Laser skin resurfacing has now been around for several decades and involves a simple treatment principle…uniform removal of the outer layers of the skin. This can be done from very superficial to deep depending upon the power settings of the laser and the depth of the skin contour problem. Fractional laser treatment represents a paradigm shift in laser skin resurfacing by treating just a fraction of the skin’s surface, hence the name. But each area treated or laser dot penetrates much deeper creating vertical columns down into the deeper layers of the skin. This results in much greater collagen stimulation. But because less skin is injured (5% to 22%), it heals much faster. This has been a revolutionary advance in the treatment of previously difficult problems like scars.

The eyes may be the window to the soul but they are also a measure of aging. Because of the expressive movement of tissues around the eye and the thinness of the skin, this area shows the first sign of aging changes on the face. The sphincteric action of the orbicularis oculi muscle generates an array of radiating wrinkles to the side and below the eye and exerts a downward pull on the eyebrow. Because we look at this area with great frequency, often the first thing we look at in a mirror, the development of wrinkling is quickly discovered.

Surgical removal of eyelid skin (blepharoplasty) and elevation of the eyebrows (browlift) are well known and effective strategies for periorbital aging. But they are best used in moderate to advanced stages of aging. In addition, some people simply don’t want surgery whether it is because of the recovery or the cost.

The use of lasers for facial wrinkle reduction is well known and has been around now for over two decades. But their use around the eyes and on the eyelids where the skin is thinner is the use of lesser depth laser treatments known as micropeels but with more restricted depths of penetration come less results as well.

The newer fractional laser treatments offer a paradigm shift is how laser energy is delivered. Rather than being ablative to 100% of the treated skin, the fractional laser treats but a portion of the surface. Rather than producing a complete layer of burn tissue, columns are created instead. This leaves a lot of uninjured skin between the vertical columns which allows for faster healing and less risk of scarring. But each column does deeper down into the dermis, creating a collagenous remodeling effect.

When fractional laser treatments are applied in the periorbital area, significant improvements have been reported in numerous clinical studies. Measurable improvements have been seen in reduction of wrinkles, skin tightening and eyebrow elevation. This was found to be true in all skin types, including those with darker pigmentations. The results come exclusively from the changes in the skin and such problems as fat herniation, significant malar and brow sagging and orbicularis muscle hypertrophy will not be improved by this or any form of laser resurfacing.

The caveat to success with fractional laser periorbital rejuvenation, and being able to treat the eyelids directly, is the use of low energies and multiple treatments. This allows for both safety with minimal risk of any adverse scarring and very quick recoveries in the order of a few days. Spaced about six weeks to eight weeks apart, a series of three or four treatments is needed to get the best results. One should anticipate a single maintenance treatment per year. It is also important to use a good topical regimen daily with both exfoliative and regenerative agents such as retinoic acid and ascorbic acids.

The use of the fractional laser offers a new treatment option for the aging eyelids and brows. Some have termed this the fractional eyelid lift or the ‘Madonna Lift’. But names aside, this laser treatment provides an intermediary step before surgery that can serve as an effective treatment for those with early sign of aging or as a delay manuever before blepharoplasty surgery is done later.

Dr. Barry Eppley

Indianapolis, Indiana

While many methods for skin rejuvenation have been developed, few such methods are helpful for acne scars. The typical skin treatments of microdermabrasion, chemical peels, intense pulsed light and even ablative CO2 laser resurfacing do not produce substantative improvements in the unique contour problems caused by acne. Traditional CO2 laser resurfacing is the best of the bunch but results are often left wanting. The most effectve treatment is dermabrasion but it carries with it risks of hypopigmentation and even hypertrophic scarring.

Acne scars can be divided into two main types; atrophic and proliferative. Atrophic acne scars are identified as either ice-pick or macular-type forms. Proliferative or hypertrophic acne scars are raised and are more like keloids. Atrophic acne scars are particularly difficult to improve because the collagen degeneration extends down into the dermis. Regeneration of the dermal layers is virtually impossible so traditional ablative laser resurfacing has tried to bring down the surrounding more normal skin layer to the depth of the dermal depression…with limited success.

Fractional laser resurfacing has introduced a new concept in skin surface treatments. Rather than bringing down the entire outer surface layer of the skin, it only treats a portion of it hence the name fractional. In essence think of a dot pattern of individual laser spots penetrating the skin distributed over a grid pattern by a computer delivery system. But each laser spot penetrates much deeper, reaching the dermis and causing collagen stimulation/regeneration. While each laser spot goes deeper, the smaller portion of skin treated (anywhere from 5% to 22% of the total surface area) results in more rapid epithelial healing and a faster recovery.

Fractional laser resurfacing has been shown in numerous studies to be very effective for atrophic acne scars. Delivered in a punctuate pattern, the epidermis and a part of the dermis is vaporized. At the same time, collagen contraction occurs by its heating effect causing skin tightening. This skin tightening effect is thought to be very beneficial for acne scars. Multiple fractional laser treatments will be needed and they should be spaced about a month apart to allow for complete epithelial regeneration. Histologic and electron microscopic studies have shown the regeneration of elastic-like fibers with fractional treatments, a sign of dermal remodeling.

The fractional laser allows for different parameters to be set including power, pulse width, and dot pitch being the distance between each laser point. It is not clear as to the optimal setting for any individual patient and consideration has to be given to the patient’s concern for recovery. Given the challenge of atrophic acne scars, deeper depths of penetration up to 350 microns are best used.

Dr. Barry Eppley

Indianapolis, Indiana

The best way to treat surgical incisions that ultimately ends up with the most obscure scars is controversial. How a surgical incision heals and looks aesthetically is influenced by many variables such as the instrument used to make it, where on the body it is loacted, and the techniques used for wound closure. Many incisions go on to heal exquisitely well with the tincture of time alone.

But some wound closures are not favorable ones and may benefit by early scar treatment therapies. Then there is also the psychotherapy benefit of the patient doing something early in the healing process, taking an active role in the scar outcome. This has led to a plethora of topical scar creams and gels, most of which contains silicone fluid or silicone particles. The scientific benefits of their use remain far from scientifically proven but they are certainly harmless and usually relatively inexpensive.

More ‘high-tech’ therapies have been similarly applied to help modulate scar healing including laser and pulsed light therapies. There are no well tested scar treatment protocols but various practitioners use either pulsed dye laser or high intensity light (IPL/BBL) treatments as one option. Others use superficial or lower power fractional laser resurfacing treatments in the early healing period. No studies have ever been done that I am aware of that has directly compared these two scar therapy methods.

From a biologic standpoint the use of pulsed light therapies in early scar treatments makes good sense and is less likely to cause any adverse effects. Affecting the vascular elements and how the collagen is cross-linked theoretically could make the redness in the scar fade faster, decrease the risk of hyperpigmentation and help it soften sooner, particularly if it is prone to scar hypertrophy. In essence, it may expedite what the body naturally does through its scar maturation process. Such light-based treatments can begin early as soon as two or three weeks after surgery. Interestingly, but never talked about, is whether shortening this scar process may weaken its ultimate tensile strength attainment. Does making a scar look better sooner affect what its primary role is…that of holding the wound edges together? On the face, however, this is probably not a relevant issue.

The use of early fractional laser scar treatment is now more popular based on how well it performs in wrinkles and acne scars. It is definitely more invasive given the tiny channels that it cuts into the scar tissue. Because of this biologic action, it should not be started too soon when the wound edges have barely mended together. But by three to four weeks after surgery, it should be  safe to begin. The small channels really introduce another wound element in an already healing wound. This would make good sense in delayed treatment when the scar tissue is mature but its merits in early after surgery scar care remain speculative for me.

What is the best early treatment for incisions/scars? Between topical, light-based and laser therapies is one better than the other or is there a good combination? The reality is that no one knows for sure and any claims otherwise are marketing/sales driven but not backed by good science. For a safe and cost-effective approach, topical scar methods are certainly harmless but probably minimally effective. Which one of the many topical scar products is better is open to debate. For a more aggressive early approach, I recommend pulsed light treatments starting at three weeks after surgery done once a week for one month. If a scar in the first few months appears problematic (beginning hypertrophy) then fractional laser treatments should be started.

Until we have more scientific studies evaluating these scar treatment methods, their use will have to be on theoretical science and clinical experience.  

Dr. Barry Eppley

Indianapolis, Indiana   

I read a recent article that reports that drinking directly from water bottles can cause just as many upper lip wrinkles as smoking. I wouldn’t doubt it as any activity that makes your lips pucker, which activates the orbicularis oris muscle which encircles the mouth, can cause wrinkles to appear on the upper lip. The development of such wrinkles is a function of both the activity and how often it is done. Drinking water these days for some people is about as frequent as a regular smoker who does one or two packs per day.

 
As a general principle, wrinkles form on the face perpendicular to the direction of action of the underlying muscle movement. For example, horizontal forehead wrinkles are the result of ther vertically-oriented and moving frontalis muscle which extends from the brows upward into the scalp. Since the mouth’s main muscle (like the eyes) is a sphincter or encircling muscle which lies parallel (horizontal) to the upper and lower lip (except at the corners), it is no surprise that the lips (particularly the upper) develops vertical wrinkles in some people. The other factor that highly contributes to lip wrinkles is the thickness of your skin and the size of your lips. (which is interrelated) The thicker your skin, the less likely you will ever develop them. Take a look at African-Americans and people of Middle Eastern Descent, you rarely ever see them develop wrinkling of the lips. (and they have larger lips to begin with….as their skin is thicker)

 
Treatment of lip wrinkles is a challenging problem. I tell patients to think of it as improvement as there is no complete cure in most cases. For small and fine lines that are mainly located at the junction of the skin and the lip, an injectable filler can make a nice improvement…if you can accept having slightly to substantially larger lips. (whichever you desire) When the lip wrinkles are deeper and run higher into the upper lip, the concept of skin resurfacing comes into play. Usually this means laser resurfacing and it is just a question of how deep to go and how much recovery does the patient want. Laser resurfacing with lip augmentation with an injectable filler is the most common method by which I treat more significant lip wrinkling issues. This is done in the office under local anesthesia unless the patient is having other facial procedures which requires a trip to the operating room with the use of deeper anesthesia. There is some current debate between the laser techniques of resurfacing or peeling and the use of fractional (fraxel) laser treatments, but there is no hard clinical evidence at this point to say conclusively that fractional laser treatments are better. In the more severe cases, a small amount of Botox to help reduce the amount of muscle movement can also be helpful when done with fillers or laser resurfacing but you must be careful to not use to much lest you make your smile have an unnatural appearance.

 
Other methods of upper lip resurfacing for lip wrinkles is currently being evaluated. One method is to combine laser resurfacing with the use of sandpaper (yes I said sandpaper), known as laserbrasion. With this technique, the laser is only used for the first pass (to remove the very top layer of skin) and the deeper layers are then taken done by fine sandpaper. The concept here is that the use of sandpaper causes less trauma (no heat) and will heal faster without the prolonged redness. And it is just as effective as the laser but safer and with less complications than if one used traditional dermabrasion. The other method is known as percutaneous collagen induction therapy. (PCIT) Known aerating your lawn, a small wheel with fine needles is run over the upper lip, cutting many fine holes into the deeper portions of the skin. As this heals it causes the skin to thicken which helps reduce the amount of visible wrinkling.

 
Upper lip wrinkles in some women are unavoidable and can be very troubling. Injectable lip fillers, laser resurfacing, abd Botox can help but there is no permanent cure. The alternative treatments of fractional laser treatments, laserbrasion, and collagen induction therapy are interesting but it is too early to know if they will offer better results.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

I frequently get asked what is the new in the world of medical skin care by my patients as well as others. As I think back over 2007, I have put into my practice the following anti-aging medical treatments which I feel are quite promising.

The removal of an outer facal skin layer to improve its tecture is a concept that has been around for decades. Historically, this has included chemical peels and, in the past decade, laser resurfacing. Laser resurfacing essentially ‘burns’ off a top layer (the depths can be very varied from 6 microns to hundreds of microns) and allows new skin (epithelium) to heal over it, removing some imperfections and improving the texture of the skin. Recovery from laser resurfacing varies by the depth to which it is done, a 10 micron laser peel may be a few days, a 100 micron laser peel will be 7 to 10 days. The depth issue aside, laser resurfacing always involves some recovery (as it is a burn) and it only treats the outer layers of the skin.

Fractional CO2 laser resurfacing takes a conceptually different approach. Rather than ‘burning’ 100% of the skin’s surface that it hits, it only treats or penetrates a ‘fraction’ of it. For every area treated, it may only actually hit 10 - 20% of the skin area. Hence, a fractional treatment approach. But equally importantly, the laser penetrates much deeper (hundreds of microns) into the skin, actually stimulating the deepest part of the skin layers. (think of it as boring holes much like you do to your lawn to allow nutrients to get ‘to the roots’ so to speak) Because only a fraction of the skin is treated, there is less recovery than with traditional laser resurfacing even though the depth of laser penetration is much deeper. Also because it is fractional, it requires a series of treatment, at least five, to effectively get all of the skin’s surface treated. In theory, there is more of an anti-aging effect (due to the deeper penetration) but less recovery due to less skin being injured at any one time.

Fractional laser resurfacing of facial skin is being currently touted as being better than traditional laser resurfacing. The evidence to support that claim, to date, is still conclusively lacking. Plus, I am not sure how the laser knows during sequential treatments to hit previous skin areas that have yet to be treated. (of course, it cannot know, so some skin areas undoubtably get treated more than once and some probably are missed altogether as we are talking about fractions of millimeters here) For this reason, it probably take 6 or 7 treatments to truly treat all facial skin areas in the laser’s target. Despite these reservations, fractional laser resurfacing remains appealing and more time will tell exactly what its role in medical skin resurfacing actually is.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis