Key points
- •
Learn about the differences between skin resurfacing lasers.
- •
Learn about tissue effects of erbium lasers.
- •
Patient selection and expectations of results.
- •
Laser post operative care.
- •
Be able to treat complications of resurfacing.
Skin resurfacing with chemical peels and dermabrasion have been used for many years to treat epidermal and dermal damage due to aging, acne scarring and photodamage. Lasers and other devices have been more recently introduced and have replaced chemical peels and dermabrasion in most aesthetic practices. According to statistics from the American Society for Aesthetic Plastic Surgery, laser resurfacing with various devices remains popular with almost 700,000 ablative, non-ablative and fractional procedures performed in the United States in 2007. Currently, there are many devices used in various wavelengths with many newer procedures reducing downtime.
Laser resurfacing history
In the early 1990s carbon dioxide (CO 2 ) lasers were introduced and utilized for laser skin resurfacing and within a short time largely replaced dermabrasion and deep chemical peels for the treatment of photodamage, wrinkles and atrophic scarring. Energy at this wavelength of 10,600 nm is absorbed by water and dissipated in a very short distance of tissue. Initial systems were used in a continuous mode to ablate all tissue in its path and also used as a surgical cutting tool. Excessive thermal damage from continuous wave systems led to scarring. Two modifications of the CO 2 systems were initially utilized to reduce complications for skin resurfacing. One approach used a short pulse, very high energy laser beam (Ultrapulse laser, Lumenis Ltd, Yokneam, Israel). The short pulse vaporized tissue rapidly removing it as steam (plume) so that less heat was left in the tissue to allow transmission of heat to non-target tissues. The device was used with a computer pattern generator which enabled uniform application of laser energy to the skin and precise reproducibility. The other approach used an optomechanical flashscanner that scanned a continuous laser beam in a spiral pattern for a short exposure time (SilkTouch® and FeatherTouch® Ltd, Lumenis Ltd, Yokneam, Israel).
The scanner rapidly moved a continuous focused beam in a spiral, keeping the dwell time at any particular point on the spiral below 1 millisecond. The carbon dioxide lasers were used to ablate variable depths of skin and caused thermal damage to an area of 75–100 microns deep to the ablated area per pass. The area of thermal damage led to long-term collagen changes and was thought to be the cause of the remarkable tightening effects seen in many patients. Carbon dioxide resurfacing waned around 2000 as a better understanding of longer term complications such as hypopigmentation and prolonged erythema were elucidated. Recently there has been a resurgence of interest in superficial carbon dioxide resurfacing and fractional carbon dioxide resurfacing.
The erbium:YAG laser (2940 nm) was introduced at the turn of the last century and differs from the carbon dioxide laser by having 10 times the water absorption, leading to more complete ablation of tissue with much less residual thermal damage (5–10 microns). There is 3–4 microns of tissue is removed per joule of fluence utilized and a linear relationship between the energy delivered and the depth of ablation, whether one is in the epidermis or dermis. Early machines were somewhat underpowered and lacked computer scanners and the systems earned the reputation of being for superficial resurfacing only. Higher power systems were introduced with computer pattern generators and deeper erbium resurfacing became more prevalent. Two variations on erbium lasers were introduced to add more thermal damage and potentially more tightening. One machine combined erbium and carbon dioxide lasers (Derma K®, Lumenis Ltd, Yokneam, Israel) with the beams being delivered either sequentially or at the same time. This combination seems to adopt more the healing profile of the erbium laser with an apparent reduced complication risk of long term pigment change. This laser was popular for a short time but is now relatively obsolete.
The other device which remains very popular is the variable or long pulse erbium laser (Sciton Inc, Palo Alto, CA). This device mimics to a lesser extent the thermal damage of carbon dioxide lasers by lengthening the pulse width. This provides enhanced hemostasis and the tightening effect associated with carbon dioxide lasers without the associated prolonged healing times or hypopigmentation.
New laser wavelengths for skin resurfacing including 2780 nm and 2790 nm were recently introduced (Cutera Lasers, Palomar Lasers). These devices allow variable degrees of thermal damage similar to the variable pulse width erbium laser but with less flexibility. Plasma skin resurfacing was also recently introduced. These devices use nitrogen plasma energy to cause superficial skin ablation with a small degree of thermal damage. Healing times and results appear to be similar to superficial treatments with erbium devices. This chapter will outline current uses for erbium lasers from superficial to deep peeling and provide useful pre- and post-operative laser care information.
Skin thickness
To fully understand the potential uses of an erbium laser one should have a basic understanding of skin structure. The skin is composed of four distinct layers that change with age, photodamage and environmental influences. The stratum corneum is the outermost layer and is considered the barrier of the skin. This layer is approximately 10 microns thick. The epidermis is the next layer and measurements vary from 60–100 microns depending upon race, age, damage and facial area. The papillary dermis is next and measures also about 60–100 microns. The reticular dermis is deepest and measures up to more than 1000 microns in some individuals. This layer has sebaceous glands and hair follicles which are the source of new skin after laser ablation. Depth of full field resurfacing, i.e. not fractional, is considered safe to the level of the mid sebaceous glands. It is interesting that skin thickness varies in the same individual in different parts of the face. In general, the forehead and perioral skin is very thick while the eyelid skin is thin and firmly adherent to the underlying muscles.
Superficial erbium peeling
Early studies utilizing the erbium:YAG laser at low fluences (<10 J/cm 2 ) demonstrated its effectiveness for treating superficial epidermal skin lesions. We utilized this superficial experience to perform intraepidermal superficial peels and define superficial erbium peeling as intraepidermal peeling or those laser peels that are up to 80 microns in depth. The purpose of a superficial peel is to improve photodamage, mild to moderate rhytids and improve skin texture with a limited downtime. These were named ArcticPeel™ and MicroLaserPeel™ to help differentiate their use in our practices.
Arcticpeel™
The most superficial peel performed in our practices is the Arcticpeel™, so called because cold air is used for this procedure as an anaesthetic. In developing this peel, our goal was to develop a laser procedure with no downtime and no anaesthetic for the treatment of mild to moderate photodamage. The procedure was designed as a high tech, more effective alternative to microdermabrasion or light chemical peels. Our experience with deeper erbium peels and deeper intraepidermal peels, for example Microlaserpeel™, showed us that depth of resurfacing was clearly and almost linearly linked to recovery time.
The depth of resurfacing that would provide for a laser procedure with no downtime was determined by trial and error and anesthetic considerations. We evaluated various options for skin anaesthesia but felt that nerve blocks or local infiltrative anesthetics were too invasive for the type of procedure envisioned. Topical anesthetics worked effectively at deep resurfacing depths but required the patient to have the anesthetics applied for at least 45 min. While this is certainly an alternative to the air chiller, we felt that the true essence of the ArcticPeel™ was one of a quick office procedure and that a lengthy preparation period was outside the scope of our intended procedure. We tried chilling the skin with ice or chill packs but the wet skin from the ice or condensation interfered with the laser efficacy as the chromophore of Er:YAG is water. The Zimmer air chiller provided analgesia quite well at various depths but was most comfortable for most people at a maximum depth of 10 microns.
A surprising result was the skin tightening experienced after multiple ArcticPeels. The skin tightening most likely is related to some type of sub-ablative thermal effect on the collagen, although the immediate histology fails to reveal any deep thermal effect. Perhaps the 50% spot overlap creates a mild thermal effect that is not visible histologically which in turn triggers a biological response. Currently, this procedure is rarely used alone in our practices but is usually used in a sequential fashion with fractional erbium resurfacing.
Patient selection and indications
Any patient with Fitzpatrick I–V skin seeking mild facial rejuvenation.
Pre-operative preparation
Discontinue tretinoin 3 days prior to procedure. All makeup is removed. External eye shields are placed on the patient.
Technique
The procedure is performed by using the erbium laser with the computer generator set at 10 microns ablation (2.5 J/cm 2 ) with a 50% spot overlap to give the most confluent pattern overlap. A chiller (Zimmer) is used to blow cold air on the face for analgesia. The face is lased.
Post-operative care
A mildly occlusive gel is placed for a few hours. No adjunctive antibiotics or antivirals are given.
Microlaserpeel™
The mainstay of our superficial erbium resurfacings is called the microlaserpeel™ (MLP). This procedure was developed to treat mild to moderate photodamage utilizing a topical anesthetic and a limited healing period. Complete epidermal obliteration was outside the intended recovery period anticipated and by previous experience and trial and error we found this to be true. As epidermal facial depth varies from approximately 60–100 microns depending upon facial area and variations in skin thickness, we defined this procedure as a laser peel under 80 microns of depth ( Table 3.1 ).
| Area | Fluence-ablation J/cm 2 | Fluence-coagulation J/cm 2 | Passes | Density % |
|---|---|---|---|---|
| Forehead | 12.5–17.5 | 0 | 1 | 30–50 |
| Periorbital | 12.5–17.5 | 0 | 1 | 30–50 |
| Periorbital (extended Microlaserpeel™) | 15–20 | 12.5–25 | 2 | 50 |
| Perioral | 12.5–17.5 | 0 | 1 | 30–50 |
| Cheeks | 12.5–17.5 | 0 | 1 | 30–50 |
| Neck | 10 | 0 | 1 | 30–50 |
| Chest | 2.5–5 | 0 | 1 | 30–50 |
Patient selection and indications
Any patient with Fitzpatrick I–IV skin seeking moderate improvements in fine lines, wrinkles and textural anomalies.
Pre-operative preparation
Discontinue tretinoin 3 days prior to procedure. Effective topical anesthetics are crucial to this procedure. We have tried various commercially available and custom compounded agents but have found the best for us is custom-compounded 5% lidocaine/3.5% prilocaine in a methylcellulose base. Newer commercial products include a cream containing 7% lidocaine and 7% tetracaine (Pligalis®, Galderma) that air dries to form a peel-away self-occlusive membrane. Proper skin degreasing and makeup removal with alcohol is essential to the absorption of the topical anaesthetic. Occlusion for 45–60 min of topical anaesthetic with a plastic wrap helps absorption. An anti-inflammatory such as ibuprofen given prior to the procedure helps with pain during the procedure and helps alleviate the common short term burning sensation experienced post procedure. The Zimmer chiller used as an adjunct to the topical helps as well. Finally, timely lasing following removal of the anaesthetic gel is important. Prompt application of Aquaphor or Vaseline helps with post-operative pain. These caveats, while simple, seem to improve the procedure as noted by our experience and that of others attempting to perform this procedure. Internal or external eye shields are used.
The use of antiviral agents was originally thought unnecessary due to the non complete epidermal ablation. However, the outbreak of 2 of the first 8 patients not prescribed prophylactic antiviral agents with herpes simplex infections led us to prescribe antiviral agents and antibiotics to all patients as previously outlined in the carbon dioxide literature.
Technique
The procedure is performed by using the erbium laser with the computer generator set at 20–80 microns ablation (5–20 J/cm 2 ) with a 50% spot overlap to give the most confluent pattern overlap. A chiller (Zimmer) may be used as an adjunctive technology to blow cold air on the face for analgesia. The face is lased to just below the mandible. A lesser fluence is used to blend into the neck.
Post-operative care
All patients have an occlusive agent such as Vaseline or Aquaphor put on after the laser procedure. The agent is reapplied as needed to keep the skin moist and occluded until epithelialization is complete. Three to four daily washes of dilute peroxide are also used to clean the skin. Following epithelialization, a moisturizer such as Cetaphil is used as well as a sunblock. Avoidance of sun exposure is critical to prevent hyperpigmentation. The post treatment of most patients with a skin care regimen containing tretinoin is our belief in long term skin improvement with tretinoin containing-regimens. The implementation of tretinoin and a bleaching cream (hydroquinone 4%) at 1–2 weeks post procedure has led to a low incidence of temporary post inflammatory hyperpigmentation. Gradual introduction of this regimen is needed to avoid irritant dermatitis. Use of LED technology post procedure may improve healing times. We do not feel that there is any need for skin pre-treatment with these agents as prophylactic post-treatment appears to be sufficient to avoid pigmentary complications. This appears to be of considerable advantage over the Obagi Blue Peel and other TCA peels that seem to work better with skin pre-treatment. In fact, the combination of a Microlaserpeel and skin care appears to be a head start to a skin care regimen especially for those people seeking quicker results than can be achieved from skin care alone. Currently, we perform sequential MLP and fractional erbium resurfacing in the majority of our patients as we have observed increased efficacy over MLP alone with similar downtime.
The development of the extended Microlaserpeel™ arose because many patients sought consultation for loose lower eyelid skin with or without excess fat. We simply chose to perform a deeper lower eyelid resurfacing with infiltrative eyelid anesthesia and occasional transconjunctival blepharoplasty and perform a Microlaserpeel™ of the rest of their face for confluence. Similarly, deep perioral resurfacing has been combined with superficial full facial resurfacing.
The neck and chest resurfacing also grew from the original facial resurfacing to even the skin texture. Neck resurfacing has been controversial but at the light settings we have performed appears to be safe with minimal morbidity. Note that chest resurfacing may take a long time to heal and that older patients may have extremely thin skin and that while 20 microns of ablation is adequate for younger patients 10 microns of ablation may lead to delayed healing in some older patients.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
