Laser Resurfacing

LASER SKIN RESURFACING

INTRODUCTION

Over the last several years, one of the hottest topics in the national televised and print media has been the use of lasers to erase facial wrinkles. 20/20 (the national television news show), SELF magazine and many others have recently reported on this amazing new technology to remove facial wrinkles. Sound like magic? Physician's have been using lasers to treat a variety of medical conditions for the last twenty years. It is only recently that the technology has been fine-tuned enough to be used effectively by cosmetic surgeons to erase wrinkles. The first reports of successful wrinkle removal by laser came in early 1994.

HISTORY

Many techniques have been tried by health professionals over the last several decades to remove the wrinkles around the eyes and mouth. Chemical peeling has been used for many years with good results. One form of a chemical peel is a TCA peel which is quite effective in removing fine wrinkles but unpredictable in removing deeper wrinkles. In addition, the depth of penetration of TCA is quite variable and difficult to predict. For deeper wrinkles phenol peels have been used but have the disadvantage of being toxic to the kidney and heart. Dermabrasion (where the skin surface is "sanded" with an abrasive material) is used less frequently now than in the past. Collagen has been injected into wrinkles to "soften" their appearance. One disadvantage of this is that the procedure must be repeated every 3 months and approximately 6% of people are allergic to collagen. For deeper forehead wrinkles doctors have injected Botox. Botox is synthetic botulinum toxin which acts to cause a very localized paralysis of muscles immediately adjacent to the site of injection - thereby smoothing out the overlying skin.

MECHANISM OF ACTION

How does laser skin resurfacing work? Laser skin resurfacing uses a carbon dioxide laser which is applied in a very short pulse so that the tissue is evaporated and not burned. Although the exact mechanism of action of the laser has not been discovered at present, the laser is known to remove the surface layer of skin and cause shrinkage of the underlying collagen. This effectively smooths out the surface layer, tightens the underlying tissue and softens the skins appearance.

LASER CANDIDATES

Who is a candidate for this procedure? Anyone with significant facial wrinkles who has not taken Accutane (an anti-acne drug) in the previous year and has no medical contraindication. The procedure appears to work best in fair-skinned individuals. In addition to removal of facial wrinkles, the laser has also been used to remove facial lesions (moles etc.) and to soften facial scars.

COMPLICATIONS

In general laser resurfacing has been shown to be a very safe and effective treatment for facial rhytids (wrinkles). The most common complication associated with laser skin resurfacing is temporary hyperpigmentation in the treated areas. This hyperpigmentation is noted immediately after treatment as a “sunburn”. The pigmentary changes become more red over the first 5-8 days. The redness then fades and becomes slightly brown. In the majority of patients the redness fades within 12-16 weeks after treatment. The redness may recur with exercise or flushing of the face during emotional experiences. Other complications are very rare and include: infection, hypopigmentation, pain, eyelid and eye damage, scarring and permanent pigmentary changes.

PREOPERATIVE CHECKLIST FOR LASER RESURFACING

Please circle most appropriate

1. Always burns, never tans	4. Rarely burns, tans with ease
2. Usually burns, tans with difficulty	5. Very rarely burns, tans easily
3. Sometimes mild burn, average tanner	6. Doesn’t burn, tans easily

Have you ever had previous chemical peel or laser resurfacing?	Yes	No
Have you ever had a cold sore on the mouth or face?	Yes	No
Have you ever had shingles (zoster) of the face?	Yes	No
Have you ever had a reaction to Zovirax (Acyclovir)?	Yes	No
Have you ever had treatment with Accutane?	Yes	No
Have you ever had treatment with Retin-A?	Yes	No
Have you ever had treatment or used alpha-hydroxy acids?	Yes	No
Do you have “sensitive skin? Have you had trouble with any skin creams, soaps etc.?	Yes	No
Are you allergic to any antibiotics?	Yes	No

Previous skin surgeries? __________________________________________________________
Complications? _________________________________________________________________

Allergies? _____________________________________________________________________
LASER RESURFACING PREOPERATIVE INSTRUCTIONS

1. Prior to undergoing laser skin resurfacing you must be fully aware of the pre and post-operative care necessary to properly take care of your skin. In addition, you must fully understand the risks associated with this procedure and that all patients experience significant redness and swelling postoperatively.

2. You can not undergo this procedure if you have taken Accutane within the last 12 months.

3. It is sometimes helpful to pre-treat your skin with Retin-A for 1-3 weeks prior to laser skin resurfacing.

4. Retin-A is applied nightly as a thin film to the specified areas to be treated(do not get in eyes). If redness occurs dilute the Retin-A with water or discontinue and consult your doctor.

5. You can not undergo this procedure if you have active cold sores at the time of treatment.

6. You should start Antiviral treatment 1-2 days prior to undergoing resurfacing.

7. You should start oral antibiotics the day of or one day prior to undergoing resurfacing (usually Keflex, Cipro unless you are allergic).

8. You should wear no make-up on the day of treatment.

9. You should have someone to drive you home after treatment.

ANESTHESIA FOR LASER SKIN RESURFACING

There are a variety of ways to provide anesthesia for laser skin resurfacing depending on the patient, medical indications and area to be treated. If only one or two areas of the face are to be treated, most patients will undergo application of an anesthetic cream for 1.5 - 2 hours prior to undergoing resurfacing. Just prior to resurfacing the patient will have local anesthetic injected into the treatment areas as a “local” block and a “regional” block. Some patients will also have oral sedation (Valium) added.

For patients undergoing treatment of most or all of the face the above method can also be used but the patient should understand there will be a variable amount of pain when using this method to treat the whole face. Other methods include IV sedation and a general anesthetic. In general, IV sedation is preferrable to a general anesthetic because it is safer and patients recover faster. The disadvantage of these two anesthetic methods is the increased cost associated (an Anesthesiologist must be present and you may or may not need to have the procedure performed in a hospital).

LASER SKIN RESURFACING COSTS

The cost of laser skin resurfacing varies depending on how much of your face you want treated, the method of anesthesia chosen and the laser charge. The cost for anesthesia is also variable and depends upon the length of time the procedure takes. Patients with significant medical problems or those requiring deep IV sedation or general anesthesia will also incur a facility fee for use of a hospital. On top of this you will have the cost of pre & postoperative prescriptions. You may or may not also have the cost of a facility (for anesthesia).

LASER SKIN RESURFACING POSTOPERATIVE INSTRUCTIONS

1. You must follow the instructions your doctor gives you at the time of surgery.

2. Keep treated areas covered with Vaseline ointment constantly. Clean the wounds gently but thoroughly with sterile saline and cotton balls every 12 hours the first two days then 1-3 times daily thereafter.

3. Uncovered areas should be kept constantly moist with Vaseline gel

4. You should continue Antiviral medications for 5-7 days postoperatively.

5. You should continue oral antibiotics for 7 days postoperatively (i.e. Keflex, Cipro).

6. Take Medrol Dose pack as instructed if prescribed by your doctor.

7. Take pain pills as prescribed (i.e. Vicodin, Lortab, Tylenol #3)

8. Clean treated areas 2 times daily with sterile saline solution (contact lens solution). If “crystals” form on the treated areas - gently clean them off your face. Do not scrub your face or rub any scabs off your face. It is important to prevent scab formation if at all possible.

9. The more fluids you drink the better you will do. Attempt to drink 10 oz. of fluid/hour while awake; fluids such as apple juice and ginger ale are tolerated best. After 24 hours attempt to increase diet to foods of soft nature. Increase food consistency as tolerated. Take your pain medication a few hours prior to eating to maximize effect.

11. AVOID DIRECT SUNLIGHT. Refrain from overactive work or play during the first 5-8 days. During the first 24-48 hours remain at rest. Resume normal activities as your pain level permits. After the first week you must wear sunprotection (SPF 15) for the next 3-4 months when exposed to sunlight.

12. You may run a low-grade fever the first 24 hours. However, if the fever persists beyond 24 hours, notify your physician.

13. You may experience mild itching 3-8 days after treatment. Ice packs gently applied on top of the occlusive dressing will alleviate most itching. For more severe itching you may try over the counter Benadryl (this will make you sleepy - no driving).

14. NO make-up until instructed to use it by your doctor - usually the first 7-10 days. Thereafter you can conceal the redness with a concealer (green makeup) and then a flesh toned make-up may be applied on top of the concealer. The best known is Physician’s Formula of Industry, Califormia. The green concealer is called “Gentle cover Concealer.” The flesh-tone cover makeup is called “Le Velvet Film Makeup SPF-15”. Estee Lauder also makes a green concealer.

15. After you are told you can use make-up you should clean your face with a gentle soapy water several times daily and apply Cetaphil lotion several times daily, prior to applying make-up, to prevent dryness. (Dryness is your enemy).

16. You may be instructed by your doctor to start a prescription topical steroid at the end of the first week after treatment.

17. If you experience any unusual symptom (excessive pain, crusting, eye irritation etc.) you should call your doctor immediately.