Resurfacing Treatments:

There are many choices for skin resurfacing (also called exfoliation), and you must consider several different factors when making your choice. Resurfacing can achieve the following:

• Removal of abnormal tissue and rough skin
• Stimulation of new skin growth
• Stimulation of collagen and elastin production

In addition to determining the skill of the surgeon and the safety of the procedure, discuss the desired depth of the resurfacing and the capability of each procedure to reach this depth safely. All resurfacing procedures require a healing period afterward, during which the skin is red and sensitive. The deeper the procedure, the higher the risk for complications, including delayed healing, infection, loss of pigment (skin color), and scarring.

If you make the decision to pursue intensive treatments, consider the following factors, among others, and discuss them with your dermatologist or plastic surgeon:

• The ability of the procedure to safely reduce wrinkles
• The ease and safety record of the procedure
• The skill of the doctor
• The length of recovery
• Possible complications
• How long the benefits will last

A person's age also helps determine the procedure:

• For people in their 30s, a simple chemical peel is sufficient.
• After age 40, people may benefit from collagen or fat implants.
• At age 50 and over, plastic surgeons recommend laser resurfacing and customized treatments for individual needs.

In older individuals, combination procedures may be beneficial. Some examples include the following:

• Laser surgery may be used for deep lines (such as those around the mouth) and chemical peels used over the rest of the face.
• For enhancing the eye by correcting droopy eyelids, bags, and a "sinking" brow, combinations of an eyelift (blepharoplasty), Botox, and laser resurfacing may be used.

Chemical Peels

Chemical peels, also known as chemosurgery, help restore wrinkled, lightly scarred, or blemished facial skin. Much like chemical paint strippers, chemical peels strip off the top layers of skin, and new, younger-looking skin grows back. The procedure is very effective for the upper lip, but it cannot be performed around the eyes. Partial peels are often done in conjunction with a face-lift. Combinations of topical antioxidants, such as tretinoin and vitamin C, along with a chemical peel, may be particularly effective.

The Procedure.

• A dermatologist applies chemicals to the skin, including trichloroacetic acid, high concentrations of alpha hydroxy or beta hydroxy acids, or combinations of all three.
• In some cases, tretinoin or alpha hydroxy is applied 4 - 6 weeks before, and starting one day after, the peel. Such treatments can enhance the effects of a peel and reduce the risk of discoloration in people at risk for this complication. Tretinoin is also being tested as a chemical peel.
• A crust or scab generally forms within 24 hours after surgery. You can remove this scab by gently cleansing with soap and water.
• The skin takes 6 - 7 days to heal.
• After the scab disappears, the visible skin is deep red but gradually lightens as it regenerates.

Complications. Complications include white heads, cold sores, infection, scarring, numbness, and permanent discoloration, particularly in people with darker skin. Refinement of chemical peel techniques are now permitting doctors to reach deeper skin, improvements which make it easier to apply peels to non-facial skin and to individuals with darker skin.

Dermabrasion

Dermabrasion affects deeper layers of skin than chemical peels, and may be useful for removing disfiguring marks, such as deep acne scars or deep wrinkles. As with chemical peels, it is effective for wrinkles on the upper lip and chin, and cannot be used around the eyes. Some doctors prefer dermabrasion to lasers for skin resurfacing of people with darker skin colors.

Standard Dermabrasion. Standard dermabrasion uses a rotating brush that removes the top layers of a person's skin. As with chemical peels, dermabrasion selectively strips away the upper layers of skin, leaving the underlying skin layers exposed. Similar to chemical peels, after the procedure, the treated skin oozes and forms a scab, a reaction that looks and feels uncomfortable, but is only temporary. Postoperative care is similar for both procedures.

Microdermabrasion. A gentler variation called microdermabrasion uses very tiny crystals to polish the skin and a vacuum technique to remove them. It has largely replaced the older dermabrasion. Results are similar to those of light chemical peels. Patients can have this procedure done on their lunch hour and return to work. Only mild redness occurs after treatment, although for best results five or six repetitive treatments are needed every 1 - 2 weeks. To date, overall patient satisfaction has been very high.

Laser Resurfacing

Lasers are currently the most effective exfoliation tools for eliminating wrinkles. Their unique advantage over other resurfacing methods is their ability to tighten the skin. A successful procedure can make patients look 10 - 20 years younger, and the results can last for up to 10 years.

The procedure is most beneficial for the following areas:

• It is best around the mouth and eyes. Recent evidence suggests CO₂ lasers may be even better than dermabrasion for the upper lip.
• It is slightly less beneficial for the area around the nose.

When used alone, current laser therapy does not eliminate crow's feet, broken blood vessels, or dark circles under the eyes. Evidence on the effects of lasers on acne scars is incomplete.

Standard laser dermabrasion is too harsh for thinner skin layers, such as on the neck. Newer and gentler laser techniques, however, stimulate collagen without removing skin layers, and may prove useful for necklines.

The Laser Resurfacing Procedure. In general the procedure works in the following way:

• Laser pulses penetrate the skin quickly, vaporizing water and surface skin without damaging the deeper layers, allowing new top skin to grow.
• The laser delivers enough heat to shorten collagen fibers, restoring some elasticity to the skin.

Choice of Lasers. The lasers used depend on the skin type and severity of the condition. Some of the more common laser types are:

• The carbon dioxide (CO₂) laser. This is the most powerful laser treatment and is used for deep wrinkles and skin imperfections. The laser damages the skin by destroying water molecules inside and outside of the cells. In response, the skin produces more collagen, which fills in wrinkles. Research finds that the carbon dioxide laser reduces wrinkles safely and effectively over the long-term. People who have had silicone injections should not have CO₂ procedures, because they can burn and scar the skin over the implanted area.
• The erbium: YAG (Er:YAG). This laser is gentler than the CO₂ laser, and is effective for mild wrinkles and for providing a smooth skin texture. It has a shorter recovery time. Some experts have even found the YAG laser to be as effective for removing deep wrinkles as the CO₂ laser when used to sufficient depth. A variable pulse YAG laser can shift between pulses that destroy skin tissue to those that heat the skin. This process effectively resurfaces the skin with fewer side effects than CO₂ laser therapy.
• Pulsed dye laser (PDL). A pulsed dye laser uses yellow light, which is easily absorbed by hemoglobin, the molecule that gives blood its red color. Pulsed dye laser treatments are used to treat skin blemishes, such as port-wine stains, that are due to blood vessel abnormalities.

A gentle laser procedure called non-ablative laser resurfacing (NLite) or photorejuvenation is now approved for the treatment of all facial wrinkles. The procedure uses light energy to gently stimulate new collagen, and possibly elastin production, without removing the skin tissue itself. Its effects are less pronounced than those of other laser procedures. However, because it does not injure the external layers of skin, it can be used on delicate skin areas, such as the neck and around the eyes. It also causes very little irritation afterward.

Some surgeons are using combination techniques with more than one laser technology in one session, to achieve different effects. For example, one combination technique uses CO₂, YAG, pulsed-dye laser, and one other laser technology to both improve wrinkles and clear under-eye dark circles and acne scarring. Pretreatment with botulinum (Botox) injections before laser resurfacing significantly improved the treatment of crow's feet in one study.

Post-Procedure Recovery. The procedure itself is relatively painless, but the redness and irritation that occur during the healing process can be severe. Non-ablative laser resurfacing does not have the same severe after-effects as other laser treatments. For 8 - 9 days, the face looks skinned and swollen, and requires continuous moisturizing. Some doctors suggest that people with very sensitive skin who cannot tolerate the necessary medications and lubricants avoid laser resurfacing. Redness and sensitivity can persist for 1 - 4 months. The patient must stay out of the sun as much as possible during this time, and should always avoid sunbathing and damaging their skin again. Early research suggests that silicone dressings may reduce post-procedure pain and crusting.

Complications. Scarring and infections can occur in about 1% of procedures. The risk of complications depends on the surgeon's experience. People with a history of herpes simplex may experience flare-ups of fever, facial pain, and flu-like symptoms for 5 or 6 days after the procedure. In addition, people with darker skin may wish to avoid the procedure, because it can cause unpredictable and dramatic lightening of the skin.

A new skin rejuvenation technology, called Plasma Skin Resurfacing, or Portrait Plasma, was introduced in February 2005. The technology uses plasma energy (heat and light energy) to rejuvenate the skin from the deeper layers outwards. While new skin regenerates, the outer layers of the skin act as a natural bandage. When the outer layers peel off in the week after treatment, the new skin emerges. The process prevents or minimizes the raw appearance that follows laser treatments. This system uses radio waves to "excite" nitrogen gas, resulting in the release of energy. According to the manufacturer, skin regeneration using the Portrait Plasma system is rapid, and satisfaction with the procedure appears high. Long-term follow-up studies are not yet available for this new method. In 2006, the Food and Drug Administration also approved Plasma Skin Resurfacing for the treatment of wrinkles on other areas of the body.

Another technique, photodynamic therapy, appears to reduce the signs of aging even better than laser therapy alone. Photodynamic therapy uses a medication (such as 5-aminolevulinic acid) that is activated by laser light. In one study, this treatment dramatically increased levels of a protein involved in the growth of new skin cells, as well as substances involved in the production of collagen. Photodynamic treatment also increased the thickness of the skin's outer layer (the epidermis).

Other Exfoliation Procedures

Cold Ablation. Cold ablation, called coblation for short, delivers saline (salt water) to the skin, through which a cool electric current is passed. A subsequent reaction heats and vaporizes the top shallow layer of skin. The procedure is very specific and appears to minimize any damage to other areas of the skin.

Radiofrequency Resurfacing. A promising technique uses low radiowave energy to resurface the skin. Preliminary research indicates that this procedure may eventually be as effective as laser surgery in reducing severe wrinkles around the eyes and mouth, with minimal pain and a shorter recovery time. A small clinical trial found that a noninvasive radiofrequency technique called NARF safely and effectively improved drooping lower eyelids.

Intense Pulsed Light. Intense pulsed light (IPL) uses filters to deliver different wavelengths of light. Doctors use it to treat a number of photoaging skin problems, and it appears to have long-term effects. Typically, four to six treatments are performed over a 4-month period. Each treatment takes 15 - 20 minutes. Unlike laser light, which uses one color wavelength (such as green or red), intense pulsed light starts with a full spectrum of light. It then allows the doctor to selectively block off specific wavelengths, depending on how shallow or deep the procedure goes. IPL machines are less expensive and safer than lasers.