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Facial resurfacing is a broad topic referring to procedures that change the texture and appearance of skin. Resurfacing procedures are broadly classified as ablative or nonablative. Ablative procedures are considered the first line treatment for the most common indications for facial resurfacing, which are photoaging and acne scarring. The goal of this review is to provide an overview of the factors that optimize the clinical efficacy of an ablative procedure, including careful patient selection, preoperative skin preparation, correct operative technique, and vigilant postoperative care, as well as review both the traditional and some of the latest technologies that effectively resurface facial skin.
Facial resurfacing is a broad topic referring to procedures that change the texture and appearance of skin. Although reports of resurfacing date back to ancient times, renewed interest did not begin in America until the early 20th century. Since then, continued innovation in this field has ensued in an effort to find resurfacing procedures that both safely and effectively address the signs of photoaging and acne scarring. Photoaging and acne scarring are the most common reasons for which patients seek resurfacing procedures. These innovations include the introduction of mechanical dermabrasion in 1905 by Kromayer, the Baker-Gordon phenol peel in the 1960s, the laser principle of selective photothermolysis by Anderson and Parrish in 1983, and medium-depth chemical peeling by Brody in 1986.
In recent years, further innovation in the field of laser- and light-based technology has resulted in new devices that show promise, including fractional photothermolysis and plasma resurfacing technology. The goal of this review is to provide an overview of both the traditional and some of the latest technologies that effectively resurface facial skin.
Patient selection
The clinical efficacy of an ablative procedure is optimized through a combination of careful patient selection, preoperative skin preparation, correct operative technique, and vigilant postoperative care. The ideal candidate for a resurfacing procedure is one who has signs of photoaging or acne scarring. The Glogau photoaging score is a useful grading system for pretreatment classification of patients with aging skin (Table 1).
The Fitzpatrick skin type (Table 2) and the patient’s ethnicity are also important factors that determine the effectiveness and safety of ablative procedures.
Acne scarring can be classified as ice pick, rolling, or boxcar type (Figure 1). Ablative resurfacing is most beneficial for boxcar and rolling variants.
Relative contraindications to ablative procedures include a history of keloids, isotretinoin use in the previous 6 to 12 months, areas with compromised pilosebaceous units, smokers, and patients who have undergone extensive undermining of skin (ie, facelift) in the previous 6 months.
Skin preparation and protection is instrumental in optimizing the clinical benefits of ablative procedures. These steps have been succinctly summarized by Sadick as (1) preconditioning the skin with topical retinoids, alpha hydroxy acids, and hydroquinones and (2) practicing vigilant photoprotection after an ablative procedure (Figure 2).
Antiviral prophylaxis is the standard of care for patients with moderate-to-deep ablation and should be started 1 day before the procedure. The use of prophylactic antibiotics is controversial because most studies show a low risk of infection, although one study by Manuskiatti and coworkers found a bacterial infection rate of 4% in pretreated patients undergoing laser resurfacing and 8% in the untreated group.
Resurfacing procedures are broadly classified as either ablative or nonablative. Nonablative devices are currently limited to laser- and radiofrequency-based technology and are considered second line to ablative procedures for the treatment of skin laxity, rhytids, and acne scarring. Their chief advantage is minimal postoperative recovery time and low risk of scarring because they selectively wound the dermis while sparing the epidermis. Several excellent reviews are available on nonablative procedures and they will not be further addressed here.
Ablative procedures by definition refer to wounding of the skin to the level of the dermis by a chemical, mechanical, or thermal mechanism. They include chemical peels, dermabrasion, laser ablation, and a variant of electrosurgical ablation known as plasma resurfacing. These procedures are classified by the level of the wound as superficial, medium, or deep (Table 3 and Figure 3). Ablative procedures are the gold standard for addressing the signs of photoaging and scarring. Through removal of the epidermis, they address skin textural and pigmentary concerns. When the injury extends to the dermis, new collagen formation is triggered, which subsequently improves skin laxity and the appearance of rhytids. The chief disadvantages of ablative procedures are the length of “downtime” while waiting for re-epithelialization and the risks of infection, prolonged erythema, transient postinflammatory hyperpigmentation, cicatricial scarring, and permanent hypopigmentation, which increase with the depth of ablation. Additionally, systemic complications are a concern with the use of deep phenol peels.
Chemical resurfacing is the application of chemical agents to produce a controlled partial thickness injury to the skin. Several different peeling agents are available, categorized as superficial, medium, and deep based on the depth of ablation.
Indications
Indications for superficial chemical peels include comedonal acne, postinflammatory erythema, and Glogau group 1 (mild) photoaging. Medium depth chemical peels address dyschromia from dermal melasma and Glogau 2 to 3 (moderate to advanced) photoaging. Deep phenol peels are best reserved for patients with Glogau 3 to 4 photoaging and are especially effective for the deep rhytids in the perioral and periorbital regions. Superficial chemical peels are safely used in all Fitzpatrick skin types. Medium and deep chemical peels are best reserved for Fitzpatrick skin types 1 and 2, used with caution in skin types 3 to 4, and are typically not recommended for skin types 5 to 6 due to the risk of dyschromia.
A gentle soap free cleanser is used to remove all makeup and facial products. The skin is then vigorously “defatted” for approximately 3 minutes with either rubbing alcohol or acetone to remove surface sebum, allowing an even absorption of the lipophobic chemical peeling agents. The endpoint of this “defatting” procedure is a brisk erythema. The peeling solutions are uniformly applied to the 6 large cosmetic units (forehead, left cheek, right cheek, nose, chin, and periorbital area) with cotton gauze (Figure 4). The upper eyelids are typically left untreated due to the risk of the chemical agent dripping into the eyes. For the perioral and periorbital cosmetic units, cotton tipped applicators are used for better control. When performing a deep phenol peel, the entire face is treated with cotton tipped applicators. If rhytids are present, an assistant spreads the skin and the solution is applied with the broken end of a cotton applicator to ensure that the peeling solution penetrates the base of the rhytid.
A clear frost is not desirable because it indicates penetration into the dermis. Trichloroacetic acid and salicylic acid peels self-neutralize, however, alpha hydroxy acid (ie, glycolic acid) peels require neutralization with cold water or saline after certain amount of time that is determined based on the concentration and pH of the peeling agent.
Postoperative course
Mild stinging occurs during the procedure and subsides within a few minutes after treatment. Mild erythema resolves within a few hours. Depending on the strength of the agent used and the number of passes, desquamation begins on day 2 to 3 and can last between 1 to 4 days. Typically, 3 to 5 treatment sessions spaced 2 to 4 weeks apart are necessary to see optimal results.
Medium-depth peels
When combining Jessner’s or 70% glycolic acid with 35% tricholoracetic acid, the Jessner’s solution or glycolic acid is applied first to all 6 cosmetic units. A faint frosting with mild erythema typically appears within 60 seconds of application. The glycolic acid is neutralized after 2 minutes.
TCA application follows, first to the forehead, cheeks, chin, and nose. The eyelids and perioral regions are treated last. The solution can be applied within 1 to 2 mm of the lower eyelid using cotton tipped applicators.
Accidental spills into the eye should be copiously irrigated with sterile eyewash solution. The endpoint is a white frost that typically appears within 30 to 120 seconds of application. If this endpoint is not achieved after approximately 120 seconds, additional passes are done, waiting the indicated amount of time between passes for the white frost to develop. Full strength phenol (88%) is also considered a medium depth peeling agent and is most commonly used to treat periorbital rhytides. When using phenol, an assistant should be prepared to absorb tears, which can dilute the phenol and increase its depth of penetration.
Postoperative course
Ice packs are placed on the face immediately after treatment to minimize stinging. The face continues to develop erythema for the first 12 hours, followed by moderate edema. Makeup and sunscreens can be restarted after full reepithelialization occurs, typically 7 to 10 days after the procedure. Topical retinoids, superficial chemical peels, and microdermabrasion should not be resumed until 3 months post procedure. Medium depth peels can be repeated as necessary on a yearly basis.
Deep phenol peels
The classic deep phenol peel is the Baker-Gordon solution, which consists of phenol 88%, 3 mL, Septisol, 8 drops, Croton oil, 3 drops, and distilled water, 2 mL.
The latter 3 ingredients enhance the penetration depth of the phenol and if less ablation is desired, the croton oil is reduced by 1 or 2 drops. The mixture is freshly prepared before each treatment session and is frequently stirred to prevent layering of the ingredients. Due to the potential cardiac toxicity of phenol, cardiac, blood pressure, and pulse oximetry monitoring is essential during the procedure. Intravenous fluid boluses and infusions are also administered to volume load and dilute the phenol that enters the bloodstream. Most surgeons perform the procedure under “twilight” anesthesia using either hydromorphone or propofol in combination with midazolam. The branches of the trigeminal nerve are blocked using either lidocaine 1% or marcaine 0.5%. The use of epinephrine is controversial because its vasoconstrictive effects can affect the absorption and elimination of phenol. In the perioral region, the solution is extended 3 mm past the vermilion border. Treatment of the eyelids with the Baker-Gordon solution is controversial because of the increased risk of scarring in this area. As previously stated, any tearing near the eye should be absorbed immediately to prevent further dilution of the phenol. The endpoint is a white frost followed by a deep brawny erythema. When performing a deep phenol peel, applications are made in 15-minute intervals between each individual esthetic unit to prevent systemic phenol toxicity, which results in a total procedure time of 60 to 90 minutes.
Postoperative course
The primary goal during the first 3 to 4 days after the procedure is to protect and moisturize the denuded skin. A variety of occlusive and nonocclusive dressings have been described in the literature to accomplish this goal.
The dressings are changed several times a day after cleansing the face with acetic acid soaks and warm water. Full re-epithelization occurs in 10 to 14 days. Uniform erythema is an expected side effect of the procedure and typically resolves within 2 months. However, streaky erythema suggests that areas may be at risk for cicatricial scarring and should be treated with topical or intralesional steroids after full re-epithelization has occurred.
Dermabrasion
Mechanical ablation of the skin is most commonly performed by full-thickness dermabrasion. Microdermabrasion is defined as mechanical debridement of the most superficial layers of epidermis. The most commonly used device consists of a closed-loop, negative pressure vacuum system that uses aluminum oxide crystals to abrade the skin. The technique is simple and the technical key is to stabilize the skin with the nondominant hand so that the handpiece makes even contact with the skin. The depth of ablation is controlled by the pressure of the crystals being pro-pulsed, the pressure of the handpiece, and the speed of the pass.
Typically, 2 passes are completed, in directions perpendicular to one another. Its indications are similar to superficial chemical peels and multiple treatment sessions are necessary to see an optimal result. Indications for full thickness dermabrasion include deep periorbital or perioral rhytids,
boxcar and rolling acne scars, initial debulking of rhinophyma before using CO2 resurfacing to restore the natural contour of the nose, and removal of benign and premalignant epidermal growths.
Device used
The procedure is most commonly performed using an engine-driven rotating handpiece that can be attached to various drill bits, including, a diamond fraise, wire brush, or a serrated wheel that vary in size and coarseness. The diamond fraise abrades more slowly, which allows for a more controlled injury. An alternative to this heavy equipment includes sterile, medium grade (∼220 grit) silicone carbide sandpaper that is wrapped around gauze. This form of derabrasion is useful for dermabrasion of scars, small growths, and as an adjunctive procedure to CO2 resurfacing for perioral or periorbital rhytides.
The equipment necessary for dermabrasion is of relatively low cost, however, for most surgeons this practical advantage is outweighed by the disadvantages, which include the potential exposure of health care personnel to blood borne pathogens aerosolized by the procedure, the highly operator-dependent technique, and the risks of cicatricial scarring and hypopigmentation.
General technique
Adequate anesthesia is necessary before the procedure and involves a combination of regional nerve blocks, oral sedation, and intravenous sedation. Anesthetic considerations include the size of the area to be dermabraded, the depth of dermabrasion, the patient’s pain tolerance and the patient’s overall health. Routine cardiac, blood pressure, and pulse oximetry monitoring is performed if intravenous sedation is used. The affected area is treated in 1 to 2 square-inch segments by stabilizing the area with the nondominant hand and applying several short bursts of a freezing agent (Frigiderm), to create a more even surface for abrasion. Ten to twelve seconds of dermabrasion can be performed after a series of bursts with the freezing agent. It is best to begin in dependent areas to avoid pooling of blood in adjacent facial subunits and treatment should not extend into the hairline, across the mandible, or across the orbital rims. The level of ablation ranges from the papillary dermis, which is characterized by punctate bleeding to the superficial reticular dermis, characterized by a whitish yellow appearance (Table 4).
Table 4Visual endpoints during dermabrasion
Depth of ablation
Visual cue
Epidermis
Decrease in pigmentation
Papillary dermis
Pink color, punctuate bleeding vessels
Reticular dermis
Yellow–white color
Note: If subcutaneous fat is seen, ablation has proceeded too far.
Wet gauze is used to clean the skin and postoperative care and course is similar to a deep phenol peel.
Thermal Ablation
Overview of CO2 and Er:YAG Resurfacing
Thermal ablation is defined as the destruction of the epidermis and dermis through the controlled heating of tissue. It is most commonly achieved with laser or electrosurgical technology. Ablative lasers include the CO2 and Er: YAG devices, which have wavelengths of 10,600 nm and 2940 nm, respectively. They work on the principle of selective photothermolysis and cause homogenous tissue vaporization with surrounding residual thermal damage after selective absorption by intracellular water in the epidermis. Er:YAG lasers have a 10-fold greater absorption by water compared with CO2 lasers and therefore ablate tissue more precisely with less residual thermal damage.
The primary determinant of depth of tissue vaporization is the total fluence applied to the target skin. Standard fluences for CO2 resurfacing begin at 5 J/cm2, which creates 20 to 30 μm of tissue vaporization and 40 to 120 μm of residual thermal damage. For Er:YAG resurfacing, standard fluences begin at 0.6 to 5 J/cm2 with approximately 4 μm of tissue being ablated for every J/cm2 and residual thermal damage ranging from 10 to 40 μm. CO2 lasers have the advantage of hemostasis through thermal coagulation of blood vessels, thus are able to ablate tissue into the reticular dermis while Er:YAG lasers are limited to ablation into the papillary dermis because the resulting bleeding absorbs the laser light and prevents further tissue vaporization. The adverse effects associated with laser resurfacing include those described previously for all medium to deep ablative procedure. The risk for cicatricial scarring is higher with CO2 resurfacing compared with erbium resurfacing because the residual thermal damage is greater with the former. Prolonged erythema lasting up to 3 months has been more commonly reported with laser resurfacing compared with other resurfacing modalities.
Indications for CO2 and Er:YAG resurfacing
CO2 and Er:YAG lasers have similar indications, which include acne scarring and Glogau 3 to 4 photoaging. CO2 laser resurfacing is considered a better option for addressing skin laxity and deep rhytides because not only does it achieve deeper ablation but also because it creates greater residual thermal damage, which is theorized to be the mechanism for greater and more long-term collagen remodeling and regrowth.
Comparison of carbon dioxide laser, Erbium:YAG laser, dermabrasion, and dermatome: a study of thermal damage, wound contraction, and wound healing in a live pig model: implications for skin resurfacing.
Both CO2 and Er:YAG devices are typically equipped with a computerized pattern generator or optomechanical flash scanner, which allow for the rapid and precise placement of laser pulses in several different patterns. Short and ultrashort pulsed devices have replaced continuous wave lasers as the devices of choice for CO2 facial resurfacing. Er:YAG resurfacing devices are typically either short or variably pulsed. Variably pulsed lasers were developed to increase the residual thermal damage to promote better hemostasis allowing for deeper ablation and improved long term collagen remodeling.
General technique
The endpoint of treatment is a visible smoothing of rhytids and textural abnormalities while ensuring the damage does not extend deeper than the superficial reticular dermis. This is achievable in 1 to 4 passes with CO2 resurfacing.
Cosmetic units are treated individually and care is taken to feather the treatment between units and at the periphery of the face to prevent lines of demarcation. All hair bearing areas should be protected to prevent damage to terminal hair follicles. Overlapping of pulses is not recommended with CO2 resurfacing.
If treating with more than one pass, the epidermal debris should be gently wiped away between passes. The technique for Er:YAG resurfacing is similar to CO2 resurfacing; however, pulses can be overlapped 10% to 50% because of the minimal risk of compounding the residual thermal damage.
Additionally, it is not necessary to wipe away debris between passes with erbium resurfacing. Combination treatment with CO2 resurfacing followed by erbium resurfacing has also been reported as a method for achieving deep ablation with limited residual thermal damage.
The time to full re-epithelization is faster with laser resurfacing (7-10 days) compared with deep phenol peeling (10-14 days). Significant erythema, edema, oozing and crusting occur during the first 3 to 4 days after treatment. The immediate postoperative care is similar to that described for deep phenol peels.
Overview of Fractional Photothermolysis (FP)
FP is a new concept that was developed to address the limitations in ablative and nonablative lasers. In contrast to these lasers, which aim to create a homogenous zone of thermal damage at a particular level of skin, FP creates multiple microsomal thermal zones (MTZ) surrounded by normal skin (Figure 5).
The fractional thermolysis device creates zones of tissue coagulation with an intact stratum corneum rather than tissue vaporization, which results in a shorter healing time compared with traditional ablative resurfacing (Figure 6). Each MTZ results in a column of microsomal epidermal and dermal necrotic debris ranging in size from 70 to 100 μm wide and 250 to 800 μm deep, which is transepidermally eliminated as the normal surrounding keratinocytes migrate into the thermally wounded area.
Unwanted epidermal and dermal pigment is removed via this mechanism without actually targeting melanin. Additionally, zones of collagen denaturation in the dermis result in collagen remodeling and new collagen formation.
Figure 5Fractional resurfacing. A comparison photograph of a patient at baseline (A) and after (B) 3 treatments with the Fraxel One 750 using 10 mJ and 8 passes at 250 MTZ/cm2. There is some subtle improvement of fine rhytides and evening of skin texture and skin pigment. (Color version of figure is available online.)
Figure 6Conceptual comparison of ablative skin resurfacing, nonablative skin resurfacing, and fractional photothermolysis. ASR completely removes the epidermis and thermally wounds the dermis. Re-epithelization is dependent on the migration of skin keratinocytes from skin appendages. NSR thermally wounds the dermis without removing or damaging the epidermis. Fractional photothermolysis creates microsomal zones of damage in the epidermis and dermis. Re-epithelization is faster than ablative resurfacing due to less epidermal injury.
The Fraxel Laser (Reliant Technologies, Mountainview, CA) received approval from the Food and Drug Administration in 2003. It is indicated for the treatment of periorbital rhytides, pigmented lesions, melasma, acne scarring, and surgical scarring.
Device
The Fraxel laser (Reliant Technologies) is a 1,550-nm erbium doped glass fiber laser that targets water as its chromophore. The handpiece is attached to an articulated arm and contains an optical tracking system that utilizes OptiGuide Blue tint, a water soluble FDC dye. The tracking system recognizes subtle differences in the density of blue dye on the skin and ensures that an even MTZ spot pattern is laid down independent of the handpiece velocity. The newest fractional photothermolysis device (FraxelSR1500, Reliant Technologies) has eliminated the use of this blue dye, which is difficult to remove from the skin after application.
Technique
Discomfort from the procedure is most commonly alleviated with topical anesthesia and an optional forced air cooling system (Zimmer Cryo 5, Zimmer Medizin Systems). When using the blue dye, the dye is applied first to cleansed, dry skin followed by the topical anesthetic. The handpiece is moved across the treated area in a steady sweeping motion and individual cosmetic units are treated. The laser parameters that determine the overall clinical effect include the thermal energy, total MTZ density (a product of the pass MTZ density and the number of passes), coverage, and treatment intervals. Increasing the thermal energy increases the width and depth of each MTZ. Typical thermal energies range from 6 to 30 mJ with higher treatment energies recommended for dermal melasma, deep rhytids, and acne scars.
As the thermal energy is increased, the total MTZ density must be decreased so that the overall coverage, defined as the percentage of surface skin treated, remains less than 30% to prevent adverse sequelae. Typical total MTZ densities range from 1000 to 3000 MTZ/cm2. Because the pass density is typically preset at either 250 MTZ/cm2 or 125 MTZ/cm2, the total MTZ density is controlled by the number of passes. Treatment intervals range from 1 to 6 weeks depending on the aggressiveness of the treatment. Typically, higher energy treatments (>15 mJ) are spaced every 2 to 4 weeks.
Postoperative care
Patients can apply sunscreen and makeup immediately after a treatment session. Application of ice during the first 24 hours helps reduce postoperative erythema and edema, which typically resolves in less than 1 week. Oozing and crusting is rare because the stratum corneum is intact, however, excessive desquamation can occur after an aggressive treatment session.
Plasma resurfacing technology
Plasma refers to a type of energy that is delivered in the form of an ionized gas or fluid. On target with tissue, the plasma delivers thermal energy without reliance on a chromophore. The depth of the thermal effect depends on the energy setting and causes tissue coagulation rather than tissue vaporization, thus shortening the healing time.
Device
The Portrait PSR3 (Rhytec) is a recent prototype of this technology that uses an ultra-high frequency radiofrequency generator to create energy that ionizes inert nitrogen gas into a gaseous nitrogen vapor. This ionized gas has an optical emission spectrum in the visible to near infrared range giving the gas its characteristic violaceous color. The plasma is emitted in 1 to 4 pulses per second (Hz) and causes a nonchromophore dependent uniform and controlled heating of the skin with minimal charring. Pilot studies suggest that a single-pass, high-energy (3-4J) plasma treatment is equivalent to a single-pass low-to-medium fluence CO2 laser treatment (∼70 μm of thermal damage).
No reports of cicatricial scarring or hypopigmentation have been reported. A recent study by Bogle and coworkers suggests that three low energy treatments given at 3-week intervals achieves the efficacy of a single-pass, high-energy treatment with less discomfort during the procedure and a shorter postoperative healing time.
The indications for plasma resurfacing are similar to fractional photothermolysis.
Technique
Topical anesthetic agents along with trigeminal branch nerve blocks are recommended to reduce discomfort during the procedure. A full face treatment takes ∼20 to 30 minutes and involves holding the handpiece approximately 5 mm from the skin surface to create a 6-mm spot size, which is visually represented by a blue target ring on the skin surface. Individual cosmetic units are treated by placing the pulses in a paintbrush pattern with minimal overlap between pulses. A feathering technique is used at the hairline and along the jaw by pulling the handpiece back to ∼15 mm, which reduces the plasma energy to the skin. Treatments are typically a single pass, although a second or third pass may be necessary for deeper rhytids. The epidermal debris acts as a biologic dressing, therefore should not be wiped away between passes or at the end of a single pass.
Postoperative care
Treatment energy dependent erythema and edema followed by desquamation occurs during the first 7 to 10 days after treatment with a high energy setting. A bland ointment such as aquaphor or petroleum is applied to the face for the first 3 to 4 days after which time a sunscreen and makeup can be worn. The healing time is shorter (4-5 days) after a low energy setting treatment.
Conclusions
Facial resurfacing is a broad field in which there continues to be innovation to achieve clinical efficacy with minimal downtime and risk of adverse effects. To optimize the end result, careful patient selection, skin preparation and protection, and choice of an appropriate resurfacing device are important variables. This review is a basic overview of these factors.
Comparison of carbon dioxide laser, Erbium:YAG laser, dermabrasion, and dermatome: a study of thermal damage, wound contraction, and wound healing in a live pig model: implications for skin resurfacing.
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