthetic cream such as
EMLA (a eutectic mixture of lidocaine 2.5% and
prilocaine 2.5%) under occlusion with a plastic wrap.
This is left intact for 2–2.5 hours. One of us (NLS)
will reapply the topical anesthetic 45 minutes prior to
the procedure. The EMLA not only helps to provide
cutaneous anesthesia, but also hydrates the skin, which
decreases the procedure’s side-effect profile.14 Further
anesthesia or analgesia can be obtained with nerve
blocks, local infiltration of lidocaine, tumescent anes-thesia
or diazepam, and, in our office, intramuscular
meperidine and midazolam, or ketorolac, is used.The
topical agents are removed prior to beginning the laser
procedure.
When using the UltraPulse CO
2
laser (Lumenis,
Santa Clara, CA), the face is treated at 90 mJ/45W,
and the first pass is usually performed at a density of 7
for central facial areas (periorbital, glabellar, nose, and
perioral): the upper and lower eyelids are treated at a
density of 6 with the energy setting at 80 mJ.The den-sity
should be decreased to 6 and then 5 when feather-ing
to the hairline and jawline. The first pass is
intended to remove the epidermis, which is wiped free
with a wet gauze in the central facial areas only, and a
second pass is performed to central facial areas at a
density of 4–5 (90 mJ), depending on the tightening
needed. If required, the second pass on the eyelids is
performed at a density of 4. Energies are decreased
towards the periphery of the face.A third pass may be
needed in areas of acne scarring or in the perioral
area with deeper wrinkles. As with any laser proce-dure,
careful monitoring of tissue response during
treatment is performed to determine the necessity of
any additional passes and energy level used.
20 Clinical procedures in laser skin rejuvenation
32. Carbon dioxide laser resurfacing, fractionated resurfacing and YSGG resurfacing 21
A similar approach is taken when using one of the
combined Er:YAG lasers such as the Sciton laser (Palo
Alto, CA).The first pass is used to remove the epider-mis
and frequently 25 J/cm2 (100 μm ablation, zero
coagulation) with 50% overlap is used. A second or
third pass is used to heat and hopefully to induce skin
tightening. Ablative and coagulative settings are used
with a typical second, pass and a commonly used set-ting
would have 50% overlap with 10 μm ablation and
80μm coagulation.
Where there are very deep rhytids or scars, the
erbium laser in just the ablative setting can be used in a
single spot to help sculpt the edges. It is important to
remember that when used in the ablative mode, there
is very little (if any) hemostasis, and pinpoint bleeding
can help identify the depth of resurfacing.
Laser resurfacing is best done to the entire face
to avoid lines of demarcation between treated and
untreated skin.The procedure should be carried into
the hairline and at the jaw and chin; a feathering tech-nique
should be used. This includes a zone of
decreased energy, decreased density, or pulse over-lap.
When treating a patient with moderate to severe
photodamage, it is important to blend into the neck
as much as possible. One approach is to lightly resur-face
the neck with a chemical peel; in our office, a
Jessners and/or glycolic acid peel is used. Another
option is to laser the neck, which will be reviewed
later in the chapter.
Postoperative care
Wound care is critical, and regimens vary among
physicians. Occlusive and nonocclusive dressings are
available. Occlusive dressings cover the skin and are
usually removed in 1–3 days. These can decrease
patient discomfort, but may promote infection by har-boring
bacteria or yeast.When opaque, the dressings
can mask visualization of the wound, thus delaying the
detection of an infection. Clear dressings (e.g., Second
Skin) allow the patient and medical team to look at the
lasered skin. When used in our office, they are most
commonly removed on the second day postoperatively
and the patient is switched to open healing.
Open dressings or nonocclusive dressings are usu-ally
petroleum-based ointments. Frequent soaking and
cleaning are necessary (at least 4 times daily), followed
by frequent application of petroleum jelly, Aquaphor
ointment or one of the many wound care ointments
that are available. Additives, fragrances, or dyes will
increase the chance of contact allergic or irritant der-matitis
developing and should be limited as much as
possible. In very sensitive individuals, pure vegetable
shortening can be used. Dilute vinegar can be used to
soak and debride the wound, promote healing, and
inhibit bacterial growth.
Wound care needs to be performed until re-epithelialization
is complete. Depending on the type of
laser used and how aggressive the surgeon was with his
or her settings, re-epithelialization should be complete
within 5–10 days. Prolonged healing times can
indicate an infection, contact dermatitis, or other
problem, and increases the risks of complications.
COMPLICATIONS AND THEIR
MANAGEMENT
Complications following laser surgery are relatively
infrequent, but when they do occur, they need to be
treated quickly and efficiently to minimize patient
anxiety and long-term morbidity.15 Obviously, good
patient selection, surgical management, and postoper-ative
care are necessary to help prevent complications,
but, even in the best of cases, complications do occur
(Box 3.2).
Box 3.2 Complications of ablative laser resurfacing
• Activation of herpes simplex virus (HSV)
• Bacterial infection
• Candidal infection
• Delayed healing
• Prolonged erythema
• Hyperpigmentation
• Hypopigmentation
• Acne
• Milia formation
• Contact dermatitis
• Scarring
• Line of demarcation with untreated skin
33. The most common complications seen immediately
postoperatively are swelling and exudative weeping
related to the degree of wounding. If facial swelling
is severe, oral or intramuscular steroids, and non
steroidal anti-inflammatory agents (NSAIDs) can be
administered. Milia formation is common, with the
development of small white papules, usually < 1mm
in size, which need to be distinguished from pustules.
Papules are an occlusive phenomenon, and will
resolve without treatment.
Infections can occur, and may be bacterial, viral, or
fungal in nature (Table 3.2).16 Signs and symptoms
include pain, redness, pruritus, drainage (usually not
clear), yellow crusting, and sometimes erosions, vesi-cles
or pustules may develop (Fig. 3.2). Pruritus, espe-cially,
should alert the physician to a possible infection.
Appropriate evaluation may include tzanck smear,
potassium hydroxide (KOH) prep, gram stain, and
cultures to accurately diagnose the causative agent.
Treatment should begin early, pending culture results.
Fitzpatrick’s group found that half of their patients
who developed a post-laser infection had more than
one microorganism. Thus, broad coverage should be
initiated, and should generally include an agent that
will cover Pseudomonas aeruginosa.
Acne is another complications that can be seen rela-tively
early in the course. Oral antibiotic therapy and
discontinuation of petroleum-based ointments usually
suffice.Topical acne therapies are not generally well
a
b
tolerated, due to skin sensitivity, and need to be used
judiciously.
Contact dermatitis can occur, and may be due to an
allergic reaction or an irritant reaction. It may occur
within the first few weeks or months after laser resur-facing.
Redness, pruritus, and delayed healing may be
noted, but vesiculation is rare.Topical antibiotics are
a common cause of allergic contact dermatitis, and
should be avoided. Patients may be using them without
the knowledge of their physician. Topically applied
agents should be reviewed and discontinued. Dyes and
fragrances that are added to laundry detergents, fabric
softeners, and skincare items are also potential causes.
Discontinuation of the offending agent(s) and topical
corticosteroids should be initiated early.17
22 Clinical procedures in laser skin rejuvenation
Table 3.2 Causative agents encountered in CO
2
laser
infections16
Organism Percent
Pseudomonas 41.2
Staphylococcus aureus 35.3
S. epidermidis 35.3
Candida 23.5
Enterobacter 11.8
Escherichia coli 5.9
Proteus 5.9
Corynebacterium 5.9
Serratia 5.9
Herpes simplex virus (HSV) 5.9
Fig. 3.2 A postoperative infection at day 3, with redness,
edema, yellow drainage and crusting, and pustules.The
patient noted increasing discomfort and pruritus.
34. Carbon dioxide laser resurfacing, fractionated resurfacing and YSGG resurfacing 23
PIGMENTARY ABNORMALITIES
Hypopigmentation
Lightening of the skin is desirable for most patients
undergoing facial rejuvenation. Patients who undergo
resurfacing of cosmetic units such as the perioral area or
periocular area may exhibit a noticeable difference
between the ‘new’ treated skin and the untreated skin
that exhibits the various dyschromias associated with
photoaging. This should be avoided as indicated previ-ously,
but when faced with such a patient, treating the
remaining skin will lighten the hyperpigmentation and
help to blend in the differences. Although topical agents
such as retinoids and hydroquinones can be used, visible
results take months and are not practical for most
patients. Resurfacing is the fastest way to improve
patients’ appearance in these cases. Depending on the
severity, a chemical peel such as a Jessner’s/35%
trichloroacetic acid (TCA) peel may be sufficient, or
laser resurfacing can be performed. Superficial resurfac-ing
is all that is required for most, and the Er:YAG laser
is an excellent device.The goal is to remove the epider-mis,
and one or two passes maybe all that is required.
This heals rapidly and with minimum risks.
In the very sun-damaged patient, it may be difficult
to find a good stopping point. In these instances, treat-ing
the full face may only accentuate the discoloration
of the neck. Light rejuvenation of the neck can be
done, but may accentuate the damage to the chest.
Light resurfacing can be performed down the neck and
chest area, extending onto the breast – but this may
then accentuate the damage to the arms and forearms,
etc. In these patients, a combination of modalities can
be used: topical agents as described above for the
entire area; laser resurfacing of the face; lighter resur-facing
of the neck and chest (we generally use chemi-cal
agents such as 20–30% TCA or 70% glycolic acid,
but Er:YAG laser resurfacing is used successfully by
many physicians); and chemical resurfacing of the
arms, forearms, and hands with 20–30% TCA or 70%
glycolic acid.
Another option is the use of nonablative laser tech-nology
such as the ‘Photofacial’ technique. Several
intense pulsed light (IPL) systems are now available,
which use a broad-spectrum intense pulsed light
source with changeable crystals attached to the hand-piece
Fig. 3.3 Persistent depigmentation 2½ years
to filter out undesirable wavelengths. This
modality has been applied to the face, neck, chest, and
upper extremities. Numerous treatment sessions are
required, but are generally well tolerated, with little
to no ‘healing-time’ for the patient.The fluence varies
with skin type and area, but the neck is generally
treated more conservatively and using lower fluences.
It is important that the operator carefully place the fil-ters
to avoid overlapping and also to prevent skipped
areas or ‘footprinting’.
Depigmentation
True depigmentation of the skin following laser resur-facing
is more difficult to treat than the pseudohypo-pigmentation
described above. The skin acquires a
whitish coloration and does not flush or change color
with normal sun exposure (Fig. 3.3). A slight textural
change can even be noted at times such that make-up
does not ‘stick’ to the skin well or does not last as long
as make-up applied to other areas. The latter repre-sents
superficial scarring or fibrosis. It can occur after
any form of resurfacing, but it is more commonly
encountered with CO
2
laser resurfacing and is much
less common with Er :YAG resurfacing. Like pseudo-hypopigmentation,
depigmentation seems to be more
following CO
2
laser resurfacing that was performed in the
perioral area only.
35. evident when cosmetic units are treated individually
or when a cosmetic unit such as the upper lip is treated
more aggressively than the surrounding skin.
Depigmentation has been considered a permanent
complication of CO
2
laser resurfacing.When evaluated
histologically, there is a varying quantity of epidermal
melanin present. Residual epidermal melanocytes are
present, indicating that repigmentation should be pos-sible.
Mild perivascular inflammation has been noted
in 50% of biopsies, and superficial dermal fibrosis was
present in all biopsies.18 This suggests that the patho-genesis
of the laser-induced hypopigmentation may be
related to a suppression of melanogenesis and not
complete destruction of the melanocytes.
Grimes et al18 have reported successful treatment of
hypopigmentation following CO
2
laser resurfacing
using topical photochemotherapy twice weekly.18 Seven
patients were treated with topical 8-methoxpsoralen
(0.001%) in conjunction with UVA therapy. Moderate
to excellent repigmentation was demonstrated in 71%
of the patients. Using the same reasoning, narrowband
UVB and an eximer laser may both be effective.
Narrowband UVB, which emits at 311–312 nm, has
been reported to be efficacious for vitiligo, while
excimer lasers emit at 308 nm and can be targeted
to a given site.19 Alexiades-Armenakas et al20 have
reported two patients who were treated for laser-induced
leukoderma using an excimer laser. They
speculate that repigmentation is related to the stimu-lation
of melanocyte proliferation and migration,
along with the release of cytokines and inflammatory
mediators in the skin.
Potential disadvantages of any of these therapies,
however, include the time necessary to see repigmenta-tion,
cost, erythema and pruritus during therapy, and
hyperpigmentation of skin immediately surrounding
the treated skin, which can take months to return to
normal. Unfortunately, the results are mixed, and
return to baseline can occur after therapy is discontin-ued.
Repigmentation has been an unrealistic goal, and
until more data are available on investigative tools such
as phototherapy, an honest discussion must take place
with the patient. Additional resurfacing of the unaf-fected
skin may be helpful to reduce any hyper pigmen-tation
or dyschromia if present, but will only help to
reduce the differences with adjacent areas.Once again,
care should be taken not to re-treat too aggressively.
Scarring
The development of scarring following laser surgery is
perhaps the most feared and distressing complication
encountered. Deeper wounds are more likely to result
in scarring, which is not usually encountered unless
the wound extends into the reticular dermis.
However, since this is the level that is generally tar-geted
with the CO
2
laser to eradicate wrinkles, acne
scars, and varicella scars, cosmetic surgeons will be
faced with scarring if they perform enough proce-dures.
Hypertrophic scars can develop anywhere, but
are most likely to occur around the mouth, chin,
mandibular margin, and less often over other bony
prominences such as the malar and forehead regions.
Nonfacial skin is also more likely to develop scarring
due to the relative paucity of pilosebaceous units and
adenexal structures. It has been the experience of one
of us (DAG) that patients with a history of acne scar-ring,
regardless of prior isotretinoin use, are more
likely to develop delayed wound healing and hyper-trophic
scarring when compared with the average
patient.
The surgeon should be alerted to possible scarring
when there is delayed wound healing for any reason.
Infections need to be treated early and aggressively.
Candidal, bacterial, and herpetic infections can delay
healing, prolong the inflammatory stage, and increase
the chance that the wound will heal with scar develop-ment.
Likewise, contact dermatitis that is not con-trolled
early and poor wound care are potential
precursors for postoperative scarring.
Early on, the treated skin may appear redder than
the surrounding skin. As the process continues, tex-tural
changes can be discerned with palpation of the
area (Fig. 3.4), and, as time progresses, a mature scar
will develop. In the early stages, topical steroids may
have a role.A medium to potent steroid should be used
twice daily, but should be applied only to the area of
concern and not to the entire lasered area. If pro-longed
erythema alone is noted without any dis-cernible
textural changes, a class II or III steroid may
suffice but if thickening or induration is present, a class
I steroid should be considered.The patient needs to be
monitored closely so that steroid-induced atrophy,
stria, or telangectasia do not develop and so that
progression of the scarring can be followed.
24 Clinical procedures in laser skin rejuvenation
