Laser Skin Resurfacing

Qualitative aging changes to the face occur with the cumulative effects of ultraviolet light from the sun. This results in the development of wrinkles due to a loss of elasticity in the skin. Wrinkles most commonly occur at right angles to muscle contraction forces but can also be seen to occur in areas of chronic folding, as in creases that occur due to sleeping in a certain position chronically over a long period of time. Surgical procedures which are highly successful at correcting quantitative aging changes such as puffy eyelid fat, sagging neck skin and the like, are not nearly as effective at correcting skin wrinkles, or qualitative aging changes. By the same token, laser resurfacing is no substitute for facial aesthetic surgery - the two types of treatment are mutually exclusive.

Controlled burning of the skin has been used for decades to smooth the skin. By removing the outer layer of the skin (epidermis) and the superficial layer of the deep layer of the skin (dermis), and allowing the skin to heal from the deeper skin appendages such as the hair follicles and sweat glands, the appearance of the skin is smoothed and a varying degree of improvement in the texture, pigmentation, and tightness of the skin is obtained. This has been historically done using the methods of dermabrasion (sanding), salabrasion (salt abrasion), and chemical peeling (with various acids, or a phenol mixture). These methods, though often effective, lack the degree of control with regard to the depth of penetration of the desired burn, and are often exceedingly painful. Because of the lack of control over the depth of the peel, the risk of complications, specifically scarring, is not insignificant (though in very experienced hands is usually very safe).

The introduction of the carbon dioxide ultrapulse laser for use in skin resurfacing in the early 1990's brought a significant diminution in the degree of variability of depth of penetration in the skin and thus brought down the degree of physician experience, the degree of risk, and the level of pain of skin resurfacing. This is not to say that no experience with use of the laser is necessary, but without question laser resurfacing is a superior modality for smoothing skin wrinkles than anything previously available. Dramatic results are achievable with the laser in the properly chosen, properly prepared, properly treated patient. Two dominant types of lasers exist, the CO2 (Carbon dioxide) Ultrapulse Laser, and the Erbium Laser. The CO2 is used for most wrinkle treatment; but the Erbium Laser is used for milder degrees of wrinkling, as it penetrates the skin to a lesser extent. In general, the degree of smoothing of a wrinkle is directly proportional to the depth of tissue removed. Dr. Creasman will suggest the appropriate type of treatment after he examines your skin and takes your medical history.

Laser resurfacing is not for all types of skin, for all ages, nor is it suitable in terms of the length of recovery for all lifestyles. It is not risk-free, but the risks are acceptably low to justify its use for the treatment of skin wrinkling in selected instances.

The Consultation :

Dr. Creasman will take a medical history and do a directed physical examination of your skin and other facial features during your visit. This will involve identifying functional issues as well as cosmetic issues of concern to you. It is important for you to provide us with any history of skin sensitivity, previous skin peels or laser peels, history of acne particularly if you have been treated with the acne drug ACCUTANE. You should inform the doctor or any history of cold sore problems that you have had. If you have skin that is olive or darker in color, this is not a procedure that you should consider because there is a significantly higher risk of pigmentary changes (darkening or bleaching of the skin) following laser resurfacing.

After examining you skin and discussing your current skin care regime, Dr. Creasman will generally want to discuss your surgical options with you and may make use of computer imaging, which can demonstrate for you the changes brought about with laser resurfacing. He will obtain digital images of your face that he can then manipulate to show an educated estimate of what might be achievable with the particular laser treatment he recommends. Though this is not to be implied as a warranty of the surgical result, it does provide a visual communication aid both for you to give feedback, and for him to convey to you the limitations of what can be done, as well as the possibilities of laser resurfacing. Though it is important and often reassuring to view any doctor's work with other patients, it is equally important to see how one actually looks with the skin smoothed to the degree achievable, rather than just leaving it to the verbalization of the surgeon while looking in a mirror.

It is not uncommon that adjunctive procedures are performed prior to resurfacing, such as a browlift, eyelid surgery (blepharoplasty), or a facelift. You may wish to visit those sections of the website prior to your consultation to familiarize yourself with the effects achieved with these procedures. If Dr. Creasman feels that you would benefit from another procedure other than the laser resurfacing, he will tell you during the consultation as part of a comprehensive facial esthetic evaluation. Laser resurfacing cannot be done safely at the same time as a facelift is performed. The doctor prefers to wait at least 3 months between a facelift and laser resurfacing.

It is very important for you to consider whether your particular aging is quantitative or qualitative, as the treatment of each is different.

Risks of Laser Resurfacing:

Complications of laser resurfacing are infrequent and usually minor. Nevertheless, there is always a possibility of complications, including infection, which can be from viral, bacterial or even fungal organisms. For this reason, Dr. Creasman places you on both an anti-viral and an antibiotic prior to the procedure. Skin infection can potentially lead to visible permanent scarring, which is a risk of laser resurfacing. The procedure is done under a general anesthetic to achieve the best results, and rarely patients have a reaction to the anesthetic medications. There is a period of 7-14 days required for complete healing of the skin. In that interim, there is swelling, pain, weeping, and redness. This can be dramatic and disturbing to the uninformed. There is a variable period of redness after healing that can last from weeks to months, that may require camouflage makeup for concealment. Exposure to the sun must be avoided for at least one year because the skin is far more sensitive to the effects of the sun after the procedure. There is the possibility that the skin will darken with activation of the pigment cells in the deeper layers of the epidermis. For this reason, Dr. Creasman prepares his patients with a bleaching agent to suppress the tendency of the pigment cells to respond to the stimulus of the laser light. In most patients, some degree of bleaching occurs, which is usually advantageous. The overall pigmentation is usually made more consistent than the untreated skin, which usually shows variegation in the pigmentation. For this reason, Dr. Creasman always suggests a full face treatment if one is a candidate for the procedure, as this avoids pigmentary lines of demarcation within the aesthetic unit of the face. One can usually expect anywhere from a 50 - 70% improvement in the appearance of facial wrinkles, when evaluated at one year. Early results can be more dramatic than results evaluated at one year. Secondary laser resurfacing is sometimes necessary for staged treatment of very deep wrinkles.

Complications of laser resurfacing are infrequent and usually minor. Nevertheless, there is always a possibility of complications, including infection, which can be from viral, bacterial or even fungal organisms. For this reason, Dr. Creasman places you on both an anti-viral and an antibiotic prior to the procedure. Skin infection can potentially lead to visible permanent scarring, which is a risk of laser resurfacing. The procedure is done under a general anesthetic to achieve the best results, and rarely patients have a reaction to the anesthetic medications. There is a period of 7-14 days required for complete healing of the skin. In that interim, there is swelling, pain, weeping, and redness. This can be dramatic and disturbing to the uninformed. There is a variable period of redness after healing that can last from weeks to months, that may require camouflage makeup for concealment. Exposure to the sun must be avoided for at least one year because the skin is far more sensitive to the effects of the sun after the procedure. There is the possibility that the skin will darken with activation of the pigment cells in the deeper layers of the epidermis. For this reason, Dr. Creasman prepares his patients with a bleaching agent to suppress the tendency of the pigment cells to respond to the stimulus of the laser light. In most patients, some degree of bleaching occurs, which is usually advantageous. The overall pigmentation is usually made more consistent than the untreated skin, which usually shows variegation in the pigmentation. For this reason, Dr. Creasman always suggests a full face treatment if one is a candidate for the procedure, as this avoids pigmentary lines of demarcation within the aesthetic unit of the face. One can usually expect anywhere from a 50 - 70% improvement in the appearance of facial wrinkles, when evaluated at one year. Early results can be more dramatic than results evaluated at one year. Secondary laser resurfacing is sometimes necessary for staged treatment of very deep wrinkles.

It is imperative that patients refrain from ingesting any medications or other substances that could potentially be the cause of surgical complications. A list of medications should be reviewed and discontinued at least two weeks prior to operation. PATIENTS SHOULD NOT UNDERGO LASER RESURFACING IF THEY HAVE INGESTED THE ACNE DRUG ACCUTANE WITHIN 18 MONTHS PRIOR TO THE PROCEDURE. Patients are seen just prior to their surgery date for a general physical examination to ensure that no underlying medical problems exist that may interfere with the safety of their surgery. Specifically, any infections that arise prior to operation, however seemingly trivial, should be reported to our office. Even an otherwise innocent infection can result in a surgical wound infection, and must be treated prior to surgery. IT IS IMPORTANT THAT YOU REPORT ANY OUTBREAKS OF COLD SORES.

Prophylactic antibiotics are prescribed prior to and for a few days after surgery to reduce the risk of surgical wound infection. An antiviral medication is started prior to the procedure as well. For 2-4 weeks prior to treatment with the Ultrapulse CO2 laser, patients are placed on a skin prep using Retin-A and a bleaching cream. This is not necessary if the doctor is using the Erbium laser. A prescription for pain medication is also written, so that you have your pain pills when you return home from the procedure.

Pre-operative photographs are taken so that you can see the improvement from your surgery afterwards. We generally take post-operative photographs at 3 - 6 months after your procedure.

You will be asked to sign a surgical consent, which enumerates the risks of the procedure in detail. These risks are explained herein and also at the consultation.

The current fee for laser resurfacing can be obtained by calling our office (408-369-9300), and includes surgeon, operating room, anesthesia, and follow-up care. There may be additional charges for prescription medications before and after the procedure.

You will need to arrange for an escort to drive you to and from our office operating suite. Patients cannot operate motor vehicles after surgery, and we will not place recently sedated patients into a taxi for transport home. We can arrange for medical transportation in the event that you cannot find an escort. It is mandatory to have someone stay with you for at least 24 hours after surgery, for your comfort and safety.

The Operation :

The overwhelming majority of Dr. Creasman's resurfacing procedures are performed under a general anesthetic. Patients are completely unconscious during the procedure, and an anesthesiologist is responsible for administering the anesthetic. Though the resurfacing can be done under a local anesthetic with sedation, the injection of the local anesthetic results in swelling of the tissues that interferes with the ability to gauge the location and severity of the wrinkles during the procedure.

The procedure usually takes one to one and a half hours. After the skin is prepared with a surgical prep solution, the appropriate settings are dialed into the laser equipment by a technician at the direction of Dr. Creasman. Dr. Creasman performs the procedure in its entirety. Specialized contact lens type eye shields are placed over your corneas for your protection throughout the procedure. Your teeth are also protected against inadvertent injury. A long-acting local anesthetic is injected selectively to block the major sensory nerves of your face for pain control after the procedure.

The skin is "painted" with the laser beam in small square patterns generated by a computer. The first "pass" removes the superficial layer of skin (epidermis). Any heat generated in the vaporization of the skin cells is dissipated in a smoke plume; heat is not absorbed to any significant extent because the laser beam is "pulsed" at a rate such that heat buildup is avoided. Subsequent passes are done to sculpt the underlying dermal layers, where the wrinkles really exist. The endpoint of treatment is determined by Dr. Creasman based on the color of the treated area as well as the contour. There may be small pinpoint bleeding, but this is usually minimal. At the conclusion of the treatment, an occlusive dressing is applied to all treated areas. The dressing completely covers your face, except small openings for your eyes, nose, and mouth. You are awakened from the general anesthetic and monitored in the recovery area for approximately one hour until you are ready to be discharged.

The Recovery Period:

For two to three days, you are left in the occlusive dressing, which provides a bacterial barrier as well as comfort. There is a normal response to removal of the outer layer of skin that involves the outpouring of fluid from the skin as it heals from the deeper structures such as the hair follicles. This fluid has a high protein content and can coagulate on the skin, creating crusting. Crusts tend to slow down the re-epithelialization process, can get infected, and can result in deeper degrees of injury than intended; in general, it is best to avoid crusting to the extent possible. This is done by frequent cleansing of the face and application of a hypoallergenic ointment until the skin forms a protective new layer of epidermis. IT IS IMPORTANT THAT YOU NOT PICK AT ANY CRUSTS THAT DO FORM. THIS CAN LEAD TO PERMANENT SCARRING.

You are seen on a frequent basis by Dr. Creasman to monitor your healing progress. This period of the recovery is often quite disturbing, because there is a significant degree of distortion of the face due to swelling, weeping, crusting, and minute amounts of bleeding. Patients report a much higher degree of anxiety during this period than during a comparable period of surgical healing (following a facelift, for example), but within a week or so much of the healing has occurred and the swelling has nearly subsided. It generally takes about ten days to two weeks to begin to see the benefits from the procedure, as they occur with the resurfacing, which your body needs time to do. The laser creates the injury; the benefit comes with the healing of that injury.

Healing by re-epithelialization is an inflammatory process. The skin is stimulated to form new blood vessels, and blood flow to the skin is increased; thus, the face turns red. The intensity of this redness varies between patients, as does the length of time it takes for it to subside. At a minimum, the redness lasts 2 weeks, but it can last 3 or more months in some patients and require camouflage makeup to conceal it. This can appear like a sunburn, or even a deeper shade of red or even maroon color, though this is unusual. Steroid lotion is used during this intense period of redness to suppress the inflammation, as is sunscreen. Sun exposure during this period can lead to deep sunburns and skin damage, and is to be avoided at least until the skin has returned to its normal color.

Transient hyperpigmentation (skin darkening), as mentioned in the section above on risks, can occur but almost always resolves itself over time. Hypopigmentation (skin lightening), on the other hand is universal to one degree or another. It may take months to appreciate how much lighter the skin is, because of the redness during the early recovery period. Dr. Creasman advises you initiate or return to a maintenance skin care program approximately six weeks following your resurfacing procedure. It is extremely important that you adopt an aversion to the sun; after all, it is the effects of ultraviolet light that create the wrinkles in the first place! SPF 15 sunscreen is recommended 365 days a year for life.