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Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230
Cosmetic ablative skin resurfacing
Stephen W. Watson, MD, DDS*, Todd J. Sawisch, DDS
Willow Bend Cosmetic Surgery Center, 5824 W. Plano Parkway, Suite 101, Plano, TX 75093, USA
Cosmetic surgery has increased 225% over the in 625 AD, Paul of Aegina described the technique
past 6 years, and advanced technology has been one
of the primary stimulants [1]. Ablative skin resur-
facing using CO2 and Erbium:YAG lasers is one of
those advanced technologies. One recent survey
reveals that ablative laser skin resurfacing accounts
for approximately 1% of all cosmetic surgical proce-
dures performed in the United States during 2002.
However, when contrasted with the widespread in-
troduction of laser technologies for rhytid reduction
in the early 1990s, culminating with a peak in 1998
[1], the use of the CO2 and Erbium:YAG lasers has
dropped dramatically. Hence the technologic advan-
ces in these two lasers have changed very little, if at
all, since the development of superpulsed energy and
computer pattern generators. The drop in demand for
laser skin resurfacing is due in large part to the
unwillingness of an informed public to undergo the
prolonged and involved recovery associated with
ablative laser resurfacing coupled with the introduc-
tion of nonablative technologies and intense pulsed
light. As a result, surgeons are returning in large
numbers to more conventional resurfacing such as
trichloroacetic acid peels and modified phenol peels
[2]. Preoperative and postoperative protocols have
been altered somewhat, and more conservative sur-
gical approaches that use lower fluences and fewer
passes are now generally used; however, ablative
lasers have changed little during the past 5 years.
Historical perspectives
Descriptions of facial rejuvenation techniques
were recorded as early as 1000 years ago. In Greece
1042-3699/04/$ – see front matter D 2004 Elsevier Inc. All right
doi:10.1016/j.coms.2004.02.005
* Corresponding author.
E-mail address: drswatson@aol.com (S.W. Watson).
used by Greeks and Romans of the seventh century to
reduce facial wrinkles. A troche, or lozenge made of
bruised-fish gelatin, ivory shavings, male frankin-
cense, and bitter weeds that grew among wheat was
mixed with white wine and rubbed into the skin to
treat wrinkles. Alternatively, bruised fat figs, burned
powder of bitter wheat weeds, and the shells of squid
were mixed with a small amount of honey and ap-
plied to the face. It is quite possible that the combined
effects of these abrasive materials and plant acids
were the first recorded dermabrasion and chemical
peel techniques [3].
Dermabrasion
Dermabrasion is a term used to describe a proce-
dure that removes variable amounts of skin, particu-
larly the epidermis. In ancient times, Egyptians were
the first to use this procedure to remove blemishes
and smooth the skin. Pumice and alabaster were used
as abrading tools. Modern advances in dermabrasion
began in 1905 with the German physician Kromayer
[4]. He was the first physician to formulate a method
of skin abrasion. In 1935, Janson reported the use of a
stiff-bristle brush to abrade tattoos [5] and the use of a
common sandpaper was introduced by Iverson in
1947 to remove a facial tattoo produced by gun
powder [6]. The greatest advances in the technique
are attributable to Abner Kurtin [7]. He and a
coworker developed and produced the instruments
of today, including the modified power-driven instru-
ments and refrigerants that aid dermabrasion.
Chemical peel
Chemical peeling of skin has been used since the
time of ancient Rome. Over the intervening years,
s reserved.
S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230216
interest in peeling has waxed and waned. In the late
1800s, chemical peeling had a resurgence and caustic
agents were used. In 1961 Baker and Gordon pio-
neered chemical peeling with phenol [8]. Since 1961
the general trend has been toward less aggressive
types of peels, including trichloroacetic acid and,
more recently, alpha-hydroxy acids. The field of
chemical peel and facial rejuvenation continues to
evolve [9].
Laser resurfacing
The initial role of laser for skin resurfacing in-
volved the continuous wave CO2 laser in a defocused
mode. The idea was to gradually pull the laser hand
piece away from the skin, thus reducing the power
density and ideally sparing the deeper skin structures
from thermal damage. However, because of the tech-
nical sensitivity involved with this technology, ther-
mal relaxation times were often violated, resulting in
prolonged healing times and scarring [10–19]. These
unacceptable consequences of continuous wave lasers
led to the development of more reliable and effective
technologies [20,21]. By delivering CO2 laser energy
in short pulses (‘‘superpulsed mode’’), investiga-
tors were able to stay within the thermal relaxation
time of the targeted tissues. This dramatically reduced
the incidence of the scarring and prolonged healing
times that occurred with continuous wave modalities
[22–24].
The Erbium:YAG laser was introduced next. This
laser emits a wavelength of 2940 nm, which is ab-
sorbed by water 10 times more efficiently than with
the superpulsed CO2 laser [25–27]. The result is very
superficial absorption with the capacity to precisely
ablate tissue by creating thermal injury by ablative
photodecomposition. Nonthermal collateral damage
is minimal, ranging from 0 to 30 mm. The reduced
healing times and decreased postoperative erythema
after treatment with the Erbium:YAG appeared to
establish this technology as the treatment of choice
for mild to moderated rhytids, bridging the gap be-
tween CO2 resurfacing and chemical peels [26].
However, with the increased absorption and short
thermal relaxation times, heat generation is insuffi-
cient to promote collagen shrinkage. Its primary use
today is relegated to following the CO2 laser during
the same surgical procedure in an effort to shorten
healing times and reduce erythema.
Computerized scanning also became available
with the combination of high-energy, short-pulsed
lasers and allowed the surgeon to lay down various
patterns and to condense or expand these patterns on
the skin to promote more even resurfacing [28].
Laser physics and tissue interaction
LASER is an acronym for Light Amplification by
Stimulated Emission of Radiation. Atoms and elec-
trons are normally in their lowest energy or ‘‘resting’’
state. If the energy of a photon of light is absorbed by
an electron, the electron is raised to an ‘‘excited’’
state. An excited electron returns to its resting state
by emitting a photon identical to the photon that was
initially absorbed. If a photon is absorbed by an
excited electron, this electron may emit two photons
when returning to its resting state, a process called
stimulated emission [29]. Repeating this stimulated
emission innumerable times generates a laser beam
[30,31].
All laser units consist of three basic elements: a
pumping system, a lasing medium, and an optical
cavity. The pumping system supplies the power and
the lasing medium supplies the electrons needed for
stimulated emission of radiation. This medium can be
gaseous (CO2), liquid, solid (Erbium:YAG), or com-
posed of free electrons. The optical cavity is a reso-
nant cavity consisting of two parallel mirrors that
sustain the stimulated emission and allow for release
of the laser beam [32].
Laser light has three important properties: it is
monochromatic, coherent, and collimated. Mono-
chromacity means that the light is of a single, discrete
wavelength, and this property determines the clinical
specificity of the laser beam. A specific wavelength
allows for selective absorption of the laser light by
specific chromophores of the skin (eg, melanin, hemo-
globin, or tattoo ink). Coherence means that the light
waves are temporally and spatially related. Clinical
predictability of the laser beam is a result of its
coherence. Collimation means that the light waves
are parallel. Consequently, the beam can be propa-
gated across long distances without spreading. This
tight focusing gives the laser its clinical preciseness.
As far as the skin is concerned, the laser is a
‘‘black box,’’ with clinical outcomes depending only
on the properties of the laser light entering the skin
and the presence of biologic targets of chromophores
within the skin [33]. Knowing the properties of the
laser (ie, wave length, pulse duration, energy fluence,
irradiance, and spot size) and how to alter them
allows the surgeon to predict and attain the desired
clinical outcome. The specific wavelength of the laser
light determines which chromophores in the skin will
absorb the desired light energy. If more than one type
of chromophore is present, the absorption will be
divided in relation to the relative absorption coeffi-
cients at that wavelength. Although some chromo-
phores may shield deeper tissues by absorbing most
S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230 217
of the laser energy, this chromophore shielding has
little if any clinical consequence in skin resurfacing,
because the biologic target of both the CO2 laser
(10,600-nm wavelength) and Erbium:YAG laser
(2940-nm wavelength) is the superficial intracellular
water [30–34].
Heat dissipates from the site of laser absorption
mainly by heat diffusion, and large objects lose heat
much more slowly than small objects. All objects
have a characteristic time—called the thermal relaxa-
tion time—that it takes to cool down to an ambient
temperature after having been heated. For most
chromophores in the skin, this time is determined
by the size of the object or lesion. If an object is
heated for longer than its thermal relaxation time,
thermal diffusion occurs with heating of surrounding
structures (Table 1) [35,36]. If an object is heated for
a period shorter than its thermal relaxation time, the
heat and resultant damage is confined to the target
object alone. Therefore, proper pulse duration of the
laser beam is essential for achieving the desired
clinical effect and dramatically reducing the risk
of scarring.
Currently available lasers used for skin resur-
facing incorporate advancements based on Anderson
and Parish’s theory of selective photothermolysis.
This theory states that selective heating is achieved
by preferential laser-light absorption and heat pro-
duction in the target chromophore when the pulse
duration is shorter than the target’s thermal relaxation
time. The CO2 laser can be modified to take advan-
tage of selective photothermolysis [34,36,37]. To va-
porize water within biologic tissues, approximately
4.5 J/cm2 has to be deposited in the tissue [30–34].
The CO2 laser has a depth of penetration of 0.1 mm.
This thickness of tissue has a thermal relaxation time
of approximately 1 msec. Therefore, the energy of
vaporization (4.5 J/cm2) should be deposited within
the tissue in less than 5 milliseconds. Conventional
CO2 lasers deposit energy too slowly. However, there
are two methods available to achieve selective photo-
Table 1
Thermal relaxation times
Target
Thermal relaxation
time
100-mm port wine stain blood vessel 5 ms
50-mm blood vessel 1 ms
50 mm of epidermis 1 ms
7-mm erythrocyte 20 ms1-mm melanosome 1 ms0.1-mm tattoo particle 10 ns
thermolysis with the CO2 laser: (1) individual very
high peak power (ultra) pulses of less than 1 milli-
second can achieve vaporization with less than
0.1 mm of collateral thermal damage; or (2) a fo-
cused, continuous wave laser beam can be swept
across the tissue with a dwell time at any one spot
of less than 1 millisecond [35].
Energy fluence is important, because to achieve a
clinical change in a target site, a certain amount of
energy has to be absorbed by the target site. This is
measured by the energy delivered per unit area (ie,
the energy fluence). As the energy fluence increases,
the destructive force increases [38,39]. Energy flu-
ence is generally used when referring to pulsed lasers
because it is easily calculated for each pulse.
Energy fluence
For selective photothermolysis, most pulsed lasers
achieve clinical effects using energy fluences over a
narrow range of 3 to 15 J/cm2. In laser skin resur-
facing, vaporization occurs when fluence raises the
tissue temperature past the boiling point of water
(100�C) in less than the thermal relaxation time. Char-
ring occurs when the fluence is not sufficient to evap-
orate the water, and pumping of further laser energy
into the charred tissue results in thermal radiation into
the surrounding tissue and increased scarring.
Irradiance is the rate of energy delivery per unit
area (ie, the intensity of energy delivery). The shorter
the pulse duration of a laser, the higher the irradiance
must be to deliver sufficient energy for clinical effect.
High irradiance will achieve faster heating of an
object than low irradiance. Slow heating coagulates
tissue, while fast heating may vaporize tissue [32–34,
40–42].
Irradiance
Spot size determines whether or not the laser
penetration is controlled sufficiently so that clean va-
porization or ablation results and undesirable thermal
radiation or damage is avoided. A smaller spot has
higher power density, creating deeper ablation cra-
ters; hence smaller spots can be used for cutting. A
larger spot with sufficient power density to achieve
vaporization enables a more uniform vaporization of
tissue and faster treatment time, but without the cra-
tering or depth of penetration noted with the smaller
spot [33,39].
Finally, the beam quality or distribution of energy
across the diameter of the beam significantly impacts
S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230218
the control of uniform tissue absorption and ablation.
The TEM-00 mode beam (common with many CO2
and low-power Erbium:YAG lasers) has a Gaussian
shape and therefore uneven power densities along the
beam diameter. In larger diameters this can be con-
trolled to some degree by pulsing the beam, but it still
has a higher density in the center. The lower density
along the rim causes charring at the edges of the
ablation crater [39]. By pulsing or stacking the
beams, a flat top or non-Gaussian beam is approach-
able with the CO2 lasers [35]. The higher-energy
Erbium:YAG lasers have a uniform (non-Gaussian)
beam [43–45] that produces a uniform tissue ablation
and is particularly preferable for larger ablation areas
such as those encountered in skin resurfacing.
Table 2
Fitzpatrick’s Classification of Sun-Reactive Skin Types
Skin
type Color Reaction to first summer exposure
I White Always burn, never tan
II White Usually burn, tan with difficulty
III White Sometimes mild burn, tan average
IV Moderated
brown
Rarely burn, tan with ease
V Dark browna Very rarely burn, tan very easily
VI Black No burn, tan very easily
a Asian, Indian, Oriental, Hispanic, or light African
decent.
Skin aging
Aging of the skin has medical as well as cosmetic
consequences. Intrinsic aging generally results purely
from the passage of time, becoming visible around
age 35 and remaining subtle into more advanced
years. These changes are most easily seen on areas
that are not exposed to the sun [46–49]. Histologi-
cally, intrinsic effects are manifested by a thinning of
the epidermis, hypocellularity of the dermis, and a
gradual decrease in number of blood vessels, type I
collagen, and elastic tissue [49–52].
Extrinsic aging is primarily due to the effects of
ultraviolet radiation. Sun exposure is the most im-
portant factor, hence the terms photo-aging and
photo-damage [47,48,53]. For the majority of the
population, sun exposure and ultraviolet damage
occurs not in the pursuit of a tan but rather during
multiple, brief exposures to the sun during normal
daily activities. Cumulative ultraviolet exposure can
result in actinic keratosis, squamous cell carcinoma,
basal cell carcinoma, and melanoma [48]. Histolog-
ically, ultraviolet alterations present as a thickened,
basket-woven stratum corneum; a thinner or atrophic
epidermis; generalized epidermal cellular atypia; ir-
regular melanin dispersion; and abnormal-appearing
elastic fibers in the dermis [54,55].
Photo-damage accounts for more than 90% of the
unwanted changes in skin appearance. Clinically,
these changes include fine to coarse wrinkling, laxity,
leathery and coarse skin textures progressing to ir-
regular pigmentation, dry scaling and roughness of
the skin surface along with telangiectasias and skin
sallowness. Solar elastosis results in the deposition of
an abnormal, yellow elastotic material in the upper
dermis that replaces normal collagen and elastin and
does not have the resiliency of normal elastic tissue
[53,54,56].
Patient selection
Dr. David Apfleberg has stated that laser ablation,
in and of itself, is a simple procedure. However, he
goes on to point out that it is the patient selection,
preparation, and postoperative management that
makes the skin rejuvenation process difficult [31].
In this regard, patient selection is probably the most
difficult and certainly the most variable part of the
entire process. The single most important factor in
patient selection is his/her chief complaint. Only after
determining the patient’s chief complaint can the
surgeon apply more objective criteria and subse-
quently guide the patient in selecting the appropriate
technique or techniques to address the chief com-
plaint. A patient’s selection should not be based on
limitations of the surgeon’s technical acumen.
To decide if laser resurfacing will be a primary or
secondary component of treatment, certain evaluation
criteria can be applied. The most commonly used
scales for evaluation are the Fitzpatrick Classification
of Sun-Reactive Skin Types (Table 2) [38] and the
Glogau Photo-aging Wrinkle Classification (Table 3).
Categories include: (1) absolute contraindications,
(2) extreme caution, and (3) relative contraindica-
tions. Among patients considered as absolute contra-
indications are those who have had prior radiation
exposure, who have had Accutane (isotretinoin) treat-
ments during the past 6 to 12 months, who have had
deep phenol peels or burn scars, and who are de-
pressed or disturbed [30,57,58]. Patients with prior
radiation exposure, burn scars, and, in some cases,
deep phenol peels have undergone permanent de-
Table 3
Glogau Photo-aging Classification
Type I Type II Type III Type IV
Condition No wrinkles Wrinkles in motion Wrinkles at rest Only wrinkles
Photo-aging Early Early to moderate Advanced Severe
Pigmentation Mild changes Early senile lentigines visible Obvious dyschromia,
telangiectasia
Yellow-gray skin color
Keratoses None Palpable but not visible Visible Prior skin malignancies
Wrinkles Minimal Parallel smile lines beginning
to appear
Wrinkles when not
moving
Wrinkles throughout, no
normal skin
Patient’s age 20–30 30–40 50 or older 60–70
Makeup use Minimal or none Usually wears some foundation Always wears heavy
foundation
Can’t wear makeup (‘‘cakes
and cracks’’)
S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230 219
struction of fibroblasts and are not candidates for
even light laser skin resurfacing [59,60]. Accutane,
on the other hand, retards re-epithelialization by
selective inhibition of collagenase and suppression
of the pilosebaceous apparatus and can result in
severe scarring after laser resurfacing [61,62].
The patient groups in which extreme caution
should be used include ethnic skins with Fitzpatrick
classifications of 4 or 5. These individuals can still
undergo laser skin resurfacing but must be made
aware that they will have long-term, severe hyper-
pigmentation that may last for months [63]. A second
type of patient in this classification includes those
that have deep acne scars along with high expectation
of resolution. Before becoming candidates, these
patients must be warned that repeat treatments will
probably be necessary and total resolution is unlikely.
Relative contraindications include systemic dis-
ease that may pose anesthetic or surgical risk (eg,
diabetes, problematic hypertension, significant car-
diovascular or pulmonary disease, history of al-
lergies). Also within this group are fair-skinned
individuals with a tendency to flush or blush easily
(eg, Celtic skins). These individuals tend do develop
scarring in tension areas, particularly along the man-
dibular inferior border [57,58,64,65]. These patients
are still candidates but care should be taken as to the
depth or number of passes used in laser resurfacing.
Dark-skinned individuals (those with a Fitzpatrick
classification of 6 or individuals with a history of
hyperpigmentation after trauma) may also be consid-
ered relative candidates, but in the experience of
some, complications with hyper- or hypopigmenta-
tion have not occurred after laser scar revisions with
these patients.
Patients whose primary concern is alleviation of
rhytids associated with lines of expression caused by
muscle contraction (eg, forehead lines, glabelar lines,
crow’s feet, lateral canthal lines) are relative contra-
indications. Even though laser resurfacing may deac-
centuate these lines, they will always recur. It is
important for patients in this group to understand this
limitation before treatment.
Should such animation rhytids comprise the
patient’s chief complaint, then other primary or ad-
junctive procedures should be considered. Primary
procedures such as laser-assisted endoscopic browlifts
allow for denervation, debulking, and repositioning of
problem areas and can be performed simultaneously
with laser skin resurfacing.
Consideration of volume enhancement should
also be entertained in this particular patient. This
may include endoscopic midface lifts for deep naso-
labial folds, hyaluronic acid (Restylane) for perioral
rhytids, and fat transfer for other deep rhytids.
A widely used adjunctive technique is the injec-
tion of Botox (botulism-A toxin). These injections
temporarily block nerve transmission to the affecting
muscle groups, leading to subsequent atrophy and
deaccentuation of the associated rhytids. Injections
should be performed 1 to 2 weeks before laser treat-
ment to prevent activation of the muscles during 3 to
6 months of new collagen remodeling and reforma-
tion that follow laser treatment. Botox injections may
also be repeated after laser resurfacing to achieve
more prolonged results. Each repeat injection results
in progressive muscular atrophy [66,68].
Great care should be exercised in patients who
desire only regional resurfacing [7,30,57,58]. The
perioral and periorbital regions are the two areas of
photo-damage and wrinkling that respond most dra-
matically to laser skin resurfacing, but if both areas
necessitate treatment, it is far better to laser resurface
the whole face. In general, full face resurfacing will
produce a better clinical result because treatment of
the full cheeks results in better tightening of nasola-
S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230220
bial lines and lateral crow’s feet. The same can be
said of the entire forehead and its effect on the
glabelar furrows and lateral temporal lines. In addi-
tion, the even pigmentation and smoothing of the skin
that result from full-face resurfacing produces a more
pleasing cosmetic appearance. Finally, it is much
easier for the patient to deal with postoperative ery-
thema occurring over the entire face rather than ery-
thema located in regions or patches.
Preoperative preparation
The literature is replete with preoperative regi-
mens purported to maximize the results of laser skin
resurfacing. The protocols are largely extrapolated
from chemical peel and dermabrasion literature or the
anecdotal experience of seasoned laser surgeons.
Ratner and colleagues have reported that there are
no controlled, randomized prospective studies to
either confirm or repute the need for skin priming
before laser resurfacing. The Ratner study goes on to
state, ‘‘The application of priming principles to laser
resurfacing is not necessarily warranted. It has not
been shown that preoperative use of tretinoin signifi-
cantly enhances laser beam penetration or predict-
ability. Some suggest that pretreatment with tretinoin
contributes to prolonged erythema, which often per-
sists for months [69]. Similarly there are no data to
support the utility of preoperative alpha-hydroxy
acids. Topical hydroquinones affect the melanocytes
in the basal layer of the target skin. This is desirable
for superficial chemical peels because this population
of melanocytes is implicated in postinflammatory
hyperpigmentation [70,71]. Because deeper chemical
peeling, dermabrasion, or the first pass of the CO2
laser usually ablates the entire epidermis, the popu-
lation of pretreated melanocytes is eliminated. Ke-
ratinocytes and melanocytes migrate from the wound
margins and underlying adnexal structures during
wound healing [72,73]. The adnexal structures are
not expected to be accessible to topical hydroqui-
nones administered before the procedure, but this has
not been confirmed. Thus only when melanocytes
have emerged from the adnexa to repopulate the skin
surface would they be amenable to hydroquinone
therapy [74].’’
Ratner continues, ‘‘Patients may already be on a
skin care program consisting of the aforementioned
agents. They may expect a pre-laser regimen and seek
the sense of personal control over this care that may
bestow. The physician can use such a regimen to
monitor patient compliance before a more aggressive
resurfacing procedure is performed and to uncover
any baseline irritant or allergic sensitivities [75].
These are all legitimate reasons to offer a preopera-
tive skin care program as long as one recognizes this
as a part of the art, not the fundamental science of
laser resurfacing.’’
Anesthesia
The goal of anesthesia for laser skin resurfacing is
basically the same as that for any surgical procedure:
to ensure the safety and comfort of the patient and
provide ease of operation for the surgeon. Laser
resurfacing of the face and neck, whether performed
with the CO2 or Erbium:YAG, is a very painful pro-
cedure. Either deep sedation with local anesthetic
blocks and infiltration or general anesthesia is re-
quired [76,77]. Fortunately, there have been numer-
ous advances in anesthesiology that add efficacy and
safety to the outpatient surgical setting [77–80].
The newer sedative-hypnotic, propofol, is unlike
any agent currently available and offers definitive
advantages over the more traditional drugs like
methohexital [79–82]. Newer inhalation agents like
sevoflurane and desflurane possess different phar-
macokinetic profiles from older agents like isoflurane
and halothane, and thus offer advantages in the office
setting [83,84]. Because airway maintenance and
protection is paramount during anesthesia for facial
surgery, the laryngeal mask airway is an alternative
method of airway maintenance that offers advantages
over traditional techniques [85–87].
Procedure
Laser energy and techniques
At present, almost all CO2 rapid-pulse systems
use computer pattern generators (CPGs). The impor-
tant property of a CPG is not necessarily its pattern
design or its ease of operation but rather the consis-
tency of its pattern density (ie, the amount of over-
lap). Furthermore, the laser energy and power settings
are less important (with or without CPGs) than is the
visible end point in determining the final result.
The appropriate energy and power settings depend
on the depth of the pathologic condition (ie, the re-
gion being treated) and the experience of the operator
(ie, hand speed) and therefore are less important
factors with CPGs [88].
To cleanly vaporize a volume of tissue, a CO2
laser must produce a fluence greater than 4.5 J/cm2,
Table 4
Depth of resurfacing techniques
No. of
laser passes
Ablation
depth (mm)
Residual thermal
damage (mm) Level of thermal damage Comparable treatment
1 20–50 20–40 Epidermis/superficial Medium depth peel
Papillary dermis
2 20–50 80–150 Papillary dermis medium depth peel /
dermabrasion
3 20–50 120–150 Superficial reticular dermis Dermabrasion
S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230 221
the vaporization threshold of tissue. Lower-powered
CO2 lasers are incapable of exceeding this fluence
and therefore coagulate the tissue, resulting in tem-
peratures exceeding 600�C and creating extensive
(1–5 mm) zones of thermal damage, similar to those
produced by electrocautery. Char-free tissue vapor-
ization occurs if the laser can deliver a fluence of
4.5 J/cm2 within less than 1 millisecond.
CPG pattern densities and their effect on ablation
were investigated by Kauvar and colleagues [89].
Density patterns corresponding to 10%, 35%, and
60% overlap were studied. At a density of 10%, only
partial epidermal vaporization occurred after one
laser pass. Islands of epidermis remained when the
debris was wiped away. The CPG at 35% overlap
resulted in clean vaporization of the entire epidermis.
One laser pass at a density of 60% overlap produced
ablation of the entire epidermis and superficial papil-
lary dermis, similar to a medium-depth chemical peel.
Depths of residual thermal damage also increased
with increasing densities, but did not exceed 150 mmafter three passes. These findings, and those from
studies for repeat laser passes, have led to increased
understanding and predictability of resurfacing with
the CO2 computer pattern generator systems (Table 4)
[89].
The much shorter wavelengths of Erbium:YAG
lasers are so highly absorbed by water that only mini-
mal skin penetration (approximately 5 mm) is possible
[90]. Therefore, the Erbium:YAG laser requires more
passes over the skin than do CO2 lasers (Table 5).
However, the depth of thermal damage remains ap-
proximately the same, regardless of the number of
passes [90]. The endpoint closely resembles the punc-
tuate, multiple point bleeding, similar to that seen
with dermabrasion.
In summary, there are four general rules that apply
with laser skin resurfacing:
1. Avoid regional resurfacing.
2. Always feather the peripheral areas by decreas-
ing the density of pulse applications, the pulse
energy, or both.
3. Keep the feathered margins irregular.
4. The endpoint of treatment is when one of the
following conditions are seen:
(a) The wrinkle or scar being treated is clini-
cal effaced
(b) A punctuate bleeding pattern is noted after
Erbium:YAG laser
(c) No further skin tightening occurs.
This endpoint can usually be achieved with the
CO2 laser in two passes over most of the face. Ad-
ditional passes may be used around the mouth. The
authors use decreasing fluence and overlap with each
pass and never do more than three passes total (even
though in the late 1990s it was common to perform
five to six passes).
Facial regions
It is helpful to consider the face as consisting of
six cosmetic units: (1) the periocular region, (2) the
perioral region, (3) the cheeks, (4) the forehead,
(5) the nose, and (6) the nonfacial region (ie, the
neck and ears). Each of these regions requires a
somewhat different laser technique.
Periocular region
The periocular region is small and may be further
divided into two separate areas: the thinner infraor-
bital skin and the thicker skin plus the crow’s feet
area. In the infraocular region, the upper reticular
dermis is thinner (0.2 mm) than in other facial re-
gions. Before performing laser resurfacing of the
periocular region, local anesthetic eye drops are
placed into the eyes so that the sandblasted metal
plate (for protection of the cornea) may be inserted
painlessly. The eyelashes are displaced from the
operating field by a moistened cotton swab to prevent
them from becoming singed or removed. The entire
periocular unit is resurfaced evenly on the first laser
pass. Subsequent passes with either the CO2 or the
Erbium:YAG laser are determined by the clinical
endpoint. A full-face laser skin resurfacing routinely
Table 5
Erbium laser skin resurfacing protocol
Glogau type
Type I: Early aging 6-mm spot, 2–4 passes,
600–800 mJ, 6–8Hz
Type II: Moderate aging 6-mm spot, 2–6 passes,
800–1000 mJ, 8–10 Hz
Type III: Advanced
photo-aging
6-mm spot, 6–8 passes,
1200–1400 mJ, 10–12 Hz
Type IV: Severe
photo-aging
6-mm spot, 6–8 passes,
1400–1700 mJ, 10–12 Hz
Region and lesion
Eyelid 4-mm spot, two passes,
600–800 mJ, 4–8 Hz
(Consider for neck, hands),
repeat prn
Perioral 4-mm spot, two passes,
800–1200 mJ, 8–12 Hz
Acne scarring 4-mm spot, two passes at
1000 mJ, then 1–3 passes
at 600–800 mJ
Start at 6–8 Hz, increase prn
Flat epidermal lesions 4-mm spot, two passes,
800–1000 mJ, 4–8 Hz
Small paular lesions 2-mm spot, one to three
pulse bursts, 300–400 mJ
S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230222
includes resurfacing of the upper eyelids. In many
instances, upper eyelid resurfacing produces signifi-
cant skin contraction that may mimic upper eyelid
blepharoplasty. Some authors have noted vertical skin
shortening of 4 to 5 mm and up to 10 mm of short-
ening between the superior tarsal fold and the brow.
Perioral region
Perioral rhytids are ideally suited for laser resur-
facing. Frequently, these wrinkles are moderately
deep throughout this region, but because of extreme
motion in this region, it is more prone to hypertrophic
scarring than any other area of the face. Consequently,
precise depth control is particularly important. The
initial pass should cover the complete cosmetic unit
evenly. Subsequent passes may be selective and
concentrate on flattening the shoulders of the rhytids.
The required number of passes will depend on the
depth of the rhytids as well as the energy density se-
lected. The desired endpoint can be readily achieved,
but be aware that excessively deep treatment with the
CO2 laser will almost always result in scarring. The
transition from papillary to reticular dermis appears
(with the assistance of magnifying loupes) as a
smooth, fine, sponge-like appearance giving way to
a yellow, roughened, chamois-colored appearance.
With the Erbium:YAG laser, the end point will re-
semble that of dermabrasion. Discerning the absolute
endpoint for deeper resurfacing is difficult and ex-
ceeding this endpoint virtually assures an un-
necessarily high rate of scarring. It is better to be
conservative and re-treat 3 months later if necessary. If
the rhytids extend onto the vermilion border of the lip,
it is advisable to extend the resurfacing onto the
mucosa to eliminate these creases. Lip mucosa heals
especially well following laser resurfacing.
Cheeks
Cheek skin is generally thicker than eyelid and
perioral skin. Greater laser energy or an increased
number of passes may be used to produce the desired
cosmetic improvement. Unlike the upper lip, the
cheeks are more forgiving. The one exception is the
mandibular margin because of the transition zone
occurring at the inferior border of the mandible and
also because of the extremes of movement and
stretching that occur there. This region should be
treated more cautiously and is prone to scarring
[64,65].
Forehead
In the forehead region, resurfacing is particularly
indicated for removal of frown lines (horizontal and
vertical). This is the most effective and long lasting
when combined with endoscopic forehead and brow-
lifting, and simultaneous ablation of corrugator and
frontalis muscle activity. Both endoscopic browlift
and laser resurfacing may be performed during the
same operation. Botox injections of the corrugator,
procerus, and frontalis muscles may also be used to
enhance the result [66–68]. Laser skin resurfacing of
the forehead should be carried into the fine vellus
hairs at the hairline. If this is not done, a zone of
white skin, which cannot be concealed with makeup,
will be conspicuous between the resurfaced area and
the hair.
Nose
The nose generally has a thick, sebaceous skin
with an excellent blood supply and is consequently a
forgiving region for laser skin resurfacing. Resur-
facing of the nose is usually indicated for rhinophyma
and acne scarring but is also resurfaced during total
face rejuvenation for blending purposes [91,92].
When performing an open structure rhinoplasty in
conjunction with facial skin rejuvenation, is it ad-
visable to laser resurface the nasal skin. Failure to do
so can result in a very noticeable transition zone that
is troublesome to patients.
lofacial Surg Clin N Am 16 (2004) 215–230 223
Nonfacial regions
Rules that apply to the face cannot be applied to
other regions of the body. It is generally considered
hazardous to perform CO2 resurfacing of the neck or
hands because of the paucity of pilosebaceous units,
thin skin, and high mobility. Hypertrophic scarring
and alteration in pigmentation occurs readily. How-
ever, the decreased thermal radiation of the Erbium:-
YAG laser now permits skin resurfacing of these
areas without the scarring or pigmentary changes
seen with the CO2 laser. Nonetheless, results in non-
facial regions are not as substantial or dramatic as
those seen on the face.
S.W. Watson, T.J. Sawisch / Oral Maxil
Fig. 1. Patient before laser skin resurfacing and facelift.
Postoperative care
After laser skin resurfacing, patients are left with a
partial thickness wound that heals by re-epitheliaza-
tion from cutaneous appendages, much like a burn
wound. Methods of care are essentially the same for
CO2 and Erbium:YAG lasers, although the duration of
care may be dramatically less with the latter. In any
case, it should be remembered (as Dr. James Folton
has stressed) that ‘‘healing delayed is healing denied.’’
Following laser use, epithelial healing begins
within 12 hours. Keratin formation stops and hori-
zontal migration and proliferation of epithelial cells
begins [93,94]. The initial attachment of this new
epidermis to the underlying dermis is weak and must
be treated gently. The speed of healing and to some
measure the quality of skin regeneration is propor-
tional to the pilosebaceous density and not the size of
the wound [93,95,96]. Hence wounds on the face heal
much more quickly and aesthetically than those on
the chest and extremities.
The most important concept to assist re-epitheli-
zation is providing the proper substrate for epidermal
migration. Epidermis will only migrate over type I,
IV, or V collagen, fibronectin, or laminin [97]. It will
not migrate over dry crust, desiccated collagen, neu-
trophils, or wound debris [97,98]. In addition, heal-
ing is slowed by dryness, crust caustics, hemostatic
agents, some antiseptics (0.5% chlorhexidine, 1%
povidineiodine, 3% H2O2, gentian violet), radiation
within 24 hours, lower than normal temperatures, in-
fection, steroids (although topical 1% hydrocortisone
is acceptable), and significant vitamin deficiencies.
Clearly, these conditions must be avoided.
The use of bio-occlusive dressings has been shown
to be beneficial during the first 2 to 5 days after
surgery because they keep the skin clean of exudates
and permit re-epithelialization [97,99,100]. In addi-
tion to promoting moist healing and preventing the
exudative phase, closed dressings are also felt to
increase growth factors, and decrease pain and ery-
thema. Hydrogels and silicone polymer films are
semitransparent, allowing some degree of inspection
of healing wounds and permit fluid absorption, which
is useful for exudative wounds after laser resurfacing
[101]. Hydrogels are currently the most commonly
used biosynthetic semiocclusive dressings after laser
resurfacing. Foam composite dressings are opaque
and more adherent but are useful nonetheless because
of their ability to conform to the face and flex with
facial movements. These dressings have the disadvan-
tages of being difficult to keep in place, time-consum-
ing to apply, and sometimes uncomfortable because of
the accumulation of serous exudates under the dress-
ing. In addition, they sometimes hide the wound
surface, which makes it difficult to diagnose a wound
infection. In spite of these drawbacks, patients ap-
pear to progress to a more cosmetically acceptable
point more quickly than when using the open tech-
nique [102].
Complications
Herpes simplex
It has been estimated that up to 90% of the Cau-
casian population in the United States has Herpes
simplex virus (Figs. 1–3), but only 10% manifest its
symptoms. Even if a patient has no prior history of
cold sores, Herpes simplex is commonly activated by
Fig. 2. Herpes simplex infection 5 days postoperatively.
S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230224
laser skin resurfacing [103]. It occurs after laser skin
resurfacing, spreads rapidly, and may lead to scarring.
If an outbreak occurs, either the preoperative dose of
acyclovir should be doubled daily until clinical im-
provement is noted or acyclovir should be changed to
Valtrex or Famivir. This regimen should be continued
and slowly tapered until complete re-epithelization
has occurred. Herpes simplex is difficult to recognize
on resurfaced skin, so a high index of suspicion is
Fig. 3. Patient 2 months postoperatively.
necessary. If on day 5 the patient suddenly develops
malaise and fever, this should be considered Herpes
simplex until proven otherwise, and appropriate mea-
sures should be taken.
Bacterial infection
Resurfacing of the skin produces a large, open
wound, yet bacterial infection (Fig. 4) is relatively
uncommon. This scarcity of skin infections is felt to
be due to colonization and competitive inhibition by
the relatively innocuous normal skin flora, aided by
the excellent blood supply to the head and neck,
judicious wound care, patient selection, and prophy-
lactic antibiotics. If a bacterial infection is suspected
in the laser skin-resurfaced patient, appropriate swabs
for culture and sensitivity should be obtained [94].
Fungal infection
The incidence of Candida infection (Fig. 5) in the
laser skin-resurfaced patient was not uncommon
before the introduction of semipermeable dressings
when heavy occlusive ointments were used. It is more
common in the perioral region, particularly in those
patients with upper and lower dental prosthesis. It
presents either as a fine white film with a bleeding
under surface when wiped away or as widespread
pustules. The diagnosis is confirmed by microscopic
examinations and cultures. Treatment consists of
Fig. 4. Bacterial infection following laser skin resurfacing.
Fig. 5. Candida infection in perioral region.
Fig. 6. Severe scarring in perioral region resulting from low
fluence continuous wave laser skin resurfacing.
S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230 225
topical Nizoral cream and 100 mg of Diflucan orally
every morning for two successive days.
Contact dermatitis
The frequent use of postoperative double and
triple antibiotic ointments leads to contact dermatitis
after laser skin resurfacing and thus should be
avoided [104]. This also occurs in patients who are
using topical vitamin E ointments or oils [104]. Be-
cause it lacks the normal features of contact derma-
titis, the diagnosis is difficult and a high index of
suspicion is necessary. If contact dermatitis is sus-
pected, the patient should be questioned thoroughly
about any and all types of skin application regimens.
The treatment of contact dermatitis, after discontinu-
ation of the offending agent, consists of the admin-
istration of oral nonsteroidal anti-inflammatory
medications or systemic steroids and an application
of the appropriate topical steroid cream.
Pigmentation changes
Temporary hyperpigmentation occurs commonly
after laser skin resurfacing. This is especially true with
darker skin types (Fitzpatrick’s III–V). In addition to
postoperative measures described previously, postop-
erative hyperpigmentation can generally be resolved
with the use of Kligman’s solution or with a 5%
hydroquinone and 1.5% glycolic acid combination.
Hypopigmentation is more likely to occur in fair-
skinned individuals any may not become apparent
until several months after laser skin resurfacing
[63,105]. Although there are many theories to explain
this phenomenon, the exact cause is poorly under-
stood. Many believe that hypopigmentation is caused
by destruction of melanocytes or controlled fibrosis
with opacification of the epidermis. If hypopigmen-
tation occurs, it is likely to be permanent. Resurfacing
the whole face is therefore less likely to produce
demarcation zones.
Scarring
The most unfortunate and damaging complication
of laser resurfacing is scarring (Fig. 6). Incipient
scarring is usually heralded by an area of persistent
erythema, which subsequently becomes slightly thick-
ened. If left untreated, this will inevitably progress to
hypertrophic scarring. Scarring is most likely to occur
in the presence of any of the following conditions:
(1) laser use in the highly mobile areas of the perioral
region and jaw line, (2) low energy densities, creating
a heat sink and subsequent thermal injury, (3) over-
lapping of laser pulses, (4) laser use too deeply be-
cause of excess fluence or an increased number of
passes, (5) postoperative infection (viral, bacterial,
fungal), (6) crusting or desiccation of the wound,
(7) isotretinoin therapy, (8) previous electrolysis ther-
apy on the upper lip, or (9) deep chemical peels on the
face [34,57–60,64,65,105].
Texture changes
Changes in skin texture inevitably occur with all
laser skin resurfacing procedures. The degree of
change is primarily related to the depth of the laser
skin resurfacing. The change is usually desirable
because the skin appears smoother and more uniform
when the entire face is resurfaced. Deeper laser skin
resurfacing procedures may lead to more profound
textural changes with the skin becoming shiny and
atrophic. Younger patients with large open pores may
experience an increased opening of pores secondary
to fibrosis at the pore margins. These patients should
therefore be informed that the pores will appear
larger postoperatively.
Fig. 7. Patient preoperatively before laser skin resurfacing
and facelift (but no blepharoplasties).
Fig. 8. Patient postoperatively with lateral ectropion on
her right.
Fig. 9. Patient before laser skin resurfacing and facelift.
Fig. 10. Patient 2 months postoperatively.
S.W. Watson, T.J. Sawisch / Oral Maxillofacial Surg Clin N Am 16 (2004) 215–230226
lofacial Surg Clin N Am 16 (2004) 215–230 227
Scleral show
Resurfacing infraorbital skin may cause temporary
increases in scleral show (Figs. 7, 8). This condition
usually responds briskly to daily massage, but in
some cases it may last up to 14 weeks. Ectropion is
more likely to occur in patients who have pre-existing
lower lid laxity and have had or are undergoing
concomitant lower lid blepharoplasty either percuta-
neously or transconjunctivally [106].
Recurrent rhytids
Recurrence of wrinkles is best addressed by
closely examining the patient’s preoperative chief
complaint and establishing appropriate postoperative
expectations. Patients must be warned that not all
wrinkles will disappear after laser skin resurfacing,
particularly those associated with lines of animation
or those associated with excessive skin laxity. To
avoid disappointment, the patient may need to un-
dergo simultaneous browlift, facelift, or blepharo-
plasty procedures to accomplish their desired goal.
By doing so, a realistic outcome can be anticipated.
S.W. Watson, T.J. Sawisch / Oral Maxil
Summary
Dr. Leon Goldman’s classic advice, ‘‘If you don’t
need a laser, don’t use one,’’ is well worth repeating
at this point [31]. However, in the authors’ opinion,
the pulsed CO2 laser with computer pattern generator
remains the gold standard for the treatment of facial
photo-damage with dyschromias and facial rhytids—
especially those with a fine, cross-hatched pattern
(Figs. 9, 10). These high-energy pulsed lasers have
been shown to be an excellent modality for the safe
and precise removal of dermatologic defects and
facial rhytids. The action of the laser removes the
epidermis, stimulates collagen formation, shortens
collagen strands, and welds collagen fragments. The
result is rejuvenated, tightened skin, a satisfied pa-
tient, and a gratified surgeon.
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