Procedures

Procedures : Laser Resurfacing

Who is a good candidate for laser resurfacing?

We age in 3 ways. I discuss this very important concept at length. Most patients are well aware of the effects of gravity on aging. They also realize that dynamic muscle movements cause wrinkles over the time, such as crow’s feet and frown lines. However, many patients neglect to consider the skin itself. It is the canvas on which the painting is produced. If the canvas (skin) appears aged then it significantly contributes to the aging process and detracts from even excellent cosmetic surgery. If one has been restored by a facelift to youthful contours but yet the canvas appears older, the result is less than optimal and can give the appearance of being artificial.

Laser resurfacing is, in my opinion, the optimal approach to dealing with aging skin. Other options, such as chemical peels and dermabrasion are reasonable considerations, but are not as consistent and successful as laser in my hands. Therefore anyone who has skin with environmental changes caused by sun damage, wind, dryness, or other environmental factors is a good candidate for laser rejuvenation. These changes would appear as dark age spots or sun spots, broken blood vessels, and of course; mild, moderate, and even severe wrinkles. These wrinkles can occur over the entire face, but are often noticed around the mouth. Although these are often termed “smoker’s lines” on the upper lip, many non smokers unfortunately are troubled by this condition.

There are many types of laser procedures now. Which one, if any, is right for me?

Specific Procedures:

There are several types of laser procedures that can rejuvenate the skin from milder forms of treatment that can be delivered at our outpatient medical spa EPICENTRE to more aggressive procedures performed under general anesthesia at our outpatient surgery center Dallas Day Surgery Center.

Here are some terms to better understand the process.

Ablative resurfacing – vaporization; ablative resurfacing is interpreted as vaporizing or eliminating the skin being treated. The vaporization occurs immediately upon contact with the laser. Ablation is caused by heat. Depending on the laser, there is always a non- ablative injury surrounding the ablative injury. See below.

Non-ablative resurfacing – the tissue is heated to various temperatures. High temperatures can kill the tissue in question, but other temperatures can denature protein and damage the tissue which prompts a healing response. This healing response causes the body to produce new collagen in the area.

Lasers therefore can target the obliteration of sun-damaged skin as well as stimulate new collagen. All lasers discussed restore and rejuvenate sun-damage with some mix of these mechanisms.

Erbium laser resurfacing (Ablative)This procedure offers the best results for rejuvenating the skin. (LiAlthough no guarantees can be made for any individual, the average improvement on difficult upper lip wrinkles is 80%. This technique is an ablative technique and literally takes off total removal of the upper layers of skin. This procedure has replaced CO2 laser resurfacing which was popular in the late 90’s. The CO2 resurfacing procedure was almost as effective as Erbium resurfacing in my hands but had a much higher complication rate.

Fractional resurfacing (Ablative and non-ablative options) – I was fortunate enough to be the editor of the first paper produced about fractional resurfacing.

This approach is relatively new in the lasts few years. It is a distinct departure from the mechanism of action from standard Erbium or CO2 resurfacing lasers. A fractional approach means that a fraction (usually 20-40 %) of the skin is treated, but to depths 3 to 5 times deeper than standard techniques. Imagine pixels on your computer and effecting only 20 to 40 % of them. In one square cm of skin there is an average of 2000 microscopic columns of injury, yet so small that 60-80 % of skin remains normal. This sparing of normal skin allows faster healing. Therefore the advantage of this approach is quicker recovery and fewer potential complications. There are two types of fractional resurfacing approaches.

  • Ablative fractional resurfacing Usually done with the CO2 Fraxel Re:pair laser which can be used in combination with Erbium. This is the most aggressive of the fractional approaches. The average improvement is 40-50%. Multiple treatments may be advantageous but are not practical at this point due to the need for general anesthesia in almost all cases.
  • Non-ablative fractional resurfacing – Fraxel Re:store Our most popular out patient rejuvenative procedure. This can be done under topical anesthesia. Because there are no “open wounds” there is much less downtime. Therefore multiple treatments can be utilized to maximize results yet minimize significant side effects. We recommend 4-5 treatments for maximal results. The average result after multiple treatments is 20% improvement in wrinkles.

What results can I expect with the different procedures?

Final results should be judged at 6 months since all treatments stimulate collagen production and remodeling. This simply takes 6 months to complete.

Method Average wrinkle improvement
Erbium laser resurfacing 80%
CO2 Re:pair fractional ablative 30-50%
Re:store fractional non-ablative 15-30%

What is the post treatment course?

For each individual results can vary as each person must respond to the treatment based on their own particular immune system and collagen restorative response. Other complicating factors such as diabetes and smoking are known inhibitors to healing and must realize that their results can not be expected to achieve average success. Some patients occasionally see these averages as a guarantee which quite simply they are not.

Laser Resurfacing Comparisons

  Erbium LRS Fractional ablative (CO2 re:pair) Fractional non-ablative(re:store)
Open wound/oozing 5-7 days 3-4 days none
Dressing covers wound 3-5 days None :topical ointment None: topical ointment
Wrinkle improvement (avg) 80% 40-50% 15-30%
anesthesia general General / (local possible for mouth ) topical
redness 6-12 weeks avg 2-4 weeks avg 2-4 days avg

What are the risks?

We do not feel that it would be appropriate or ethical to post prices for procedures on the internet. We do, however, understand that cost is a factor you must consider. We would be happy to speak with you about this issue so that you may determine whether the procedure you are considering falls within your budget. Our pricing structure is based on the time, complexity, and surgical costs involved. Please feel free to call our office at 214-823-1978 and speak with either Kurthene or Annette for more details.

  • Prolonged redness The key word here is “prolonged” as redness occurs as a natural response to heat and is to be expected. The more aggressive treatments such as Erbium and CO2 resurfacing have more redness than fractional treatments. The normal redness is outlined in the table above. If redness lasts significantly longer than these times then it could be considered a complication.
  • Hypopigmentation Skin treated with ablative lasers can lose their natural pigment. This is NOT to be confused with the obliteration of dark age spots/sun spots and the natural sun bronzing that occurs with aging. One needs only to look at the sun protected areas to see the natural color of their skin. However, if true skin pigment is lost, the skin can appear unnaturally light. This was very common with CO2 laser and is the main reason I no longer utilize it. Erbium has supplanted CO2 in my practice. Although hypopigmentation may occur with aggressive Erbium resurfacing, it is much less common and less severe than with previous methods such as CO2. Fractional ablative resurfacing produces extremely rare hypopigmentation. Such cases to this point are usually found in areas other than the face. The exception is non ablative fractional laser treatments in which hypopigmentation is virtually non existent.
  • Scarring Scarring may occur with any technology in which heat is produced such as lasers. This is rare overall and very rare in my practice with any laser. It is only logical that scarring is more likely with more aggressive techniques.
  • Infection Infection is also rare with laser resurfacing and occurs primarily with ablative techniques in which open wounds are created. Again, this is also more common with more aggressive techniques. The most common infection is actually a viral herpes infection. This virus lays dormant in almost everyone and a herpetic outbreak can occur with the stress of laser resurfacing. For this reason, all patients undergoing ablative resurfacing will be given viral prophylaxis medication.
  • Post inflammatory hyperpigmentation PIH is a condition in which the melanocytes in the dermis pour out melanin pigment in response to inflammation. This occurs more commonly in darker skin types and is most common in Asian and/or Pacific Rim nationalities. This condition is usually self limiting and fades over time, but can be treated with topical medicines to hasten recovery.

Are there any conditions which would preclude laser treatments?

Contraindications to Treatment

There are several conditions which I believe preclude laser resurfacing with Erbium Laser ablative. Such an opinion may not be shared by some treating physicians. However, I have dedicated over 20 years to the technology of laser science and clinical practice and I feel strongly that it is in the best interest and safety of my patients to hold this position. Such conditions are, but not limited to:

  • Intense electrolysis in the area proposed to be resurfaced. This most commonly occurs in the upper lip. Most patients have had only a “few” electrolysis treatments and are fine. However there are patients who have multiple intense repeated treatments who now have no hair growth in an area. The hair follicles are destroyed and play a key role in wound healing with complete ablative resurfacint.
  • Accutane usage within the last year precludes treatment. The sebaceous glands are inactivated with Accutane which greatly interferes with wound healing. One must discontinue accutane and wait until oil is detected again on the skin in the area to be treated
  • Autoimmune diseases such as Lupus and Scleroderma also preclude treatment due to the inherent effects these diseases have on wound healing

It should be noted that fractional resurfacing non ablative can be used on all of these restricted categories. Even ablative fractional resurfacing can be utilized in patients with a history of electrolysis due to it’s mechanism of action. Again every patient needs to be managed individually with a personal consult visit.

HOW TO CHOOSE WHICH PROCEDURE IS RIGHT FOR YOU

As with most procedures, there is a trade off of results verses downtime. You must decide your priorities when considering how much improvement you desire. You can weigh the downtime and potential complications of each procedure. If you desire the best result no matter what the downtime is, then Erbium total ablative resurfacing is a wise choice. If you want to insure the lowest possible problems or recovery and can compromise results, then non-ablative Fractional resurfacing (Fraxel Re:store) is a great option with multiple treatments. Many patients are somewhere in between, therefore Fractional ablative (Fraxel Re:pair) is a reasonable choice.

SPECIAL CIRCUMSTANCES and INDICATIONS

To this point, the discussion has been focused on sun damage and wrinkles. However there are other conditions which can be treated with lasers.

  • Acne scarring In my opinion and the opinion of many other experts, fractional laser treatment has become the state of the art for the treatment of acne scarring. Non ablative treatment can be utilized as an outpatient with 4 to 5 treatment sessions or fractional ablative can be carried out under general anesthesia.
  • “Off Face Treatments” Many patients have concern with sun damage and wrinkling on their neck, chest (décolleté), arms, and hands. These areas can not be treated with standard resurfacing techniques due to safety issues. These areas have less blood supply, and less inherent healing capacity than the face; therefore the fractional approach is the best viable option for these areas. Fractional treatment is extremely useful for patients who have had facial rejuvenation but have previously had no remedy for treating the remaining sun damaged areas below their face. Remember that with fractional treatment only a portion of each area is treated leaving untreated skin to help heal the treated areas. Non ablative fractional is, by far, the safest treatment alternative. Ablative fractional is a treatment choice as well, but must be used judiciously off the face. Individualized treatment plans should be chosen after a detailed in office consultation.
  • All Erbiums are not the same I have been blessed to have extensive laser experience as stated. As a result I have worked with many systems and I can say emphatically that not all Erbiums are the same. The best system by far that I have used is the Sciton Profile system, which is the one I utilize currently. All of the results you see shown here (link to results) are achieved only with the Sciton tunable Erbium system. I say this not to be self serving, but only to clearly communicate that this excellent system is available and utilized in our office. It is perfectly reasonable to choose other excellent physicians who utilize Erbium, but one should be careful to ask the right questions about the technology utilized.
  • How much does it cost?

    We do not feel that it would be appropriate or ethical to post prices for procedures on the internet. We do, however, understand that cost is a factor you must consider. We would be happy to speak with you about this so that you may determine whether the procedure you are considering falls within your budget. Our pricing structure is based on the time, complexity, and surgical costs involved. Please feel free to call our office at 214-823-1978 and speak with either Kurthene or Annette for more details.

    Click here to see before and after photos of this procedure.