The use of lasers in facial rejuvenation has largely revolved around skin resurfacing or the reduction of wrinkles and the improvement in texture. When introduced nearly 20 years ago, the CO2 was the standard and produced a deep burn injury, some dramatic results and an associated significant recovery. Today’s skin resurfacing lasers use more superficial depths of penetration as well as newer fractional platforms. While fractional laser technologies are highly marketed and are often proclaimed to be better than traditional ablative lasers, those claims have never been substantiated.
Traditional high energy CO2 lasers treat 100% of the skin surface through a computer-generated pattern method. Fractional laser treatment means that just a fraction of the skin’surface is treated, in the range of 10% to 15% of the total surface and leaves normal skin next to small microscopic burn holes. Given that less of the skin surface is treated, it is no surprise that recovery is quicker as less skin has been injured. This, however, does not mean that the result is better…as it is not. Less recovery is usually associated with less of a result.
These more superficial and incomplete skin resurfacing lasers are good for two types of patients in my opinion. If you are younger and do not have a lot of skin damage or wrinkle problems, then this would be the better laser resurfacing approach. The other type of patient to benefit is at the opposite end of the spectrum, the patient who has a lot of skin damage but can not tolerate much recovery. This applies to many working women who do not have a lot of the time from work for recovery. One other benefit to these superficial microlaser and fractional laser treatments is that they can be performed in the office under just topical anesthesia. Because of their more superficial effects, a series or package of treatments is often needed to get the best long-term results.
When it comes to lasers you get what you pay for, not in terms of fee, but in terms of recovery time. There is no doubt that deeper laser resurfacing is harder on both the patient and the treating plastic surgeon. More wound care is needed until the skin is healed and the skin will remain red for weeks. There are also risks of permanent loss of skin pigment and burn injuries, particularly if done by someone with limited experience. As a result, many surgeons have abandoned these deeper laser treatments. However, I find I do them as much as ever. It is all about good patient selection and education. Many of the results seen can not be rivaled by more superficial laser treatments.
There are several things I have learned that can make a big difference in deeper laser resurfacing recovery. During the procedure, the skin debris left behind after the first pass should be left alone rather than removed. This helps to serve as a biologic dressing and the patient will not ooze as much serum in the first two or three days afterwards. I have also stopped using any external dressings and have my patients just use Aquaphor or even plain Vaseline. This makes it much easier for the patient. After five days it is a good time to employ some newer healing topical agents such as amino acid complexes, stem cell serums and oxygenated mists. All of these help the skin increase the final rate of re-epithelialization, the last step in completing early healing.
One other good use of laser resurfacing is in the operating room to treat the facelift patient. Many limited or even full facelift patients have significant skin wrinkling and texture irregularities. The central face can be treated aggressively as would be done normally but the sides of the face where the skin flaps are undermined should be done with caution. This can be a great addition to the skin tightening from the facelift and help reduce a lot of fine wrinkles.
Dr. Barry Eppley
Indianapolis, Indiana