♦ General Considerations

Although skin resurfacing is recognized as a component of facial rejuvenation that equals or, in some cases, exceeds the importance of surgical lifting procedures, the search for an effective, precise, and relatively complication-free method of resurfacing continues.

The application of laser technology to cutaneous resurfacing ushered in a new age of operator-controlled skin peeling, an exciting development given the fact that chemical peeling, the previous gold standard of resurfacing, exerted its effects via a self-limiting chemical interaction with the skin that was not entirely under the control of the operator (even though its proponents argued that the self-limiting nature of the reaction provided an inherent margin of safety).

Indeed, the advent of the laser age did prove that, although operator controllability offered distinct advantages, it was, in actuality, a double-edged sword. In many cases, well-intentioned attempts to extend the therapeutic envelope with “one more pass” too often resulted in production of sufficient additional thermal damage to substantially prolong healing and, in some cases, to sabotage the clinical efficacy of the procedure as a result of complications, most notably pigmentary disorders and hypertrophic scarring.

These concerns have had particular influence in application of current technology to resurfacing of the Asian face. Although sporadic reports of successful skin resurfacing in this population using various types of lasers have appeared in the literature, most surgeons remain reluctant to employ these modalities in the Asian face.

An ideal skin-resurfacing method would be characterized by operator controllability coupled with an inherent margin of safety, resulting in an acceptable rate of healing and low incidence of complications. Radio-frequency resurfacing (Coblation, ArthroCare Corp., Sunnyvale, CA) exhibits a therapeutic profile that more closely approximates the characteristics of an ideal method than most other currently available modalities. Coblation provides, by virtue of its mechanism of action, a margin of safety that exceeds that of carbon dioxide (CO₂) laser systems. While early clinical reports suggested that the clinical efficacy of radio-frequency resurfacing fell between that of CO₂ and Erbium (ER:YAG) lasers, more recent reports suggest that aggressive use of the radio-frequency unit (i.e., a greater number of passes) produces clinical improvement approximating that of the CO₂ laser while maintaining the healing profile of the Er:YAG laser.

I have found that radio-frequency resurfacing produces excellent results in the Asian face, although the time requirement for complete healing is somewhat longer than in the Caucasian face. Of special importance is my observation that the most debilitating pigmentary complication of resurfacing, hypopigmentation, has not occurred during my experience with this procedure.

♦ Mechanism of Action

Figure 7-1 (A,B) Radio-frequency resurfacing device with wand used for skin contact.

Histologic studies of skin subjected to radio-frequency resurfacing show that the first pass results in ablation of the epidermis (20–40 millimicron zone of ablation) accompanied by a 10 millimicron zone of collateral thermal injury. A second pass increases the collateral injury zone (dermal) to ~50 millimicrons without actual ablation of the dermis, and a third pass increases the depth of thermal injury to ~80 microns. Subsequent passes result in minimal additive effect with regard to thermal injury of the dermis. These findings contrast with the effects of the CO₂