eMedicine Specialties > Plastic Surgery > Skin

Skin Resurfacing, Carbon Dioxide Laser: Follow-up

Author: Andrew Jacono, MD, Chief, Section of Facial Plastic and Reconstructive Surgery, The North Shore University Hospital at Manhasset; Assistant Professor, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, New York Medical College; Assistant Professor, Department of Head and Neck Surgery, Albert Einstein College of Medicine; Director, The New York Center for Facial Plastic and Laser Surgery
Coauthor(s): Michael B Stevens, MD, PhD, Consulting Staff, Department of Plastic Surgery, Kaweah Delta Hospital
Contributor Information and Disclosures

Updated: Sep 27, 2006

Outcome and Prognosis

  • Results of laser resurfacing are good to excellent depending on the indication for which the procedure was performed.
  • Patient satisfaction is based on the delivery of natural results with minimal downtime and a low incidence of complications.
  • Actinic changes are improved to the greatest degree. Wrinkles typically are improved by 60-80%, while scars are improved to a lesser degree.
  • Improvement can be seen in deeper skin folds of the cheeks, forehead, and neck, malar bags, and even in the excess skin of the upper eyelid (pseudoblepharoplasty effect), but their improvements are less predictable.
  • Static lines are improved to a greater degree than dynamic lines. Treatment of these dynamic lines with botulinum toxin A provides significant improvement.
  • To best estimate degree of improvement after healing is complete, assess results at 6 months postresurfacing. Usually, some loss of early improvement and some recurrence of wrinkles can be observed as postoperative edema resolves.
  • Repeat treatments are possible but should be spaced approximately 6 months apart.
  • Laser skin resurfacing is a relatively new procedure, and long-term skin effects are largely unknown.
  • Overall success in laser skin resurfacing is related to the following elements:
    • Proper patient and skin type selections
    • Attention to preoperative, intraoperative, and postoperative details
    • Aggressive management of emerging complications
    • Good patient-physician relationship

Future and Controversies

In general, given the overall success and safety of carbon dioxide laser resurfacing, the demand for this procedure will continue to increase at a relatively notable speed.

Every resurfacing procedure (lasers, peels, dermabrasion) has specific indications to make it the procedure of choice. Each procedure has inherent advantages and disadvantages, complicating the decision to use one resurfacing procedure over another. Choice of resurfacing modality certainly depends on the physician's skills in that procedure and the patient's needs.

Furthermore, whether the long-term results of various resurfacing procedures differ if the depth achieved is equal is unknown. The advantage of carbon dioxide laser resurfacing over other resurfacing procedures is the precise control over the depth of tissue ablated.

Combined resurfacing modalities

Realizing that different regions of the face display various degrees of skin damage, often one needs to combine more than one resurfacing modality to achieve the best result possible.

A common example is a patient with deeper rhytids around the eyes and mouth but without many wrinkles on the rest of the face. To achieve good improvement in these wrinkles, a papillary or reticular dermis level of resurfacing is needed. However, subjecting the rest of the face to this same depth of resurfacing is not necessary; an upper papillary dermis level procedure or even epidermal exfoliation may be all that is needed in these areas. In this case periorbital and perioral carbon dioxide laser resurfacing can be combined with a more superficial TCA peel over the rest of the face. This helps to blend the results well and prevent any lines of demarcation.

While carbon dioxide laser resurfacing of undermined skin such as a rhytidectomy flap is controversial, carbon dioxide laser resurfacing can be performed safely on nonundermined skin and combined with a superficial TCA peel over the undermined skin flap if the depth of the peel is kept superficial (see Image 4, Image 5).

Newer resurfacing modalities

Three resurfacing modalities recently have emerged with claims of achieving faster healing and less potential for complications than carbon dioxide laser resurfacing.

  • Erbium:Yttrium-aluminum-garnet (Er:YAG) laser
    • This laser has a wavelength of 2940 nm and a pulse duration of 250-500 microseconds.
    • Because of greater water absorption, Er:YAG laser ablates less tissue per pass (approximately 4-5 µm) with a narrower zone of thermal necrosis (approximately 20-30 µm) than carbon dioxide laser.
    • Er:YAG laser neither can induce the same collagen tightening nor impart the hemostasis commonly observed with carbon dioxide laser. It is most suitable for exfoliation (epidermis level) or papillary dermis level resurfacing (pinpoint bleeding as an endpoint) and may not be as effective when used to correct deeper wrinkles or scars.
  • Neodynium:YAG (Nd:YAG) laser
    • This laser has a wavelength of 1320 nm.
    • It can induce a certain degree of thermal collagen coagulation in the papillary dermis while generally sparing the epidermis (nonablative resurfacing). Coagulation necrosis in the papillary dermis leads to collagen contracture and subsequent neocollagenesis.
    • This procedure is best suited for mild wrinkles.
    • Multiple treatments are required over many weeks to achieve an optimal result.
  • Electrosurgical skin resurfacing (Visage)
    • The manufacturer uses the term coblation to describe this procedure's selective lesional tissue damage by radiofrequency waves while inflicting minimal damage on adjacent structures.
    • Ablation depth with this procedure is approximately 70-80 µm with collateral tissue damage that extends into the upper papillary dermis.
    • Coblation differs from laser resurfacing by the almost complete lack of heat generated by the former, theoretically decreasing the likelihood of erythema and other postresurfacing complications.
    • Little is known about this resurfacing modality, since clinical studies have not been performed.

 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Samer Alaiti, MD, FACP, to the development and writing of this article.



More on Skin Resurfacing, Carbon Dioxide Laser

Overview: Skin Resurfacing, Carbon Dioxide Laser
Treatment: Skin Resurfacing, Carbon Dioxide Laser
Follow-up: Skin Resurfacing, Carbon Dioxide Laser
Multimedia: Skin Resurfacing, Carbon Dioxide Laser
References
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References

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  2. Chernoff WG, Cramer H. Rejuvenation of the skin surface: laser exfoliation. Facial Plast Surg. Apr 1996;12(2):135-45. [Medline].

  3. Fulton JE, Rahimi AD, Helton P, Dahlberg K. Neck rejuvenation by combining Jessner/TCA peel, dermasanding, and CO2 laser resurfacing. Dermatol Surg. Oct 1999;25(10):745-50. [Medline].

  4. Horton S, Alster TS. Preoperative and postoperative considerations for carbon dioxide laser resurfacing. Cutis. Dec 1999;64(6):399-406. [Medline].

  5. Hruza GJ, Dover JS. Laser skin resurfacing [editorial; comment]. Arch Dermatol. Apr 1996;132(4):451-5. [Medline].

  6. Kilmer SL. Laser resurfacing complications: How to treat them and how to avoid them. Int J Aesth Restor Surg. 1997;5:1:41-45.

  7. Obagi ZE, Obagi S, Alaiti S, Stevens MB. TCA-based blue peel: a standardized procedure with depth control. Dermatol Surg. Oct 1999;25(10):773-80. [Medline].

  8. Ross EV, Domankevitz Y, Skrobal M, Anderson RR. Effects of CO2 laser pulse duration in ablation and residual thermal damage: implications for skin resurfacing. Lasers Surg Med. 1996;19(2):123-9. [Medline].

  9. Stevens MB. Laser resurfacing and combined procedures. In: Obagi Skin Health Restoration and Rejuvenation. Vol 1. 1999:247-283.

  10. Trelles MA, Brychta P, Stanek J,. Laser techniques associated with facial aesthetic and reparative surgery. Facial Plast Surgery. 2005;21:83-98. [Medline].

  11. Walia S, Alster TS. Cutaneous CO2 laser resurfacing infection rate with and without prophylactic antibiotics. Dermatol Surg. Nov 1999;25(11):857-61. [Medline].

  12. Ziering CL. Cutaneous laser resurfacing with the Erbium YAG laser and the char-free carbon dioxide laser. A clinical comparison of 100 patients. Int J Aesth Restor Surg. 1997;5:1:29-37.

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Further Reading

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Keywords

laser skin resurfacing, cutaneous laser resurfacing, carbon dioxide laser, CO2 laser, CO2 laser, aging, photoaged skin, chemical peeling agents, thermal damage, rhytids, wrinkles

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Contributor Information and Disclosures

Author

Andrew Jacono, MD, Chief, Section of Facial Plastic and Reconstructive Surgery, The North Shore University Hospital at Manhasset; Assistant Professor, Division of Facial Plastic Surgery, The New York Eye and Ear Infirmary, New York Medical College; Assistant Professor, Department of Head and Neck Surgery, Albert Einstein College of Medicine; Director, The New York Center for Facial Plastic and Laser Surgery
Andrew Jacono, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Michael B Stevens, MD, PhD, Consulting Staff, Department of Plastic Surgery, Kaweah Delta Hospital
Michael B Stevens, MD, PhD is a member of the following medical societies: American College of Surgeons, California Medical Association, Lipoplasty Society of North America, and Lipoplasty Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Tolbert Wilkinson, MD, Consulting Staff, Department of Surgery, Southwest Texas Methodist Hospital
Tolbert Wilkinson, MD is a member of the following medical societies: American College of Surgeons, American Society for Aesthetic Plastic Surgery, Phi Beta Kappa, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Wayne Stadelmann, MD, Stadelmann Plastic Surgery, PC
Wayne Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Subhas Gupta, MD, PhD, CM, FRCSC, FACS, FACS, Professor of Surgery, Chair, Department of Plastic Surgery, Director of Plastic Surgery Residency, Director of Comprehensive Wound Service, Department of Plastic Surgery, Loma Linda University School of Medicine
Subhas Gupta, MD, PhD, CM, FRCSC, FACS, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Phlebology, American College of Surgeons, American Medical Association, American Medical Informatics Association, American Society of Plastic Surgeons, California Society of Plastic Surgeons, Canadian Medical Association, Canadian Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, College of Physicians and Surgeons of Ontario, Plastic Surgery Research Council, Quebec Medical Association, Royal College of Physicians and Surgeons of Canada, and Wound Healing Society
Disclosure: Nothing to disclose.

 
 
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