Laser Eyelid Tissue Resurfacing

Updated: Mar 15, 2019

Author: Adam J Cohen, MD; Chief Editor: Hampton Roy, Sr, MD

Overview

Background

Lower eyelid aging results in prominent adipose tissue, skin redundancy, increased rhytids, and laxity.

The traditional technique includes a subciliary incision with removal of fat, skin, and hypertrophied orbicularis muscle and canthal tightening. This approach can result in ectropion, retraction, and canthal angle blunting in 5-20% of patients.[1, 2]

The transconjunctival approach allows for fat rearrangement, debulking, and arcus marginalis release, leading to improved eyelid contour. This approach does not address dermatochalasis, rhytids, or skin texture. The use of the carbon dioxide laser for resurfacing has been used successfully to reduce these findings.[1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13]

The images below depict a patient who underwent combined upper and lower laser blepharoplasty, perioral and periorbital carbon dioxide laser resurfacing, SMAS facelift, and full-face blue peel.

Laser tissue resurfacing. Female patient with skin and muscle laxity, photoaging, and dermatochalasis.

Same patient as in image above underwent combined upper and lower laser blepharoplasty, perioral and periorbital carbon dioxide laser resurfacing, SMAS facelift, and full-face blue peel. This photograph was taken 6 months after the procedure.

Pathophysiology

Lasers target water-containing tissue. Treatment with lasers results in tissue vaporization.[14, 15]

Indications

Indications for carbon dioxide laser skin resurfacing include the following:

Seborrheic keratosis
Verruca vulgaris/plana
Junctional and compound nevi
Lentigo simplex
Small syringomas
Epidermal melasma
Dermatochalasis[16]
Superficial and fine rhytids (see the image below)

Depigmentation seen periorbitally, periorally, and on the forehead following carbon dioxide laser resurfacing.
Scars[17]
Dermatoheliosis

Relevant Anatomy

Extensive knowledge of skin microanatomy, histology, and physiology is essential before proceeding with resurfacing procedures. Familiarity with relative facial skin thickness (ie, thin, medium, thick) is necessary to limit overtreatment and potential complications.

Contraindications

Absolute contraindications to carbon dioxide laser skin resurfacing are as follows:

Active bacterial, viral, or fungal infections
Oral isotretinoin use within the previous 6 months
Tendency for keloid or hypertrophic scar formation
Ectropion
Unrealistic expectations
Uncooperative patient

Relative contraindications to carbon dioxide laser skin resurfacing are as follows:

Poor general health
Continued ultraviolet exposure
Prior radiation to area of proposed treatment
Fitzpatrick skin phototypes V-VI
Reticular dermis-level resurfacing procedure within the preceding 2-3 months
Unwillingness to accept the possibility of postoperative erythema or hypopigmentation
Significant eyelid laxity
Excessively thin or thick skin
Collagen vascular disease, HIV, or hepatitis C infection

Treatment

Medical Therapy

Antibiotics are sometimes started one day prior to resurfacing for prophylaxis. There is no data supporting antibiotic use, given the extremely low incidence of postlaser bacterial infections.[18] Commonly used antibiotics include cephalexin (500 mg PO qid), ciprofloxacin (500 mg PO bid), and azithromycin (Z-Pak). Topical antibiotic prophylaxis may result in dermatitis and should be avoided.

Since laser skin resurfacing can activate latent herpes simplex infection or cause infection during reepithelialization, antiviral medications are prescribed. Surgeons begin treatment on the day before or on the day of laser resurfacing. Regimens include acyclovir (400 mg PO tid for 7 d), valacyclovir (500 mg PO tid for 7 d), and famciclovir (250 mg PO bid for 5-7 d).[19]

Preoperative Details

Examination of the lower eyelids for dermatochalasis, eyelid retraction, ectropion, lagophthalmos, tendon laxity, and cutaneous lesions is necessary. With significant lower eyelid laxity, aggressive carbon dioxide laser resurfacing should be avoided. Carcinomas should be dealt with prior to eyelid resurfacing.[20]

Skin types and degree of photodamage should be assessed using the Obagi or Fitzpatrick skin classification systems.[21] Carbon dioxide laser resurfacing is not recommended for Fitzpatrick phototypes IV-VI. Excessively thin or thick skin is a relative contraindication to this procedure. Paucity of adnexal structures is an idiopathic phenomenon, or it can be related to previous deep resurfacing procedures or radiation therapy.

If patients have a history of frequent vaginal candidal infections, they should be given a prophylactic course of oral antifungal medications.

Several prelaser regimens exist, including a combination of retinoic acid, hydroquinone, alpha-hydroxy acids, and sunblock.

Intraoperative Details

Laser tissue interaction

Carbon dioxide laser emits light at a wavelength of 10,600 nm, which is strongly absorbed by water (the primary chromophore for carbon dioxide light that is abundant in the skin).[22]

Although approximately 90% of the carbon dioxide laser energy is absorbed by the initial 20-30 µm of skin, traditional, continuous wave lasers leave a zone of thermal damage measuring 0.2-1 mm in thickness.

The theory of selective photothermolysis states selective heating of the target chromophore can be achieved when using laser pulses shorter than the thermal relaxation time (TRT) of the chromophore (the time that it takes the chromophore to lose 50% of its heat to the surrounding tissue). The TRT for 20-30 µm of skin tissue is about 1 millisecond.

By using the theory of selective photothermolysis, carbon dioxide lasers with a pulse duration of less than 1 millisecond are capable of selectively vaporizing tissue with only a very thin zone of residual thermal necrosis measuring about 100 µm.

To have a clinical effect in the skin, laser energy must be absorbed by the target chromophore.

It was determined that the energy fluence (density) necessary to vaporize tissue is approximately 5 joules/cm2 (ablation threshold). Overall, delivering a 1-millisecond carbon dioxide laser pulse with an energy fluence of approximately 5 joules/cm2 leads to tissue vaporization measuring 20-30 µm and residual thermal injury measuring 40-120 µm.

This zone of thermal necrosis is sufficient to seal small dermal blood vessels and lymphatics, yet narrow enough to reduce the incidence of scarring.

Laser technology and systems

See the list below:

Pulsed carbon dioxide laser
Scanning carbon dioxide laser
Pulsed Er:YAG laser
Fractional Er:YAG laser resurfacing
Combination carbon dioxide and Er:YAG lasers[23]

Two different types of carbon dioxide lasers are used for resurfacing.[14]

Pulsed carbon dioxide laser delivering approximately 500 millijoules of energy in each submillisecond pulse resulting in energy fluence measuring 5-7 joules/cm2. Some systems have computerized pattern generators (CPG) that can rapidly and precisely place individual laser pulses in several different patterns.

Scanning lasers use optomechanical flash scanners connected to a conventional, continuous wave, carbon dioxide laser. This scanner distributes the laser energy into a train of pulses with a dwell time shorter than skin TRT mimicking pulsed carbon dioxide lasers.

Carbon dioxide lasers with very short pulse duration (60 microseconds) ablate less tissue per pass and leave behind a narrower zone of thermal necrosis.

All of the above laser systems appear to be equally effective in skin resurfacing when they achieve similar depths of skin injury.

Follow-up

Close monitoring of patients during the postoperative period is essential to provide much-needed support and to detect any complications early in the course.[20]

Recovery is dependent on the depth of ablation. During the first week, patients experience variable degrees of oozing and crusting. Dressings should be applied until complete reepithelialization takes place; the patient can start applying a light water-based moisturizer for the next 2-3 weeks.

Postprocedure skin reconditioning should begin early during the healing process. Hydroquinone and retinoic acid can be reintroduced 3-4 weeks postoperatively. Alpha-hydroxy acids should be avoided until the stratum corneum is fully regenerated and skin tolerance has returned. Sunblock should be used once reepithelialization takes place.

Patients are evaluated at 2-3 days, 1 week, 3-4 weeks, 3 months, 6 months, and 1 year after resurfacing.

Complications

Similar to all other resurfacing modalities, the incidence of complications following carbon dioxide laser resurfacing primarily is related to the depth attained.

Expected sequelae commonly encountered after carbon dioxide laser resurfacing must be clearly differentiated from true complications. Sequelae include the following[24, 25, 26] :

Swelling

Post–resurfacing swelling is expected; it peaks at 48 hours. The edema usually subsides by the fifth day.

Intravenous betamethasone intraoperatively and a course of oral prednisone postoperatively for 5 days can significantly help in decreasing the swelling.

Erythema

Erythema, to some degree, is seen in all patients who had been resurfaced to the level of the upper dermis with carbon dioxide laser.[26] It is related to increased blood flow, collagen remodeling, inflammation, and increased metabolic activity.

Erythema is more obvious in patients with lighter skin complexion and patients with flushing or blushing tendency, such as acne rosacea.

While erythema usually is transient, it may persist for weeks to months but generally can be camouflaged with green- or yellow-tinted makeup.

Topical steroids should not be used to treat post–resurfacing erythema because they reduce collagen synthesis.

Carbon dioxide lasers that do not induce erythema have only produced superficial injury, and the procedure will not induce collagen remodeling.

The diffuse erythema of laser resurfacing should be differentiated from focal, itchy, palpable, or persistent erythema, which is a sign of a developing hypertrophic scar or keloid.

Itching (pruritus)

Although itching is common after laser resurfacing, it could signal infection, contact dermatitis, or early scarring.

In the absence of these conditions, pruritus responds to an oral antihistamine or midpotency topical steroid (eg, mometasone furoate 0.1%, Elocon, Schering).

Acne flare/milia

Milia and acne commonly are seen 2-4 weeks after carbon dioxide laser resurfacing and are partially related to the use of occlusive ointments.

Many of these patients are acne prone to start with, and they can be significantly improved with reintroducing retinoic acid and topical antibiotics to their post–resurfacing regimen.

Additionally, a 2- to 3-month course of oral antibiotics (eg, tetracycline, Achromycin V, Lederle Labs) or oral isotretinoin usually is very helpful.

Comedones and milia can be expressed manually using a comedo extractor.

Post–resurfacing hyperpigmentation

Hyperpigmentation after resurfacing is common, especially in patients with dark skin. Usually, it is seen in the first 14-21 days after the procedure and represents a postinflammatory hyperpigmentation phenomenon.

Preconditioning the skin prior to carbon dioxide resurfacing with retinoic acid and hydroquinone decreases the incidence, severity, and duration of the hyperpigmentation. Any resulting hyperpigmentation may be more amenable to therapy.

Aggressive post–resurfacing skin reconditioning using hydroquinone (2-4%) twice a day, retinoic acid (0.5-0.1%) every night at bedtime, sun protection, and sunscreen leads to resolution of this condition in 2-4 weeks.[27]

Infection (bacterial, viral, yeast, fungal)

A typical presentation would be a papulopustular eruption with itching or pain and delayed healing.

Sometimes, infection can present as maceration and necrotic tissue in a previously healed area.

Lesions should be cultured using the appropriate medium (viral, bacterial, fungal).

Appropriate topical and systemic medications should be started as soon as possible.[25]

Contact dermatitis

Irritant or allergic contact dermatitis may be secondary to topical antibiotics, moisturizers, or cleansers.

Dermatitis can be treated successfully with potent topical corticosteroids (eg, clobetasol propionate 0.05%, Temovate, Glaxo-Wellcome).

Systemic steroids rarely are needed.

Hypopigmentation (see the image below)

The occurrence of hypopigmentation relates to the depth of resurfacing and resultant thermal injury. It usually occurs in darker skin types and is seen 6-12 months after resurfacing.

Hypopigmentation can be avoided by the following: avoiding regional resurfacing (especially in darker individuals), limiting the resurfacing depth to the papillary dermis or upper reticular dermis, and stimulating the skin to regenerate pigment in the epidermis by recruiting the melanocytes in the adnexal structures, which can be attempted by using retinoic acid every night.

Depigmentation seen periorbitally, periorally, and on the forehead following carbon dioxide laser resurfacing.

Sharp demarcation lines can be avoided by the following:

Creating a transitional zone of resurfaced skin (ie, gradual depth change of resurfacing between the face and neck).
Combining full-face resurfacing with a light chemical peel, such as a 15-20% trichloroacetic acid peel (TCA) on the neck. This creates a less noticeable gradient zone between the face and neck.

Hypertrophic scars and keloids

Scar formation is strongly related to the following: depth of resurfacing, development of infection, and postoperative wound care. It is seen more commonly in nonfacial skin resurfacing.

Any localized persistent erythema with or without pruritus should be considered an evolving hypertrophic scar until proven otherwise.

Aggressive treatment with high potency topical steroids (eg, clobetasol propionate 0.05%, Temovate, Glaxo Wellcome), intralesional steroids (eg, triamcinolone acetonide 10 mg/mL, Aristocort, Fugisawa), 5-fluorouracil or verapamil, silicone gel sheeting and flash lamp, pulsed dye, and laser therapy are helpful.[28]

Ectropion, eyelid retraction, and lagophthalmos

Ectropion usually is related to aggressive carbon dioxide laser resurfacing of the lower eyelids, preexisting laxity of the lower lids, preexisting skin excision during blepharoplasty, or infection.

Ectropion can be avoided by testing the lid for laxity before resurfacing and by limiting the depth of resurfacing on the eyelids to the papillary dermis.

If ectropion develops, using eye lubricants, upward massaging of the lower eyelid, and prescribing a potent steroid cream can help reverse the malpositioned eyelid and prevent cicatrix formation.

In some cases of ectropion, surgery is necessary to restore normal eyelid position. Thermal eye injuries can be avoided by using the eye shields. Particular emphasis is placed on choosing the correct size and applying copious eye lubricants prior to inserting the metal shields.

Outcome and Prognosis

The results of laser resurfacing are good to excellent, depending on the indication for which the procedure was performed.[29] 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.[30] Typically, wrinkles are improved by 60-80%, while scars are improved to a lesser degree.

To best estimate the degree of improvement, results should be assessed at 6 months after resurfacing. Usually, some loss of early improvement and some recurrence of wrinkles can be seen as postoperative edema resolves. Repeat treatments are possible but should be spaced approximately 6 months apart.

Overall success in laser skin resurfacing is related to the following: proper patient and skin type selection; attention to preoperative, intraoperative, and postoperative details; aggressive management of emerging complications; and a good patient-physician relationship.

Future and Controversies

Combined resurfacing modalities

Realizing that different regions of the face display various degrees of skin damage, there is often a need 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, there is no need to subject the rest of the face to this same depth of resurfacing; 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 better and to prevent any lines of demarcation.

Newer resurfacing modalities

Three resurfacing modalities have emerged with claims of achieving faster healing and less potential for complications than carbon dioxide laser resurfacing.[31]

The erbium:YAG (Er:YAG) laser has a wavelength of 2940 nm and a pulse duration of 250-500 microseconds. Because of greater water absorption, the Er:YAG laser ablates less tissue per pass (approximately 4-5 µm) with a narrower zone of thermal necrosis (approximately 20-30 µm) than the carbon dioxide laser. The Er:YAG laser can neither induce the same collagen tightening nor impart the hemostasis commonly seen with carbon dioxide laser. It is most suitable for exfoliation (epidermis level) or papillary dermis-level resurfacing (pinpoint bleeding as an endpoint), and it may not be as effective when used to correct deeper wrinkles or scars.

The neodynium:YAG laser (Nd:YAG) 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). The coagulation necrosis in the papillary dermis leads to collagen contracture and subsequent neocollagenesis. This procedure is suited best for mild wrinkles. Multiple treatments are required over many weeks to achieve an optimal result.

Nonablative skin resurfacing modalities, such as the Fraxel SR laser (Reliant Technologies, Inc, Mountain View, Calif) and intense pulsed light (IPL) (Sciton Corp), are newer technologies offering few adverse effects.

Author

Adam J Cohen, MD Physician/CEO, Eyelid and Facial Plastic Surgery and MediSpa; Assistant Professor, Director of Oculoplastic and Reconstructive Surgery, Department of Ophthalmology, Rush University Medical Center

Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Triad Inc.<br/>Serve(d) as a speaker or a member of a speakers bureau for: Mimedx; InMode.

Coauthor(s)

Samer Alaiti, MD, RVT, RPVI, FACP Medical Director, Miracle Mile Medical Center for Dermatology and Cosmetic Surgery, Inc

Samer Alaiti, MD, RVT, RPVI, FACP is a member of the following medical societies: American Academy of Dermatology, American College of Phlebology, American College of Physicians-American Society of Internal Medicine, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery

Disclosure: Nothing to disclose.

Michael B Stevens, MD, PhD, FACS Private Practice

Michael B Stevens, MD, PhD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, California Medical Association, King County Medical Society, Lipoplasty Society of North America

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD † Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Stephen D Plager, MD

Stephen D Plager, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, California Medical Association

Disclosure: Nothing to disclose.

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