The workings of lasers were explained in the previous section. The carbon dioxide and Erbium-Yag lasers can both be used to burn away thin layers of skin. This technique, known as laser resurfacing or "laser peeling" works like chemical peels and dermabrasion. The carbon dioxide laser is more deeply penetrating than the erbium-yag laser which removes 25 micron layers of skin compared to 50 - 100 microns by the carbon dioxide laser. Both these lasers come with computerised scanners which scan the laser beam quickly across the skin and allow the skin to be resurfaced quickly with minimal heating of the skin and consequently, minimal risk of scarring. Unlike dermabrasion, laser resurfacing is not hampered by the spattering of blood and tissue and there is not much bleeding to obscure the view. There is also less post-operative discomfort and faster healing. Laser resurfacing is generally more expensive than chemical peels or dermabrasion because of the high cost of laser machines. The depth of penetration increases with the number of passes the laser beam makes over the skin which allows greater flexibility in treating different severity of scarring and wrinkling. The benefits of laser resurfacing last an estimated 5 - 6 years. As with dermabrasion and chemical peels, deep ice-pick acne scars require prior scar revision using punch excision, punch elevation or punch grafting before laser resurfacing for the best results. Remember also that the laser resurfacing only pushes the age clock back, it doesn't stop it entirely. Treatment may need to be repeated.

Benefits

• Improve wrinkles, especially mild to moderate wrinkles and those around the eyes (crow's feet) and mouth.
• Improve nasolabial furrows and forehead frown lines.
• Improve scars caused by chickenpox, surgery and trauma and some types of acne scars.
• Improve sun-damaged skin.

  Pre-treatment
  This is similar to the preconditioning treatment described on page . It has been observed that healing after laser resurfacing is enhanced when the skin has been pre-treated with tretinoin 0.025 or 0.05% nightly so most doctors put their patients on this regimen for 2 - 4 weeks prior to treatment. If hyperpigmentation is anticipated, especially with skin phototypes III and IV, the doctor may prescribe a lightening cream, as well. Patients with a history of recurrent herpes labialis (cold sores) and those having laser resurfacing around the mouth are usually started on antiviral medicines such as acyclovir or famcyclovir one day before surgery and continued for a total of 7 - 10 days.
  
  

  Anaesthesia
  Depending on the extent of the area being treated, general anaesthesia, local anaesthesia or nerve blocks with or without IV sedation may be used.

  
  Laser procedure

  • The face is cleansed with a non-flammable cleanser to remove makeup, oil and dirt.
  • You will then be asked to wear protective goggles. If the area being treated is near the eyes, special eyeshields need to be worn.
  • The wrinkles may be outlined prior to the local anaesthetic injections (because the injections alter their appearance) and the area of treatment delineated.
  • The laser beam is delivered to the skin via a special handpiece which is moved over the treatment area with minimal overlapping.
  • After each pass of the skin, the doctor uses a saline-soaked gauze to wipe away the burnt tissue. A dry gauze is then used to dry the area.
  • Additional passes are made to smoothen out wrinkles and scars, as necessary.
  • The doctor may apply a dressing over the area or he may use an open dressing method involving the application of an antibiotic ointment or vaseline several times a day.

  It takes approximately 45 minutes to treat the areas around the eyes and mouth or 1 1/2 hour to treat the whole face. Laser resurfacing may be repeated after 6 - 12 months, if necessary.

   

  Post-operative course and care
  Lasers produce a second degree burn and the wound must be properly cared for in order to prevent complications.
  

  • Swelling or oedema may be severe especially around the eyes. You should be accompanied by someone if you are not being hospitalised for the first few days. Sleeping with the head slightly elevated for the first 3 - 5 days helps to reduce the swelling.
  • Dry ice packs can be applied (over the dressing, if any) as often as is necessary during the first 3 days and paracetemol can be taken for pain relief. Avoid taking aspirin or aspirin-like drugs.
  • Dressings, if used, are replaced after 24 hours and removed after 48 hours.
  • The skin may be weepy and crusts need to be removed because they form a medium for bacterial growth. Crusts can be removed gently after soaking the skin in cool or tepid water (some doctors advise adding some vinegar) several times a day followed by application of the antibiotic ointment of vaseline. Keep the skin moist at all times as it speeds up the healing process.
  • The newly resurfaced skin is very red and this may last for 2 months or more. The redness can be camouflaged with green foundation, followed by a skin coloured make-up over it.
  • Hydroquinone lightening creams can be resumed after the skin has resurfaced and tretinoin cream 2 - 3 days later.
  • Avoid excessive exposure to the sun and use sunscreens especially when the skin is still red because pigmentation may develop. UV protective sunglasses should also be worn after laser skin resurfacing around the eyes.
  • Avoid strenuous physical activity for at least 5 days and alcohol which may increase blood flow and encourage the development of telangiectasias (broken capillaries).
  • The benefits of laser resurfacing may not be apparent until some 2 - 4 months after surgery so don't despair.
  • Most patients can return to work after the swelling has subsided in 7 - 10 days.

  Complications
  Although laser resurfacing is relatively safe, our skin's ability to heal varies so the outcome is not always predictable. However, serious complications are uncommon.
  

• Redness is expected and is not really a complication of treatment. It lasts 6 -12 weeks after resurfacing. Green cosmetics are good for camouflaging the redness.
• Scarring is uncommon but may occur when the procedure is carried out too deeply or if the wound gets infected. Early indications of the possible development of keloids (lumpy scars) include redness, elevation and itching of the skin after it has apparently healed. Early treatment with steroid creams may reduce the severity. The risk of scarring may be increased in patients recently treated with isotretinoin which is why laser resurfacing is normally performed at least 12 - 18 months after completing isotretinoin treatment. Areas such as the upper lip and jawline are more prone to develop scarring.
• Ectropion (pulling away of the lower eyelid) may occur when laser resurfacing is done too soon after blepharoplasty (eyelid surgery).
• Hypopigmentation (reduced pigmentation) may occur with deep resurfacing.
• Hyperpigmentation (increased pigmentation) may develop people with skin phototypes III and IV. It is usually temporary and can be treated with lightening creams as in melasma together with strict avoidance of sunlight (see melasma). It may be avoided with the use of preconditioning treatment.
• Bacterial infections are rare and can be treated with antibiotics.
• Candidiasis a fungal infection caused by a yeast-like fungus called Candida albicans is a rare complication. It can be treated with antifungal medicines and creams.
• Herpes labialis may recur after laser resurfacing which is why patients with a history of herpes labialis are started on anti-herpes medicines 1 day before resurfacing and continued for a total of 7 - 10 days.
• Milia or tiny whitehead-like cysts may occur transiently. They can be extracted with a number 11 scalpel blade. Pre-treatment of the skin with tretinoin helps to reduce the formation of milia.
• Acne flares may occur and can usually be treated with topical or oral antibiotics.

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