Author: Jay Burns, MD FACS
Laser resurfacing took the cosmetic world by storm in the mid 90’s with the invention of carbon dioxide (CO2) laser resurfacing. This treatment involved removing the entire superficial skin layer all at once and is commonly referred to as an ablative (taking away or removing) skin treatment. It significantly improved wrinkles and tightened skin. In 2000 the Erbium laser was introduced as an alternative ablative laser treatment. Both standard CO2 and Erbium laser resurfacing remain the most effective treatment for significant wrinkles caused by sun damage.
Classic CO2 and standard Erbium laser resurfacing treat the common manifestations of sun damage: mild to severe wrinkles as well as uneven brown pigmentation. Good candidates are those who have sun damaged facial skin. Patients who are not good candidates include those with poor general health and autoimmune diseases such as scleroderma, lupus, and rheumatoid arthritis that would adversely affect healing. Patients cannot be taking Accutane and must have been off of that medication for one year before the laser treatment can be performed as it will delay healing and potentially result in scarring. Patients who have had prolonged and intensive laser hair removal or electrolysis are also not good candidates because hair follicles are necessary for reformation of skin and wound healing.
Smokers can be treated though we strongly encourage patients to stop smoking with any surgery, and particularly laser resurfacing, to enhance the effectiveness of the treatment.
Classis CO2 and Erbium laser resurfacing remove the upper layers of the skin (epidermis and superficial dermis) by vaporizing the skin cells. Underneath, the dermis is heated to resulting in collagen formation and further skin tightening. The amount of ablation and residual heat injury to the skin are the main differences between the Erbium and the CO2 laser. The newer, healthier collagen coupled with the removal of wrinkles, gives an overall improvement to texture and decreased irregularity in the skin.
Expertise is required to determine the endpoint of treatment. The endpoint during the treatment is either the obliteration of the wrinkle or reaching a safe depth, beyond which abnormal lightening of the skin and/or scarring can result. It is important for the patient to realize that if the safety endpoint is reached before the wrinkles are totally removed, then the treatment must be stopped to ensure proper healing. Therefore, the patient must realize that obliteration of every wrinkle should not be an expectation. Significant improvement should be expected and is usually the rule, but even this varies from patient to patient. The patient must realize that his or her immune response and reaction to the treatment itself varies and that the patient or the doctor cannot control this.
Many physicians still prefer CO2 laser resurfacing because it causes greater collagen deposition from increased heating of the dermis. Others disagree because the Erbium laser can reach deeper levels with its vaporization than the CO2 laser resurfacing. Most would agree that the CO2 creates much more heat in the dermis, and therefore has a much higher rate of lightening of the skin as compared to Erbium. The residual heat also results in a longer healing time and prolonged redness.
When one obliterates wrinkles and new collagen is added, these results are permanent. However, if the sun damage involves the full thickness of the skin (both epidermis and dermis), then the entire extent of sun damage cannot be corrected with any single treatment. Therefore, the results of life long sun damage will eventually manifest themselves. Also, aging continues and wrinkles continue to be formed by the dynamic movement of muscles underneath them. However, the results of any single treatment are beneficial and life long.
Recovery is dependant almost entirely on the depth of treatment. The depth of any given treatment is dependent on the goals. If the goal of the treatment is to clear pigment primarily, then treatment to a shallower depth is all that is needed. Healing after such treatment will involve an open wound for approximately 3 days and 2-3 weeks of redness on average. For more significant sun damage, which is usually seen on upper lip lines (i.e. smokers lines) a deeper treatment into the mid dermis or deeper (with the Erbium only) are needed. Such treatment results in 5-10 days of open wounds followed by 8-16 weeks of redness. With each week the redness and pinkness declines. With Erbium laser there is approximately a 25-30% faster healing rate at any given depth of treatment with as compared to CO2.
The worse side effect of any laser treatment, or any treatment that applies heat to the skin, is scarring. Though the risk of scarring is small, it can occur, as there is always patient variability with regard to healing. Other potential complications include blistering and brownish pigmentation of the skin, also known as post inflammatory hyperpigmentation (PIH). Such hyperpigmentation is more common with patients of darker skin types. The pigmentation is typically temporary and treatable with mild steroids and a bleaching agent (hydroquinone). With more aggressive treatment, particularly with the CO2 laser, there is a higher incidence of abnormal and permanent lightening of the skin, also known as hypopigmentation. This can happen with Erbium laser, but it is less severe and less likely. Bacterial infections are rare. Viral (herpes zoster) breakouts can be triggered by laser treatment and as such every patient should be treated prophylactically with antiviral medication.
The chief alternative to laser resurfacing would include chemical peels and dermabrasion. Both of these techniques can achieve excellent results. Chemical peels are inherently less precise than laser treatments and dermabrasion is largely outdated.