37 Chemical and Laser Skin Resurfacing
INTRODUCTION
The human face is a dynamic tool important in communication. Beyond conveying emotion, it also serves to highlight such characteristics as gender, age, ethnicity, kinship, overall vigor, and apparent fertility. Given the relatively high value placed on a youthful appearance in today’s society, it is not surprising that patients often seek to delay the damaging social effects of age, gravity, environment, and sunlight on the appearance of facial skin.
Skin damage treatments consist of both incisional procedures and nonsurgical techniques. The latter includes chemical peels, light-based therapy, and ablative and nonablative laser treatments. Surgical treatment is designed to address deeper changes such as rhytids due to dermal collagen changes, while nonsurgical methods are designed to primarily correct epidermal changes such as solar lentigenes.
Of note, dermabrasion is another method of skin resurfacing, which uses a handheld mechanical rotary burr, wire brush, or diamond wheel to debride the superficial skin layers. The procedure is effective, but requires experience, aerosolizes blood, lacks predictability and uniformity of treatment depth, and is unforgiving in terms of scarring and pigment changes.
Medium depth chemical peels include trichloroacetic acid as the active ingredient. Extreme care should be taken to avoid corneal injury. These peels are often followed by several days of dry scaling skin as sloughing ensues. They create a longer lasting improvement in fine wrinkling, a vigorous healthy skin appearance, marked reduction in sun-related pigment changes, and reduce the number of actinic keratoses.
Phenol peels are used for deep chemical peeling. Risks of phenol peels include cardiac arrhythmias, renal toxicity, and hepatic toxicity. Deep chemical peeling with phenol results in a raw, weeping skin surface, which may last up to 2 weeks. Patients also experience marked facial edema and erythema that may persist for 12 weeks. The dramatic results are similar to ablative CO2 laser resurfacing. EKG monitoring and IV hydration are necessary because skin absorption of product may result in cardiotoxicity. Hypopigmentation is a common side effect. Complications of treatment include corneal injury and skin scarring.
Light-based skin resurfacing treatments include Intense Pulsed Light (IPL), BroadBand Light (BBL), and visible-wavelength laser treatments. IPL uses a broad spectrum flash lamp and a filter to narrow the output. For example, flash lamp output usually ranges from 500 to 1,200 nm. A 560 nm filter effectively blocks light from 500 to 560 nm and only allows wavelengths from 561 to 1,200 nm to reach the target. Light-based treatments, whether IPL or laser, all work through the principle of selective photothermolysis wherein the desired wavelength of energy is selected in order to match the absorption spectrum of the target chromophore while minimizing collateral injury. With this method, wavelengths may be selected to deliberately target pigmented lesions (melanin chromophore), rosacea and blood vessels (chromophore hemoglobin), or hair follicles (melanin). Other parameters that also influence tissue energy delivery include pulse duration, role of wavelength in tissue penetration, Fitzpatrick skin-type, spot size, pulse frequency, tissue temperature or cooling device, and the need for coupling gels or devices.