Laser skin resurfacing is a procedure that uses lasers to create a new, smooth skin appearance.  The laser “ablates”, or destroys, the outer layers of skin which have been damaged by age, sun, acne, wrinkles, or pigmentation problems or spots.  The destruction of the older layers of skin prompts the body to generate a new layer of skin cells which are unaffected by the previous skin condition.  Some lasers may be inappropriate for darker skin complexions.

Reasons for Considering Laser Skin Resurfacing:

• Reduce  facial wrinkles
• Improve sun-damaged skin
• Correct pigmentation problems and spots
• Improve scars from acne, birthmarks, moles, and tattoos
• Tighten skin that has lost elasticity due to aging

General Procedure

First, the face is cleansed of oils in order to prepare for the laser procedure, and an antibiotic ointment is applied.  The laser is then used to ablate various layers of skin in a controlled manner until the appropriate depth of skin is reached.

Recovery Process

Generally, post-operative instructions call for rest and limited movement.  Antibiotic cream and bandages are applied to the affected area immediately following surgery in order to aid with the healing process, to minimize swelling, and to control the risk of infection.  The skin will be red and will ooze.  Discomfort is expected to be similar to other types of burns.

Patients can minimize potential problems by carefully following the post-operative directions.   Recovery time varies with the extent of the resurfacing and the number of procedures completed.

The following article was writter to inform other types of doctors about this category of procedures.

SKIN “RESURFACING”

“Skin resurfacing” is a phrase which encompasses the use of any means to remove a significant portion of the surface of the skin, with the expectation that regeneration will result in improved skin characteristics. Several of the modalities used to remove the skin surface are various types of lasers, harsh chemicals, and abrasion techniques (“dermabrasion”). Benefits are roughly proportionate to the amount of “injury” induced upon the skin. This article is not intended to discuss very superficial exfoliative skin treatments.

The advantages of skin resurfacing include: a reduction in the depth of surface irregularities such as rhytids (wrinkles) and acne marks; improvement of hyperpigmented areas, and removal of certain exophytic skin lesions. In addition, injury to the underlying dermis can cause the production of new collagen, which partially reverses solar elastosis seen on histologic examination of sun-damaged dermis. This effect on the dermis also shrinks and tightens the skin.

To understand more about resurfacing, it is helpful to review each of the major therapeutic modalities used. The mechanism of action of lasers (acronym for light amplification by the stimulated emission of radiation) is as follows: the energy of the intense monochromatic light is absorbed by target tissue of the appropriate color, causing very high temperatures. This literally evaporates the target tissue. The energy of the Erbium YAG laser (wavelength 2940nm) and the CO₂ laser (wavelength 10,600nm) is absorbed by water. Because skin contains water, skin is burned off by these lasers. The depth of this burn can be controlled with a fair degree of precision. The CO₂ laser produces more collateral heating of the subjacent dermis than other skin resurfacing modalities. This dermal burn results in some tissue dehydration and constriction (“tightening”). In areas of the face where there are fine rhytids, such as the “crowsfeet” lateral to the orbits, the CO₂ laser can often obtain the maximum improvement with slightly less postoperative pain than other resurfacing modalities. There is also a laser which simultaneously cools the skin surface and penetrates to burn the dermis, causing it to shrink. But the quantity of shrinkage is limited by the amount of dermal burn, which could cause devascularization of the overlying skin.

The many chemicals (mostly acids) which are used for “chemical peels” cause a coagulation necrosis of the surface of the skin. The strength of the chemical, its concentration, and the length of time it is applied are factors controlling the depth of the burn. Over-the-counter chemicals such as alpha-ketoglutaric acid, glycolic acid, “fruit acids”, etc. are more like skin care exfoliants.

Dermabrasion is often applied with a diamond-impregnated wheel approximately 1.5 cm. in diameter on a low speed handpiece. Several configurations and sizes of wheels are available. Many plastic surgeons feel that dermabrasion gives the best results for vertical lip rhytids and mildly indented acne scars. “Microdermabrasion” is a more superficial sandblasting-like technique, which is more like an exfoliant. Microdermabrasion causes a mild first degree burn effect, and thus less improvement than skin resurfacing.

The depth that the resurfacing technique is carried into the skin is critical. Each technique essentially produces a second degree burn. The epidermis regenerates from epithelial cells left behind in the depth of sebaceous glands and hair follicles. When a very superficial second degree burn heals, the skin is not very different from its pre-injury state. A deep second degree burn produces the maximum change from the preoperative condition. If the injury is a little deeper, it destroys the regenerative epithelium in the hair follicles, sweat glands, and sebaceous glands. This would cause a third degree burn, resulting in terrible scarring unless skin grafts are applied. Skin grafts usually have a different color and texture from the surrounding skin. Fortunately, the face has a relative abundance of adnexal glands when compared to the neck and hands. Thus, only superficial methods of resurfacing can be used on the neck and hands. Also, oral retinoids (such as Accutane) change the sebaceous glands, causing a high risk of scarring after resurfacing. Bacterial and viral (herpetic) infections are not uncommon unless the patient is pre-treated with antiviral and antibiotic medications. Fungal infections are less common. Patients must be watched very carefully, as a minor infection would deepen the level of injury.

As would be expected, the postoperative pain and the length of time in recovery are proportional to the depth of the injury. The degree of discomfort is considerable, as one who understands the process would expect. The principles of postoperative management are to prevent the exposed tissue from desiccating by using occlusive dressings or a Vaseline-based product. Desiccation would deepen the level of tissue injury, and this could cause a third degree level of injury. On the other hand, Vaseline or occlusive dressings can induce acne, which can pre-dispose to bacterial infections such as impetigo. It is normal for the area to ooze serum for about two weeks, and it is important to keep crusts from staying on the treated area. New pink skin then becomes evident. Soon afterward, the resurfaced area takes on a sunburn-like appearance. It takes two to six months for this erythema to fade. In general, the longer the sunburned appearance lasts, the more improvement in skin smoothness that will be attained. Make-up with a greenish hue can be used to mask the reddish skin color. Patients need to be apprised of the difficult recovery period, and they often require significant reassurance and support following the procedure.

One of the side-effects of skin resurfacing, skin lightening, results from the fact that melanocytes are more susceptible to injury than the keratinocytes in skin. This usually causes a permanent decrease in skin pigmentation that is proportional to the degree of skin injury. Thus, the treated area looks lighter in color, and thus treatment has to be “feathered” into adjacent untreated areas to prevent sharp color demarcations. This loss of pigment results in less protection from the ultraviolet rays from the sun. Treatment with skin bleaching agents, such as hydroquinolones, prior to resurfacing partially protects against obvious postoperative hypopigmentation. True to logic, the more smoothness that is attained, the more noticeable will be the hypopigmentation.

Importantly, even minimal exposure to ultraviolet light during the first several postoperative months (such as inside a car on a sunny day without sunscreen) can cause darker hyperpigmented patches on the skin. This effect of resurfacing on melanocytes also means that extreme caution and skill are required to treat people of color with skin resurfacing techniques.

This overview of skin resurfacing reveals that there is as yet no easy and risk free method of obtaining smooth and youthful skin. Some other approaches include good skin care, fat grafting to fill out areas, Botox, and surgical skin tightening.