eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Facial Analysis for Skin Resurfacing

Author: Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota
Coauthor(s): Adam J Cohen, MD, Eyelid and Facial Aesthetic and Reconstructive Surgery, Diseases and Surgery of the Orbit and Lacrimal System, Cosmetic Laser Surgery; Edward W Chang, MD, DDS, Consulting Staff, Department of Cosmetic Services, Head and Neck Surgery, Kaiser Permanente of Northern California at Santa Rosa
Contributor Information and Disclosures

Updated: Aug 28, 2009

Introduction

A comprehensive knowledge of laser systems, details and treatment parameters, appropriate patient selection, preoperative and postoperative care, and application of new technologies can produce aesthetic results that are satisfactory to both the patient and the surgeon. Before any intervention, a thorough facial analysis must be undertaken in order to promulgate an appropriate treatment plan.

Preoperative History

With preoperative evaluations, surgeons seek to identify where potential contraindications to laser resurfacing may exist. As with any procedure, a detailed medical and dermatological history with emphasis on wound healing and scar formation is essential. In addition, obtaining a family history of abnormal wound healing, skin disorders, and ethnic background can facilitate an optimal outcome.

The authors routinely request that patients complete a medical questionnaire and an aesthetic questionnaire to help identify prior or concomitant facial cosmetic treatments.

With the widespread use of digital photography, standard lighting and photographing techniques are essential to provide appropriate comparative "photos."  Additional imaging using blue light, different color light, and polarizing light can also provide information to the patient and practitioner regarding subepithelial skin changes, especially with regards to pigmentation.   

Isotretinoin and Radiation

Ascertaining if the patient has used isotretinoin (Accutane) within 1 year before laser resurfacing is important. Some authors recommend discontinuation of isotretinoin for a minimum of 6 months before resurfacing with the erbium:yttrium-aluminum-garnet (Er:YAG) laser or the carbon dioxide laser. Others recommend waiting at least 1 year or longer. This concern stems from the effect isotretinoin has on the cells that repopulate the lasered skin surface.

The epithelial cells of the adnexal structures are a regenerative source for the re-epithelialization of lasered skin. Isotretinoin and radiation exposure destroy these adnexal structures. Facial radiation has been used in the past for the treatment of acne and thyroid gland enlargement. With the fractional laser modalities, regeneration of the epithelium is less of a major concern because small islands of epithelial cells are left intact. Nonablative modalities leave the epithelium with much less and even minimal changes. However, atypical healing can occur with any resurfacing modality, and appropriate caution should be exercised.

Types of Rhytides

Differentiation between static and dynamic wrinkles and the degree of rhytidosis must be ascertained and documented before laser resurfacing. Certain aesthetic scenarios require a combination of laser ablation and more invasive and traditional rejuvenative techniques to achieve adequate rhytide reduction. Face or midfacial lifting, forehead or brow elevation, and blepharoplasty may be coupled with resurfacing and tailored to the patient's needs. This combination of modalities may be performed together or in stages. Safety concerns do exist with traditional carbon dioxide laser resurfacing and full face lifting surgery. However, resurfacing can safely be performed in certain scenarios such as mini lifts.

Rhytides exacerbated by active facial muscle contraction are more impervious to laser resurfacing than static lines are (see Image 1). Crow's feet and lateral smile lines around the eyes are deepened with smiling and can be treated with some success, as evidenced by reduction in wrinkle depth. Botulinum toxin treatment before resurfacing can lessen the mimetic-induced lines and provide a more pleasing aesthetic outcome.

Fitzpatrick Skin Type Classification

Evaluation of facial skin pigmentation before laser resurfacing is paramount to successful results. Pigment can be inherited ethnically or acquired as in melasma or Addison disease. A higher degree of preablative pigmentation increases the risk of hyperpigmentation and hypopigmentation (see Image 2) after laser resurfacing.

Hormonal changes during pregnancy can vary the amount of pigmentation, and performing resurfacing in women who are pregnant is contraindicated.

Fitzpatrick devised a description of skin types known as the Fitzpatrick skin type classification. This classification denotes 6 different skin types, skin color, and reaction to sun exposure.

• Type I (very white or freckled) - Always burn
• Type II (white) - Usually burn
• Type III (white to olive) - Sometimes burn
• Type IV (brown) - Rarely burn
• Type V (dark brown) - Very rarely burn
• Type VI (black) - Never burn

The higher the type and the degree of pigmentation, the greater the risk of postinflammatory hyperpigmentation. However, persons who have minimal pigmentation or light skin can develop prolonged postoperative erythema but are less likely to develop the pigmentary sequelae.

Pretreatment regimens with bleaching agents commonly are employed; however, in 1999, West and Alster reported that these pretreatment regimens may not be necessary.¹ However, the standard hydroquinone-based bleaching agents are not without concerns and are not available in all countries.

Classification Of Rhytidosis

Glogau developed the traditional rhytide/photoaging classification scheme that is used most often today.

• Mild (age 28-35 years) - Little wrinkles, no keratosis, requires little or no makeup for coverage
• Moderate (age 35-50 years) - Early wrinkling, sallow complexion with early actinic keratosis, requires little makeup
• Advanced (age 50-60 years) - Persistent wrinkling, discoloration of the skin with telangiectasias and actinic keratosis, always wears makeup
• Severe (age 65-70 years) - Severe wrinkling, photoaging, gravitational and dynamic forces affecting skin, actinic keratosis with or without cancer, wears makeup with poor coverage

Fitzpatrick reported an alternative classification system that is useful in assessing the degree of perioral and periorbital rhytidosis:

• Class I - Fine wrinkles
• Class II - Fine-to-moderately deep wrinkles and moderate number of wrinkle lines
• Class III - Fine-to-deep wrinkles, numerous wrinkle lines, and redundant folds possibly present

Fitzpatrick also correlated these 3 classes with the following scoring system and degree of elastosis:

• Class I (score 1-3) - Mild elastosis
• Class II (score 4-6) - Moderate elastosis
• Class III (score 7-9) - Severe elastosis

Mild elastosis is defined as fine textural changes with minimal skin lines. Moderate denotes a yellow discoloration of individual papules (papular elastosis). Severe describes marked confluent elastosis with thickened, multipapular, and yellowed skin.²

Future Trends

Fractional carbon dioxide lasers, erbium lasers, and combinations of the 2 technologies have considerably advanced in the past decade. Nonablative lasers, such as the frequency-modified neodymium:yttrium-aluminum-garnet (Nd:YAG); the broadband high-intensity pulsed light; and the flashlamp dye laser, radiofrequency, and photothermal technologies have also advanced producing regeneration of dermal collagen without resultant exfoliation.

A noted benefit is the marked reduction in recuperative time, allowing patients to be treated and return to work within a shortened period of time and, in some cases, with no "downtime." These modalities and combinations of these different modalities have allowed practitioners to treat a wider array of skin types. Patient acceptance has also increased due to the ostensible "less invasive" nature of these modalities, represented by the reduced healing times. However, these modalities continue to evolve, and appropriate patient assessment is always warranted.

Conclusion

Laser resurfacing, ablative and nonablative, is an adjunct in the antiaging treatment spectrum. These technologies can be used separately or in conjunction with other noninvasive and invasive treatments. Regardless of how these techniques are used, the recipient of them must be assessed carefully before treatment can begin.

The physician must ascertain the patient's expectations and render a critical and honest judgment as to whether these technologies can deliver the expected results. If the answer is no, or if the expectations are unrealistic, treatment should be deferred and other modalities considered, if applicable. Careful pretreatment analysis is an indisputable necessity in the evaluation and treatment of facial rhytidosis.

Multimedia

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Media file 1: Contraction of the frontalis muscle is responsible for the creation of the forehead rhytides depicted here. Laser resurfacing may soften these, but the mimetic muscles are better treated with botulinum toxin injections or forehead elevation and release of the frontalis muscle.

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Media file 2: The perioral pigmentation depicted here can worsen after laser resurfacing.

Keywords

facial analysis for skin resurfacing, skin resurfacing, facial rhytidosis, facial wrinkles, facial analysis, preoperative analysis, preoperative laser resurfacing, nonablative laser resurfacing, ablative laser resurfacing, skin resurfacing, Fitzpatrick skin classification, types of rhytides

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