Ch38.qxd 22/12/04 7:26 PM Page 611
38 Laser Skin Resurfacing:
Ablative and Non-ablative
Tina S Alster MD and Elizabeth L Tanzi MD
Although dermatologic laser surgery is nearly four decades
s Many aspects of cutaneous photodamage are old, the ﬁeld was revolutionized in 1983 when Anderson
amenable to treatment with a variety of ablative and
and Parrish elucidated the principles of selective
non-ablative lasers and light sources.
photothermolysis.4 This basic theory of laser-tissue
s Ablative laser skin resurfacing offers the most interaction explains how selective tissue destruction is
substantial clinical improvement; but is associated with
possible. In order to effect precise thermal destruction of
several weeks of postoperative recovery.
target tissue without unwanted conduction of heat to
s Severe side effects and complications after ablative surrounding structures, the proper laser wavelength must
laser skin resurfacing can be minimized by careful
be selected for preferential absorption by the intended
patient selection, proper surgical technique, and
meticulous postoperative care. tissue chromophore. Furthermore, the pulse duration of
laser emission must be shorter than the thermal relaxation
s Non-ablative laser skin remodeling is a good
time of the target–thermal relaxation time (TR) being
alternative for patients who desire modest
improvement of photodamaged skin without significant deﬁned as the amount of time necessary for the targeted
post-treatment recovery. structure to cool to one-half of its peak temperature
immediately after laser irradiation. The delivered fluence
s Good candidates for non-ablative laser and
light-source treatments are patients with (energy density) must also be sufﬁciently high to cause the
mild-to-moderate photodamage and rhytides and desired degree of thermal injury to the skin. Thus, the laser
realistic clinical expectations. wavelength, pulse duration, and fluence each must be
s With ongoing advancements in laser technology and carefully chosen to achieve maximal target ablation while
techniques, more improved clinical outcomes with minimizing surrounding tissue damage.
minimal postoperative recovery will be realized. The ﬁrst system developed for cutaneous laser
resurfacing was the carbon dioxide laser, which was
Table 38.1 Lasers and light sources for photorejuvenation
Years of damaging UV light exposure manifests clinically as
a sallow complexion with roughened surface texture, and Laser Type Wavelength
variable degrees of dyspigmentation, telangiectasias,
Ablative Carbon dioxide (pulsed) 10 600 nm
wrinkling, and skin laxity.1,2 Histologically, these Erbium:YAG (pulsed) 2490 nm
extrinsic aging effects are usually limited to the Non-ablative Pulsed dye 585–595 nm
epidermis and upper papillary dermis and are Nd:YAG (Q-switched;
normal mode) 1064 nm
therefore amenable to treatment with a variety of ablative
Nd:YAG, long-pulsed 1320 nm
and non-ablative lasers and light-sources.3 Diode, long-pulsed 1450 nm
The armamentarium of lasers and light-based sources Erbium:glass 1540 nm
available to treat cutaneous photodamage is larger than ever Intense pulsed light source 515–1200 nm
before (Table 38.1). The most appropriate technique will
depend upon the severity of photodamage and rhytides, the Nd, neodymium; Q-switched, quality-switched;
expertise of the laser surgeon, and the expectations and YAG, yttrium–aluminum–garnet.
lifestyle of the individual patient. 611
Ch38.qxd 22/12/04 7:26 PM Page 612
approved by the Food and Drug Administration (FDA) in accelerate postoperative re-epithelialization after der-
1996. The earliest systems were continuous-wave (CW) mabrasion or deep chemical peels.12 However, because
lasers, which were effective for gross lesional destruction.5,6 ablative laser-induced wounds are intrinsically different
However, these systems could not reliably ablate ﬁne layers from those created by physically destructive methods, laser
of tissue because of prolonged tissue dwell times and skin penetration is not typically affected by the topical
production of unacceptably high rates of scarring and application of any of these medications. In addition, being
pigmentary alteration.7–9 The unpredictable nature of these that postinflammatory hyperpigmentation is relatively
lasers prevented their widespread use in facial resurfacing common after ablative cutaneous laser resurfacing, many
procedures. With the subsequent development of high- laser surgeons originally believed that the prophylactic use
energy, pulsed lasers it became possible to safely apply of topical bleaching agents would reduce the incidence of
higher energy densities with exposure times that were this side effect, but investigators subsequently demon-
shorter than the thermal relaxation time of water- strated that the preoperative use of topical tretinoin,
containing tissue, thus lowering the risk of thermal injury to hydroquinone, or glycolic acid had no effect on the
surrounding non-targeted structures.3,10 incidence of postablative laser hyperpigmentation.13
The short-pulsed erbium:yttrium–aluminum–garnet Due to the moist, de-epithelialized state of ablative laser-
(Er:YAG) laser was approved by the FDA in 1996 for resurfaced skin and the possibility of bacterial contam-
cutaneous resurfacing. It was introduced as an alternative to ination and overgrowth, many laser surgeons advocate oral
carbon dioxide skin resurfacing in an attempt to minimize antibiotic prophylaxis, however, this practice remains
PART 3 Aesthetic Surgical Procedures
the recovery period and limit side effects while maintaining controversial due to the results of a controlled study that
clinical beneﬁt. demonstrated no signiﬁcant change in post-laser resurfacing
In an attempt to limit the prolonged postoperative infection rate in patients treated with prophylactic
recovery period associated with ablative laser skin antibiotics.14
resurfacing and in response to growing public interest in
minimally-invasive treatment modalities, non-ablative laser
and light source technology was developed. Rapid advances s TECHNICAL ASPECTS
in this technology have produced several lasers and light-
Carbon dioxide laser
based sources capable of improving ﬁne facial rhytides,
dyspigmentation, and telangiectasia associated with cutaneous The Ultrapulse 5000 (Lumenis Corp, Yokeam, Israel), one
photodamage. of the ﬁrst high-energy, pulsed-laser systems developed,
emits individual carbon dioxide pulses (ranging 600 µs to
1 ms) with peak energy densities of 500 mJ, whereas the
s ABLATIVE LASER SKIN SilkTouch (Lumenis Corp, Yokeam, Israel), another high-
RESURFACING energy pulsed laser system, is a continuous-wave carbon
dioxide system with a microprocessor scanner that
Preoperative preparation continuously moves the laser beam so that light does not
The ideal patient for ablative cutaneous laser resurfacing is dwell on any one area for more than 1 ms. The peak
one with a fair complexion (skin phototype I or II), fluences delivered per pulse or scan range from 4–5 J/cm2,
cutaneous lesions that are amenable to treatment with a which are the energy densities necessary for complete tissue
resurfacing laser, and realistic expectations of the vaporization.7,15–17 Studies with these and other pulsed and
resurfacing procedure. Adequate preoperative patient scanned carbon dioxide laser systems have shown that after
evaluation and education are absolute essentials to avoid a typical skin resurfacing procedure, water-containing tissue
pitfalls and optimize the clinical outcome. Proper patient is vaporized to a depth of approximately 20–60 µm,
selection is paramount as ablative laser resurfacing can be producing a zone of thermal damage ranging from 20–150
complicated by a prolonged postoperative recovery, µm.7,16,18–20
pigmentary alterations, or unexpected scarring. The patient’s The depth of ablation is directly correlated with the
emotional ability to tolerate an extended convalescence is number of passes performed and usually is restricted to the
an important factor in determining the most appropriate epidermis and upper papillary dermis.21 However, stacking
choice of laser. Although carbon dioxide lasers or of laser pulses by treating an area with multiple passes in
modulated Er:YAG lasers will produce the most dramatic rapid succession or by using a high overlap setting on a
results, some patients may be unable to tolerate the scanning device leads to excessive thermal injury with
intensive recovery period. For patients unable or unwilling subsequent increased risk of scarring.22,23 An ablative
to tolerate extended postoperative healing, a short-pulsed plateau is reached, with less effective tissue ablation and
Er:YAG laser or application of non-ablative laser procedures accumulation of thermal injury. This effect is most likely
may be more suitable choices. caused by reduced tissue water content after initial
Currently, there is no consensus among laser experts desiccation, resulting in less selective absorption of energy.23
regarding the most appropriate preoperative regimen for The complete removal of partially desiccated tissue and
ablative laser skin resurfacing patients. The use of topical avoidance of pulse stacking is paramount to prevention of
retinoic acid compounds, hydroquinone bleaching agents, or excessive thermal accumulation with any laser system.
α-hydroxy acids for several weeks before ablative cutaneous The objective of ablative laser skin resurfacing is to
resurfacing has been touted as a means of speeding recovery vaporize tissue to the papillary dermis. Limiting the depth
and decreasing the incidence of postinflammatory of penetration decreases the risk for scarring and permanent
hyperpigmentation.11 Topical tretinoin enhances penetration pigmentary alteration. When choosing treatment parameters,
612 of chemicals through the skin and has been shown to the surgeon must consider factors such as the anatomic
Ch38.qxd 22/12/04 7:27 PM Page 613
location to be resurfaced, the skin phototype of the patient, modulating factors that serve to enhance continued collagen
and previous treatments delivered to the area.15,24 In shrinkage.36
general, areas with thinner skin (e.g. periorbital) require The carbon dioxide resurfacing laser is a most effective
fewer laser passes and non-facial (e.g. neck, chest) laser tool for improving photo-induced facial rhytides; however,
resurfacing should be avoided due to the relative paucity of dynamic rhytides are not as amenable to laser treatment.
pilosebaceous units in these areas.24 To reduce the risk of Many patients experience recurrence of movement-
excessive thermal injury, partially desiccated tissue should associated rhytides (particularly in the glabellar region)
be removed manually with wet gauze after each laser pass within 6–12 months postoperatively. Thus, cosmetic
to expose the underlying dermis.23 denervation with intramuscular injections of botulinum
The clinical and histologic beneﬁts of cutaneous laser toxin type A is often used concomitantly with laser
resurfacing are numerous. With the carbon dioxide laser, resurfacing to provide prolonged clinical improvement.37
most studies have shown at least a 50% improvement over Absolute contraindications to carbon dioxide laser skin
baseline in overall skin tone and wrinkle severity resurfacing include active bacterial, viral, or fungal infection
(Fig. 38.1a–b).10,25–29 The biggest advantages associated or an inflammatory skin condition involving the skin areas to
with carbon dioxide laser skin resurfacing are the excellent be treated. Isotretinoin use within the preceding 6–12-
tissue contraction, hemostasis, prolonged neocollagenesis month period or history of keloids also are considered
and collagen remodeling that it provides. Histologic contraindications to carbon dioxide laser treatment because
examination of laser-treated skin demonstrates replacement of the unpredictable tissue healing response and greater risk
CHAPTER 38 Laser Skin Resurfacing: Ablative and Non-ablative
of epidermal cellular atypia and dyplasia with normal, for scarring.38,39
healthy epidermal cells from adjacent follicular adnexal In an attempt to address many of the difﬁculties as-
structures.7,19 The most profound effects occur in the sociated with the use of multiple-pass carbon dioxide laser
papillary dermis, where coagulation of disorganized masses skin resurfacing, reﬁnements in surgical technique have
of actinically induced elastotic material are replaced with been developed. In 1997, a minimally traumatic single-pass
normal compact collagen bundles arranged in parallel to the carbon dioxide laser resurfacing procedure was described
skin’s surface.30,31 Immediately after carbon dioxide laser that resulted in faster re-epithelialization and an improved
treatment, a normal inflammatory response is initiated, side effect proﬁle than reported after use of the multiple-
with granulation tissue formation, neovascularization, and pass technique.40 Rather than remove partially desiccated
increased production of macrophages and ﬁbroblasts.19 tissue (as is typical with multiple-pass procedures), the
Persistent collagen shrinkage and dermal remodeling are lased skin is left intact to serve as a biologic wound dressing.
responsible for much of the continued clinical beneﬁts Additional laser passes can then be applied focally only in
observed after carbon dioxide resurfacing and are influenced areas of more extensive involvement in order to limit
by several factors.32,33 Thermal effects of laser irradiation of unnecessary thermal and mechanical trauma to less
skin produce collagen ﬁber contraction at temperatures involved skin. Subsequent reports have substantiated the
ranging from 55 ºC to 62 ºC through disruption of inter- improved side effect proﬁle of this less aggressive
peptide bonds resulting in a conformational change to the procedure.41–43
collagen’s basic triple helical structure.34,35 The collagen
molecule is thereby shortened to approximately one third
of its normal length. The laser-induced shrinkage of collagen
ﬁbers may act as the contracted scaffold for neocollagenesis, The Er:YAG laser is a more precise ablative tool than the
leading to subsequent production of the newly shortened carbon dioxide laser and emits 2940 nm wavelength light
form. In turn, ﬁbroblasts that migrate into laser wounds that corresponds to the 3000 nm absorption peak of water.
after resurfacing may up-regulate the expression of immune The absorption coefﬁcient of the Er:YAG is 12 800 cm–1
Figure 38.1 Perioral rhytides (A) before and (B) several months after carbon dioxide laser skin resurfacing. 613
Ch38.qxd 22/12/04 7:27 PM Page 614
(compared with 800 cm–1 for the carbon dioxide laser), Pinpoint bleeding caused by inadequate hemostasis and
making it 12 to 18 times more efﬁciently absorbed by tissue color change with multiple Er:YAG passes can
water-containing tissue than is the carbon dioxide laser.44 impede adequate clinical assessment of wound depth.
The pulse duration (mean 250 µs) is also much shorter than Irradiated areas whiten immediately after treatment and
the carbon dioxide laser, resulting in decreased thermal then quickly fade. These factors render it far more difﬁcult
diffusion, less effective hemostasis, and increased for the surgeon to determine treatment endpoints and thus
intraoperative bleeding which often hampers deeper dermal requires extensive knowledge of laser–tissue interaction.
treatment. Because of limited thermal skin injury, the Conditions amenable to short-pulsed Er:YAG laser
amount of collagen contraction is also reduced with Er:YAG resurfacing include superﬁcial epidermal or dermal lesions,
treatment (1–4%) compared to that observed with carbon mild photodamage and subtle dyspigmentation. The major
dioxide laser irradiation.11,45 advantage of short-pulsed Er:YAG laser treatment is its
The erbium laser’s efﬁcient rate of absorption, short shorter recovery period. Re-epithelialization is completed
exposure duration, and direct relationship between fluence within an average of 5.5 days, compared with 8.5 days for
delivered and amount of tissue ablated leads to 2–4 µm of multiple-pass carbon dioxide procedures.16,46 Postoperative
tissue vaporization per J/cm2, producing a shallow level of pain and duration of erythema are reduced after short-
tissue ablation. Much narrower zones of thermal necrosis, pulsed Er:YAG laser resurfacing, with postoperative
averaging only 20–50 µm, are therefore produced.44,46–48 erythema resolving within 3–4 weeks. Because there is less
Laser-induced ejection of desiccated tissue from the target thermal injury and trauma to the skin, the risk of
PART 3 Aesthetic Surgical Procedures
site produces a distinctive popping sound. Thermal energy pigmentary disturbance is also decreased, making the short-
is conﬁned to the selected tissue, with minimal collateral pulsed Er:YAG laser a good alternative in patients with
thermal damage. Because little tissue necrosis is produced darker skin phototypes.3,49 The major disadvantages of the
with each pass of the laser, manual removal of desiccated short-pulsed Er:YAG laser are its limited ability to effect
tissue is often unnecessary. signiﬁcant collagen shrinkage and its failure to induce new
The short-pulsed erbium laser fluences used most often and continued collagen formation postoperatively.3,46,50 The
range from 5–15 J/cm2, depending on the degree of ﬁnal clinical result is typically less impressive than that
photodamage and anatomic location. When lower fluences produced by carbon dioxide laser skin resurfacing for
are used, it is often necessary to perform multiple passes to deeper rhytides. However, for mild photodamage, improve-
ablate the entire epidermis. The ablation depth with the ment of approximately 50% is typical (Fig. 38.2A–B).
short-pulsed Er:YAG does not diminish with successive Although clinical and histologic effects are much less
passes, because the amount of thermal necrosis is minimal impressive than those produced with the carbon dioxide
with each pass. It takes three to four times as many passes laser, short-pulsed Er:YAG laser skin resurfacing still affords
with the short-pulsed Er:YAG laser to achieve similar modest improvement of photodamaged skin with a shorter
depths of penetration as with one pass of the carbon dioxide recovery time.15,46
laser at typical treatment parameters.3,11 To ablate the To address the limitations of the short-pulsed Er:YAG
entire epidermis with the short-pulsed Er:YAG laser at laser, modulated Er:YAG lasers systems were developed to
5 J/cm2, at least two or three passes must be used which improve hemostasis and increase the amount of collagen
increases the possibility of uneven tissue penetration. shrinkage and remodeling effected. The Er:YAG-carbon
Deeper dermal lesions or areas of the face with extreme dioxide hybrid laser system delivers both ablative Er:YAG
photodamage and extensive dermal elastosis may require up and coagulative carbon dioxide laser pulses. The Er:YAG
to nine or ten passes of the short-pulsed Er:YAG laser, component generates fluences up to 28 J/cm2 with a
whereas the carbon dioxide laser would effect similar levels 350 µsec pulse duration, while excellent hemostasis is
of tissue ablation in two or three passes.7,16,44 provided by the carbon dioxide component which can be
Figure 38.2 Periorbital rhytides and infraorbital hyperpigmentation (A) before and (B) several months after erbium laser skin
Ch38.qxd 22/12/04 7:27 PM Page 615
programmed to deliver 1–100 msec pulses at 1–10 W erythema and edema, are expected in the immediate
power. Zones of thermal necrosis measuring as much as postoperative period and are not considered adverse events.
50 µm have been observed depending on the treatment Erythema can be intense and may persist for several months
parameters used and signiﬁcant increase in collagen after the procedure. The degree of erythema correlates
thickness has been noted 3 months after four passes with directly with the depth of ablation and the number of laser
this hybrid technology.51 Another modulated Er:YAG passes performed.3,57 It may also be aggravated by
device is a dual-mode Er:YAG laser that emits a com- underlying rosacea or dermatitis. Postoperative erythema
bination of short (200–300 µsec) pulses and long resolves spontaneously but can be reduced with the
coagulative pulses to achieve tissue ablation depths of up to application of topical ascorbic acid which may serve to
200 µm per pass. The output from the two Er:YAG laser decrease the degree of inflammation.58,59 Its use should be
heads are combined into a single stream in a process called reserved for at least 4 weeks after the procedure in order to
optical multiplexing.52 The desired depth of ablation and avoid irritation. Similarly, other topical agents such as
coagulation can be programmed by the laser surgeon into retinoic acid derivatives, glycolic acid, fragrance-containing
the touch-screen control panel. Several investigators have or chemical-containing cosmetics and sunscreens should be
studied the histologic effects of dual-mode Er:YAG laser strictly avoided in the early postoperative period until
resurfacing and found a close correlation between the substantial healing has occurred.57
programmed and actual measured depths of ablation.53,54 Adequate preoperative patient evaluation and education
The actual zones of thermal injury correlate well to the ﬁrst are absolute essentials to avoid the pitfalls discussed below
CHAPTER 38 Laser Skin Resurfacing: Ablative and Non-ablative
pass with decreasing coagulative efﬁciency on subsequent and optimize the clinical outcome.
passes. The variable-pulsed Er:YAG laser system delivers Mild side effects of laser resurfacing include milia
pulse durations ranging from 500 µsec to 10 msec. Shorter formation and acne exacerbation, which may be caused by
pulse durations are used for tissue ablation and longer the use of occlusive dressings and ointments used during
pulses are used to effect coagulation and zones of thermal the postoperative period, particularly in patients who are
injury similar to the carbon dioxide laser.52,55 prone to acne.22,24,57,60 Milia and acne usually resolve
Since the modulated Er:YAG lasers were developed to spontaneously as healing progresses and the application of
produce a greater thermal effect and tissue contraction than thick emollient creams and occlusive dressings ceases. Oral
their short-pulsed predecessors, investigators compared antibiotics may be prescribed for acne flares that do not
collagen tightening induced by the carbon dioxide laser with respond to topical preparations.29,57,60 Contact allergies,
that of the carbon dioxide–Er:YAG hybrid laser system.56 irritant or allergic, can also develop from various topical
Intraoperative contraction of approximately 43% was medications, soaps, and moisturizers used postoperatively.
produced after three passes of the carbon dioxide laser, Most of these reactions are irritant in nature due to
compared with 12% contraction following Er:YAG decreased barrier function of the newly resurfaced skin.57,61
irradiation. At 4 weeks, however, the carbon dioxide and Wound infections associated with ablative laser
Er:YAG laser treated sites were contracted to the same resurfacing include Staphylococcus, Pseudomonas, or
degree, highlighting the different mechanisms of tissue cutaneous candidiasis and should be treated aggressively
tightening observed after laser treatment. Immediate with an appropriate systemic antibiotic or antifungal agent.62
thermal-induced collagen tightening was the predominant However, the use of prophylactic antibiotics remains
response seen after carbon dioxide irradiation, whereas controversial.14 The most common infectious complication
modulated Er:YAG laser resurfacing did not produce is a reactivation of labial herpes simplex virus (HSV), most
immediate intraoperative contraction but instead induced likely caused by the thermal tissue injury and epidermal
slow collagen tightening.52,56 disruption produced by the laser.22,57 Any patient
undergoing full-face or perioral ablative resurfacing should
receive antiviral prophylaxis, even if a history of HSV is
s OPTIMIZING OUTCOMES denied. It is impossible to predict who will develop HSV
reactivation, because a negative cold sore history is an
Carbon dioxide laser skin resurfacing
unreliable method to determine risk, as many patients do
Side effects associated with carbon dioxide laser skin not remember having had an outbreak or are asymptomatic
resurfacing vary and are related to the expertise of the laser HSV carriers. After carbon dioxide resurfacing, approxi-
surgeon, the body area treated, and the skin phototype of mately 7% of patients develop a localized or disseminated
the patient (Table 38.2). Certain tissue reactions, such as form of HSV.57 These infections develop within the ﬁrst
Table 38.2 Side effects and complications of ablative laser skin resurfacing
Expected Side Effects Complications
Mild Moderate Severe
Erythema Extended erythema Infection (bacterial, viral, fungal) Hypopigmentation
Edema Milia Hyperpigmentation Hypertrophic scarring
Pruritus Acne Ectropion
Ch38.qxd 22/12/04 7:27 PM Page 616
postoperative week and can present as erosions without
intact vesicles because of the denuded condition of newly
lased skin. Even with appropriate prophylaxis, a herpetic
outbreak still can occur in up to 10% of patients and must
be treated aggressively.15 Oral antiviral agents, such as
acyclovir, famciclovir, and valacyclovir are effective agents
against HSV infection, although severe (disseminated) cases
may require intravenous therapy. Patients should begin
prophylaxis by the day of surgery and continue for
7–10 days postoperatively.
The most severe complications associated with ablative
cutaneous laser resurfacing include hypertrophic scar and
ectropion formation.22,57 Although the risk of scarring has
been signiﬁcantly reduced with the newer pulsed systems
(compared to the continuous wave lasers), inadvertent
pulse stacking or scan overlapping, as well as incomplete
removal of desiccated tissue between laser passes can cause
excessive thermal injury that could increase the
PART 3 Aesthetic Surgical Procedures
development of ﬁbrosis. Focal areas of bright erythema,
with pruritus, particularly along the mandible, may signal
impending scar formation.24,63 Ultrapotent (class I) topical
corticosteroid preparations should be applied to decrease
the inflammatory response. A pulsed dye laser also can be
used to improve the appearance and symptoms of laser-
induced burn scars.63
Figure 38.3 Post-treatment hyperpigmentation is often
Ectropion of the lower eyelid after periorbital laser skin observed 3–4 weeks after carbon dioxide laser skin resurfacing.
resurfacing is rarely seen but, if encountered, usually Its resolution can be hastened by the topical application of
requires surgical correction.24 It is more likely to occur in hydroquinone and/or glycolic, retinoic, and ascorbic acids.
patients who have had previous lower blepharoplasty or
other surgical manipulation of the periorbital region.
Preoperative examination is essential to determine eyelid recovery period after modulated Er:YAG laser skin
laxity and skin elasticity. If the infraorbital skin does not resurfacing remain more favorable than after multiple-pass
return briskly to its normal resting position after a manual carbon dioxide laser treatment. In an extended evaluation
downward pull (snap test), then ablative laser resurfacing of 50 patients, investigators reported complete re-
near the lower eyelid margin should be avoided. In general, epithelialization in an average of 5 days after dual-mode
lower fluences and fewer laser passes should be applied in Er:YAG laser skin resurfacing with only three patients
the periorbital area to decrease the risk of lid eversion. having prolonged erythema beyond 4 weeks.67 In a split-
Hyperpigmentation is one of the more common side face comparison of 16 patients after pulsed carbon dioxide
effects of cutaneous laser resurfacing and occurs to some and variable-pulsed Er:YAG laser skin resurfacing, other
degree in all patients with darker skin tones (Fig. 38.3).24,57 investigators reported decreased erythema, less edema, and
The reaction is transient, but its resolution can be hastened faster healing on the Er:YAG laser-treated facial half. 68
with the postoperative use of a variety of topical agents, Postinflammatory hyperpigmentation is not uncommon
including hydroquinone, retinoic, azeleic, and glycolic acid. after any cutaneous laser resurfacing procedure. While
Regular sunscreen use is also important during the healing hyperpigmentation following modulated Er:YAG laser skin
process to prevent further skin darkening. The prophylactic resurfacing (mean 10.4 weeks) can last longer than after
use of these products preoperatively, however, has not been treatment with a short-pulsed Er:YAG laser, it is not as
shown to decrease the incidence of post-treatment persistent as that observed after multiple-pass carbon
hyperpigmentation.13 Postoperative hypopigmentation is dioxide laser resurfacing (mean 16 weeks).67 However,
often not observed for several months and is particularly when comparing the most current trends in ablative
difﬁcult because of its tendency to be intractable to cutaneous laser resurfacing—single-pass carbon dioxide
treatment. The use of an excimer laser or topical photo- versus multiple-pass, long-pulsed Er:YAG laser skin
chemotherapy to stimulate repigmentation has proven resurfacing—postoperative healing times and complication
successful in some patients.64,65 proﬁles are comparable, even in patients with darker skin
phototypes. In a retrospective review and analysis of 100
consecutive patients, Tanzi and Alster43 showed average
Erbium:YAG laser skin resurfacing time to re-epithelialization was 5.5 days with single-pass
Side effects and complications following Er:YAG laser carbon dioxide and 5.1 days with long-pulsed Er:YAG laser
resurfacing are similar to those observed after carbon resurfacing. Postoperative erythema was observed in all
dioxide laser skin resurfacing, although they differ in patients, lasting an average of 4.5 weeks after single-pass
respect to duration, incidence, and severity.49,66,67 Although carbon dioxide laser treatment and 3.6 weeks after long-
greater postoperative erythema is seen after modulated pulsed Er:YAG laser treatment. Hyperpigmentation was
Er:YAG laser treatment than is usually produced with a seen in 46% of patients treated with single-pass carbon
616 short-pulsed Er:YAG system, the side effect proﬁle and dioxide and 42% of patients treated with the long-pulsed
Ch38.qxd 22/12/04 7:27 PM Page 617
Er:YAG laser (average duration 12.7 weeks and 11.4 weeks, What is the patient’s skin phototype?
respectively). Delayed-onset permanent hypopigmentation
Pale skin tones have a lower incidence of undesirable
—a serious complication that has been observed sev-
postoperative hyperpigmentation compared to patients
eral months after multiple-pass carbon dioxide laser skin
with dark skin tones after ablative laser skin resurfacing.
resurfacing—has not yet been seen following single-pass
treatment. To date, only three cases of hypopigmentation
after modulated Er:YAG laser skin resurfacing have been Does the patient have a history of
reported.69,70 Since it is possible for hypopigmentation to herpes labialis?
present several years postoperatively, clinical studies are
Reactivation and/or dissemination of prior herpes simplex
ongoing to determine its true incidence following either
infection can occur with laser resurfacing. The de-
single-pass carbon dioxide or modulated Er:YAG laser skin
epithelialized skin is also particularly susceptible to primary
inoculation by herpes simplex virus, therefore all patients
should be treated with prophylactic antiviral medication
s POSTOPERATIVE CARE prior to ablative laser skin resurfacing.
Wound care during the immediate postoperative period is
vital to the successful recovery of ablative laser-resurfaced Does the patient have an autoimmune disease
skin. During the re-epithelialization process, an open- or or other immunologic deﬁciency?
CHAPTER 38 Laser Skin Resurfacing: Ablative and Non-ablative
closed-wound technique can be prescribed. Partial-
thickness cutaneous wounds heal more efﬁciently and with Because the postoperative course associated with ablative
a much reduced risk of scarring when maintained in a moist skin resurfacing is prolonged, intact immunologic function
environment because the presence of a dry crust or scab and collagen repair mechanisms are necessary to optimize
impedes keratinocyte migration.71 Although there is the tissue-healing response. In addition to possible delayed
consensus on this principle by laser surgeons, disagreement wound healing, patients with scleroderma, lupus erythe-
exists regarding the optimal dressing for the laser-ablated matosus, and vitiligo may also exhibit worsening of their
wound. The ‘open’ technique involves frequent application conditions after ablative skin resurfacing.
of thick healing ointment to the de-epithelialized skin
surface; whereas occlusive or semi-occlusive dressings are Are there other dermatologic conditions
placed directly on the lased skin in the ‘closed’ technique. present which could potentially
While the open technique facilitates easy wound spread after treatment?
visualization, the closed technique requires less patient
involvement and may also decrease postoperative pain. Psoriasis, verrucae, and molluscum contagiosum are but a
Proposed advantages of closed dressings include increased few conditions that could conceivably undergo Koebnerization
patient comfort, decreased erythema and edema, increased after ablative laser skin resurfacing. Thus, the skin should be
rate of re-epithelialization, and decreased patient involve- carefully inspected to rule out the presence of these and
ment in wound management.71,72 On the other hand, other inflammatory or infectious cutaneous lesions so that
additional expense and a higher risk of infection have been the ﬁnal clinical result is optimized.
associated with the use of these dressings.3,60,62
In addition to the prescribed wound care, ice pack Is the patient taking any medications
application and anti-inflammatory medications should be that are contraindicated?
used during this time. Furthermore, pain medication is
particularly important for ablative laser-resurfaced patients Concomitant isotretinoin use could potentially lead to an
during the ﬁrst few postoperative days. increased risk of postoperative hypertrophic scar formation
due to its detrimental effect on wound healing and colla-
genesis. Because the alteration in healing is idiosyncratic, a
s PITFALLS AND THEIR MANAGEMENT safe interval between the use of oral retinoids and ablative
Proper patient selection laser skin resurfacing is difﬁcult to calculate; however, most
practitioners delay the treatment for at least 6–12 months
While a variety of epidermal and dermal signs of facial after cessation of the drug.
photodamage are amenable to laser skin resurfacing,
suspicious growths should be biopsied for histologic
examination prior to laser irradiation.
Does the patient have a tendency to form
hypertrophic scars or keloids?
Patients with a propensity to scar will be at greater risk of
Has the patient ever had the areas treated
scar formation after laser resurfacing, independent of the
laser’s selectivity and the operator’s expertise.
Ablative laser resurfacing may unmask hypopigmentation or
ﬁbrosis produce by prior dermabrasion, cryosurgery, or
Is the patient prone to acne breakouts?
phenol peels. In addition, the presence of ﬁbrosis may limit
the vaporization potential of ablative lasers, thereby Complete control of acne eruptions should be obtained
decreasing clinical efﬁcacy. Patients who have had prior prior to ablative laser skin resurfacing with appropriate
lower blepharoplasties (using an external approach) are at topical or systemic antibiotics. Occlusive ointments used in
greater risk of ectropion formation after infraorbital ablative the immediate postoperative period may induce acne and
skin resurfacing. complicate the postoperative course. 617
Ch38.qxd 22/12/04 7:27 PM Page 618
Does the patient have realistic expectations of delivering variable duration spray spurts either before, during,
the procedure and will he/she be compliant and/or after laser irradiation. Since laser beam penetration
with postoperative instructions? and dermal wounding must be targeted to the relatively
superﬁcial portion of the dermis, contact cooling devices
Patients who believe that every rhytide will be removed
that theoretically lead to excessive dermal cooling may
with the ablative laser resurfacing procedure are not good
affect the level or degree of energy deposition in the skin.
treatment candidates. Furthermore, those who can not
As such, there remains no general consensus concerning
physically or emotionally handle the prolonged post-
which method of cooling is most efﬁcacious during
operative course should also be dissuaded from pursuing
ablative laser skin resurfacing procedures.
In general, treatment of facial photodamage with non-
ablative technology does not produce results comparable to
s SUMMARY those of ablative carbon dioxide and Er:YAG lasers;
Ablative laser skin resurfacing has revolutionized the however, many patients are willing to accept modest clinical
approach to photodamaged facial skin. Technology and improvement in exchange for fewer associated risks and
techniques continue to evolve, further enhancing the ability shorter recovery times.
to achieve substantial clinical improvement of rhytides and
dyspigmentation with reduced postoperative morbidity. Pulsed dye laser
PART 3 Aesthetic Surgical Procedures
Utilizing proper technique and treatment parameters,
Clinical studies have demonstrated the ability of 585 nm
excellent clinical results can be obtained with any one or
and 595 nm pulsed dye laser (PDL) to reduce mild facial
combination of carbon dioxide and Er:YAG laser systems
rhytides with few side effects.74 The most common side
available. Therefore, the best choice of laser ultimately
effects of PDL treatment include mild edema, purpura, and
depends on the operator’s expertise, clinical indication, and
transient postinflammatory hyperpigmentation. Although
individual patient characteristics. Regardless of the type of
increased extracellular matrix proteins and types I and III
ablative resurfacing laser used, the importance of careful
collagen and procollagen have been detected following PDL
postoperative follow-up cannot be overemphasized.
treatment, the exact mechanism whereby wrinkle improve-
ment is effected remains unknown.75 One theory states that
s NON-ABLATIVE LASER SKIN vascular endothelial cells damaged by the yellow laser light
REMODELING release mediators that stimulate ﬁbroblasts to produce new
Proper patient selection is critical to the success of non- Intense pulsed light source
ablative laser skin remodeling. Patients with mild-to-
moderate facial photodamage with realistic expectations of Several investigators have shown successful rejuvenation of
treatment are the best candidates for non-ablative photodamaged skin after intense pulsed light (IPL)
procedures. Patients seeking immediate improvement in treatment.77,78 The IPL source emits a broad, continuous
photodamaged skin or those who desire a dramatic result spectrum of light in the range of 515 nm to 1200 nm. Cut-
may be less than satisﬁed with the overall clinical outcome. off ﬁlters are used to eliminate shorter wavelengths
For patients with a strong history of herpes labialis, depending on the clinical application, with shorter ﬁlters
prophylactic oral antiviral medications should be considered favoring heating of melanin and hemoglobin. Bitter78
when treating the perioral skin. Reactivation of prior herpes showed improvement in wrinkling, skin coarseness,
simplex infection can occur after non-ablative laser skin irregular pigmentation, pore size, and telangiectasia in the
remodeling due to the intense heat produced by the laser or majority of 49 patients treated with a series of IPL treat-
light source. ments (fluences 30–50 J/cm2). In a retrospective review
Prior to non-ablative laser procedures, sun exposure should of 80 patients with skin phototypes I-IV, Weiss and
be avoided, particularly when using shorter-wavelength colleagues79 reported signs of photoaging, including
systems such as the pulsed dye laser or intense pulsed-light telangiectasias and mottled pigmentation of the face, neck,
source. Unwanted absorption of irradiation by activated and chest, improved by a series of IPL treatments. While
epidermal melanocytes can increase the risk of side effects, substantial clinical improvement of dyspigmentation and
including crusting, blistering, and dyspigmentation. telangiectasia associated with cutaneous photodamage is
often seen, neocollagenesis and dermal collagen remodeling
with subsequent improvement in rhytides following IPL
s TECHNICAL ASPECTS treatment has been more modest. The effect on dermal
Many of the non-ablative laser systems currently in use emit collagen is thought to be induced by heat diffusion from the
light within the infrared portion of the electromagnetic vasculature with subsequent release of inflammatory
spectrum (1000–1500 nm). At these wavelengths, mediators stimulated by vessel heating.80
absorption by superﬁcial water-containing tissue is relatively
weak, thereby effecting deeper tissue penetration.73 Since 1064 nm Q-switched Neodymium:YAG Laser
non-ablative remodeling involves creation of a dermal The 1064 nm quality(Q)-switched (QS) neodymium:YAG
wound without epidermal injury, all of these laser systems laser was the ﬁrst mid-infrared laser system used for non-
employ unique methods to ensure epidermal preservation ablative remodeling. Although absorption of energy by
during treatment. These methods typically include contact tissue water is relatively weak at the 1064 nm wavelength,
618 cooling hand-pieces or dynamic cryogen devices capable of it was possible to achieve dermal penetrative depths that
Ch38.qxd 22/12/04 7:27 PM Page 619
could potentially induce neocollagenesis. The nanosecond irradiation, thereby effecting collagen contraction and
range pulse duration of the QS Nd:YAG laser was also neocollagenesis. In order to prevent unwanted sequelae
determined to limit signiﬁcant thermal diffusion to (e.g. blistering) from excessive heat production, it is
surrounding structures, thereby making it suitable for non- imperative that epidermal temperatures be kept lower than
ablative rejuvenation. 50 °C. A series of three or more treatment sessions are
In 1997, Goldberg and Whitworth81 published their scheduled at regular intervals (typically once a month) for
experience using a 1064 nm Nd:YAG laser for facial rhytide maximum mitigation of ﬁne rhytides.73 Side effects of
reduction. Eleven patients (skin phototypes I, II) with mild treatment are generally mild and include transient
to moderate periorbital or perioral rhytides underwent erythema and edema.
treatment on one side of the face with a QS Nd:YAG laser Menaker et al.84 reported effective rhytide reduction in an
at a fluence of 5.5 J/cm2 (3 mm spot size) and carbon early study using a prototype 1320 nm Nd:YAG laser. Ten
dioxide laser ablation on the contralateral side for patients with periocular rhytides received three consecutive
comparison purposes. Pinpoint bleeding was used as the laser treatments at bi-weekly intervals. Three 300 µs pulses
clinical endpoint of treatment on the QS Nd:YAG laser- were delivered at 100 Hz and fluence of 32 J/cm2 with a 5-
treated facial half. Not unexpectedly, all of the carbon mm spot size hand-piece. Epidermal protection was achieved
dioxide-laser irradiated sites demonstrated signiﬁcant with application of a 20 ms cooling spray after a 10 ms preset
rhytide improvement at the end of the study. On the delay. Patients were evaluated at 1 and 3 months after
QS Nd:YAG laser-treated side, however, only three treatment. Although four of the ten patients showed clinical
CHAPTER 38 Laser Skin Resurfacing: Ablative and Non-ablative
patients demonstrated improvement. These three patients improvement in rhytide severity by end-study, these ﬁndings
had also developed prolonged post-treatment erythema were not statistically signiﬁcant. Similarly, the slight
(lasting up to one month)—suggesting that the amount of homogenization of collagen noted on histology at 1 and
dermal wounding (with subsequent collagen remodeling) 3 months following treatment was not statistically signiﬁcant
was directly related to the degree of cutaneous injury. and inconsistent with the clinical ﬁndings.
Another study using the QS Nd:YAG laser for rhytide In another study, Kelly et al.85 treated 35 patients with
reduction in 61 patients (242 sites) was conducted mild, moderate, and severe rhytides using a 1320 nm
using a topical carbon solution for improved optical Nd:YAG laser. Three treatments were delivered at 2-week
penetration of the 1064 nm light.82 Patients underwent intervals using fluences ranging 28–36 J/cm2 with a 5 mm
a series of three monthly treatment sessions with a spot size. Cryogen spray cooling was applied in 20–40 ms
QS Nd:YAG laser at a fluence of 2.5 J/cm2, 7 mm spot spurts with 10 ms delays. Patients were evaluated at 12 and
size, and pulse duration 6–20 ns. At least slight 24 weeks following treatment with statistically signiﬁcant
improvement was seen in 97% of class I rhytides and 86% improvement noted in all clinical grades after 12 weeks.
of the class II rhytides. Side effects of treatment were mild Only the most severe rhytides; however, showed persistent
and limited, including transient erythema, purpura, and improvement 24 weeks following treatment.
postinflammatory hyperpigmentation. Goldberg devised two similar studies to examine the
A long-pulsed Nd:YAG laser has also been used for effectiveness of the 1320 nm Nd:YAG laser for the
photorejuvenation. Lee83 evaluated a combination tech- treatment of facial rhytides. In the ﬁrst study, ten patients
nique using a long-pulsed 1064 Nd:YAG laser and long- with skin types I–II and class I–II rhytides in the periorbital,
pulsed 532 nm potassium-titanyl-phosphate (KTP) laser, perioral, and cheek areas were treated.86 Four treatments
both separately and combined, for non-invasive photo- were administered over a 16-week period using fluences of
rejuvenation in 150 patients, skin phototypes I through V. 28–38 J/cm2 with a 30% overlap and a 5 mm spot size. One
Patients treated with the combined laser approach showed or two laser passes were applied to achieve the treatment
at least 70% improvement in erythema and pigmentation endpoint of mild erythema. Skin surface temperatures were
and 30–40% improvement in ﬁne rhytides. In the patient limited to 40–48 °C using the aforementioned dynamic
groups treated with monotherapy, patient satisfaction was cooling spray in order to provide epidermal protection,
greater with KTP laser treatment than with long-pulsed whilst effecting dermal temperatures ranging 60–70 °C.
Nd:YAG laser treatment primarily due to a reduction in Six months following treatment, two patients showed
dyspigmentation and telangiectasias. no clinical improvement, six showed ‘some’ improvement,
and two showed ‘substantial’ improvement. This study
emphasized several key points in non-ablative laser
1320 nm Nd:YAG laser
resurfacing. It suggested a thermal feedback sensor is best
A 1320 nm Nd:YAG laser was the ﬁrst commercially used intraoperatively with this technology in order for
available system marketed solely for the purpose of non- appropriate treatment fluences to be selected based upon
ablative laser skin remodeling. The 1320 nm wavelength is the individual patient’s cutaneous temperature, thereby
associated with a high scattering coefﬁcient that allows for maximizing dermal temperatures that effectively lead to
dispersion of laser irradiation throughout the dermis. The collagen reformation. Furthermore, longer follow-up
latest model is capable of delivering energy densities up to periods are usually required to fully appreciate the effect of
24 J/cm2 with a pulse duration of 350 µs through a 10-mm serial treatment sessions on dermal collagen stimulation.
spot size hand-piece. The 1320 nm Nd:YAG laser hand- In the second study, ten patients underwent full-face
piece contains three portals: the laser beam itself, a thermal treatments with the 1320 nm Nd:YAG laser at 3–4-week
feedback sensor that registers skin surface temperature, and intervals.87 As with the ﬁrst study, treatment results were
a dynamic cryogen spray apparatus used for epidermal inconsistent—four patients showed no improvement, four
cooling. When skin surface temperatures are maintained at showed some improvement, and two showed substantial
40–45 °C dermal temperatures reach 60–65 °C during laser improvement in facial rhytides and overall skin tone. 619
Ch38.qxd 22/12/04 7:27 PM Page 620
Others also studied the 1320 nm Nd:YAG laser for sequence during the application of laser energy in order to
treatment of facial rhytides in ten women.88 Full-face avoid excessive thermal build-up within the superﬁcial
treatment was administered to three patients, whereas two layers of the skin.
patients had periorbital treatment, and ﬁve patients Goldberg et al.90 reported on the effects of 1450 nm
received perioral treatment. Laser fluences of 30–35 J/cm2 diode laser irradiation in 20 patients with class I-II rhytides.
were delivered in triple 300 µs pulses at a repetition rate of Two to four treatment sessions were delivered with
100 Hz. Dynamic cryogen spray cooling was used with a 6 months follow-up evaluation. Patients were treated with
30 ms spurt and a 40 ms delay between cryogen spurt and laser and cryogen spray cooling on one facial half and
laser irradiation. A thermal sensor was also used to maintain cryogen spray cooling alone on the contralateral side. On
peak surface temperatures in the range of 42–45 °C in the laser-treated facial halves, seven did not demonstrate
order to avoid excessive tissue heating. Treatments were any improvement, ten showed mild improvement, and
administered twice a week over a period of 4 weeks, for a three had moderate improvement. None of the sites treated
total of eight treatment sessions. Only two out of ten with cryogen alone showed any improvement after
patients expressed satisfaction with their ﬁnal result despite 6 months. Side effects of treatment were mild and included
clinician evaluations showing signiﬁcant improvement in transient erythema, edematous papules, and one case
ﬁve of ten patients and fair improvements in another three. of postinflammatory hyperpigmentation persisting for
Moreover, there was no correlation between histologic 6 months. The authors concluded that the 1450 nm diode
changes and the degree of subjective clinical improvement laser was effective for treatment of mild to moderately
PART 3 Aesthetic Surgical Procedures
as judged by the patients. severe facial rhytides with minimal morbidity. Additionally,
A more recent study by Fatemi et al.89 demonstrated that their study demonstrated that non-ablative laser treatment
the 1320 nm Nd:YAG laser produced mild subclinical alone was responsible for the clinical improvements and
epidermal injury that could potentially lead to enhanced that the non-speciﬁc injury induced by cryogen spray
skin texture and new papillary collagen synthesis by cooling could not effect the changes seen.
stimulation of cytokines and other inflammatory mediators. Hardaway and colleagues91 demonstrated statistically
Thus, the long-term histologic improvement seen in signiﬁcant mean wrinkle improvement of 2.3 (range 0–4,
photodamaged skin may not be based solely on direct laser with 4 representing severe wrinkling) at baseline to 1.8 at
heating of collagen, but by further stimulation of cytokine 6 months following a series of three 1450 nm diode laser
release by heating the superﬁcial vasculature. In addition, treatments. They concluded that although the 1450 nm
the histologic ﬁndings suggested that multiple passes with diode laser is capable of targeting dermal collagen and
fluence and cooling adjusted to a Tmax of 45–48 °C can yield stimulating ﬁbrosis, clinical improvement of rhytides was
improved clinical results, as compared to those specimens mild and did not correlate well with the degree of histologic
in which epidermal temperatures above 45 °C were not change noted in previous studies.
achieved. In a controlled clinical and histologic study, Tanzi and
Alster92 demonstrated improvement in mild to moderate
perioral or periorbital rhytides in 25 patients treated with
1450 nm diode four consecutive 1450 nm diode laser treatments. Peak
The 1450 nm mid-infrared wavelength diode laser targets clinical improvement was seen 6 months after the series of
dermal water and penetrates the skin to an approximate laser treatments. The periorbital area was more responsive
depth of 500 µm. This low-power laser system achieves to laser treatment than the perioral area—a ﬁnding
peak powers in the 10–15 W range with relatively long consistent with results obtained using other non-ablative
pulse durations of 150–250 ms. Because of these long laser systems (Fig. 38.4A–B).92 Side effects were limited to
exposure times, epidermal cooling must be delivered in transient erythema, edema, and postinflammatory hyper-
620 Figure 38.4 Facial rhytides (A) before and (B) 6 months after a series of 3-monthly 1450 nm long-pulsed diode laser treatments
Ch38.qxd 22/12/04 7:27 PM Page 621
pigmentation. In a separate controlled study performed by proﬁlometry data from silicone imprints. The majority of
the same group, 20 patients with transverse neck lines patients demonstrated modest improvement in objective
received three consecutive monthly treatments using a and subjective measurements which remained stable
long-pulsed 1450 nm diode laser.93 Modest improvements throughout the 14-month evaluation period.
in appearance and texture of the transverse neck lines was
reported, as measured by blinded clinical assessments Non-ablative radiofrequency
and through three-dimensional in vivo microtopography
(PRIMOS Imaging System; GFM, Germany). Mean A novel radiofrequency device (ThermaCool TC; Thermage
fluences of 11.6 J/cm2 were used with a 6 mm spot size and Inc, Hayward, CA) has also been studied for deep dermal
50 msec total cryogen. heating with subsequent tightening of photodamaged skin.
Unlike a laser in which light energy is converted into heat,
the radiofrequency device generates electric current which
1540 nm Erbium:glass laser produces heat through resistance in the dermis. The energy
The 1540 nm erbium-doped phosphate glass laser is another is delivered to the patient through a sophisticated hand-
mid-infrared range laser that has also been used for piece and treatment tip with a coupling membrane, which
amelioration of ﬁne facial rhytides and atrophic facial scars. allows for uniform delivery of heat over the entire treat-
Similar to other infrared laser systems, the erbium:glass ment area. Epidermal protection is provided by simultaneous
laser targets intracellular water and penetrates tissue to a cryogen cooling within the contact treatment tip. Using this
CHAPTER 38 Laser Skin Resurfacing: Ablative and Non-ablative
depth of 0.4–2 mm.73 The 1540 nm wavelength has the technique, a reverse thermal gradient is generated. The
least amount of melanin absorption compared with the depth of heat penetration is dependent upon the size and
1320 nm and 1450 nm laser systems—a potential advantage speciﬁcs of the detachable treatment tip and can be
of this system when treating tanned or darker-skinned changed according to the clinical application. Preliminary
patients. Mordon et al.94 studied the 1540 nm erbium:glass animal studies demonstrated selective dermal heating at the
laser on hairless rat abdominal skin with pulse train levels of the papillary dermis and as deep as the
irradiation (1.1 J, 3 Hz, 30 pulses) and varying cooling subcutaneous fat could be achieved.80 Ruiz-Esparza and
temperatures (+5 °C, 0 °C, −5 °C). Biopsies were obtained Gomez98 reported facial tissue tightening in 14 of 15
after 1, 3, and 7 days following treatment, and demon- patients 3 months after a single radiofrequency treatment
strated ﬁbroblast proliferation and new collagen synthesis as with minimal side effects. Ongoing research trials are
early as the third day. The authors concluded that this laser currently taking place at several centers to determine the
system held promise for treating facial rhytides because of most appropriate clinical indications and best treatment
its high water absorption and reduced scattering effect parameters for this innovative radiofrequency technology.99
allowing light energy deposition to remain in the upper
dermis where most solar elastosis is evident. s OPTIMIZING OUTCOMES
Ross et al.95 used the 1540 nm erbium:glass laser with a Rarely, postoperative hyperpigmentation can develop
sapphire cooling hand-piece to treat the preauricular skin of several weeks after non-ablative skin remodeling and is
nine patients. A 5 mm collimated beam was used to deliver more likely to be experienced by patients with darker skin
fluences of 400–1200 mJ/cm2. Epidermal necrosis and scar tones. In some cases, investigators demonstrated an
formation were noted at the highest pulse energies. Several association of post-treatment hyperpigmentation with
key points were illustrated by this study; namely, that excess intraoperative epidermal cryogen cooling.92 Although
denatured collagen located deep in the dermis (more always transient, topical bleaching agents and light glycolic
than 600 µm) is associated with granuloma formation, and acid peels can hasten the resolution of postinflammatory
that the peaks of heating and cooling with non-ablative laser hyperpigmentation.
remodeling are in proximity, by necessity, since maximum In the weeks following a series of non-ablative laser
wrinkle reduction may be achieved by a zone of thermal procedures, follow-up visits can help identify patient
injury 100–400 µm beneath the skin surface. concerns and increase the overall satisfaction with
Lupton et al.96 reported their use of a 1540 nm treatment. Clinical improvements after a series of non-
erbium:glass laser to treat 24 patients with ﬁne periorbital ablative laser procedures may take weeks to realize, thus
and perioral rhytides. Patients underwent a series of three reassurance by the laser surgeon regarding the patient’s
treatments on a monthly basis using a 4 mm spot size, progress can be particularly important.
10 J/cm2 fluence, and 3.5 ms pulse duration. Epidermal
protection was achieved with concomitant application of a s POSTOPERATIVE CARE
contact sapphire lens cooled to 5 °C. Histologic specimens
demonstrated increased dermal ﬁbroplasia at 6 months Since the epidermis remains intact following non-ablative
following the series of laser treatments. Average clinical laser skin remodeling, postoperative care is minimal. Some
scores were improved at 1 and 6 months following the third patients experience mild erythema and edema lasting less
treatment session with slightly better results observed in than 24 hours.
the periorbital regions. Side effects of treatment were mild
and included transient erythema and edema. s PITFALLS AND THEIR MANAGEMENT
More recently, Fournier and colleagues97 treated 42
Is the amount of photodamage amenable to
patients (skin phototypes I–IV) with ﬁve consecutive
non-ablative laser skin remodeling?
1540 nm diode laser treatments at 6-week intervals. Patients
were evaluated using clinical data, patient satisfaction Patients with mild-to-moderate facial photodamage are the
surveys, digital photography, ultrasound imaging, and best candidates for non-ablative procedures. Patients with 621
Ch38.qxd 22/12/04 7:27 PM Page 622
severe rhytides and skin laxity may be disappointed with 2. Lavker RM. Cutaneous aging: chronological versus photoaging. In
Gilchrest BA, ed. Photodamage. Cambridge, MA: Blackwell Science
the overall clinical outcome. 1995; 123–135.
3. Alster TS. Cutaneous resurfacing with CO2 and erbium:YAG lasers:
preoperative, intraoperative, and postoperative consideration. Plast
Does the patient have a history of Reconstr Surg 1999; 103:619–632.
herpes labialis? 4. Anderson RR, Parrish JA. Selective photothermolysis: precise micro-
surgery by selective absorption of pulsed radiation. Science 1983;
Reactivation of prior herpes simplex infection can occur 22:524–527.
with perioral non-ablative laser skin remodeling due to the 5. Shapshay SM, Strong MS, Anastasi GW, Vaughan CW. Removal of
intense heat produced by the laser. Patients with a strong rhinophyma with the CO2 laser. A preliminary report. Arch
history of herpes simplex labialis may require prophylactic Otolaryngol 1980; 106:257–259.
oral antiviral medication to avoid an outbreak. 6. Dufresne RG, Garrett AB, Bailin PL, et al. CO2 laser treatment of
chronic actinic cheilitis. J Am Acad Dermatol 1988; 19:876–878.
7. Alster TS, Kauvar ANB, Geronemus RG. Histology of high-energy
What is the patient’s skin phototype? pulsed CO2 laser resurfacing. Semin Cutan Med Surg 1996;
Although the majority of current non-ablative systems used 8. Tanzi EL, Lupton JR, Alster TS. Review of lasers in dermatology: four
are within the mid-infrared range of the electromagnetic decades of progress. J Am Acad Dermatol 2003; 49:1–31.
9. Lanzafame RJ, Naim JO, Rogers DW, Hinshaw JR. Comparisons of
spectrum and not avidly absorbed by epidermal melanin, continuous-wave, chop wave, and superpulsed laser wounds. Lasers
patients with darker skin phototypes may develop
PART 3 Aesthetic Surgical Procedures
Surg Med 1988; 8:119–124.
postinflammatory hyperpigmentation after non-ablative 10. Alster TS, Garg S. Treatment of facial rhytides with a high-energy
laser treatment. This temporary reaction most likely pulsed CO2 laser. Plast Reconstr Surg 1996; 98:791–794.
develops following inflammation created by concomitant 11. Alster TS: Preoperative preparation for CO2 laser resurfacing. In
Coleman WP Lawrence N, eds. Skin resurfacing. Baltimore: Williams
cryogen-spray epidermal cooling. & Wilkins; 1998:171–179.
12. Hevia O, Nemeth AJ, Taylor JR. Tretinoin accelerates healing after
trichloroacetic acid chemical peel. Arch Dermatol 1991; 127:678–682.
Does the patient have realistic expectations of
13. West TB, Alster TS. Effect of pretreatment on the incidence of
non-ablative laser skin remodeling? hyperpigmentation following cutaneous CO2 laser resurfacing.
Dermatol Surg 1999; 25:15–17.
Patients seeking immediate improvement after a single non-
14. Walia S, Alster TS. Cutaneous CO2 laser resurfacing infection rate with
ablative treatment are not good candidates as clinical and without prophylactic antibiotics. Dermatol Surg 1999; 25:857–861.
improvement occurs after multiple sequential treatment 15. Alster TS, Lupton JR. An overview of cutaneous laser resurfacing. Clin
sessions (usually three to ﬁve) and is often delayed Plast Surg 2001; 28:37–52.
3–6 months after the ﬁnal non-ablative laser procedure. 16. Alster TS, Nanni CA, Williams CM. Comparison of four CO2
Moreover, patients seeking dramatic results following non- resurfacing lasers: a clinical and histopathologic evaluation. Dermatol
Surg 1999; 25:153–159.
ablative laser skin techniques should be dissuaded from
17. Walsh JT, Deutsch TF. Pulsed CO2 laser tissue ablation: measurement
treatment as clinical improvement may be subtle. of the ablation rate. Lasers Surg Med 1988; 8:264–275.
18. Fitzpatrick RE, Ruiz-Esparza J, Goldman MP The depth of thermal
necrosis using the CO2 laser: a comparison of the superpulsed mode
s SUMMARY and conventional mode. J Dermatol Surg Oncol 1991; 17:340–344.
For those patients who desire a less aggressive approach to 19. Stuzin JM, Baker TJ, Baker TM, et al. Histologic effects of the high-
energy pulsed CO2 laser on photo-aged facial skin. Plast Reconstr Surg
photorejuvenation than ablative laser skin resurfacing, non- 1997; 99:2036–2050.
ablative dermal remodeling represents a viable alternative 20. Walsh JT, Flotte TJ, Anderson RR, et al. Pulsed CO2 laser tissue
for patients willing to accept modest clinical improvement ablation: effect of tissue type and pulse duration on thermal damage.
in exchange for ease of treatment and a favorable side-effect Lasers Surg Med 1988; 8:108–118.
proﬁle. Treatments are typically delivered at monthly 21. Rubach BW, Schoenrock LD. Histological and clinical evaluation of
facial resurfacing using a CO2 laser with the computer pattern
intervals with ﬁnal clinical results taking several months generator. Arch Otolaryngol Head Neck Surg 1997; 123:929–934.
after laser irradiation to be realized. Although clinical 22. Bernstein LJ, Kauvar ANB, Grossman MC, et al. The short- and long-
outcomes with these non-ablative systems are not yet term side effects of CO2 laser resurfacing. Dermatol Surg 1997;
comparable with those of ablative carbon dioxide or 23:519–525.
Er:YAG lasers, they do improve overall skin texture, tone 23. Fitzpatrick RE, Smith SR, Sriprachya-anunt S. Depth of vaporization
and the effect of pulse stacking with a high-energy, pulsed CO2 laser. J
and elasticity—subjective ﬁndings often difﬁcult to Am Acad Dermatol 1999; 40:615–622.
represent in photographs. None of the non-ablative laser 24. Alster TS, Lupton JR. Prevention and treatment of side effects and
systems has yet emerged as being clearly superior—each complications of cutaneous laser resurfacing. Plast Reconst Surg 2002;
produces similar degrees of improvement in dermal 109:308–316.
25. Lowe NJ, Lask G, Grifﬁn ME, et al. Skin resurfacing with the
pathology after multiple sessions at standard treatment ultrapulse CO2 laser: observations on 100 patients. Dermatol Surg
parameters. With continued research efforts focused on 1995; 21:1025–1029.
non-ablative laser skin remodeling, it is possible that further 26. Alster TS. Comparison of two high-energy, pulsed CO2 lasers in the
reﬁnements and advances in this technology will more treatment of periorbital rhytides. Dermatol Surg 1996; 22:541–545.
closely approximate the effects of ablative laser treatment 27. Apfelberg DB. Ultrapulse CO2 laser with CPG scanner for full-face
resurfacing of rhytides, photoaging, and acne scars. Plast Reconstr Surg
without its associated complications and risks. 1997; 99:1817–1825.
28. Lask G, Keller G, Lowe NJ, et al. Laser skin resurfacing with the
SilkTouch flashscanner for facial rhytides. Dermatol Surg 1995;
s REFERENCES 21:1021–1024.
1. Taylor CR, Stern RS, Leyden JJ, Gilchrest BA. Photoaging/ 29. Waldorf HA, Kauvar ANB, Geronemus RG. Skin resurfacing of ﬁne to
photodamage and photoprotection. J Am Acad Dermatol 1990; deep rhytides using a char-free CO2 laser in 47 patients. Dermatol Surg
622 22:1–15. 1995; 21:940–946.
Ch38.qxd 22/12/04 7:27 PM Page 623
30. Ratner D, Viron A, Puvion-Dutilleul F, et al. Pilot ultrastructural 58. Alster TS, West TB. Effect of topical vitamin C on postoperative
evaluation of human preauricular skin before and after high-energy carbon dioxide resurfacing erythema. Dermatol Surg 1998;
pulsed CO2 laser treatment. Arch Dermatol 1998; 134:582–587. 24:331–334.
31. Ratner D, Tse Y, Marchell N, et al. Cutaneous laser resurfacing. J Am 59. McDaniel DH, Ash K, Lord J, et al. Accelerated laser resurfacing
Acad Dermatol 1999; 41:365–389. wound healing using a triad of topical antioxidants. Dermatol Surg
32. Fulton JE, Barnes T. Collagen shrinkage (selective dermoplasty) with 1998; 24:661–664.
the high-energy pulsed carbon dioxide laser. Dermatol Surg 1998; 60. Horton S, Alster TS. Preoperative and postoperative considerations for
24:37–41. cutaneous laser resurfacing. Cutis 1999; 64:399–406.
33. Ross E, Naseef G, Skrobal M, et al. In vivo dermal collagen shrinkage 61. Fisher AA. Lasers and allergic contact dermatitis to topical antibiotics,
and remodeling following CO2 laser resurfacing. Lasers Surg Med with particular reference to bacitracin. Cutis 1996; 58:252–254.
1996; 18:38. ,
62. Sriprachya-anunt S, Fitzpatrick RE, Goldman MP et al. Infections
34. Flor PJ, Spurr OK. Melting equilibrium for collagen ﬁbers under stress: complicating pulsed carbon dioxide laser resurfacing for photo-aged
elasticity in the amorphous state. J Amer Chem Soc 1960; 83:1308. facial skin. Dermatol Surg 1997; 23:527–536.
35. Flor PJ, Weaver ES. Helix coil transition in dilute aqueous collagen 63. Alster TS, Nanni CA. Pulsed-dye laser treatment of hypertrophic burn
solutions. J Am Chem Soc 1989; 82:4518. scars. Plast Reconstr Surg 1998; 102:2190–2195.
36. Alster TS. Commentary on: Increased smooth muscle actin, factor 64. Friedman PM, Geronemus RG. Use of the 308-nm excimer laser for
XIII a, and vimentin-positive cells in the papillary dermis of CO2 laser- postresurfacing leukoderma. Arch Dermatol 2001; 137:824–825.
debrided porcine skin. Dermatol Surg 1998; 24:155. 65. Grimes PE, Bhawan J, Kim J, et al. Laser resurfacing-induced
37. West TB, Alster TS. Effect of botulinum toxin type A on movement- hypopigmentation: histologic alteration and repigmentation with
associated rhytides following carbon dioxide laser resurfacing. topical photochemotherapy. Dermatol Surg 2001; 27:515–520.
Dermatol Surg 1999; 25:259–261. 66. Rohrer TE. Erbium:YAG laser resurfacing-experience of the ﬁrst 200
CHAPTER 38 Laser Skin Resurfacing: Ablative and Non-ablative
38. Katz BE, MacFarlane DF. Atypical facial scarring after isotretinoin cases. Aesthet Dermatol Cosmet Surg 1999; 1:19–30.
therapy in a patient with a previous dermabrasion. J Am Acad 67. Tanzi EL, Alster TS. Side effects and complications of variable-pulsed
Dermatol 1994; 30:852–853. erbium:yttrium–aluminum–garnet laser skin resurfacing: extended
39. Roegnik HH, Pinski JB, Robinson K, et al. Acne, retinoids, and experience with 50 patients. Plast Reconstr Surg 2003; 111:
dermabrasion. J Dermatol Surg Oncol 1985; 11:396–398. 1524–1529.
40. David L, Ruiz-Esparza J. Fast healing after laser skin resurfacing: the .
68. Rostan EF, Fitzpatrick RE, Goldman MP Laser resurfacing with a long
minimal mechanical trauma technique. Dermatol Surg 1997; pulse erbium:YAG laser compared to the 950 ms pulsed carbon
23:359–361. dioxide laser. Lasers Surg Med 2001; 29:136–141.
41. Ruiz-Esparza J, Gomez JMB. Long-term effects of one general pass 69. Ross VE, Miller C, Meehan K, et al. One-pass carbon dioxide versus
laser resurfacing: a look at dermal tightening and skin quality. Dermatol multiple-pass Er:YAG laser resurfacing in the treatment of rhytides: a
Surg 1999; 25:169–174. comparison side-by-side study of pulsed carbon dioxide and Er:YAG
42. Alster TS, Hirsch RJ. Single-pass CO2 laser skin resurfacing of light lasers. Dermatol Surg 2001; 27:709–715.
and dark skin: extended experience with 52 patients. J Cosmet Laser 70. Zachary CB. Modulating the Er:YAG laser. Lasers Surg Med 2002;
Ther 2003; 5:39–42 26:223–226.
43. Tanzi EL, Alster TS. Single-pass CO2 versus multiple-pass Er:YAG 71. Tanzi EL, Alster TS. Effect of a semiocclusive silicone-based dressing
laser skin resurfacing: a comparison of postoperative wound healing after ablative laser resurfacing of facial skin. Cosmetic Dermatol 2003;
and side-effect rates. Dermatol Surg 2003; 29:80–84. 16:13–16.
44. Walsh JT, Flotte TJ, Deutsch TF. Er:YAG laser ablation of tissue: effect 72. Batra RS, Ort RJ, Jacob C, et al. Evaluation of a silicone occlusive
of pulse duration and tissue type on thermal damage. Lasers Surg Med dressing after laser skin resurfacing. Arch Dermatol 2001;
1989; 9:327–337. 137:1317–1321.
45. Ross EV, Anderson RR. The erbium laser in skin resurfacing. In Alster 73. Alster TS, Lupton JR. Are all infrared lasers equally effective in skin
TS, Apfelberg DB, eds. Cosmetic laser surgery, 2nd edn. New York: rejuvenation. Sem Cutan Med Surg 2002; 21:274–279.
John Wiley; 1999:57–84. 74. Zelickson B, Kilmer S, Bernstein E, el al. Pulsed dye laser therapy for
46. Alster TS. Clinical and histologic evaluation of six erbium:YAG lasers sun damaged skin. Lasers Surg Med 1999; 25:229–236.
for cutaneous resurfacing. Lasers Surg Med 1999; 24:87–92. 75. Zelickson B, Kist D. Effect of pulse dye laser and intense pulsed light
47. Hibst R, Kaufmann R. Effects of laser parameters on pulsed Er:YAG source on the dermal extracellular matrix remodeling. Lasers Surg Med
laser ablation. Lasers Med Science 1991; 6:391–397. 2000; 12:68.
48. Hohenleutner U, Hohenleutner S, Baumler W, et al. Fast and effective ,
76. Bjerring P Clement M, Heickendorff L, et al. Selective non-ablative
skin ablation with an Er:YAG laser: determination of ablation rates and wrinkle reduction by laser. J Cutan Laser Ther 2000; 2:9–15.
thermal damage zones. Lasers Surg Med 1997; 20:242–247. 77. Goldberg DJ, Cutler KB. Non-ablative treatment of rhytides with
49. Alster TS, Lupton JR. Erbium:YAG cutaneous laser resurfacing. intense pulsed light. Lasers Surg Med 2000; 26:196–200.
Dermatol Clin 2001; 19:453–466. 78. Bitter PH. Non-invasive rejuvenation of photodamaged skin using
50. Khatri KA, Ross EV, Grevelink JM, et al. Comparison of erbium:YAG serial, full-face intense pulsed light treatments. Dermatol Surg 2000;
and carbon dioxide lasers in resurfacing of facial rhytides. Arch 26:835–843.
Dermatol 1999; 135:391–397. 79. Weiss RA, Weiss MA, Beasley KL. Rejuvenation of photoaged skin:
51. Goldman MP Marchell N, Fitzpatrick RE. Laser skin resurfacing of the 5 years results with intense pulsed light of the face, neck, and chest.
face with a combined CO2/Er:YAG laser. Dermatol Surg 2000; Dermatol Surg 2002; 28:1115–1119.
26:102–104. 80. Hardaway CA, Ross EV. Non-ablative laser skin remodeling. Dermatol
52. Sapijaszko MJA, Zachary CB. Er:YAG laser skin resurfacing. Dermatol Clin 2002; 20:97–111.
Clin 2002; 20:87–96. 81. Goldberg DJ, Whitworth J. Laser skin resurfacing with the Q-switched
53. Pozner JM, Goldberg DJ. Histologic effect of a variable pulsed Er:YAG Nd:YAG laser. Dermatol Surg 1997; 23: 903–907.
laser. Dermatol Surg 2000; 26:733–736. 82. Goldberg DJ, Metzler C. Skin resurfacing utilizing a low-fluence
54. Ross EV, McKinlay JR, Sajben FP et al. Use of a novel erbium laser in Nd:YAG laser. J Cutan Laser Ther 1999; 1: 23–27.
a Yucatan minipig: a study of residual thermal damage (RTD), ablation,
83. Lee MW. Combination visible and infrared lasers for skin rejuvenation.
and wound healing as a function of pulse duration. Lasers Surg Med
Semin Cutan Med Surg 2002; 21:288–300.
55. Newman JB, Lord JL, Ash K, et al. Variable pulse erbium:YAG laser 84. Menaker GM, Wrone DA, Williams RM, et al. Treatment of facial
skin resurfacing of perioral rhytides and side-by-side comparison with rhytids with a non-ablative laser: A clinical and histologic study.
carbon dioxide laser. Lasers Surg Med 1998; 24:1303–1307. Dermatol Surg 1999; 25: 440–444.
56. Fitzpatrick RE, Rostan EF, Marchell N. Collagen tightening induced by ,
85. Kelly KM, Nelson S, Lask GP et al. Cryogen spray cooling in
carbon dioxide laser versus erbium:YAG laser. Lasers Surg Med 2000; combination with non-ablative laser treatment of facial rhytides. Arch
27:395–403. Dermatol 1999; 135: 691–694.
57. Nanni CA, Alster TS. Complications of carbon dioxide laser 86. Goldberg DJ. Non-ablative subsurface remodeling: Clinical and
resurfacing: an evaluation of 500 patients. Dermatol Surg 1998; histologic evaluation of a 1320 nm Nd:YAG laser. J Cutan Laser Ther
24:315–320. 1999; 1: 153–157. 623
Ch38.qxd 22/12/04 7:27 PM Page 624
87. Goldberg DJ. Full-face non-ablative dermal remodeling with a 94. Mordon S, Capon A, Creusy C, et al. In vivo experimental evaluation
1320 nm Nd:YAG laser. Dermatol Surg 2000; 26: 915–918. of non-ablative skin remodeling using a 1.54 µm laser with surface
88. Trelles MA, Allones I, Luna R. Facial rejuvenation with a non-ablative cooling. Lasers Surg Med 2000; 27:1–9.
1320 nm Nd:YAG laser. A preliminary clinical and histologic ,
95. Ross EV, Sajben FP Hsia J, et al. Non-ablative skin remodeling:
evaluation. Dermatol Surg 2001; 27: 111–116. selective dermal heating with a mid-infrared laser and contact cooling
89. Fatemi A, Weiss MA, Weiss RA. Short-term histologic effects of non- combination. Lasers Surg Med 2000; 26:186–195.
ablative resurfacing: Results with a dynamically cooled millisecond- 96. Lupton JR, Williams CM, Alster TS. Non-ablative laser skin
domain 1320 nm Nd:YAG laser. Dermatol Surg 2002; 28: 172–176. resurfacing using a 1540 nm erbium:glass laser: A clinical and histologic
90. Goldberg DJ, Rogachefsky AS, Silapunt S. Non-ablative laser analysis. Dermatol Surg 2002; 28:833–835.
treatment of facial rhytides: A comparison of 1450 nm diode laser 97. Fournier N, Dahan S, Barneon G, et al. Non-ablative remodeling: a 14-
treatment with dynamic cooling as opposed to treatment with dynamic month clinical ultrasound imaging and proﬁlometric evaluation of a
cooling alone. Lasers Surg Med 2002; 30: 79–81. 1540 nm Er:glass laser. Dermatol Surg 2002; 28:926–931.
91. Hardaway CA, Ross EV, Paithankar DY. Non-ablative cutaneous 98. Ruiz-Esparza J, Gomez JB. The medical face lift: a non-invasive, non-
remodeling with a 1.45 micron mid-infrared diode laser: phase II. J surgical approach to tissue tightening in facial skin using non-ablative
Cosmet Laser Ther 2002; 4:9–14. radiofrequency. Dermatol Surg 2003; 29:325–332.
92. Tanzi EL, Williams CM, Alster TS. Treatment of facial rhytides with a 99. Alster TS, Tanzi EL. Improvement of neck and cheek laxity with a non-
non-ablative 1450-nm diode laser: a controlled clinical and histologic ablative radiofrequency device: a lifting experience. Dermatol Surg
study. Dermatol Surg 2003; 29:124–129. 2004; 30: 503–507.
93. Tanzi EL, Alster TS. The treatment of transverse neck lines with a non-
ablative 1450 nm diode laser. Dermatol Surg 2004 (in press).
PART 3 Aesthetic Surgical Procedures