During the past few years, laser resurfacing has become popular among laser surgeons and the public alike. Resurfacing lasers selectively target water-containing tissue resulting in controlled tissue vaporization. The associated thermal injury (heat) in the dermis results in collagen shrinkage and remodeling.
Multiple lasers of a variety of different mechanisms are currently available for resurfacing including a high-energy pulsed or scanned carbon dioxide laser, a short-pulsed erbium:yttrium-aluminum-garnet (Er:YAG), and modulated (short-and-long-pulsed) Er:YAG systems. High-energy pulsed or scanned carbon dioxide laser skin resurfacing can achieve excellent clinical improvement of photodamaged skin, wrinkles and atrophic scars. However, this resurfacing is associated with an extended healing period and, in some cases, prolonged erythema or redness of the skin that may persist for several months. It also has the potential for delayed permanent hypopigmentation seen in as many as 20% of patients when multiple-pass carbon dioxide resurfacing is performed. The demand for less aggressive forms for skin rejuvenation led to the development of the Er:YAG laser.
The CO2 laser is more powerful than the YAG and it covers a larger area per pulse. Because of the lesser amount of tissue per laser pass, and smaller zone of residual thermal damage, this results in faster healing with less side-effects. The only problem initially was that the results of treatments with the YAG were not as dramatic as with the CO2 lasers. Various technical changes gave birth to the modulated Er-YAG which provided deeper tissue ablation, improved hemostasis and increased collagen remodeling.
The Er:YAG laser is a powerful tool that can have beneficial effects when used properly for the correct indication. Mild-to-moderate photo-induced wrinkles, superficial pigmentation, atrophic scars, and a variety of epidermal and dermal lesions can be treated successfully with the Er:YAG laser. Treatment with the short-pulsed Er:YAG laser is particularly well suited for patients with darker skin.
Skin resurfacing with a short-pulsed Er:YAG laser is most commonly used for the improvement of fine rhytides. For moderate photodamage and rhytides, modulated Er:YAG laser skin resurfacing results in greater collagen contraction and improved clinical results.
Er:YAG laser systems may greatly improve atrophic scars caused by acne, trauma, or surgery. Pitted acne scars may require ancillary procedures for optimal results. These procedures can be performed either prior to or concomitant with Er:YAG laser resurfacing.
A variety of benign epidermal and dermal conditions respond favorably to Er:YAG laser resurfacing, including sebaceous hyperplasia, eruptive hair cysts, adenoma sebaceum, angiofibroma, hidradenoma, xanthelasma, and syringomas.
Ablative laser skin resurfacing can be combined with surgical lifting procedures to provide complete rejuvenation in appropriate patients.
The success of laser resurfacing relies upon the presence of adnexal structures (eg, pilosebaceous units, sweat glands) to function as a reservoir of epithelial cells that can migrate upward to form a new epidermis. Er:YAG laser resurfacing is most suitable for facial skin, which has more adnexal structures and, thus, a greater capacity to regenerate new cells than the skin of the trunk. Several studies document successful rejuvenation of the neck, chest, arms, and hands with the Er:YAG laser. However, the risk of scarring is significant because of the paucity of adnexal structures in these areas.
At the initial consultation, a complete medical and surgical history should be obtained.
Unrealistic patient expectations, tendency toward keloid or hypertrophic scar formation, isotretinoin within 6 months prior to surgery, and when a patient cannot comply with postoperative instructions. Patients with reduced numbers of adnexal skin structures, such as those with scleroderma, burn scars, or history of prior ionizing radiation to the skin, are not good candidates for ablative resurfacing.
A thorough examination of the skin to be treated includes careful attention to skin phototype and specific areas of scarring, dyschromia, and rhytide formation. For patients desiring periorbital laser treatment, the eyes must be examined for scleral show, lid lag, and ectropion.
Other cutaneous disorders should also be noted, including seborrheic keratoses, solar lentigines, actinic keratoses, and cutaneous carcinomas. The latter must be treated adequately before any resurfacing procedure is performed.
Laser skin resurfacing can lead to reactivation of latent herpes simplex virus infection or predispose the patient to a primary infection during the reepithelialization phase of healing. It is recommended that prophylactic antiviral medication be prescribed during the postoperative period, regardless of a patient's herpes simplex virus history.
Antibiotics are usually not recommended or given, unless they are clinically indicated.
It is crucial that the laser-treated area be kept moist and not allowed to dry during the reepithelialization period.
Your physician will provide you with the guidelines that you need to follow after treatment.
Er:YAG laser resurfacing ablates superficial cutaneous tissue and imparts a thermal injury to denuded skin. Therefore, adverse effects are to be expected and should be differentiated from complications.
Minor adverse effects of cutaneous laser resurfacing include transient erythema, edema, burning sensation, and pruritus.
Mild complications of Er:YAG laser resurfacing include milia, acne exacerbation, contact dermatitis, or perioral dermatitis. Moderate complications include localized viral, bacterial and candidal infection, prolonged erythema, transient posttreatment hyperpigmentation, and delayed hypopigmentation. The most severe complications include fibrosis, hypertrophic scarring, disseminated infection, and the development of ectropion. Diligent evaluation of the patient is necessary during the reepithelialization phase of healing. This is important because a delay in recognition and treatment of complications can have severe deleterious consequences such as permanent dyspigmentation and scarring.