Author: Dr Mark Gray, Dermatologist, Auckland, New Zealand, 1997. Updated by Vanessa Ngan, Staff Writer, 2008.
Over the last 20 years there have been major advances in the field of nonsurgical skin rejuvenation. With advances in laser technology it is possible to reduce, and in some cases remove, facial wrinkles, acne scars and other facial scars, and a variety of skin growths and blemishes, with minimal disruption and downtime for the patient.
Throughout the 1980s and 1990s continuous wave carbon dioxide (CW CO2) laser was being used to resurface photodamaged skin by removing the sun-damaged skin layer-by-layer and allowing the growth of new, smoother and more evenly toned, tightened skin. Although results were, and still are, excellent, side effects following CW CO2 laser resurfacing are frequent and predictable. These include redness and swelling (erythema), skin discolouration (dyspigmentation), skin eruptions and eczema, skin infections, herpes simplex and scarring. Vitiligo is a contraindication, because laser resurfacing can trigger new areas of pigment loss.
To reduce the thermal damage that occurs in skin tissue, pulsed and scanned CO2 laser systems were developed. These remove layers of sun-damaged skin in a more controlled manner. Erbium:YAG laser was also developed and its overall efficacy is comparable to pulsed and scanned CO2 laser techniques. Both these laser systems are “ablative” laser skin resurfacing techniques as they target mainly the top layers of skin (epidermis) but also affect the lower layers of skin (dermis).
Further developments in the field of skin resurfacing within the last 10 years have seen a huge growth in the different technologies available. The main laser resurfacing techniques used today are non-ablative laser systems, fractional resurfacing systems, and combined systems. Non-laser techniques include radiofrequency systems and plasma skin regeneration.
Non-ablative laser systems target only the dermis, leaving the epidermis intact. The results of non-ablative laser resurfacing are not as effective as ablative laser resurfacing but the excellent safety profile and rapid recovery post-treatment have made these systems popular. These systems have been divided into 3 main groups, mid-infrared lasers and the two visible light lasers, the pulsed dye laser (PDL) and intense pulsed light (IPL) systems.
People with mild, moderate or severe facial wrinkles and sun-damaged skin can all benefit from laser resurfacing. It is also used for actinic keratoses, actinic cheilitis, facial pigmentation (eg, solar lentigines), hypertrophic scars, and rhinophyma.
Those who are concerned about the risks of complications, and who wish to avoid long recovery times, are the best candidates for non-ablative laser resurfacing. However, they must understand that results may not be as effective as ablative resurfacing.
All wrinkles are reduced, but those caused by the sun, especially those around the eyes and lips respond best. It is never too late - or too early - to treat wrinkles once they are established. Acne scars and facial scars from surgery or trauma may be reduced but very deep scars cannot be completely removed. Many benign skin growths and scaly patches on the face and elsewhere are removed with ease.
Dark skinned and tanned patients may experience some dyspigmentation of the skin after treatment with non-ablative laser therapy. A test spot should be performed in these patients and they should avoid direct sunlight and use sunscreens after treatments.
The procedure does provide a general ‘lift’ to the face, but a face lift is necessary to reverse advanced sagging of the skin of the face. Wrinkles on the lips and around the eyes usually do not respond to face lifting but respond well to laser resurfacing. In some instances both procedures are necessary to achieve the best results.
This depends on the type of laser resurfacing being used. Ablative laser treatments are typically more painful than non-ablative laser treatments.
When treating small areas topical anaesthetic agents are usually applied when using ablative laser systems. For larger procedures, in addition to topical anaesthetics, injectable or inhaled local or regional anaesthetics may also be used.
Non-ablative laser resurfacing is minimally painful and may not require any anaesthesia. If necessary, topical anaesthetic agents are used and applied one hour before the start of the procedure. Cold packs may also be applied immediately after treatment to minimise any discomfort.
The huge advantage of non-ablative laser resurfacing is that there is little, if any post-recovery period. In most cases patients can apply makeup and return to normal daily life immediately following treatment.
In contrast, ablative laser resurfacing is associated with a long post-recovery period. There may be swelling, redness, exudation and sloughing of the treated area. For the first few days’ treatment with ice packs and keeping the head raised at night should help. Healing is greatly aided by the use of a skin-coloured adhesive dressing for the first couple of days. In some cases an occlusive healing ointment is preferred as it improves patient comfort and has shown to speed up the growth of new skin. Usually it takes two weeks to heal completely, with a range from one to four weeks depending on the treatment performed and the depth of skin removal. After two weeks, it is possible to wear camouflage make-up. Sun protection with a non-irritating sunscreen is vital until the redness subsides completely.
In most cases the results are a moderate to marked reduction in facial lines and wrinkles, a more even skin tone and texture, and fresher, healthier-looking skin. Ablative laser resurfacing therapy produces the best result and is still considered the gold standard against which all other facial rejuvenation systems are compared. Although the results with non-ablative laser therapy are not as significant as those seen with ablative laser therapy it has the huge advantage of low risk and rapid recovery.
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