Introduction

Fine lines, and wrinkles are the inevitable long-term effects of aging, sun damage, and smoking. In addition many individuals also suffer from the permanent effects of acne or chicken pox. In the past, methods such as dermabrasion and chemical peeling were used to resurface or smooth out and improve skin surface irregularities. The main working principle in either of these methods was to remove the top layer of creased or uneven skin to thus give the skin a smoother look. However, since the recent refinement of laser technology these methods have been superseded.

Lasers in medicine have been around for a number of years and have always been synonymous with "state of the art". Through constant development and research, laser technology eventually linked with computer technology, and the skin resurfacing laser was created. This undoubtedly has been one of the most exciting recent developments in cosmetic surgery. Although many lasers now exist for different purposes, there are now two main types use for resurfacing, the carbon dioxide laser (CO2) and the fractional laser . Both can be very effective in rejuvenating aging skin particularly around the mouth and eyes. Often the procedure is done in conjunction with another cosmetic operation such as facelift or eyelid surgery. Certain skin blemishes, moles and warts can also be addressed with laser. Laser resurfacing is also suitable for treatment of the neck, hands, and even chest.

As mentioned laser resurfacing is also effective for reducing hypertrophic as well as acne scarring and sometimes-even stretch marks. Some types of scarring however, such as the so-called "icepick" type of acne scarring may be best treated, initially at least, surgically.

It is important to understand that only finer lines can be completely eradicated with this procedure. Deeper wrinkles or smile line etc. can only be reduced in depth and not removed altogether. In these cases, the improvements are in the order of about 50%. Additionally laser skin resurfacing will not remove dynamic lines where the skin is attached to the muscle, such as the nasolabial(nose to mouth). These are naturally occurring creases and therefore cannot be eliminated altogether by laser treatment - they need fillers or Botox.

How does it work?

Bluntly speaking, laser resurfacing is using a laser to resurface the skin and supporting tissue beneath the surface. The software within the machine allows the surgeon to regulate the depth of penetration to safe levels, in order to allow even delicate areas of the face to be treated. The technique works by passing a beam of laser light of high power but very short duration (millionths of a second) onto the skin surface. It is in fact this phenomenal speed and varying wave lengths which limits the spread of the generated heat to deeper tissues, thereby limiting any risk of scarring.

CO2 Lasering

In case of a CO2 lasering the top layer of skin is then effectively boiled away in a plume of vapor (termed vaporization). What remains is a powdery residue of debris, which is rubbed away with a gauze pad saturated with saline solution, exposing a pink underlay of skin, the dermis much like what you have under a blister! A second pass with the laser will visibly tighten and shrink the naturally occurring collagen in the dermis and smooth the skin. As the laser successful seals all blood vessels during this event, the procedure remains bloodless.

Fractional Lasering

The fractionated lasering works differently by going 5 times deeper than CO2 but not vaporing the surfacing skin. Essentially columns of lasering is done each time so you need 4-6 treatments to get the whole surface treated. The good news is there is no blistering, swelling for only a few hours, so essentially no down time!

Fractional or CO2?

You must decide with your doctor, which is best for you. The CO2 is most dramatic in removing sun damaged, stained skin but the week of raw skin and prolonged redness has made most people prefer the Fractional Laser.

Am I suitable for this type of surgery?

Only a consultation can determine this. During your consultation, Dr. Loeb will ask about your general medical history including details about any skin conditions or treatments you may be or have been taking. Any history of keloid or unfavorable scarring must be mentioned. If the problem to be treated is acne scarring, then one must ensure that the acne is no longer active. If it is, treatment with the drug accutane may be necessary. It is however imperative that one waits 12 months after completion of an accutane treatment before commencing any laser resurfacing.

If you have had problems in the past with cold sores on your face, Zovirax, an antiviral medication, will be prescribed prior to treatment in order to minimize the chance of this occurring.

The color and texture of your skin will then be assessed. You will look at examples at least 50 patients as part of your consultation. Caucasians with fair skin are the best candidates. Patients with darker skin such as those Asians or Mediterranean background are at a higher risk of color changes developing after the treatment and therefore will be advised accordingly. Patients of Afro-Caribbean descent may be unsuitable candidates due to the permanent and profound color changes encountered following treatment, so test areas must be done.

If you are a smoker you will be asked to stop smoking well in advance of surgery. Smoking seriously constricts blood vessels and therefore decreases blood flow to a given area resulting in poor healing.

Two drugs in one cream are used routinely one month prior to CO2 laser treatment: Retin-A and a bleaching agent Hydroquinone. Retin-A helps prepare the skin for the laser treatment by causing the upper dead layers of the skin to peel and flake. It also aids with healing after the laser treatment. The bleaching agent is important in that it reduces the production of pigment in the skin, considerably reducing the risk of color changes after the laser treatment. In many instances these creams are also used postoperatively.

Please no sun tanning or burns one month prior to treatment!

What type of anesthetic is used?

Fractional laser is usually done with no anesthesia and feel just like a minor sting. Depending on the area to be treated, CO2 laser resurfacing can be performed with a local anesthetic. Full-face treatment however may be more appropriately performed under sedation with intravenous drugs and an anesthesiologist.

How long does the surgery take?

Treatment itself is usually swift with specific areas such as the eyes and mouth requiring 15-30 minutes. A full-face treatment will however require 40-60 minutes. Usually 1-2 passes of the laser are adequate for most cases although in certain acne scarring cases up to 4 passes may be necessary to achieve the desired result.

What kind of after effects can I expect?

Due to the nature of the laser, there are after effects that invariably will be experienced in the recovery period. Although some may be regarded as complications, others are natural effects from the laser treatment and usually resolve. It is imperative therefore that any prospective candidate be fully aware of these proceeding. A thorough understanding of these effects will help every treated patient along the prolonged road to recovery.

Fractional laser patients have redness and swelling for only a few hours. However in CO2 resurfacing prolongs postoperative redness always occurs after laser resurfacing. This lasts from 3-6 months. Some patients find this resolves sooner, while others may find it takes longer. Thankfully however a light coat of make-up easily masks this. Once this has faded however, some patients may notice a difference in shade between the treated and non-treated areas of skin. In some cases however, the skin may appear paler in color while in others darker. If this occurs, then a period of up to 18-24 months may be required before the color evens out. In many circumstances however this may remain permanently.

What should I expect after surgery? CO2 patients only!

This only applies to CO2 laser patients.

Following the CO2 resurfacing your skin will look red, sore and swollen. As a result, depending on the area treated, you will have either a layer of ointment applied on the skin or a light white colored dressing which will be used to absorb some of the fluid which leaks from your skin (called serous fluid) after this treatment. Many times the rate of this fluid production increases dramatically over the first 36-48 hours before starting to decrease again at 4-5 days.

The swelling of the face usually increases on the second day after treatment and may include the neck. The steroid(Medrol) dose pack will help this. When the eyelids have been treated, the swelling can be so marked that the eyelids remain closed. This may be associated with a degree of conjunctivitis (red eyes). You will be prescribed an antibiotic ointment to combat this, which incidentally can make the eyesight blurry temporarily after application.

Between days 2-4 days you may develop yellowish plaques on the surface of the skin, which essentially consist of a mixture of the ointment and serous fluid. These will be soaked off according to the scheduled regimen of care, which you will be given.

Between days 4-5 the skin becomes very red with the appearance of severe sunburn. This redness will fade gradually over the next 2-4 months. Once healing has occurred and the skin has completely dried out (7-10 days), make-up can be worn. It is important though to be gentle when removing the make-up in the first 2 weeks to avoid irritating the new skin.

Itching frequently occurs in the first 3 weeks after treatment. A topical steroid will be prescribed to reduce this itching as well as the accompanying redness. Cool compresses are also quite helpful in reducing the itchiness. A bleaching agent may also be prescribed to minimize postoperative darkening of the skin.

In the first weeks after the treatment it will be essential to moisturize your skin as often as possible to avoid and drying out effect. Sun exposure must be avoided at all times during the healing phase and up to one year following the treatment. You will need to apply a sunscreen of SPF15 or higher.

Your skin will be extra sensitive during this time, and therefore unnecessary sun exposure will result in sunburn and patchy skin color changes.

You will be followed carefully during the healing phase and as such, modifications, instructions and additional recommendations may be made as necessary.

Is it painful?

Pain is variable and differs from individual to individual. Most patients usually describe this as bad sunburn or stinging type pain. CO2 will be prescribed painkillers in the first few days in order to reduce the pain. If you will keep the ointment on and prevent drying out, it is usually not painful. Fractional patients do not need pain meds. They may feel like they have a sunburn.

What could go wrong?

When a qualified experienced surgeon or technician performs laser resurfacing, complications are infrequent and usually minor. However because individuals vary greatly in their anatomy, their physical reactions and their healing abilities, the outcome, is never completely predictable.

A few patients who have had lasering to the lower eyelid area may report an uncomfortable tightening of the skin in this region. This is as a result of the collagen shrinking effect of the laser. Although this may lead to a slight pulling down of the eyelid, this is usually temporary and resolves with regular massaging. You will be instructed accordingly if this develops.

Cold sores may develop following laser to the lips or in fact any part of the skin, particularly if you are prone to developing them. While Zovirax cold sore medication is usually given prior to surgery, this risk cannot be eliminated. Although particularly unpleasant, fortunately this ultimately resolves on its own within 7-9 days. This should not influence the ultimate result.

The appearance of milia or tiny white cysts frequently arises as a result of the skin pores blocking up. Careful cleansing and avoidance of excessive moisturizers improves this. Occasionally, particularly in patients with a previous history of acne, flare-up of the acne can occur. If this were to happen, long term antibiotics would then usually be administered.

Although using well-established and accepted parameters of laser settings significantly reduces the possibility of scarring, nonetheless scarring may result in about 1-2% of patients having this treatment.

The quality and appearance of any developing scar is variable and impossible to predict. Scarring may occur both on the skin and within the deeper layers of the skin. If this were to develop then subsequent treatment may be necessary to try and improve this. However despite all best efforts and intentions there can be no guarantee that any arising scars would be eliminated. In these rare circumstances therefore it would be fair to say that patients treated with the laser skin resurfacing technique may end up looking worse off.

How long before I can get back to normal?

Fractional laser patients get back to normal within hours. With CO2 lasering you will be aware that your skin will be bright pink to red and will feel very tight. You will quickly learn to use makeup to conceal these temporary color changes until it fades. Once the skin is ready to accept make-up (usually about 10 days) then you should be able to return to many of your normal activities. Make-up however will be an essential part of your daily regimen for the first few months. The liberal use of moisturizers will also be an important pat of your daily skin car regimen in order to maintain skin suppleness.

In the months following treatment, it is imperative to protect the treated area from the sun until your color has returned to normal (usually about 6 months). Regular sun protection in the form of sun blocks with SPF of 15 or higher, will help maintain your results and reduce the chance of any new sun damage to your skin.

Summary

It's important to understand that although your results will be long lasting not all of these will be permanent. Remember that no one is immune to the effects of aging and thus in the months and years following your laser treatment, your natural facial movements will eventually cause any expression lines to recur. Protecting yourself from the sun and following a good skin care regimen will help maintain your rejuvenated look.

Laser skin resurfacing is without a doubt an important adjunct in cosmetic surgery of the face. In fact, for many of the effects of the aging process, such as the development of lines around the mouth and eyes, laser resurfacing is unsurpassed; it can deliver some spectacular results. Although the recovery period is prolonged, the patient who has undergone laser skin resurfacing will ultimately be rewarded with a fresher, smoother appearance of the skin.