Treatment of the Aging Face: Facial Resurfacing Strategies

Richard Castellano, MD1

1 Address for correspondence and reprint requests: Stephen W. Perkins, MD, FACS, Private Practice, Meridian Plastic Surgery Center, 170th W 106th Street, Indianapolis, IN 46290.

2 Dept. of Otolaryngology-Head & Neck Surgery, Indiana University School of Medicine, Indianapolis, IN.

Telephone number: (317) 575-0330

Email address: SWPerkins@aol.com

Fax number: (317) 571-8667

Table of Contents Introductory Sentences

Resurfacing of the skin plays a substantial role in facial rejuvenation. To better prepare the cosmetic surgeon for this endeavor, we have set out to define aging skin changes, review resurfacing indications, outline and compare various resurfacing practices, and discuss anticipated outcomes in our experience and in the current literature. We have found appropriate patient selection, counseling, and technique have yielded a consistent result with a high degree of patient satisfaction. Furthermore, outcomes are maximized when one takes advantage of multiple modalities, combining resurfacing techniques, or combining resurfacing with surgical rejuvenation.

Treatment of the Aging Skin

Today’s facial plastic surgeon may employ a variety of modalities for rejuvenation of aging skin. Benefiting from the contributions of dermatologists, plastic surgeons, and facial plastic surgeons, this technique has evolved into a sophisticated science. There is a common goal of patients to reduce rhytids, dyschromias, solar changes, and superficial scarring, and this is contrasted with a multitude of treatments available to achieve these results. We have found that the best outcomes are achieved by utilizing a combination of these modalities to customize resurfacing to the type and location of facial skin. The goal of this paper is to define aging skin changes, review resurfacing indications, outline and compare various resurfacing practices, and discuss anticipated outcomes in our experience and in the current literature.

Patient Selection

Evaluation of the aging face begins with a complete medical history. Previous use of retinoids (isotretinoin Accutane), prior cosmetic procedures, abnormal scarring, herpes simplex virus (HSV) infection, prior radiation therapy, cardiac disease, hepatic or renal insufficiency, medications, skin sensitivities, and allergy history must be documented.

Increased scarring has been noted in patients undergoing facial resurfacing while on isotretinoin.9 It is therefore recommended to wait six to twelve months after use of isotretinoin before undergoing chemical peels. This will allow regrowth of epithelial appendages, which are essential for post-peel re-epithelialization.49

For patients with a history of herpes labialis, we recommend pretreatment with acyclovir (Zovirax) 800mg PO QID for 2 days before and 10 to 14 days after the peel. We also pretreat patients with no history of oral herpetic infections with valcyclovir (Valtrex) 500mg PO BID for the same time frame, or until reepithelialization is complete. Previous studies have demonstrated a 6.6% HSV infection rate in chemical peel patients with no prior history (8/121 patients). 45 However, not all cosmetic surgeons have felt it to be necessary to include this prophylaxis for patients with no history of HSV10 , and some authors advocate prophylaxis only for medium or deep chemical peels. 41, 43

Cardiac, renal, or hepatic disease can be contraindications to phenol peeling due to cardiotoxicity of the agent. Unhealthy myocardium or poor renal or hepatic clearance can exacerbate potential toxicity. Patients that are interested in phenol resurfacing require the following workup: CBC, differential, platelet count, PT, PTT, serum electrolytes, liver enzymes, urinalysis, HIV test, Hepatitis B surface antigen, and EKG. 4

Radiation therapy can decrease the pilosebaceous units and blood supply of the skin, resulting in a delayed healing period and potential increase risk of scarring. Alteration of lymphatics, previous incisions or preoperative scarring may decrease the blood flow to the area for resurfacing, potentially compromising healing.

Also of paramount importance is the mindset of the patient. Realistic expectations and understanding of the potential complications allows a patient to choose the appropriate peel. Those that desire deeper peels must understand the increased associated risks. If a patient’s mental health is in question, defer treatment, or schedule an additional consultation to further explore the patient’s motives for seeking cosmetic procedures. Psychological consultation may prove valuable in helping the patients that perseverate on unrealistic expectations.

Hand in hand with appropriate expectations, patients must be willing to commit to an intense postoperative skin care routine. This includes application of petrolatum or aquaphor six times daily until epithelialization is complete. For some forms of resurfacing, we ask that patients expect 2 weeks of downtime before they may feel comfortable being seen in public. To avoid compromising results, regular use of sunscreen is mandatory. Sun Protection Factor (SPF) 30 or higher is recommended. And, to deal with hypopigmentation, patients must be prepared to wear make-up on a regular basis for blending.

Physical examination begins with the identification of suspicious skin lesions and telangiectasias. Biopsy and treatment of any malignant growths is necessary before chemical peeling. Additionally, telangiectasias may become more prominent after peeling, and should be addressed preoperatively. Chemical peels do generally not ameliorate prominent pores, and it is important to correct patient expectations if pore size is a concern.

Classification of the patient’s skin type is essential to the selection of an appropriate peeling agent. Table 1 describes the Fitzpatrick categories based on response to the sun and skin color. Monheit et al indicate that types I and II are at low risk for hyperpigmentation or hypopigmentation. 43 Though the risk is somewhat higher for pigmentary changes in type III and IV patients, Bernstein cites that these candidates are appropriate for chemical peeling. Deeper or more aggressive peels in this population may develop up to 3 months of hyperpigmenation in the post-operative period. Skin types V and VI should be limited to only superficial chemical peels. 9 Brody and Haily describe the perfect candidate as a light-complected person of Celtic or Northern European descent with skin types I or II. 12 Insert Table 1.

Glogau further classifies the skin according to clinical photodamage (Table 2). Group I is best suited for medical (retinoid) skin care and superficial peeling agents (Table 3). Group II and III are also good candidates for medical skin care. Most agree that Group II and III patients are appropriately treated with superficial and medium peels, though deep peels may be applicable in select patients desiring a dramatic result. Group IV patients are best treated with medium and deep peeling agents. 25 Insert Table 2. Insert Table 3.

Pre-peel Preparations

As mentioned previously, we treat all patients prophylactically for HSV. To maximize the results of medium and deep peels, dermabrasion, and laser resurfacing, tretinoin (Retin-A, Renova) is used topically for 2-4 weeks prior to the procedure. This will facilitate the depth and uniformity of the peel by exfoliating keratinocytes, thinning the stratum corneum, and activating fibroblasts. 49 Retinoid use is discontinued for 3 months after the procedure to allow reepithelialization and maturation of the skin. 46 Hydroquinone gel 4% to 8% is also a useful pretreatment for Fitzpatrick Type III or higher. This reduces melanin precursors by blocking the enzyme tyrosinase, and can be used both preoperatively and postoperatively. 43 And, as with all cosmetic procedures, a full complement of high-quality preoperative photographs should be taken, including lateral, frontal, oblique, and close-up views of the perioral or periocular areas.

Before the procedure, the patients should cleanse their skin with a mild soap. The skin will then be defatted and cleaned of the stratum corneum with either acetone, ether, or isopropyl alcohol, allowing a uniform surface to place the peeling agent. 14

Superficial Chemical Peels

Superficial peeling agents commonly used include the following: low concentration glycolic acid, 10-20% trichloroacetic acid, Jessner’s solution (resorcinol 14g, salicylic acid 14g, salicylic acid 14g, lactic acid 14ml, ethanol 100ml), tretinoin17 , 5-FU, and salicylic acid. These peels are indicated for the treatment of comedonal acne, postinflammatory erythema, or mild photoaging. The level of epidermal damage extends from the stratum granulosum to the papillary dermis. 38 During application, the patient will experience a mild stinging followed by a level I frosting. This is defined as erythema and a streaky whitening. 42 Depending on the strength of the agent and number of applications, healing times range from 1 to 4 days. Multiple weekly or every-other week peeling sessions are necessary to obtain maximal results. Patients must be counseled that multiple superficial peels do not equal a medium or deep chemical peel. 46

Medium-Depth Chemical Peels

Medium-depth peels extend the level of tissue injury to the upper reticular dermis. Common agents used for this effect are 35% tricholoracetic acid (TCA) with Jessner’s solution, 35% TCA with 70% glycolic acid, 35% TCA with CO2 laser, or phenol 88% (full strength). Figure 1 demonstrates a wonderful result with the use of a medium depth 35% TCA peel, pretreated with Jessner’s solution. Due to a risk of scarring, TCA 50% is rarely used as often as it once was. 36 The senior author prefers phenol 88% for chemexfoliation of the lower eyelid, often as an adjunct to other peels (Figure 2). This produces more consistent results than the carbon dioxide laser alone without temporary lower eyelid tightening. The medium-depth peel has further utility as a blending agent when combined with other resurfacing modalities. Dermabrasion, carbon dioxide resurfacing, or deep chemical peels in the perioral or periocular region may develop demarcation or hypopigmentation when compared to non-treated skin (Figure 3). Figure 4 is a good example of the combination approach to resurfacing (Baker’s peel to cheeks, TCA peel to neck, phenol 88% chemical peel to lower eyelids, full face CO2 laser, perioral dermabrasion). We have found that Jessner’s solution with 35% TCA to the surrounding non-treated skin will blend the rejuvenation more evenly (Figure 5). Insert Figures 1-5.

Once the skin has been thoroughly cleansed, the Jessner’s solution is evenly applied with cotton or gauze. A faint frosting with mild erythema will appear within 60 seconds, though less than typically seen with a TCA peel. After this had dried, the 35% TCA is evenly applied with cotton pads or swabs. Keep in mind that the amount of TCA delivered to the skin depends on the number of applications, the degree of applicator saturation, the amount of pressure applied to the skin, and the contact time with the peel solution. Larger areas are treated first with cotton applicators including the forehead, cheeks, nose, and chin. Then Q-tips are used to address the perioral and eyelid region. Agent may be placed within 1-2 mm of the lower eyelid margin. Inadvertent spills into the eye should be immediately irrigated with sterile eyewash solution. A white frost should appear within 30 to 120 seconds after application. Before retreating an area, one should wait 3-4 minutes to ensure that frosting has peaked. Check for asymmetries, and reapply as needed with caution. 46 The frosting indicates keratocoagulation. An appropriate endpoint for medium depth peels is white frosting. Generally, the whiter the frost, the better the peel.

At the completion of the peel, cool saline compresses are placed on the face for comfort. The face will become erythematous over the first 12 hours, and this is soon followed by moderate edema. This will slowly resolve as new erythematous epithelium appears on day 5 to day 7 post-peel. Day 10 usually marks completion of the epithelialization process, and at this point it is safe to wear makeup. A formal consult with the esthetician has been quite valuable in educating patients on how to camouflage resolving erythema. Sunscreens are started as tolerated, and skin care services such as superficial peels and microdermabrasion are not to be resumed until 3 months post-peel. Medium-depth chemical peels need not be repeated for at least one year. 46

Deep Chemical Peels

Deep chemical peels create an injury to the level of the midreticular dermis, most commonly with the classic Baker-Gordon7 solution:

Phenol 88% 3 ml

Septisol 8 drops

Croton Oil 3 drops

Distilled Water 2 ml

This type of chemical peel is best suited for the Glogau group III or IV patient. This dilution of phenol yields a denaturation of the keratin when applied to the skin, instead of the keratocoagulation seen in higher phenol concentrations. Hence the chemical peel penetrates deeper as the sulfur bridges between the keratin molecules are disrupted. 5 Croton oil acts as an irritant, and septisol is a detergent that lowers the surface tension of the skin, allowing deeper peel penetration. 14 One may reduce the depth of the peel by reducing the number of drops of croton oil (1 drop peels deep, 2 drops peel deeper, 3 drops peel the deepest). Baker and Gordon recommend that the mixture be freshly prepared before each case, and frequent mixing is necessary to maintain uniformity of the emulsion. 4,7 Though “taping” or placement of an occlusive barrier is described as a method to deepen the peel, we have not found this technique to be necessary to obtain a good result. Stone et al investigated variable concentrations of the Baker Gordon peel chemicals, only to find that application technique was more influential to the depth of the peel. Ultimately, they found the number of phenol applications correlated best with the depth of peel. 53

Deep Chemical Peel Patient Selection

Most authors seem to agree that the ideal conditions for a deep peel are a fair complexion, fine or coarse rhytids, and a patient that is not averse to mild hypopigmentation. Patients must also accept the significant risk of complications and increased potential morbidity associated with deeper peels. This includes potential scarring, hypopigmentation, textural changes, and cardiotoxicity. 42 Educational handouts, additional meetings with the physician and/or staff to discuss questions, and a final review on the day of the procedure are warranted to ensure adequate patient counseling. Patients are instructed on postoperative expectations of facial edema and erythema, low-grade fevers, and overall discomfort.

Technique and Post-operative Care

Preoperative antibiotics (cephalexin, Keflex) are given 24 hours prior to the peel and are continued for 7 additional days. A sedative the night before the procedure has been found to be very helpful in calming patient anxiety, allowing a good night’s rest. All makeup is removed prior to arriving at the facility (mascara, eyeliner, eye shadow, lipstick, base, powder, etc.). A few hours before the peel, 5 mg of diazepam (Valium) is given orally. We also pretreat with antiemetic (promethazine) and prokinetic agents (metoclopromide) to reduce post-anesthesia nausea. Then the face is cleansed twice with septisol and rinsed vigorously after each washing. McCollough and Langsdon caution against the use of PhisoHex or pHisoDerm as they leave a residue that may interfere with the uniformity of peeling. 40

The patient is given 500 to 1000 ml of lactated Ringer’s solution at the beginning of the procedure, followed by an addition liter of normal saline. This will volume load and dilute the cardiotoxic phenol that will enter the bloodstream after topical administration. Routine cardiac, blood pressure, and pulse oximetry monitoring are performed throughout the procedure. To initiate “twilight anesthesia,” intravenous administration of hydromorphone, (Dilaudid) 1 – 2 mg and midazolam (Versed) 1 – 2 mg are given. 10 mg of dexamethasone (Decadron) IV is also given to help ease postoperative edema. Infiltration of bupivicaine (Marcaine) 0.5% with 1:200,000 epinephrine provides nerve blockade in the supraorbital, infraorbital, and mental nerve distribution.

It is important to be aware that it takes roughly 20 minutes for phenol to be excreted by the kidneys. To minimize the phenol toxicity, applications are made in 15-minute intervals to the six aesthetic units (forehead, right cheek, left cheek, nose, periorbital, and perioral regions. This will last 60-90 minutes total for the procedure. It is imperative to feather the peel at the borders of each subunit, particularly on the jawline and the brow and eyebrow hairlines. Peeling should occur in the direction of Langer’s relaxed skin tension lines, and the tip of a broken wooden applicator may be used to paint the prominent perioral rhytids.10,40 Even application is facilitated by an assistant’s finger’s stretching the skin until the white frost appears. In the periorbital region the solution should stop 2-3 mm short of the lower lid, and in the perioral region the peel should extend 2-3 mm beyond the vermillion border. 39 Along the upper eyelid, the peel is limited to 2 mm above the superior border of the tarsal plate. Minutes after phenol application a well-defined rubor will appear. Assistants should be ready to mop up tearing with cotton tip applicators that may dilute the phenol and deepen the level of the peel. 16

Postoperative analgesia includes hydrocodone/acetominophen (Vicodin, Lortab), and patients are to restrict physical activity until seen in the office the next day. A methylprenisolone taper (Medrol Dose-Pack) is also given to help reduce swelling. Aquaphor or petrolatum is to be applied continuously to the face to avoid any areas of drying or crusting. The day after the peel, we recommend washing the face with warm water only 5 to 6 times per day with subsequent reapplication of aquaphor or petrolatum in very thick layers. Antibiotics are taken for 7 days total, and we also encourage patients to take 1 to 2 g of vitamin C per day, as well as daily multivitamins.

Postoperative day 3 and 7 the face is rechecked to ensure adequate care. Wound checks are made on a daily basis if patient compliance is substandard. Adherent yellow-green crusts are characteristic of Pseudomonal infection, and should be treated with wet-to-dry acetic acid soaks and oral ciprofloxacin (Cipro). 12,44 Fungal infections should be treated with topical nystatin cream. Care should be taken not to overlook superficial infections as they may increase the risk of scarring. 12 Staph and strep infection are treatment with oral antibiotics and topical clindamycin (Cleocin T-gel). For patients that develop a herpetic outbreak while on prophylaxis, we have found that acyclovir (Zovirax) 4 g per day is quite successful in resolving the infection. 46 Patients are counseled on the use of sunscreens (SPF 30 or greater) for 6 months afterwards, with no direct sunlight exposure for at least 6 weeks after the procedure. 44 Postinflammatory hyperpigmentation is usually transient, and can be treated with 3% to 4% hydroquinone bleaching agents. 9 Figure 6 shows a dramatic reduction of facial rhytids after using Bakers peel in conjunction with upper lip dermabrasion. Insert Figure 6.

Erythema and hypersensitivity 2 to 3 weeks after reepithelialization is treated with Hytone cream 2.5%. Pramasone 2.5% steroid cream and antihistamines are used for pruritis. As needed, restoril or ambien are dispensed to assist with sleep while the patient is still in the uncomfortable recovery period. 46 We prefer to wait at least 3 months before starting Retin-A, and only then if the patient requests restarting therapy. After healing is complete, post-operative checks are made again at 3, 6 and 12 months with photographs taken at each session.

Milia, also known as inclusion cysts, may occur as a result of occlusion of the upper pilosebaceous unit 2 to 3 weeks after reepithelialization. These are easily treated with gentle epidermabrasion, or topical tretinoin before and after peeling. 11 In a few cases, it may be necessary to puncture and evacuate persistent milia with an 18-gauge needle. 6

Phenol Toxicity

Phenol is toxic to all cells, is absorbed into the bloodstream from the skin, and is primarily excreted in the urine unchanged. 44 Truppman et al investigated the cardiac effects of phenol on 43 chemical peel patients. 10 patients were noted to have the following arrhythmias: premature ventricular contractions (4), bigeminy (2), paroxysmal atrial tachycardia (2), and ventricular tachycardia (2). It was concluded that there was a high degree of correlation to the incidence of arrhythmias and both the duration of the procedure and the size of the area being peeled. All cardiac arrhythmias occurred in less than 30 minutes after the onset of the procedure and had at least 50% or more of the face peeled at that time. 56 Hence, we reiterate the importance of peeling over 60 to 90 minutes, pausing 15 minutes between each aesthetic unit. Volume loading is also preventative with lactated Ringer’s solution or normal saline, and ACLS certified personnel must be on hand to deal with potential cardiac decompensation.

Chemical Peel Complications

In addition to the complications previously mentioned (infection, cardiotoxicity), chemical peels carry the risk of lower eyelid ectropion, renal failure, laryngeal edema, facial scarring, and poor patient/physician relationship. Lower eyelid ectropion is best treated with prevention. Ensure that patients have adequate lower lid tone, and refrain from performing transcutaneous lower lid blepharoplasty for 2 months before chemical peeling in the periorbital region. If this condition persists, vigorous massage and topical or intralesional steroids may reverse or prevent scar contracture. 44 Furthermore, the patient is encouraged to wait for 3 to 6 months for gradual resolution. Brody recommends , in addition to time, placement of fluocinomide-impregnated tape to help reduce scarring. 12 Case reports of laryngeal edema and toxic shock syndrome do exist in the literature, and should always be considered in preoperative counseling.32,37

Dermabrasion

Dermabrasion is another commonly used resurfacing modality that can yield predictable results. In our experience, dermabrasion remains the best single treatment modality for treatment of deep perioral and lip rhytids (Figure 7). This modality can also achieve better results than other resurfacing techniques in softening acne scars, though is not as effective as phenol peels in removing facial rhytids beyond the perioral region (Figure 8). 6 Additionally, this dermabrasion is useful for chronic active acne that has failed maximal medical therapy. 3 General indications for dermabrasion include: acne scarring, rhinophyma, scarring, tattoos, lentigenes, facial rhytids, and seborrheic or actinic keratoses. 40 More recently, however, authors such as Fulton are espousing the belief that newer medial therapies for make dermabrasion no longer necessary for active acne. 22 Insert Figures 7-8.

The mechanism of dermabrasion is injury of the skin to the level of the papillary dermis. If the injury extends into the reticular dermis, scarring is much more likely to result. After treatment, types I and III collagen deposition and reepithelialization ensues, covering a more refined dermal landscape. 28

It is important to consider in patient selection and counseling that dermabrasion will only improve favorable facial scars up to 70 or 80%. 100% improvement, or perfection is impossible with this technique. 23 As with other resurfacing procedures, the patient must commit to an intensive postoperative wound care regimen. Healing times range from 10 to 14 days, and erythema may last for 2 to 3 months. Again, preoperative and postoperative photography is mandatory. We recommend a minimum of 12 months before dermabrasion is repeated. Dermabrasion should not be used to treat scars or rhytids on the neck as the thinner dermis and decreased density of adenexal structures make the area prone to hypertrophic scarring and depigmentation. 46

A history of accutane usage precludes the use of dermabrasion for 6 to 12 months. Reports of decreased pilosebaceous units, impaired wound healing, and keloid development are associated with accutane usage. 50,60

Dermabrasion Equipment and Technique

Dermabrasion handpieces commonly offer RPM’s in the 1,500 to 35,000 range with reversible rotation to accommodate both left and right-handed surgeons. Drill bits include a diamond fraise, wire brush, or a serrated wheel. The diamond fraise tips are the slowest at abrading the skin, but allow for a more controlled injury, whereas the wire brush and serrated wheel are more aggressive. When using the diamond fraise tip, one can treat the skin with a freezing agent and visualize the level of the sebaceous glands to control the level of the tissue injury. 3

At our facility, dermabrasion is also performed under “twilight anesthesia” as previously described. Oral diazepam (Valium) is given, and routine cardiac, blood pressure, and pulse oximetry monitoring is performed before administration of IV midazolam (Versed) 3 mg and hydromorphone (Dilaudid) 1 mg prior to regional blocks (0.25% bupivicaine with 1:200,000 epinephrine). Refrigerant spray (Frigiderm) is also utilized to reduce pain.

The area of concern is treated in 1 to 2 square inch segments. The areas are blocked off by gauze to avoid ocular or inhalational injury from the refrigerant spray. 10 to 12 seconds of dermabrasion is performed with each cooling of the skin. To avoid freezing-injury to the tissue, refrigerant is used sparingly. 46 To indicate the bottom of deeper scars, some use gentian violet as an guide Slow and even pressure is applied at right angles to the skin, in the direction of the relaxed skin tension lines . When using the diamond fraise tip, one can follow the removal of the epidermal layer, then to the small capillary loops in the papillary dermis, which disappear as the openings of the sebaceous glands in the upper reticular dermis become evident. 40,60 It is best to begin in dependent areas to avoid pooling of blood in adjacent facial subunits. It is best to approach the face in aesthetic subunits, and care must be taken to avoid crossing the border of the mandible, the hairline, and the orbital rims. Untreated areas may be blended with chemical peels (Jessner’s and 35% TCA, or Phenol 88% to the lower eyelids).

Dermabrasion p/op care and complications

Wet gauze is used to clean the skin, and xeroform gauze or silicone mask dressings (Silon) are applied. Warm water is used to remove serum and crusting from the face, and a thick coat of aquaphor or petrolatum is applied 4 to 6 times daily. Silon masks are removed 3 days afterward. Medrol dose pack, antibiotics, HSV prophylaxis, and narcotics are used in a manner similar to postoperative chemical peel care. Reepithelialization is usually complete by day 7 to 10, at which time an aesthetician consult is arranged, along with sun exposure and sunscreen SPF 30 counseling. Again, prolonged erythema is treated with 2.5% Hytone cream topically BID, and hyperpigmentation is addressed with 4% to 8 % hydroquinone cream at night. Most patients may return to work 7 to 10 days after the procedure. 46

Complications are similar to that of chemical peels. Though, acne eruptions are much more common after dermabrasion. Tetracycline is often helpful in treating this problem, and may even be used prophylactically in patients at risk for acne outbreaks. Topical clindamycin (Cleocin T-Gel) is also a useful treatment adjunct. Hypertrophic scarring should be treated with topical silicone get, topical steroid, intralesional steroid, and pulsed dye-laser treatment when unresponsive to other modalities. 29 Postoperative bacterial, fungal, and viral infections are handled in the same manner as described for chemical peels.

CO2 Laser Resurfacing

CO2 laser is the most common resurfacing tool used in our patient population (Figure 9). Developed in the 1960’s, the 10,600 nm wavelength carbon dioxide laser is absorbed primarily by water, and hence its mechanism for selective tissue destruction. Carbon dioxide lasers remove approximately 50 to 100 m with each pass. 32 This is effective in treating fine and deep perioral and periocular rhytids, scars, and photodamaged skin (Figure 10). Healing is faster (7 to 10 days) than a phenol peel (10 to 14 days), though the post-laser erythema may last for up to 3 months. 30 Insert Figure 9, 10.

Today’s carbon dioxide lasers are used with sophisticated pattern generators that are adjustable to accommodate practically any area of facial skin. Energy settings are selected to determine the fluence (power in mJ), which in turn determines the depth of tissue injury with each firing of the laser. Standard settings for full face resurfacing and moderate photodamaged skin range from 80 mJ to 90 mJ with a density of 4 or 5. These settings are used in conjunction with the largest laser spot size available, ranging from 46-60 Watts. First passes usually reach the upper papillary dermis. This can be confirmed visually as the dermis appears pink. Second passes over resurfaced areas are reduced by 20 mJ, with a density of 4, and this will achieve a tissue injury at the level of the reticular dermis. This results in a distinctive yellow color, and this is a sufficient endpoint for most resurfacing needs. Violation of the reticular dermis layer risks postoperative scarring. 1,46

Emphasis is placed on feathering the laser ablation at the periphery of the treatment area to avoid sharp demarcation (Figure 3). In particular, blending across the jawline onto the neck is an effective way to camouflage the transition from treated to untreated skin. Eyelid skin requires only one pass as the dermis is thin and superficial here compared to the rest of the face. There are many instances where the carbon dioxide laser is used as a combination modality for aging face rejuvenation (Figures 2, 4, 5, 11, 12, 13). This includes laser resurfacing and blepharoplasty, forehead lift, and facelift. Though there is concern for flap viability with the combined insult of surgical undermining and dermal resurfacing injury, there are quite a few authors and reports available to demonstrate a reasonable safety record. 27,33

Er:YAG Laser

Compared to the carbon dioxide laser, the erbium:yttrium-aluminum-garnet laser produces energy at a wavelength of 2940 nm. This is the highest absorptive peak for water, and this is an extremely precise ablative that is notably poor at controlling bleeding during resurfacing due to the lack of coagulative necrosis. 58 This pinpoint bleeding denotes the level of the papillary dermis, in contrast to the classic color changes seen with other modalities. The Er:YAG provides less collateral damage at 5 m when compared to the 30 to 50 m range of the pulsed carbon dioxide laser. 33 The technique of facial resurfacing is similar to that of the CO2 laser. The paucity of collateral damage allows 10% overlapping of the delivered pulses.

This high powered laser vaporized the superficial skin into particulate matter, and hence a smoke evacuator and laser masks that filter 0.1 m particles is recommended. This laser may be used alone or in combination with CO2 or other lasers. 46

Postoperative Laser Care

We recommend silicone-based (Silon, Biomed Sciences) occlusive mask dressings with copious aquaphor applied to uncovered areas for the first 3 to 4 days. Flexan (Dow Hickam) is used for regional areas when the full face is not addressed. At this time, warm saline washes are performed with gauze 4 to 5 times daily with repeated aquaphor or petrolatum application. In accordance with other postoperative resurfacing care, make up is allowed after reepithelialization (day 7 to 10) an aesthetician consult is performed, and sun precautions are discussed.

Sadick offers his 10 commandments of resurfacing procedures: preconditioning with retinoids, alpha-hydroxy acids, hydroquinones, etc; test laser spot sessions in susceptible individuals; minimizing overlap of laser pulses (i.e. stacking); peel first before lasering; stay within cosmetic units; treat danger zones with extra caution (neck, chin, lower lids); minimize crusting with postoperative lubricants; antiviral prophylaxis; early and aggressive treatment of persistent red streaks (silicone dressings, topical and intralesional steroids); early usage of bleaching creams (day 15-20) in dark skinned individuals. 51

Laser complications are similar to those of chemical resurfacing complications. Additionally, “hot spots” often seen with CO2 laser treatment is occluded with Duoderm (Bristol-Myers Squibb) dressing, and is changed every 24 to 72 hours until reepithelialization has occurred. 46 The Er:YAG laser has a notably shorter convalescent period of 4 to 10 days, with a more transient erythema. However, this comes at the price of less skin-tightening seen with CO2 lasers. 46

Non-ablative Resurfacing

These devices focus on stimulating the dermis without injuring the epidermal layer. They are categorized in two general groups: visible light devices that treat roseacea and pigmentary changes, and midinfrared devices that encourage direct collagen remodeling. Midinfrared light is absorbed by water and collagen and can heat tissue uniformly, independent of skin pigmentation. 47 Though these lasers avoid the down time and common resurfacing complications mentioned previously in this paper, they also avoid the dramatic benefits offered by the other modalities. The literature is beginning to show more support for non-ablative resurfacing, as evidenced by the results of Goldberg et al and Dayan et al. 19,26 Further clinical trials are warranted to define the roles of this rapidly improving technology within cosmetic facial resurfacing.

Microdermabrasion

Microdermabrasion is actually a superficial ablation of the epidermis. Hence, the name is a misonomer as the dermis is left entirely intact, and the procedure is ineffective for deeper wrinkles or scars. However, for fine lines and more superficial scars, microdermabrasion is an effective treatment with minimal risk and rapid recovery. 60 This system makes use of small particle microcrystals (i.e. aluminum oxide, sodium chloride, or sodium bicarbonate) to wound the epidermis in a closed vacuum system that removes any skin debris. A new stratum corneum is formed in 3 to 5 days in response to an inflammation of the epidermis. Typically a series of 6 to 10 treatments weekly or biweekly, followed by maintenance microdermabrasion every 4 to 6 weeks.

In addition to smoothing out mild wrinkles, the removal of the stratum corneum facilitates the penetration of topical skin care regimens. Contraindications include use of isotretinoin (Accutane), active herpes infection, malignancy, and evolving dermatoses. 60 Makeup may be reapplied immediately after treatment, and medical skin therapies are resumed in 48 hours. As with other skin care treatment, sun precautions and SPF factor 30 or higher is recommended. 46

Combined Resurfacing Techniques

Each modality mentioned previously has been used successfully in facial resurfacing. However, we would like to emphasize that the best overall outcomes have resulted when using a combination of techniques. For example, as demonstrated in Figure 1, a medium depth peel of 35% TCA pretreated with Jessner’s solution is quite an effective medium depth peel by itself. Or, this Jessner's/TCA combination can be used to treat the neck and blend a full face CO2 laser (Figure 5). A 25% TCA peel pretreated with Jessner’s may also be used to treat the chest skin. Phenol 88% for chemexfoliation of the lower eyelid is also compatible with any of the above combinations (Figures 2, 4, 11, 13). Additionally, dermabrasion can be more effective when combined with chemical or laser peels (Figure 12). One may dermabrade over TCA peels or CO2 laser resurfacing to treat acne scars, deep facial rhytids, or rhinophyma (Figure 13). Insert Figures 11, 12, 13

An important caveat of combination resurfacing is to avoid abrasion of the skin before chemical peeling. For example, we recommend a deeper chemical peel (i.e. Baker-Gordon) to be performed 1st . One may follow with a medium depth chemical peel, and then use the CO2 laser. Lastly, dermabrasion may be added to the resurfacing effort. Following this progression will help to avoid uneven results while taking advantage of each modality.

Conclusions

As described above, cosmetic surgeons are afforded a great deal of versatility in resurfacing the aging face. We have found appropriate patient selection, counseling, and technique have yielded a consistent result with a high degree of patient satisfaction. Furthermore, outcomes are maximized when one takes advantage of multiple modalities, combining resurfacing techniques, or combining resurfacing with surgical rejuvenation (browlift, facelift, blepharoplasty). Recognizing these subtle differences of anatomic subunits and treating them appropriately with a combined approach has yielded the best results in our experience, allowing a natural and even facial resurfacing.

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