Q. How long have lasers been used?
- Lasers are not new in medicine. They have been used for decades. In the 1990's, the carbon dioxide laser was modified to allow treatment of facial wrinkles, blemishes, and superficial acne scarring.
Q. How Does It Work?
- The laser emits a very short (one thousandth of a second) burst of light energy that vaporizes the superficial skin layers, eliminating old sun-damaged skin cells. In response, new skin cells are created within the skin appendages (the sweat glands and hair follicles) which are located deeper in the skin. These new skin cells multiply and spread out over the surface, replacing old with new. New collagen is formed. The skin looks healthier under the microscope. The heat from the laser also makes collagen contract, tightening the skin.
Q. Is it Safe?
- Because the burst of light is very short, there is minimal heat transmission from the surface to the lower layers of the skin. In fact, if you touch the treated area immediately after the laser treatment, it is not hot. This reduces the risk of scarring or pigmentation changes.
Q. What about other treatments such as chemical peels?
- Chemical peels cause a tissue injury rather than the physical vaporization produced by lasers. A chemical, often tricholoacetic acid or "TCA" for short is painted on the skin. The chemical then penetrates the skin. The body's reparative process produces new collagen and skin cells, providing resurfacing. The problem is that it is difficult to know how deeply the chemical is penetrating the skin. Not enough and there is minimal benefit. Too much and complications develop. The older phenol peel produced permanent whitening of the skin because of its depth of penetration and injury to melanocytes.
Phenol Chemical Peels:
Patients who have been treated in the past with phenol peels frequently have white upper lips and need to wear makeup all the time. They also need to protect the skin from sun exposure because there is no protective melanin left. So while it worked, it had some serious drawbacks (and could even cause arrhythmias). There are better options today.
What about dermabrasion instead of laser resurfacing?
Dermabrasion represents a physical destruction of the top layers of the skin, usually with a rotating wire brush on the end of a drill. It can be used by experienced plastic surgeons to produce resurfacing, although it is decidedly low tech. It is also messy, with blood splashing around in the operating room. It is hopelessly primitive.
The laser is easier to control and more precise. It is the gold standard for resurfacing today. Studies comparing it to both chemical peels and dermabrasion typically find laser skin resurfacing superior.
What is the Erbium Laser? How is it different?
- This erbium laser is a resurfacing laser that does not penetrate as deeply as the CO2 laser. It is often used in younger patients, patients with less wrinkling or patients with darker skin coloring. The erbium laser carries less risk to the melanocytes in the deeper skin layers.
Q. What about "Ano downtime" laser treatments?
- Non-ablative laser treatments offer a shorter recovery time than the CO2 and erbium lasers, because the surface layers are not vaporized. However, the treatments are not as effective and usually have to be done in a series of visits. Patients are not typically enthusiastic about the results and may wonder whether the price was worth it.
Q. What about Thermage®?
- This treatment uses radio waves to try to stimulate collagen contraction in the deep layers of the skin. A cooling unit is used to avoid burning the top skin layers. The concept is intriguing. However, the treatments can be painful and results are minimal at best. Fat absorption has been a problem. Plastic surgeons' experiences have not been positive and the technique has fallen into disfavor. This is a treatment that looks better on the drawing board than it does in practice.
Q. What about Fraxel®?
- Interesting idea. The original Fraxel® laser used a wavelength that did not cause much heating of the tissue surrounding the small laser "holes" so there was not enough skin tightening. Fractionated laser treatments are presently being evaluated. They may represent the next generation of laser resurfacing. Or not.
Q. What areas can be treated with the laser?
- Part or all of the face can be treated. Younger patients may be treated with the erbium laser and older patients who have deeper wrinkles may be treated with the CO2 laser. Laser resurfacing can be done on its own or performed simultaneously with other cosmetic procedures. For those patients who have loss of skin tone causing jowls or loose skin of the neck, a facelift is usually done with the laser resurfacing. In forty-somethings, it is common to perform laser resurfacing with eyelid surgery and/or fat injection. Sometimes, the hands are treated.
Q. Does skin color make a difference?
- Yes, it does. Fair skin usually wrinkles more, and responds well to laser resurfacing. Some of my most dramatic results have been in fair-skinned patients. Those with darker skin types are usually treated with the erbium laser to avoid over-stimulating the melanocytes which would cause hyperpigmentation or, worse, injuring melanocytes, causing hypopigmentation.
Q. Does laser resurfacing help the neck?
- The skin of the neck is different from the face. It is thinner and looser. Laser resurfacing must be done very cautiously, if at all. Usually the neck benefits most from a facelift. Any tightening from the laser treatment does not compare to what can be accomplished with a facelift. Laser resurfacing may be used to help smooth horizontal creases.
Q. What are the risks?
- Hyperpigmentation (darkening of the skin) and hypopigmentation (lightening of the skin) are risks associated with any type of skin resurfacing including laser treatments, dermabrasion and chemical peels. The risk is greater as the depth of penetration is greater.
The surgeon needs to try to balance effectiveness and risk:
- The deeper treatment will do a better job on deeper lines.
- The deeper treatment also raises the risk of scarring or pigmentation change.
- Laser resurfacing is more precise and easier to control than older methods such as dermabrasion or chemical peels.
- Additional risks:
- Infection is also a risk, but may be minimized by washing the face at least three times a day and taking the prescribed antibiotics. Sometimes patients with a history of cold sores will develop herpetic outbreaks after laser resurfacing. Valtrex® is prescribed routinely to help prevent or to treat this viral infection if it develops.
Q. Will I have a dressing on my face?
- No. The open technique is preferred. This allows the patient to keep the skin clean and reduce the likelihood of bacterial buildup which might cause infection.