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Laser Skin ResurfacingThe hi-tech and expensive equivalent of dermabrasion and chemical peels, Laser skin resurfacing is mainly performed with either carbon dioxide or Erbium:YAG lasers. Although carbon dioxide Lasers have been in medical use since the 60's as cutting tools it is only in the last few years that technological advances in laser design have allowed the laser beam to hit the skin surface for less than the thermal relaxation time of skin i.e. 695 microseconds allowing controlled vaporisation of skin with minimal unwanted "collateral" heat damage. Skin resurfacing is used principally for improving scars caused for example by acne, chicken pox or trauma and for improving the appearance of photo damaged skin. It may also be used to remove some skin lesions such as epidermal naevi or congenital pigmented naevi although I believe the results of these latter treatments depend on the depth of the naevus cells in the dermis. Hairy naevi which tend to penetrate deeper I find respond poorly. I believe that at present all such lesions should be biopsied prior to treatment and an audit of all results made. The advantage of laser skin resurfacing over older resurfacing procedures is that it allows accurate depth control with distinct colour changes as the injury becomes deeper, namely pink in the epidermis, grey in the papillary dermis and yellow in the reticular dermis in the case of carbon dioxide lasers and bleeding patterns akin to that seen when taking thin or thick split skin grafts when using the Erbium lasers. With carbon dioxide lasers the skin surface is vaporised in layers of about 65 microns with a zone of "collateral" damage of about 75 microns while Erbium: YAG lasers which have a higher absorption coefficient vaporise about 25 microns with a zone of "collateral" damage of about 5 microns. Clearly these figures will vary with different power settings. More rapidly pulsed or scattered carbon dioxide lasers will vaporise thinner layers with less "collateral" damage than the original Coherent Ultrapulse with its 314 microsecond pulses or the scanned continuous beam of the Sharplan Silktouch. These newer lasers along with the Erbium: YAG lasers tend to give shorter periods of redness although redness does vary with the depth of injury and also between different individuals. Although the redness can be distressing the formation of new collagen is important to the long term result of laser resurfacing and my impression is that lasers which cause hardly any redness do not give quite such a good long term result. Many resurfacing procedures require repeat treatments to get the best result and many patients are happy to have a shorter period of redness and accept they may need an extra treatment. New collagen formation seems to continue for about one year although this data is derived from the older lasers. We are currently conducting a trial of carbon dioxide versus Erbium: YAG versus combined carbon dioxide/Erbium: YAG treatment in terms of new collagen formation over a one year period in our unit. Suitable patient selection and counseling is vitally important in laser resurfacing as there has been a lot of media hype about this treatment. All patients will have a raw, weeping, uncomfortable superficial burn for about one week. Treatment in this initial period may either be open, with regular cleansing and the application of for example Vaseline to keep the wound moist, or closed with dressings. I prefer the open technique but do not think there is much to choose between them. Both clearly work. Infection of the superficial burn, either bacterial, viral or fungal could potentially cause scarring if not promptly treated, although this is rare. Skin erythema (redness) will last for 5 weeks to 6 months depending on which laser is used, the depth of injury and individual variation. Blushing may cause increased redness in the treated area even after this. Hyperpigmentation may be a problem particularly in darker skin types and is related to the post laser inflammation. Conversely, hypopigmentation may occur if the resurfacing has damaged the melanocytes. The latter is commoner in my experience with carbon dioxide lasers. Acne may flare up in susceptible individuals and require treatment. The role of adjuvant treatments is much debated and largely based on anecdote. Acyclovir should certainly be given to patients with a history of cold sores. Some people give it to all patients. Antibiotics given prophylactically can lead to infections with resistant bacteria and as in accidental burns I believe antibiotics should be used only when there is evidence of wound infection and wound swabs have been taken for culture. Pre and late postoperative skin care with Retin A or alpha hydroxy acids may enhance results and can be combined with hydroquinone in patients at risk of hyperpigmentation. It is often wise to perform a test patch in such patients first. Corticosteroids have been used particularly in the U.S.A. to limit erythema although as noted above the inflammation which causes erythema may in fact enhance the long term results. There remains a need for well conducted trials comparing different lasers used for resurfacing and particularly of adjuvant treatments. Training for laser operators needs to be better regulated as many people with very limited knowledge of lasers or laser safety and even less in the care of burn wounds are jumping on the laser resurfacing band wagon. Used properly, however, resurfacing lasers are a useful additional tool in managing patients with disfiguring problems such as acne scarring, with a degree of control not previously possible.
Skin Resurfacing using the CB Erbium:YAG LaserSkin resurfacing using a pulsed CO2 laser, has been available in the UK for less than three years. Even in the United States, where this laser was developed, the laser has been in use for less than six years. However, the results of skin resurfacing using the pulsed CO2 lasers are usually good in patients who have either acne scarring or unwanted wrinkles but there are some problems. One problem with a pulsed CO2 laser is that anaesthesia of some sort is necessary because this laser produces pain when it is used on the skin. In some patients, it is difficult when using local anaesthetics to completely anaesthetise the skin in the area that is being treated and, because of this, some patients prefer to have their resurfacing procedures carried out with a pulsed CO2 laser under a general anaesthetic. In addition, there is often quite severe and persistent redness after the skin has healed and this may last up to three months in some patients, particularly in those with a fine, delicate, white skin. The persistence of this redness is both undesirable and a worry to patients. Moreover, there is a significant risk of pigmentary change in the skin following a resurfacing procedure carried out with a pulsed CO2 laser. Increased darkening of the skin is one of the commonest complications following skin resurfacing with a pulsed CO2 laser and is more likely to be seen in patients who pigment easily or in patients who have previously been troubled with melasma (increased pigment on the facial skin, usually associated with either pregnancy, or the contraceptive pill). There is also a significant risk of permanent hypopigmentation (lightning of the normal skin pigmentation) following the use of a CO2 laser and this may occur many months after the resurfacing procedure has taken place. The Erbium:YAG laser, however, emits infrared light at a much shorter wavelength than the CO2 laser because of this the laser energy from the Erbium:YAG laser is taken up 10 times more avidly by water in the skin so that treatment of the skin with this laser is much less painful than with the CO2 laser. This means that most minor resurfacing procedures on the face, for instance, for wrinkles on the upper lip, or for acne scarring on the cheeks, can be carried out merely using a local anaesthetic gel or cream. A general anaesthetic is rarely required, unless the acne scarring is extremely extensive or if the eyelids require treatment. In contrast with the pulsed CO2 laser, there is much less redness after the skin has been treated with the Erbium:YAG laser and any redness which does develop fades much more rapidly than with a pulsed CO2 laser and usually in less than one month after treatment. Abnormal pigmentary change in the skin is much less likely to happen with the gentle Erbium:YAG laser because this laser causes so little damage to the underlying skin, and pigment cells in particular. The Erbium:YAG laser, therefore, is the laser of choice for patients with more pigmented skin, or in patients where it is envisaged significant pigmentary problems my occur. Other advantages of the Erbium:YAG laser are that it can be used to resurface skin, and scars in particular, on other body areas away from the face. It can also be used to remove moles, and other small lumps and bumps on and around the face, almost painlessly. The Erbium:YAG laser is ideal to re-treat any wrinkles or acne scars that may not have responded well to an initial treatment with a pulsed CO2 laser.
Post Operative Care – Lasercare ClinicsFollowing a skin resurfacing procedure, using either a pulsed CO2 or Erbium:YAG laser, your skin will appear red and weepy. It will take between five to seven days before your skin heals and, during this time, it is very important to remove any crusts that may build up on your skin. Most patients find Vaseline, applied two hourly during the day time, to be the most effective and soothing topical medication at this stage. For the first two or three nights after the skin resurfacing procedure, you may find that Vaseline gauze applied to the treated skin, after it has been first liberally covered with Vaseline, would be the most soothing dressing. Once the skin has healed, small crusts that have developed can then be removed gently, using water containing a little white vinegar. This can be prepared by adding five or six drops of vinegar to a cup of water at a comfortable temperature as far as the skin is concerned. Some pinpoint bleeding after an Erbium:YAG resurfacing procedure is normal and usually doesn’t cause any great problems. It is important to remove dry blood from the face to minimise the risks of infection. If you have had a General Anaesthetic, it is important that you do not drive for 24 hours and that, when you go home, there is someone at home all the time for at least 24 hours to look after you. Please note that it is quite usual to get some swelling around the eyes, particularly if the resurfacing procedure has been carried out in this area. This may take three or four days to disappear. Infection of the skin following a skin resurfacing procedure is rare and often antibiotics are not required. It is important to continue taking Acyclovir for the full five day course if you are prone to cold sores on the face. Otherwise, this treatment is not necessary, although a small proportion (about 6%) of treated patients without a history of cold sores may develop this complication. It is very important to let your doctor know if you develop any blisters or pustules in the treated area. If you are not a good sleeper, you may find that you will need to take a sleeping tablet for two or three nights to help you sleep after an extensive facial resurfacing procedure. It is very important that you let your partner or your family know that you are having a resurfacing procedure carried out, otherwise your appearance may give your partner quite a shock! It is best not to put on any make up until at least ten days after your skin has healed. This is because the skin is readily sensitised following a resurfacing procedure to anything potentially sensitising such as cosmetics applied to it. Please note that the redness that follows a skin resurfacing procedure is entirely normal. This is always much more marked following the use of the CO2 laser than with the Erbium:YAG laser and persists much longer. The redness can be very marked, especially in fair skinned individuals and can persist for up to three or four months following the procedure. It is nothing to be alarmed about and, in exceptional circumstances, can be treated using another laser called the Pulsed Dye Laser if individual patients find it aesthetically displeasing. It is known that the beneficial effects on your skin of the resurfacing procedure can be augmented and perpetuated by the regular use of retinoic acid topically. Most patients can begin this treatment once daily each evening to the facial skin about three weeks after the skin has healed. Once more however, fair skinned individuals with delicate white skin may have to wait much longer before they can use retinoic acid. It is important to use an Ultraviolet light blocker on the skin on a regular basis, beginning about ten days after the skin has healed. This is best applied each morning and should be used regularly thereafter. Your Consultant will advise you on which strength of ultraviolet light blocker is required in your individual case. The regular use of an ultraviolet light blocking cream on the skin minimises the risk of the development of pigmentary change in the treated area, but the risk of skin darkening after a resurfacing procedure carried out with the Erbium:YAG is much less than with the pulsed CO2 laser. Please note that the best results after a resurfacing procedure are seen 6 - 10 months after treatment and are due to new collagen formation under the site of your wrinkles or acne scarring. Do not feel despondent because you can still see wrinkles or scarring immediately after your treatment. Your laser resurfaced skin will usually continue to improve with time up to ten months after the procedure.
Further reading: Books and References
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The Disfigurement Guidance Centre |
