Cosmetic ablative skin resurfacing

Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230

Cosmetic ablative skin resurfacing

Stephen W. Watson, MD, DDS*, Todd J. Sawisch, DDS

Willow Bend Cosmetic Surgery Center, 5824 W. Plano Parkway, Suite 101, Plano, TX 75093, USA

Cosmetic surgery has increased 225% over the in 625 AD, Paul of Aegina described the technique

past 6 years, and advanced technology has been one

of the primary stimulants [1]. Ablative skin resur-

facing using CO2 and Erbium:YAG lasers is one of

those advanced technologies. One recent survey

reveals that ablative laser skin resurfacing accounts

for approximately 1% of all cosmetic surgical proce-

dures performed in the United States during 2002.

However, when contrasted with the widespread in-

troduction of laser technologies for rhytid reduction

in the early 1990s, culminating with a peak in 1998

[1], the use of the CO2 and Erbium:YAG lasers has

dropped dramatically. Hence the technologic advan-

ces in these two lasers have changed very little, if at

all, since the development of superpulsed energy and

computer pattern generators. The drop in demand for

laser skin resurfacing is due in large part to the

unwillingness of an informed public to undergo the

prolonged and involved recovery associated with

ablative laser resurfacing coupled with the introduc-

tion of nonablative technologies and intense pulsed

light. As a result, surgeons are returning in large

numbers to more conventional resurfacing such as

trichloroacetic acid peels and modified phenol peels

[2]. Preoperative and postoperative protocols have

been altered somewhat, and more conservative sur-

gical approaches that use lower fluences and fewer

passes are now generally used; however, ablative

lasers have changed little during the past 5 years.

Historical perspectives

Descriptions of facial rejuvenation techniques

were recorded as early as 1000 years ago. In Greece

1042-3699/04/$ – see front matter D 2004 Elsevier Inc. All right

doi:10.1016/j.coms.2004.02.005

* Corresponding author.

E-mail address: [email protected] (S.W. Watson).

used by Greeks and Romans of the seventh century to

reduce facial wrinkles. A troche, or lozenge made of

bruised-fish gelatin, ivory shavings, male frankin-

cense, and bitter weeds that grew among wheat was

mixed with white wine and rubbed into the skin to

treat wrinkles. Alternatively, bruised fat figs, burned

powder of bitter wheat weeds, and the shells of squid

were mixed with a small amount of honey and ap-

plied to the face. It is quite possible that the combined

effects of these abrasive materials and plant acids

were the first recorded dermabrasion and chemical

peel techniques [3].

Dermabrasion

Dermabrasion is a term used to describe a proce-

dure that removes variable amounts of skin, particu-

larly the epidermis. In ancient times, Egyptians were

the first to use this procedure to remove blemishes

and smooth the skin. Pumice and alabaster were used

as abrading tools. Modern advances in dermabrasion

began in 1905 with the German physician Kromayer

[4]. He was the first physician to formulate a method

of skin abrasion. In 1935, Janson reported the use of a

stiff-bristle brush to abrade tattoos [5] and the use of a

common sandpaper was introduced by Iverson in

1947 to remove a facial tattoo produced by gun

powder [6]. The greatest advances in the technique

are attributable to Abner Kurtin [7]. He and a

coworker developed and produced the instruments

of today, including the modified power-driven instru-

ments and refrigerants that aid dermabrasion.

Chemical peel

Chemical peeling of skin has been used since the

time of ancient Rome. Over the intervening years,

s reserved.

S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230216

interest in peeling has waxed and waned. In the late

1800s, chemical peeling had a resurgence and caustic

agents were used. In 1961 Baker and Gordon pio-

neered chemical peeling with phenol [8]. Since 1961

the general trend has been toward less aggressive

types of peels, including trichloroacetic acid and,

more recently, alpha-hydroxy acids. The field of

chemical peel and facial rejuvenation continues to

evolve [9].

Laser resurfacing

The initial role of laser for skin resurfacing in-

volved the continuous wave CO2 laser in a defocused

mode. The idea was to gradually pull the laser hand

piece away from the skin, thus reducing the power

density and ideally sparing the deeper skin structures

from thermal damage. However, because of the tech-

nical sensitivity involved with this technology, ther-

mal relaxation times were often violated, resulting in

prolonged healing times and scarring [10–19]. These

unacceptable consequences of continuous wave lasers

led to the development of more reliable and effective

technologies [20,21]. By delivering CO2 laser energy

in short pulses (‘‘superpulsed mode’’), investiga-

tors were able to stay within the thermal relaxation

time of the targeted tissues. This dramatically reduced

the incidence of the scarring and prolonged healing

times that occurred with continuous wave modalities

[22–24].

The Erbium:YAG laser was introduced next. This

laser emits a wavelength of 2940 nm, which is ab-

sorbed by water 10 times more efficiently than with

the superpulsed CO2 laser [25–27]. The result is very

superficial absorption with the capacity to precisely

ablate tissue by creating thermal injury by ablative

photodecomposition. Nonthermal collateral damage

is minimal, ranging from 0 to 30 mm. The reduced

healing times and decreased postoperative erythema

after treatment with the Erbium:YAG appeared to

establish this technology as the treatment of choice

for mild to moderated rhytids, bridging the gap be-

tween CO2 resurfacing and chemical peels [26].

However, with the increased absorption and short

thermal relaxation times, heat generation is insuffi-

cient to promote collagen shrinkage. Its primary use

today is relegated to following the CO2 laser during

the same surgical procedure in an effort to shorten

healing times and reduce erythema.

Computerized scanning also became available

with the combination of high-energy, short-pulsed

lasers and allowed the surgeon to lay down various

patterns and to condense or expand these patterns on

the skin to promote more even resurfacing [28].

Laser physics and tissue interaction

LASER is an acronym for Light Amplification by

Stimulated Emission of Radiation. Atoms and elec-

trons are normally in their lowest energy or ‘‘resting’’

state. If the energy of a photon of light is absorbed by

an electron, the electron is raised to an ‘‘excited’’

state. An excited electron returns to its resting state

by emitting a photon identical to the photon that was

initially absorbed. If a photon is absorbed by an

excited electron, this electron may emit two photons

when returning to its resting state, a process called

stimulated emission [29]. Repeating this stimulated

emission innumerable times generates a laser beam

[30,31].

All laser units consist of three basic elements: a

pumping system, a lasing medium, and an optical

cavity. The pumping system supplies the power and

the lasing medium supplies the electrons needed for

stimulated emission of radiation. This medium can be

gaseous (CO2), liquid, solid (Erbium:YAG), or com-

posed of free electrons. The optical cavity is a reso-

nant cavity consisting of two parallel mirrors that

sustain the stimulated emission and allow for release

of the laser beam [32].

Laser light has three important properties: it is

monochromatic, coherent, and collimated. Mono-

chromacity means that the light is of a single, discrete

wavelength, and this property determines the clinical

specificity of the laser beam. A specific wavelength

allows for selective absorption of the laser light by

specific chromophores of the skin (eg, melanin, hemo-

globin, or tattoo ink). Coherence means that the light

waves are temporally and spatially related. Clinical

predictability of the laser beam is a result of its

coherence. Collimation means that the light waves

are parallel. Consequently, the beam can be propa-

gated across long distances without spreading. This

tight focusing gives the laser its clinical preciseness.

As far as the skin is concerned, the laser is a

‘‘black box,’’ with clinical outcomes depending only

on the properties of the laser light entering the skin

and the presence of biologic targets of chromophores

within the skin [33]. Knowing the properties of the

laser (ie, wave length, pulse duration, energy fluence,

irradiance, and spot size) and how to alter them

allows the surgeon to predict and attain the desired

clinical outcome. The specific wavelength of the laser

light determines which chromophores in the skin will

absorb the desired light energy. If more than one type

of chromophore is present, the absorption will be

divided in relation to the relative absorption coeffi-

cients at that wavelength. Although some chromo-

phores may shield deeper tissues by absorbing most

S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230 217

of the laser energy, this chromophore shielding has

little if any clinical consequence in skin resurfacing,

because the biologic target of both the CO2 laser

(10,600-nm wavelength) and Erbium:YAG laser

(2940-nm wavelength) is the superficial intracellular

water [30–34].

Heat dissipates from the site of laser absorption

mainly by heat diffusion, and large objects lose heat

much more slowly than small objects. All objects

have a characteristic time—called the thermal relaxa-

tion time—that it takes to cool down to an ambient

temperature after having been heated. For most

chromophores in the skin, this time is determined

by the size of the object or lesion. If an object is

heated for longer than its thermal relaxation time,

thermal diffusion occurs with heating of surrounding

structures (Table 1) [35,36]. If an object is heated for

a period shorter than its thermal relaxation time, the

heat and resultant damage is confined to the target

object alone. Therefore, proper pulse duration of the

laser beam is essential for achieving the desired

clinical effect and dramatically reducing the risk

of scarring.

Currently available lasers used for skin resur-

facing incorporate advancements based on Anderson

and Parish’s theory of selective photothermolysis.

This theory states that selective heating is achieved

by preferential laser-light absorption and heat pro-

duction in the target chromophore when the pulse

duration is shorter than the target’s thermal relaxation

time. The CO2 laser can be modified to take advan-

tage of selective photothermolysis [34,36,37]. To va-

porize water within biologic tissues, approximately

4.5 J/cm2 has to be deposited in the tissue [30–34].

The CO2 laser has a depth of penetration of 0.1 mm.

This thickness of tissue has a thermal relaxation time

of approximately 1 msec. Therefore, the energy of

vaporization (4.5 J/cm2) should be deposited within

the tissue in less than 5 milliseconds. Conventional

CO2 lasers deposit energy too slowly. However, there

are two methods available to achieve selective photo-

Table 1

Thermal relaxation times

Target

Thermal relaxation

time

100-mm port wine stain blood vessel 5 ms

50-mm blood vessel 1 ms

50 mm of epidermis 1 ms

7-mm erythrocyte 20 ms1-mm melanosome 1 ms0.1-mm tattoo particle 10 ns

thermolysis with the CO2 laser: (1) individual very

high peak power (ultra) pulses of less than 1 milli-

second can achieve vaporization with less than

0.1 mm of collateral thermal damage; or (2) a fo-

cused, continuous wave laser beam can be swept

across the tissue with a dwell time at any one spot

of less than 1 millisecond [35].

Energy fluence is important, because to achieve a

clinical change in a target site, a certain amount of

energy has to be absorbed by the target site. This is

measured by the energy delivered per unit area (ie,

the energy fluence). As the energy fluence increases,

the destructive force increases [38,39]. Energy flu-

ence is generally used when referring to pulsed lasers

because it is easily calculated for each pulse.

Energy fluence

For selective photothermolysis, most pulsed lasers

achieve clinical effects using energy fluences over a

narrow range of 3 to 15 J/cm2. In laser skin resur-

facing, vaporization occurs when fluence raises the

tissue temperature past the boiling point of water

(100�C) in less than the thermal relaxation time. Char-

ring occurs when the fluence is not sufficient to evap-

orate the water, and pumping of further laser energy

into the charred tissue results in thermal radiation into

the surrounding tissue and increased scarring.

Irradiance is the rate of energy delivery per unit

area (ie, the intensity of energy delivery). The shorter

the pulse duration of a laser, the higher the irradiance

must be to deliver sufficient energy for clinical effect.

High irradiance will achieve faster heating of an

object than low irradiance. Slow heating coagulates

tissue, while fast heating may vaporize tissue [32–34,

40–42].

Irradiance

Spot size determines whether or not the laser

penetration is controlled sufficiently so that clean va-

porization or ablation results and undesirable thermal

radiation or damage is avoided. A smaller spot has

higher power density, creating deeper ablation cra-

ters; hence smaller spots can be used for cutting. A

larger spot with sufficient power density to achieve

vaporization enables a more uniform vaporization of

tissue and faster treatment time, but without the cra-

tering or depth of penetration noted with the smaller

spot [33,39].

Finally, the beam quality or distribution of energy

across the diameter of the beam significantly impacts


the control of uniform tissue absorption and ablation.

The TEM-00 mode beam (common with many CO2

and low-power Erbium:YAG lasers) has a Gaussian

shape and therefore uneven power densities along the

beam diameter. In larger diameters this can be con-

trolled to some degree by pulsing the beam, but it still

has a higher density in the center. The lower density

along the rim causes charring at the edges of the

ablation crater [39]. By pulsing or stacking the

beams, a flat top or non-Gaussian beam is approach-

able with the CO2 lasers [35]. The higher-energy

Erbium:YAG lasers have a uniform (non-Gaussian)

beam [43–45] that produces a uniform tissue ablation

and is particularly preferable for larger ablation areas

such as those encountered in skin resurfacing.

Table 2

Fitzpatrick’s Classification of Sun-Reactive Skin Types

Skin

type Color Reaction to first summer exposure

I White Always burn, never tan

II White Usually burn, tan with difficulty

III White Sometimes mild burn, tan average

IV Moderated

brown

Rarely burn, tan with ease

V Dark browna Very rarely burn, tan very easily

VI Black No burn, tan very easily

a Asian, Indian, Oriental, Hispanic, or light African

decent.

Skin aging

Aging of the skin has medical as well as cosmetic

consequences. Intrinsic aging generally results purely

from the passage of time, becoming visible around

age 35 and remaining subtle into more advanced

years. These changes are most easily seen on areas

that are not exposed to the sun [46–49]. Histologi-

cally, intrinsic effects are manifested by a thinning of

the epidermis, hypocellularity of the dermis, and a

gradual decrease in number of blood vessels, type I

collagen, and elastic tissue [49–52].

Extrinsic aging is primarily due to the effects of

ultraviolet radiation. Sun exposure is the most im-

portant factor, hence the terms photo-aging and

photo-damage [47,48,53]. For the majority of the

population, sun exposure and ultraviolet damage

occurs not in the pursuit of a tan but rather during

multiple, brief exposures to the sun during normal

daily activities. Cumulative ultraviolet exposure can

result in actinic keratosis, squamous cell carcinoma,

basal cell carcinoma, and melanoma [48]. Histolog-

ically, ultraviolet alterations present as a thickened,

basket-woven stratum corneum; a thinner or atrophic

epidermis; generalized epidermal cellular atypia; ir-

regular melanin dispersion; and abnormal-appearing

elastic fibers in the dermis [54,55].

Photo-damage accounts for more than 90% of the

unwanted changes in skin appearance. Clinically,

these changes include fine to coarse wrinkling, laxity,

leathery and coarse skin textures progressing to ir-

regular pigmentation, dry scaling and roughness of

the skin surface along with telangiectasias and skin

sallowness. Solar elastosis results in the deposition of

an abnormal, yellow elastotic material in the upper

dermis that replaces normal collagen and elastin and

does not have the resiliency of normal elastic tissue

[53,54,56].

Patient selection

Dr. David Apfleberg has stated that laser ablation,

in and of itself, is a simple procedure. However, he

goes on to point out that it is the patient selection,

preparation, and postoperative management that

makes the skin rejuvenation process difficult [31].

In this regard, patient selection is probably the most

difficult and certainly the most variable part of the

entire process. The single most important factor in

patient selection is his/her chief complaint. Only after

determining the patient’s chief complaint can the

surgeon apply more objective criteria and subse-

quently guide the patient in selecting the appropriate

technique or techniques to address the chief com-

plaint. A patient’s selection should not be based on

limitations of the surgeon’s technical acumen.

To decide if laser resurfacing will be a primary or

secondary component of treatment, certain evaluation

criteria can be applied. The most commonly used

scales for evaluation are the Fitzpatrick Classification

of Sun-Reactive Skin Types (Table 2) [38] and the

Glogau Photo-aging Wrinkle Classification (Table 3).

Categories include: (1) absolute contraindications,

(2) extreme caution, and (3) relative contraindica-

tions. Among patients considered as absolute contra-

indications are those who have had prior radiation

exposure, who have had Accutane (isotretinoin) treat-

ments during the past 6 to 12 months, who have had

deep phenol peels or burn scars, and who are de-

pressed or disturbed [30,57,58]. Patients with prior

radiation exposure, burn scars, and, in some cases,

deep phenol peels have undergone permanent de-

Table 3

Glogau Photo-aging Classification

Type I Type II Type III Type IV

Condition No wrinkles Wrinkles in motion Wrinkles at rest Only wrinkles

Photo-aging Early Early to moderate Advanced Severe

Pigmentation Mild changes Early senile lentigines visible Obvious dyschromia,

telangiectasia

Yellow-gray skin color

Keratoses None Palpable but not visible Visible Prior skin malignancies

Wrinkles Minimal Parallel smile lines beginning

to appear

Wrinkles when not

moving

Wrinkles throughout, no

normal skin

Patient’s age 20–30 30–40 50 or older 60–70

Makeup use Minimal or none Usually wears some foundation Always wears heavy

foundation

Can’t wear makeup (‘‘cakes

and cracks’’)


struction of fibroblasts and are not candidates for

even light laser skin resurfacing [59,60]. Accutane,

on the other hand, retards re-epithelialization by

selective inhibition of collagenase and suppression

of the pilosebaceous apparatus and can result in

severe scarring after laser resurfacing [61,62].

The patient groups in which extreme caution

should be used include ethnic skins with Fitzpatrick

classifications of 4 or 5. These individuals can still

undergo laser skin resurfacing but must be made

aware that they will have long-term, severe hyper-

pigmentation that may last for months [63]. A second

type of patient in this classification includes those

that have deep acne scars along with high expectation

of resolution. Before becoming candidates, these

patients must be warned that repeat treatments will

probably be necessary and total resolution is unlikely.

Relative contraindications include systemic dis-

ease that may pose anesthetic or surgical risk (eg,

diabetes, problematic hypertension, significant car-

diovascular or pulmonary disease, history of al-

lergies). Also within this group are fair-skinned

individuals with a tendency to flush or blush easily

(eg, Celtic skins). These individuals tend do develop

scarring in tension areas, particularly along the man-

dibular inferior border [57,58,64,65]. These patients

are still candidates but care should be taken as to the

depth or number of passes used in laser resurfacing.

Dark-skinned individuals (those with a Fitzpatrick

classification of 6 or individuals with a history of

hyperpigmentation after trauma) may also be consid-

ered relative candidates, but in the experience of

some, complications with hyper- or hypopigmenta-

tion have not occurred after laser scar revisions with

these patients.

Patients whose primary concern is alleviation of

rhytids associated with lines of expression caused by

muscle contraction (eg, forehead lines, glabelar lines,

crow’s feet, lateral canthal lines) are relative contra-

indications. Even though laser resurfacing may deac-

centuate these lines, they will always recur. It is

important for patients in this group to understand this

limitation before treatment.

Should such animation rhytids comprise the

patient’s chief complaint, then other primary or ad-

junctive procedures should be considered. Primary

procedures such as laser-assisted endoscopic browlifts

allow for denervation, debulking, and repositioning of

problem areas and can be performed simultaneously

with laser skin resurfacing.

Consideration of volume enhancement should

also be entertained in this particular patient. This

may include endoscopic midface lifts for deep naso-

labial folds, hyaluronic acid (Restylane) for perioral

rhytids, and fat transfer for other deep rhytids.

A widely used adjunctive technique is the injec-

tion of Botox (botulism-A toxin). These injections

temporarily block nerve transmission to the affecting

muscle groups, leading to subsequent atrophy and

deaccentuation of the associated rhytids. Injections

should be performed 1 to 2 weeks before laser treat-

ment to prevent activation of the muscles during 3 to

6 months of new collagen remodeling and reforma-

tion that follow laser treatment. Botox injections may

also be repeated after laser resurfacing to achieve

more prolonged results. Each repeat injection results

in progressive muscular atrophy [66,68].

Great care should be exercised in patients who

desire only regional resurfacing [7,30,57,58]. The

perioral and periorbital regions are the two areas of

photo-damage and wrinkling that respond most dra-

matically to laser skin resurfacing, but if both areas

necessitate treatment, it is far better to laser resurface

the whole face. In general, full face resurfacing will

produce a better clinical result because treatment of

the full cheeks results in better tightening of nasola-


bial lines and lateral crow’s feet. The same can be

said of the entire forehead and its effect on the

glabelar furrows and lateral temporal lines. In addi-

tion, the even pigmentation and smoothing of the skin

that result from full-face resurfacing produces a more

pleasing cosmetic appearance. Finally, it is much

easier for the patient to deal with postoperative ery-

thema occurring over the entire face rather than ery-

thema located in regions or patches.

Preoperative preparation

The literature is replete with preoperative regi-

mens purported to maximize the results of laser skin

resurfacing. The protocols are largely extrapolated

from chemical peel and dermabrasion literature or the

anecdotal experience of seasoned laser surgeons.

Ratner and colleagues have reported that there are

no controlled, randomized prospective studies to

either confirm or repute the need for skin priming

before laser resurfacing. The Ratner study goes on to

state, ‘‘The application of priming principles to laser

resurfacing is not necessarily warranted. It has not

been shown that preoperative use of tretinoin signifi-

cantly enhances laser beam penetration or predict-

ability. Some suggest that pretreatment with tretinoin

contributes to prolonged erythema, which often per-

sists for months [69]. Similarly there are no data to

support the utility of preoperative alpha-hydroxy

acids. Topical hydroquinones affect the melanocytes

in the basal layer of the target skin. This is desirable

for superficial chemical peels because this population

of melanocytes is implicated in postinflammatory

hyperpigmentation [70,71]. Because deeper chemical

peeling, dermabrasion, or the first pass of the CO2

laser usually ablates the entire epidermis, the popu-

lation of pretreated melanocytes is eliminated. Ke-

ratinocytes and melanocytes migrate from the wound

margins and underlying adnexal structures during

wound healing [72,73]. The adnexal structures are

not expected to be accessible to topical hydroqui-

nones administered before the procedure, but this has

not been confirmed. Thus only when melanocytes

have emerged from the adnexa to repopulate the skin

surface would they be amenable to hydroquinone

therapy [74].’’

Ratner continues, ‘‘Patients may already be on a

skin care program consisting of the aforementioned

agents. They may expect a pre-laser regimen and seek

the sense of personal control over this care that may

bestow. The physician can use such a regimen to

monitor patient compliance before a more aggressive

resurfacing procedure is performed and to uncover

any baseline irritant or allergic sensitivities [75].

These are all legitimate reasons to offer a preopera-

tive skin care program as long as one recognizes this

as a part of the art, not the fundamental science of

laser resurfacing.’’

Anesthesia

The goal of anesthesia for laser skin resurfacing is

basically the same as that for any surgical procedure:

to ensure the safety and comfort of the patient and

provide ease of operation for the surgeon. Laser

resurfacing of the face and neck, whether performed

with the CO2 or Erbium:YAG, is a very painful pro-

cedure. Either deep sedation with local anesthetic

blocks and infiltration or general anesthesia is re-

quired [76,77]. Fortunately, there have been numer-

ous advances in anesthesiology that add efficacy and

safety to the outpatient surgical setting [77–80].

The newer sedative-hypnotic, propofol, is unlike

any agent currently available and offers definitive

advantages over the more traditional drugs like

methohexital [79–82]. Newer inhalation agents like

sevoflurane and desflurane possess different phar-

macokinetic profiles from older agents like isoflurane

and halothane, and thus offer advantages in the office

setting [83,84]. Because airway maintenance and

protection is paramount during anesthesia for facial

surgery, the laryngeal mask airway is an alternative

method of airway maintenance that offers advantages

over traditional techniques [85–87].

Procedure

Laser energy and techniques

At present, almost all CO2 rapid-pulse systems

use computer pattern generators (CPGs). The impor-

tant property of a CPG is not necessarily its pattern

design or its ease of operation but rather the consis-

tency of its pattern density (ie, the amount of over-

lap). Furthermore, the laser energy and power settings

are less important (with or without CPGs) than is the

visible end point in determining the final result.

The appropriate energy and power settings depend

on the depth of the pathologic condition (ie, the re-

gion being treated) and the experience of the operator

(ie, hand speed) and therefore are less important

factors with CPGs [88].

To cleanly vaporize a volume of tissue, a CO2

laser must produce a fluence greater than 4.5 J/cm2,

Table 4

Depth of resurfacing techniques

No. of

laser passes

Ablation

depth (mm)

Residual thermal

damage (mm) Level of thermal damage Comparable treatment

1 20–50 20–40 Epidermis/superficial Medium depth peel

Papillary dermis

2 20–50 80–150 Papillary dermis medium depth peel /

dermabrasion

3 20–50 120–150 Superficial reticular dermis Dermabrasion


the vaporization threshold of tissue. Lower-powered

CO2 lasers are incapable of exceeding this fluence

and therefore coagulate the tissue, resulting in tem-

peratures exceeding 600�C and creating extensive

(1–5 mm) zones of thermal damage, similar to those

produced by electrocautery. Char-free tissue vapor-

ization occurs if the laser can deliver a fluence of

4.5 J/cm2 within less than 1 millisecond.

CPG pattern densities and their effect on ablation

were investigated by Kauvar and colleagues [89].

Density patterns corresponding to 10%, 35%, and

60% overlap were studied. At a density of 10%, only

partial epidermal vaporization occurred after one

laser pass. Islands of epidermis remained when the

debris was wiped away. The CPG at 35% overlap

resulted in clean vaporization of the entire epidermis.

One laser pass at a density of 60% overlap produced

ablation of the entire epidermis and superficial papil-

lary dermis, similar to a medium-depth chemical peel.

Depths of residual thermal damage also increased

with increasing densities, but did not exceed 150 mmafter three passes. These findings, and those from

studies for repeat laser passes, have led to increased

understanding and predictability of resurfacing with

the CO2 computer pattern generator systems (Table 4)

[89].

The much shorter wavelengths of Erbium:YAG

lasers are so highly absorbed by water that only mini-

mal skin penetration (approximately 5 mm) is possible

[90]. Therefore, the Erbium:YAG laser requires more

passes over the skin than do CO2 lasers (Table 5).

However, the depth of thermal damage remains ap-

proximately the same, regardless of the number of

passes [90]. The endpoint closely resembles the punc-

tuate, multiple point bleeding, similar to that seen

with dermabrasion.

In summary, there are four general rules that apply

with laser skin resurfacing:

1. Avoid regional resurfacing.

2. Always feather the peripheral areas by decreas-

ing the density of pulse applications, the pulse

energy, or both.

3. Keep the feathered margins irregular.

4. The endpoint of treatment is when one of the

following conditions are seen:

(a) The wrinkle or scar being treated is clini-

cal effaced

(b) A punctuate bleeding pattern is noted after

Erbium:YAG laser

(c) No further skin tightening occurs.

This endpoint can usually be achieved with the

CO2 laser in two passes over most of the face. Ad-

ditional passes may be used around the mouth. The

authors use decreasing fluence and overlap with each

pass and never do more than three passes total (even

though in the late 1990s it was common to perform

five to six passes).

Facial regions

It is helpful to consider the face as consisting of

six cosmetic units: (1) the periocular region, (2) the

perioral region, (3) the cheeks, (4) the forehead,

(5) the nose, and (6) the nonfacial region (ie, the

neck and ears). Each of these regions requires a

somewhat different laser technique.

Periocular region

The periocular region is small and may be further

divided into two separate areas: the thinner infraor-

bital skin and the thicker skin plus the crow’s feet

area. In the infraocular region, the upper reticular

dermis is thinner (0.2 mm) than in other facial re-

gions. Before performing laser resurfacing of the

periocular region, local anesthetic eye drops are

placed into the eyes so that the sandblasted metal

plate (for protection of the cornea) may be inserted

painlessly. The eyelashes are displaced from the

operating field by a moistened cotton swab to prevent

them from becoming singed or removed. The entire

periocular unit is resurfaced evenly on the first laser

pass. Subsequent passes with either the CO2 or the

Erbium:YAG laser are determined by the clinical

endpoint. A full-face laser skin resurfacing routinely

Table 5

Erbium laser skin resurfacing protocol

Glogau type

Type I: Early aging 6-mm spot, 2–4 passes,

600–800 mJ, 6–8Hz

Type II: Moderate aging 6-mm spot, 2–6 passes,

800–1000 mJ, 8–10 Hz

Type III: Advanced

photo-aging

6-mm spot, 6–8 passes,

1200–1400 mJ, 10–12 Hz

Type IV: Severe

photo-aging

6-mm spot, 6–8 passes,

1400–1700 mJ, 10–12 Hz

Region and lesion

Eyelid 4-mm spot, two passes,

600–800 mJ, 4–8 Hz

(Consider for neck, hands),

repeat prn

Perioral 4-mm spot, two passes,

800–1200 mJ, 8–12 Hz

Acne scarring 4-mm spot, two passes at

1000 mJ, then 1–3 passes

at 600–800 mJ

Start at 6–8 Hz, increase prn

Flat epidermal lesions 4-mm spot, two passes,

800–1000 mJ, 4–8 Hz

Small paular lesions 2-mm spot, one to three

pulse bursts, 300–400 mJ


includes resurfacing of the upper eyelids. In many

instances, upper eyelid resurfacing produces signifi-

cant skin contraction that may mimic upper eyelid

blepharoplasty. Some authors have noted vertical skin

shortening of 4 to 5 mm and up to 10 mm of short-

ening between the superior tarsal fold and the brow.

Perioral region

Perioral rhytids are ideally suited for laser resur-

facing. Frequently, these wrinkles are moderately

deep throughout this region, but because of extreme

motion in this region, it is more prone to hypertrophic

scarring than any other area of the face. Consequently,

precise depth control is particularly important. The

initial pass should cover the complete cosmetic unit

evenly. Subsequent passes may be selective and

concentrate on flattening the shoulders of the rhytids.

The required number of passes will depend on the

depth of the rhytids as well as the energy density se-

lected. The desired endpoint can be readily achieved,

but be aware that excessively deep treatment with the

CO2 laser will almost always result in scarring. The

transition from papillary to reticular dermis appears

(with the assistance of magnifying loupes) as a

smooth, fine, sponge-like appearance giving way to

a yellow, roughened, chamois-colored appearance.

With the Erbium:YAG laser, the end point will re-

semble that of dermabrasion. Discerning the absolute

endpoint for deeper resurfacing is difficult and ex-

ceeding this endpoint virtually assures an un-

necessarily high rate of scarring. It is better to be

conservative and re-treat 3 months later if necessary. If

the rhytids extend onto the vermilion border of the lip,

it is advisable to extend the resurfacing onto the

mucosa to eliminate these creases. Lip mucosa heals

especially well following laser resurfacing.

Cheeks

Cheek skin is generally thicker than eyelid and

perioral skin. Greater laser energy or an increased

number of passes may be used to produce the desired

cosmetic improvement. Unlike the upper lip, the

cheeks are more forgiving. The one exception is the

mandibular margin because of the transition zone

occurring at the inferior border of the mandible and

also because of the extremes of movement and

stretching that occur there. This region should be

treated more cautiously and is prone to scarring

[64,65].

Forehead

In the forehead region, resurfacing is particularly

indicated for removal of frown lines (horizontal and

vertical). This is the most effective and long lasting

when combined with endoscopic forehead and brow-

lifting, and simultaneous ablation of corrugator and

frontalis muscle activity. Both endoscopic browlift

and laser resurfacing may be performed during the

same operation. Botox injections of the corrugator,

procerus, and frontalis muscles may also be used to

enhance the result [66–68]. Laser skin resurfacing of

the forehead should be carried into the fine vellus

hairs at the hairline. If this is not done, a zone of

white skin, which cannot be concealed with makeup,

will be conspicuous between the resurfaced area and

the hair.

Nose

The nose generally has a thick, sebaceous skin

with an excellent blood supply and is consequently a

forgiving region for laser skin resurfacing. Resur-

facing of the nose is usually indicated for rhinophyma

and acne scarring but is also resurfaced during total

face rejuvenation for blending purposes [91,92].

When performing an open structure rhinoplasty in

conjunction with facial skin rejuvenation, is it ad-

visable to laser resurface the nasal skin. Failure to do

so can result in a very noticeable transition zone that

is troublesome to patients.

lofacial Surg Clin N Am 16 (2004) 215–230 223

Nonfacial regions

Rules that apply to the face cannot be applied to

other regions of the body. It is generally considered

hazardous to perform CO2 resurfacing of the neck or

hands because of the paucity of pilosebaceous units,

thin skin, and high mobility. Hypertrophic scarring

and alteration in pigmentation occurs readily. How-

ever, the decreased thermal radiation of the Erbium:-

YAG laser now permits skin resurfacing of these

areas without the scarring or pigmentary changes

seen with the CO2 laser. Nonetheless, results in non-

facial regions are not as substantial or dramatic as

those seen on the face.

S.W. Watson, T.J. Sawisch / Oral Maxil

Fig. 1. Patient before laser skin resurfacing and facelift.

Postoperative care

After laser skin resurfacing, patients are left with a

partial thickness wound that heals by re-epitheliaza-

tion from cutaneous appendages, much like a burn

wound. Methods of care are essentially the same for

CO2 and Erbium:YAG lasers, although the duration of

care may be dramatically less with the latter. In any

case, it should be remembered (as Dr. James Folton

has stressed) that ‘‘healing delayed is healing denied.’’

Following laser use, epithelial healing begins

within 12 hours. Keratin formation stops and hori-

zontal migration and proliferation of epithelial cells

begins [93,94]. The initial attachment of this new

epidermis to the underlying dermis is weak and must

be treated gently. The speed of healing and to some

measure the quality of skin regeneration is propor-

tional to the pilosebaceous density and not the size of

the wound [93,95,96]. Hence wounds on the face heal

much more quickly and aesthetically than those on

the chest and extremities.

The most important concept to assist re-epitheli-

zation is providing the proper substrate for epidermal

migration. Epidermis will only migrate over type I,

IV, or V collagen, fibronectin, or laminin [97]. It will

not migrate over dry crust, desiccated collagen, neu-

trophils, or wound debris [97,98]. In addition, heal-

ing is slowed by dryness, crust caustics, hemostatic

agents, some antiseptics (0.5% chlorhexidine, 1%

povidineiodine, 3% H2O2, gentian violet), radiation

within 24 hours, lower than normal temperatures, in-

fection, steroids (although topical 1% hydrocortisone

is acceptable), and significant vitamin deficiencies.

Clearly, these conditions must be avoided.

The use of bio-occlusive dressings has been shown

to be beneficial during the first 2 to 5 days after

surgery because they keep the skin clean of exudates

and permit re-epithelialization [97,99,100]. In addi-

tion to promoting moist healing and preventing the

exudative phase, closed dressings are also felt to

increase growth factors, and decrease pain and ery-

thema. Hydrogels and silicone polymer films are

semitransparent, allowing some degree of inspection

of healing wounds and permit fluid absorption, which

is useful for exudative wounds after laser resurfacing

[101]. Hydrogels are currently the most commonly

used biosynthetic semiocclusive dressings after laser

resurfacing. Foam composite dressings are opaque

and more adherent but are useful nonetheless because

of their ability to conform to the face and flex with

facial movements. These dressings have the disadvan-

tages of being difficult to keep in place, time-consum-

ing to apply, and sometimes uncomfortable because of

the accumulation of serous exudates under the dress-

ing. In addition, they sometimes hide the wound

surface, which makes it difficult to diagnose a wound

infection. In spite of these drawbacks, patients ap-

pear to progress to a more cosmetically acceptable

point more quickly than when using the open tech-

nique [102].

Complications

Herpes simplex

It has been estimated that up to 90% of the Cau-

casian population in the United States has Herpes

simplex virus (Figs. 1–3), but only 10% manifest its

symptoms. Even if a patient has no prior history of

cold sores, Herpes simplex is commonly activated by

Fig. 2. Herpes simplex infection 5 days postoperatively.


laser skin resurfacing [103]. It occurs after laser skin

resurfacing, spreads rapidly, and may lead to scarring.

If an outbreak occurs, either the preoperative dose of

acyclovir should be doubled daily until clinical im-

provement is noted or acyclovir should be changed to

Valtrex or Famivir. This regimen should be continued

and slowly tapered until complete re-epithelization

has occurred. Herpes simplex is difficult to recognize

on resurfaced skin, so a high index of suspicion is

Fig. 3. Patient 2 months postoperatively.

necessary. If on day 5 the patient suddenly develops

malaise and fever, this should be considered Herpes

simplex until proven otherwise, and appropriate mea-

sures should be taken.

Bacterial infection

Resurfacing of the skin produces a large, open

wound, yet bacterial infection (Fig. 4) is relatively

uncommon. This scarcity of skin infections is felt to

be due to colonization and competitive inhibition by

the relatively innocuous normal skin flora, aided by

the excellent blood supply to the head and neck,

judicious wound care, patient selection, and prophy-

lactic antibiotics. If a bacterial infection is suspected

in the laser skin-resurfaced patient, appropriate swabs

for culture and sensitivity should be obtained [94].

Fungal infection

The incidence of Candida infection (Fig. 5) in the

laser skin-resurfaced patient was not uncommon

before the introduction of semipermeable dressings

when heavy occlusive ointments were used. It is more

common in the perioral region, particularly in those

patients with upper and lower dental prosthesis. It

presents either as a fine white film with a bleeding

under surface when wiped away or as widespread

pustules. The diagnosis is confirmed by microscopic

examinations and cultures. Treatment consists of

Fig. 4. Bacterial infection following laser skin resurfacing.

Fig. 5. Candida infection in perioral region.

Fig. 6. Severe scarring in perioral region resulting from low

fluence continuous wave laser skin resurfacing.


topical Nizoral cream and 100 mg of Diflucan orally

every morning for two successive days.

Contact dermatitis

The frequent use of postoperative double and

triple antibiotic ointments leads to contact dermatitis

after laser skin resurfacing and thus should be

avoided [104]. This also occurs in patients who are

using topical vitamin E ointments or oils [104]. Be-

cause it lacks the normal features of contact derma-

titis, the diagnosis is difficult and a high index of

suspicion is necessary. If contact dermatitis is sus-

pected, the patient should be questioned thoroughly

about any and all types of skin application regimens.

The treatment of contact dermatitis, after discontinu-

ation of the offending agent, consists of the admin-

istration of oral nonsteroidal anti-inflammatory

medications or systemic steroids and an application

of the appropriate topical steroid cream.

Pigmentation changes

Temporary hyperpigmentation occurs commonly

after laser skin resurfacing. This is especially true with

darker skin types (Fitzpatrick’s III–V). In addition to

postoperative measures described previously, postop-

erative hyperpigmentation can generally be resolved

with the use of Kligman’s solution or with a 5%

hydroquinone and 1.5% glycolic acid combination.

Hypopigmentation is more likely to occur in fair-

skinned individuals any may not become apparent

until several months after laser skin resurfacing

[63,105]. Although there are many theories to explain

this phenomenon, the exact cause is poorly under-

stood. Many believe that hypopigmentation is caused

by destruction of melanocytes or controlled fibrosis

with opacification of the epidermis. If hypopigmen-

tation occurs, it is likely to be permanent. Resurfacing

the whole face is therefore less likely to produce

demarcation zones.

Scarring

The most unfortunate and damaging complication

of laser resurfacing is scarring (Fig. 6). Incipient

scarring is usually heralded by an area of persistent

erythema, which subsequently becomes slightly thick-

ened. If left untreated, this will inevitably progress to

hypertrophic scarring. Scarring is most likely to occur

in the presence of any of the following conditions:

(1) laser use in the highly mobile areas of the perioral

region and jaw line, (2) low energy densities, creating

a heat sink and subsequent thermal injury, (3) over-

lapping of laser pulses, (4) laser use too deeply be-

cause of excess fluence or an increased number of

passes, (5) postoperative infection (viral, bacterial,

fungal), (6) crusting or desiccation of the wound,

(7) isotretinoin therapy, (8) previous electrolysis ther-

apy on the upper lip, or (9) deep chemical peels on the

face [34,57–60,64,65,105].

Texture changes

Changes in skin texture inevitably occur with all

laser skin resurfacing procedures. The degree of

change is primarily related to the depth of the laser

skin resurfacing. The change is usually desirable

because the skin appears smoother and more uniform

when the entire face is resurfaced. Deeper laser skin

resurfacing procedures may lead to more profound

textural changes with the skin becoming shiny and

atrophic. Younger patients with large open pores may

experience an increased opening of pores secondary

to fibrosis at the pore margins. These patients should

therefore be informed that the pores will appear

larger postoperatively.

Fig. 7. Patient preoperatively before laser skin resurfacing

and facelift (but no blepharoplasties).

Fig. 8. Patient postoperatively with lateral ectropion on

her right.

Fig. 9. Patient before laser skin resurfacing and facelift.

Fig. 10. Patient 2 months postoperatively.


lofacial Surg Clin N Am 16 (2004) 215–230 227

Scleral show

Resurfacing infraorbital skin may cause temporary

increases in scleral show (Figs. 7, 8). This condition

usually responds briskly to daily massage, but in

some cases it may last up to 14 weeks. Ectropion is

more likely to occur in patients who have pre-existing

lower lid laxity and have had or are undergoing

concomitant lower lid blepharoplasty either percuta-

neously or transconjunctivally [106].

Recurrent rhytids

Recurrence of wrinkles is best addressed by

closely examining the patient’s preoperative chief

complaint and establishing appropriate postoperative

expectations. Patients must be warned that not all

wrinkles will disappear after laser skin resurfacing,

particularly those associated with lines of animation

or those associated with excessive skin laxity. To

avoid disappointment, the patient may need to un-

dergo simultaneous browlift, facelift, or blepharo-

plasty procedures to accomplish their desired goal.

By doing so, a realistic outcome can be anticipated.

S.W. Watson, T.J. Sawisch / Oral Maxil

Summary

Dr. Leon Goldman’s classic advice, ‘‘If you don’t

need a laser, don’t use one,’’ is well worth repeating

at this point [31]. However, in the authors’ opinion,

the pulsed CO2 laser with computer pattern generator

remains the gold standard for the treatment of facial

photo-damage with dyschromias and facial rhytids—

especially those with a fine, cross-hatched pattern

(Figs. 9, 10). These high-energy pulsed lasers have

been shown to be an excellent modality for the safe

and precise removal of dermatologic defects and

facial rhytids. The action of the laser removes the

epidermis, stimulates collagen formation, shortens

collagen strands, and welds collagen fragments. The

result is rejuvenated, tightened skin, a satisfied pa-

tient, and a gratified surgeon.

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