LASER RESURFACING FOR WRINKLE OR SCAR REMOVAL: NON-ABLATIVE WRINKLE TREATMENTS: WRINKLE REDUCTION WITHOUT HEALING

Creating a smoother, less-wrinkled skin surface with a CO 2 laser has been performed for over two decades, but in the early 1990s higher power CO 2 lasers capable of effective wrinkle or scar removal stimulated much media and public interest in this “new” technology. Erbium:YAG laser resurfacing came several years later, followed by even more hype and misinformation about this different type of skin resurfacing or "high-precision facial refreshing." Yet, despite all this, plastic surgeons and physicians in other specialties, as well as patients themselves, have seen that laser resurfacing provides such dramatic results that dermabrasion and some chemical peels were subsequently replaced by this technique. Now, media interest in some of the problems associated with laser resurfacing have fueled both patient and physician demand for accurate information about this procedure. The “newest” techniques for wrinkle reduction are now being touted by fashion, style, and self-improvement magazines as safer and noninvasive, and involve several methods that use lasers, intense pulsed light (IPL), or radiofrequency (RF) energy to stimulate collagen production below the skin surface (reducing wrinkles) without damaging the surface of the skin (no healing)! Each of these modalities will be reviewed and summarized.

Throughout all of this, physicians with little or no prior cosmetic surgery experience have sought to capitalize on the public's fascination with surgical lasers, and have started doing procedures on every patient they can aim their laser at--often for $6,000 - $8,000 or even more per procedure, or a series of less-costly non-healing procedures that total or exceed these amounts in cost! Unfortunately, the supposed "ease" of performing laser resurfacing or collagen remodeling procedures has also caused a "bandwagon" mentality that has led to performance of these precise surgical procedures by practitioners with large variations in surgical training and laser expertise.

HISTORICAL ASPECTS

The CO 2 laser has been in existence for over 20 years, and has been used for superficial skin removal—resurfacing—since its development. In the past this was usually termed "laser dermabrasion" or "laserbrasion" since it involved removal of the upper layers of skin (just as with dermabrasion) with the laser rather than a dermabrader. The disadvantage with the older form of CO 2 laser dermabrasion was that relatively low laser power (<100 watts) required longer "on-times," causing deeper thermal damage to the skin as the top layers were removed. Healing time was prolonged, and scarring (color-lightened and/or shiny skin) sometimes occurred. These factors made the older form of CO 2 laser dermabrasion much more difficult to perform and the results much more unpredictable than the best dermabrasions. As a result, low-power CO 2 laserbrasion never became a widely used procedure.

NEW LASER DESIGNS

Significant improvements in CO 2 laser design and capability have been made by several laser manufacturers in the early 1990's. The first, and most widely publicized, CO 2 laser innovation was termed "Ultrapulse" technology, in which a much higher power CO 2 laser is used in extremely short pulses (<1msec) that allow vaporization of a precise thickness of skin (100 microns) with char-free tissue removal. Each pulse can be spaced at 1/4th second between pulses, and each spot covers 3mm of skin, allowing a reasonable area to be treated in a short period of time. Since only 100 microns ( 40 microns) are removed per pulse, two to four passes of the laser in each anatomic area are necessary to remove enough of the skin layers to effectively treat wrinkles or scars that would have been previously done by chemical peel or dermabrasion. However, since each pulse of the laser generates enough energy for tissue vaporization in less than 1msec, collateral (forward) thermal damage and scar risk is limited. Laser detractors call this type of laser vaporization a "burn," but in fact, resurfacing with a laser is more accurately a precise, thin-layer tissue vaporization with minimal heat generation--yet just enough to cause collagen fibers to contract and shorten, which is the first part of wrinkle removal. The patient’s healing phase then causes new collagen and new elastic fibers to form in the upper dermis, further tightening the skin over the four to six months following resurfacing.

Other CO 2 laser manufacturers have machines such as the SilkTouch/FeatherTouch ™, Tru-Pulse ™, Paragon, or Luxar that can be used for cutaneous resurfacing, subject to the limitations of power, spot size, mobility of machine, and cost. Each has pros and cons, and no physician should purchase a laser without first ensuring it fits his or her own specific needs, capabilities, and patient requirements. One disadvantage of the “early adopter” or bandwagon philosophy of laser resurfacing is that these physicians may have brief exposure to new laser technology as it is developed, and are then induced to purchase or lease a very expensive laser (usually on 5-year terms) in order to offer the “latest and greatest.” However, new laser technology and different wavelengths come out faster than the 5-year lease or purchase lifetime of the now-old (or at least outdated) laser. Thus, many physicians who do limited amounts of laser surgery are “stuck” with old technology, along with any problems and limitations that newer lasers have overcome.

The results following CO 2 laser resurfacing were without doubt remarkable, and are long-lasting. But, as with most things, time and experience have shown that several concerns should be addressed. One of these is prolonged redness during the healing phase (after CO 2 resurfacing). Laser detractors have stated that this can last as long as six months. While each patient is unique and individual in their healing response, most patients are able to return to normal makeup in several weeks. Most male patients are able to pass off the residual redness as sun exposure in that same several-week period of time. Still, prolonged redness after healing was a significant downside to first-generation CO 2 laser resurfacing. Another significant concern is that longer-term follow-up (1-2 years later) of CO 2 resurfacing patients has shown that some develop hypopigmentation (lightening of skin color) after aggressive wrinkle removal. This can leave a visible and unsightly line of demarcation at the jawline or between the treated and untreated areas, particularly in patients with vascular or pigmented areas of neck skin (poikiloderma of Civatte). Thus, healing rates, redness, and possible skin lightening are potential drawbacks or limitations of CO 2-only resurfacing.

(ERBIUM/YAG LASER)

Because of these concerns, another entry in the skin resurfacing arena has been advertised to both physicians and the lay public--the erbium:YAG laser. This laser operates in the near-infrared wavelength, and is capable of extremely thin layer tissue removal with scant thermal damage. The promise of "equal effectiveness, but less redness and more rapid healing" has essentially proven to be mainly hype, since this machine has many of the same potential limitations noted with the Trupulse laser (many passes needed, less thermal collagen shortening and therefore less ability to remove deeper wrinkles). There is indeed less redness, less time needed for healing, but unfortunately less wrinkle removal. Or, if deeper tissue removal is desired, more passes are necessary (since less tissue is removed per pass), more energy must be delivered into the tissue for at least some collagen shrinkage (longer pulses), and resultant healing times and redness similar to CO 2 laser resurfacing will be seen with the erbium:YAG laser. While the erbium:YAG laser has positive characteristics, my own experience with this laser indicates is that it is an alternative for less severe aging, sundamage, and/or wrinkling, that it does allow faster healing with less erythema (redness), but this wavelength alone does not achieve the degree of deep wrinkle removal seen with the CO 2 resurfacing lasers (unless the experienced operator makes many more passes than the less-experienced one is usually inclined to make). Less depth of tissue removal (dependant upon number of passes, of course) and less thermal damage has corrected the disadvantage of hypopigmentation or visible lines of demarcation, but unless an adequate number of passes is carried out by the operating surgeon, the results are very superficial and minimal. If you want to hype this as a “plus,” erbium:YAG resurfacing can be called “facial refreshing” or “lunchtime rejuvenation.” Except that healing still takes about a week, during which social contact is impossible!

COMBINATION (ERBIUM:YAG/CO 2) LASER

The most recent development in skin resurfacing was the third-generation combination of both the CO­ 2 and erbium:YAG lasers in the same "box." The two different laser wavelengths are utilized together (both beams in the same spot) to take advantage of the best characteristics of both types of resurfacing, without the disadvantages. Thus, the erbium:YAG wavelength first vaporizes a very thin layer of skin tissue, followed by a low-power CO 2 laser pulse (0 - 10 watts) which shrinks the collagen, but causes much less thermal damage and redness (inflammation), and allows healing which is more rapid (like erbium:YAG as compared to CO 2 ). This reduction of the CO 2 thermal damage avoids the hypopigmentation and visible lines of demarcation seen with the higher-power first-generation CO 2 lasers, and finaly gives the results the first two generations of devices sought but couldn’t quite achieve. The Derma-K laser by ESC Medical Systems is the first combination laser in the marketplace; in response to this technology and patent, other manufacturers developed long-pulse erbium:YAG lasers to simulate the combined-wavelength effect of adding some thermal input to allow collagen shortening and better wrinkle removal. Thus far, other manufacturers have not designed and marketed their own version of a combination or dual-wavelength laser. This third-generation resurfacing laser is the one we obtained for use at Minneapolis Plastic Surgery, Ltd., after extensive experience with multiple first-generation CO 2 lasers (including the Coherent Ultrapulse™) and multiple second-generation erbium:YAG lasers. Our personal experience with this state-of-the-art resurfacing laser since 1998 has shown very good overall results in more patients with varying severity of wrinkles; healing takes about one week with mild redness, while still delivering fresher, less wrinkled skin. Thus far, we have not noted the hypopigmentation or visible lines of demarcation troubling many patients treated with the older CO 2 resurfacing lasers.

All-in-all, the newest type of laser technology truly represents a significant advance in skin resurfacing as compared to older "laser dermabrasion" or earlier-generation resurfacing machinery. Laser skin resurfacing can now be done more easily, more exactly, and much more safely than in the past, which is why Minneapolis Plastic Surgery has continued to embrace this latest third-generation technology over older techniques found to be too labor intensive, difficult, unpredictable, and prone to complications. Ease of use and relative predictability of results does not mean that any physician (particularly one in a specialty that does not routinely train physicians in all types of cosmetic surgery) can perform laser resurfacing after attending a weekend course or watching a videotape. Courses serve to expose physicians to experienced laser operators, new equipment, and actual surgical techniques, but cannot take the place of one-on-one preceptorship and conservative establishment of a safe laser practice. In addition, preoperative and postoperative care is particularly important in avoiding disasters with resurfacing patients. Lastly, but certainly not least important, having the actual technology that “works” without the drawbacks or limitations of previous or outdated lasers (even ones as “new” as the first- or second-generation CO 2 or erbium:YAG resurfacing lasers), is critical. You should ask for information about the exact name and type of laser proposed for use on you, regardless of who or what type of physician you are seeing.

Unfortunately, the “first on the bandwagon” mentality caused many physicians to adopt and buy expensive first or second-generation lasers. What followed were many patients that had long healing times, excessive redness, or ultimately developed hypopigmentation or lines of demarcation (first-generation). Other patients had great expectations and after the healing was done, had really little improvement (inadequate second-generation treatment). Some burns and scars also diminished the “good press” and the pendulum of public opinion and media support began to swing towards condemnation of so-called ablative skin resurfacing. Doctors who were careful used their lasers less frequently and with less energy to avoid the problems, but then had less-dramatic results. Others had greater problems, more severe problems, unhappy patients, scars, and a few lawsuits. Some just gave up and their lasers went to a storage room or to a reseller. Clearly, the “next best thing” was needed.

NEW TECHNOLOGY

In the past several years, information has entered the lay press and public awareness regarding wrinkle treatment by other methods such as microdermabrasion (Dermapeel™, Power Peel™, Diamond Peel™, Parisian Peel™, etc.) and more recently, techniques that do not remove the surface of the skin, but are designed to treat the wrinkles below the surface to avoid the mess, inconvenience, and “down-time” of healing a “standard” laser resurfacing. These new “non-ablative” techniques sought to replace the resurfacing that had now “suddenly” become passé.

Microdermabrasion is a nonsurgical technique that involves the use of fine crystals (usually aluminum oxide) delivered via a handpiece or “wand” to the skin’s surface. The topmost layers of dead skin cells are removed in a process that is not painful, requires no healing, and can be done over a lunchtime. Patients have embraced these techniques because of their ease and low cost; many spas and skin care clinics (such as our own Carillon Clinic, Ltd.) now offer microdermabrasion. The patient must understand that the amount of improvement (even with multiple sessions) is analogous to the amount of tissue removed. Because of this difference, microdermabrasion does not replace true laser resurfacing.

Other techniques of subsurface wrinkle treatment are designed to leave the surface of the skin intact (no healing) and deliver some sort of stimulating energy to the deeper skin layers in an effort to reduce the visibility of sun damage or wrinkles. These non-ablative techniques involve the use of low-energy infrared lasers (Cooltouch™), intense pulsed light (non-laser IPL, such as Photoderm™, Fotofacial™, radiofrequency energy (Thermage ™, Thermacool ™) devices, and other similar trademarked names designed to try to distinguish a specific machine, process, or even physician!) to thermally stimulate the production of collagen below the surface of the skin and thereby reduce some of the visible wrinkling. These techniques are mild, nonspecific, and also require multiple sessions for minimal improvement. In my personal opinion, the results of these latter techniques do not justify their cost; however, the (lower) price and lack of healing time are strong inducements for patients to try these treatments.

Another form of nonsurgical wrinkle reduction involved the use of a pulsed dye laser (this laser has been in clinical use since 1988 for the treatment of port wine stain birthmarks) reengineered to stimulate the tiny capillaries just below the skin’s surface to release factors that cause collagen to form, improving the tone and texture of the skin. This N-Lite™ laser treatment has been shown to reverse a portion of the inevitable loss of collagen in the upper layers of the skin as we age (we lose about 1% per year over age 40). Our experience showed that only one third of patients experienced some visible degree of improvement, though it is usually subtle. The othere two thirds of patients treated with this device showed essentially no improvement

Since virtually all of these devices seek to make visible or even dramatic changes in the structure of skin in order to visibly reduce lines or wrinkles, enough energy must be delivered to the skin to achieve this. But how to do it without damaging the skin surface still seems to be analogous to shooting a target through a glass window without damaging the glass! Cooling gels, refrigerated handpieces, or other proprietary “innovations” were developed to try to overcome this inherent difficulty in all of these devices. Most clinics or physicians who “over-hyped” any of these technologies have found out that aggressive marketing and subtle or minimal results do not mix!

PATIENT SELECTION FOR LASER RESURFACING

Laser skin resurfacing can be performed for any patient who would have been treated in the past with dermabrasion or chemical peel, that is, patients with fine lines or wrinkles, acne scars (finer ice-pick type scars do better than deep cystic pits), areas of blotchy pigmentation, sun damage, or overall skin aging. In contrast to what has been implied by some magazine articles or by TV talk shows featuring this technique, laser resurfacing is not like a trip to the facial salon, but a true operation that requires preoperative skin care, some form of surgical anesthesia, detailed postoperative care, and a period of recovery. Surgery recovery starts with a 7 to 10 day period of what we tell patients will be "absolute unsuitability for any social contact whatsoever," followed by several weeks to several months of reddish pink-skin coloration that requires sunscreen and cover makeup.

ANESTHESIA

Laser resurfacing procedures can take 15 to 30 minutes for small areas such as the crow's foot region, around the mouth, or in small patches of acne or other scarring, and local anesthesia alone is sufficient. Topical anesthetic creams are generally inadequate for effective pain control during this procedure. Larger areas, or an entire face, can take one to two hours or more (depending on type of laser, severity of wrinkles or scarring, and skill and experience of the surgeon) and will require local anesthesia plus IV sedation or a mild general anesthetic. Accuracy of the procedure (especially around the eyelids, nostrils, lips, brows, and scalp) and patient comfort is often enhanced by using general anesthesia. At present, we usually perform full-face resurfacing under a light general anesthetic as an in-office outpatient surgery, and can complete the entire procedure, including induction, skin prep, laser resurfacing, and dressing the treated area in 60 minutes for the typical patient.

Although partial areas of the face can be safely and effectively resurfaced, there is a distinct difference between treated areas and untreated parts of the skin; this is partially because of the degree of effectiveness in the resurfaced zones. Therefore, almost all patients who initially choose to undergo partial-face resurfacing (because of cost, anxiety about anesthesia, or because “the rest doesn’t really need it”) end up undergoing full-face resurfacing. This, of course, means another operation, another recovery, and additional cost. We generally recommend full-face resurfacing to avoid these problems and reduce the attendant costs, not to increase them.

POST-OP MEDICATIONS

After a short time in the recovery area, the patient is discharged to the care of another responsible person who will drive the patient home. The patient has already received detailed instructions for care of the treated area, antibiotics to reduce the risk of infection, an antiviral medication to reduce the chance of developing cold sore (virus) outbreak, and mild pain pills. The pain after laser resurfacing is somewhat less than with dermabrasion or chemical peel, as nerve endings and blood vessels are sealed by the laser, but this operation is not painless. Tylenol or mild prescription pain medication is all that is necessary, and is usually not needed for more than a day or so.

HEALING

Some articles or doctors' brochures claim fast recovery from laser resurfacing, but skin removal (by any technique) still requires healing for about a week. A slightly longer time to heal is needed for the continuous scanner (Silktouch) technology, as a tiny thickness more tissue is removed with each pass of the laser. One pass with the Ultrapulse laser can indeed heal quite rapidly, but will have removed only the tiniest of lines or wrinkles. Even more rapid healing can be seen with one pass of the Tru-pulse laser, as only the epidermis is removed; the degree of improvement would be expected to be similarly minimal. The number of passes, proper energy per pass, as well as how to feather the edges is learned by proper educational instruction and experience with many patients. Rapid, red-free healing has become an "advantage" touted by some laser manufacturers, as well as some physicians, but may simply be reflective of the fact that less tissue removed heals faster and with less redness, but will also remove fewer (deep) wrinkles or acne scars. This would be analogous to comparing a glycolic acid facial peel (which removes few wrinkles and has essentially no healing time or redness) to a phenol peel (which permanently removes deep wrinkles and takes 12-14 days to heal with a prolonged period of redness): there is no comparison! Our impression is that it is inappropriate to imply that a Trupulse or erbium:YAG laser resurfacing is superior to an Ultrapulse resurfacing because the former heal quicker and with less redness; these remove less tissue and are not as effective on deep wrinkles or acne scars. Redness is indicative of inflammation and metabolic healing activity, which occurs with thermal collagen shortening and new collagen formation, both necessary for effective skin tightening of deeper wrinkles. Most of our own combination erbium:YAG/CO 2 laser (Derma-K) patients have healed skin ready for mild makeup in no more than 7-10 days, provided they take their medications as prescribed and follow post-op directions exactly!

INFECTION PREVENTION; REDNESS

At the end of 7 - 10 days when the new epidermal surface is healed (the point when there is no more blister-like weeping), the color of the skin is pink to bright red. We believe it is inappropriate to tell patients that this color is like "the Monday morning after a ski weekend." Rather, the patient will be unsuitable for social contact of any kind for the 7 - 10 days immediately after treatment as the skin heals, and may well be red enough to require cover makeup for several weeks as the color fades. Restoration of skin tone and color is usually achieved in several weeks, but may take as long as several months. The rate of initial healing, and the resolution of the pink coloration depends on many factors, including the type of laser technology used, the number of passes (depth of skin removal), the rate of healing in each individual patient, and attention to details of wound care. If there is any past history of cold sores or herpes outbreak (even chicken pox as a child), treatment with Zovirax (or other antiviral) as recovery proceeds reduces the potential for herpes outbreak, which will prolong the recovery even more. We have learned the hard way to treat all patients with Zovirax, so this medication and an antibiotic are routine in our procedure. In all patients, irrespective of history of cold sores or fever blisters, we prescribe an antiviral medication for 10 days, starting two days prior to surgery. A broad-spectrum antiobiotic starting the day of surgery is routinely given. Perioperatively, we usually give 10mg of intravenous Decadron to reduce swelling, postoperative discomfort, and redness; in selected patients, Medrol dosepaks are given during the healing phase whenever necessary to reduce severe redness or irritation.

SKIN PIGMENTATION RECOVERY

The red-pink coloration of the skin after laser resurfacing is seen with other types of skin resurfacing such as dermabrasion and chemical peel, and will take weeks to 3 months or longer to completely fade. During this time, avoidance of prolonged sun exposure or use of a sunscreen with as high a SPF number as possible is essential. At about three weeks from resurfacing, the skin is well healed, still pink (but fading), and often begins to develop a blotchy darker coloration. This usually will settle on its own or with treatment with certain prescription skin creams, but we have found that pretreatment two to four weeks prior to skin resurfacing with a prescription skin care program that includes Retin-A, hydroquinones, mild topical steroid, cleanser, moisturizer, and sunscreen will greatly improve the postoperative result of the resurfacing, reduce the time and degree of redness, and reduce any blotchy repigmentation. This program is gradually restarted when the skin is ready (usually two to four weeks) after resurfacing. We have found (also the hard way) that this skin care regimen should not be optional but required, so that recovery is predictable, safe, and without the difficulties that seem to follow any "new" procedure.

COSTS

At present, surgical fees for erbium:YAG/CO 2 laser resurfacing are similar to those for full-face dermabrasion. Laser costs and costs for anesthesia should also be considered. Insurance coverage may be obtained for the rare medical indications of precancerous skin changes or severe acne, but laser resurfacing is almost always considered cosmetic. In most cases, full-face resurfacing costs about half of what a complete facelift/necklift/eyelid surgery costs, but it should be remembered that resurfacing will not tighten loose or sagging facial muscles or skin, but will remove the surface wrinkles, lines, and sun-damaged skin changes that remain even after other cosmetic surgery. The improvements seen with laser resurfacing are very long-lasting (10-20 years) since this procedure causes the development of new collagen fibers in the upper dermis, and an entirely new epithelial (surface) layer.

SURGICAL TRAINING AND CREDENTIALS

Although laser resurfacing is truly one of the most exciting advances in cosmetic surgery in many years, it is still an operation that should be performed by a physician skilled not only in cosmetic surgery, but also with training and expertise in the safe and effective use of the laser. Check with your local hospital or laser center to see if the physician you are seeing about laser resurfacing has privileges in the use of the laser, even if he or she is performing the laser resurfacing in an office facility; hospital credential committees and privilege-approval boards provide peer review for physicians on their staff who may also have an office operating facility. The plastic surgeons at Minneapolis Plastic Surgery, Ltd. have this training, the hospital credentials, and years of experience with these techniques.

Microdermabrasion, glycolic peels, and other skin rejuvenation modalities, as well as preoperative and postoperative skin care programs for laser resurfacing patients can make a significant difference in your results; the professional staff at Carillon Clinic, Ltd. are experts in helping you achieve your goals.

For more information or to schedule a complimentary consultation with our plastic surgeons, please call 763-545-0443.