A comprehensive knowledge of laser systems and nonlaser treatment modalities, including light, radiofrequency, and ultrasonic 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. The term resurfacing historically referred to ablative procedures of the epidermis of the skin, most often by either carbon dioxide or erbium:YAG laser. Technically, chemical peels, dermabrasion, and to a lesser extent microdermabrasion, among other treatments, could also be considered resurfacing. Current terminology not only includes ablative, but also fractional, nonablative, and sublative, which further stratify modalities of facial resurfacing.
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.
If the patient has a history of collagen vascular diseases (eg, lupus, scleroderma, keloid formation) or immunologic abnormalities such as vitiligo, laser treatment may need to be avoided because these conditions can cause problems with healing and can be relative contraindications to laser resurfacing.
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.
Different imaging systems are available to assist in facial analysis. Standard- and high-definition digital photography are the most commonly used to document the state of the facial skin prior to, during the postoperative period, and after completion of treatment. Basic photo management software can provide precomparison and postcomparison photos. Systems such as the OMNIA imaging system from Canfield Scientific or the Body Pro from Emage Medical include a camera, lighting system, and background to facilitate image capturing.
The OMNIA imaging system uses a Canon EOS Rebel T5i 18-megapixel resolution camera and a 35-mm lens with Canfield Intelliflash XenonFlash. It can be modified with polarizing filters on the camera and flash and relayed to the Mirror medical imaging software to assess hemoglobin and melanin in the facial skin. 
An example of an imaging system including both the hardware and software is the VISIA Complexion Analysis System including the VISIA -CR geared for clinical research and The Reveal Imager, a portable device all from Canfield Scientific or the Image Pro Series from Emage Medical. The VISIA Complexion Analysis System uses the RBX multispectral imaging incorporating cross-polarized flash and ultraviolet lighting with Canfield’s Intelliflash system to reduce specular reflection emanating from the skin, allowing for assessment of hemoglobin and melanin within the papillary dermis and epidermis, respectively, while providing photodocumentation. 
The proprietary RBX system allows the melanin and hemoglobin constituents in the skin to be analyzed and presented. This system reportedly gives more accurate representation of the melanin and hemoglobin than that obtained with polarizing or UV filters.  See the image below. The Reveal imager also from Canfield Scientific uses the RBX technology and is postable.
The Image Pro II uses a 15.1-megapixel display incorporating Emage Medical Triple Spectral Imaging capability, which uses normal, polarized, and ultraviolet light, providing on-screen analysis including measurements, wrinkles, pores, sebum, moisturization, vascularity, and both superficial and deep pigmentation.  See the images below.
The Mirror medical imaging software has different programs that provide photodocumentation and offer representations of facial changes from facial treatments and surgeries.  .
Canfield Scientific offers nonportable 3-dimensional imaging of the face and neck with its VECTRA M3, VECTRA XT, and VECTA WB360 imaging system. Emge provides the IMAGE Pro 3D.
Isotretinoin and Radiation
Ascertaining if the patient has used isotretinoin (generic 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. Even fractionated treatment ablates microislands of epithelium while leaving other islands of epithelium intact.
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 below). 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 below) 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.  However, the standard hydroquinone-based bleaching agents are not without concerns and are not available in all countries.
Nonwhite patients also seek aesthetic treatments and procedures. Special consideration must be given to these patients, especially with regard to pigmentation and scarring. 
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
The following Modified Fitzpatrick wrinkle scale can also be used to assess the depth of wrinkles to a finer degree:
0 - No wrinkle; no visible wrinkle; continuous skin line
0.5 - Very shallow yet visible wrinkle
1 - Fine wrinkle; visible wrinkle and slight indentation
1.5 - Visible wrinkle and clear indentation; less than 1 mm wrinkle depth
2 - Moderate wrinkle; clearly visible wrinkle; 1-2 mm wrinkle depth
2.5 - Prominent and visible wrinkle; greater than 2 mm but less than 3 mm wrinkle depth
3- Deep wrinkle; deep and furrow wrinkle; greater than 3 mm wrinkle depth
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. 
Roberts also developed a skin type classification system incorporating how the skin responds to "injury and insult from cosmetic procedures." 
} 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. Ablative and nonablative lasers have been combined to produce results comparable to other modalities, with reportedly fewer complications.  Different lasers can be used to customize facial rejuvenation. 
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.
Many different modalities of facial resurfacing, including but not limited to, laser, nonlaser, ablative, nonablative, sublative, and even chemical peels, are adjuncts 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.