Laser Resurfacing: Safety and Technique

INTRODUCTION

The use of laser resurfacing in facial rejuvenation is expanding. Ablative lasers, including erbium:yttrium-aluminum-garnet (Erbium:YAG) and carbon dioxide (CO₂) devices, smooth skin by inducing dermal remodeling (Scheuer et al¹). Erbium:YAG lasers (wavelength 2940) can impart less dermal injury and have less potential for hypopigmentation than CO₂ laser devices when used in the ablation mode, in the authors' experience, which additionally favors faster healing.^2,3 In an attempt to mitigate thermal injury, fractional CO₂ lasers have been developed. These deliver microcolumns of energy, leaving an unaffected tissue scaffold with intact dermal vasculature.¹ By default, however, fractional CO₂ lasers leave areas of untreated, aged skin. Erbium lasers allow for complete ablative resurfacing with limited unintended dermal injury.

PREOPERATIVE PREPARATION

Erbium laser resurfacing is best suited for patients with Fitzpatrick I and II skin types. Patients apply topical tretinoin 2–3 times per week for 4–6 weeks and stop 7 days before laser treatment. A 1-week course of acyclovir 500 mg 4 times daily is started 1 day before the procedure. (See Video 1 [online], which displays preoperative facial analysis.)

Video 1. Pre-operative facial analysis. Video 1 from “Laser Resurfacing: Safety and Technique”.

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SAFETY CONSIDERATIONS

Safety against thermal injury, and potentially fire, is paramount. Eye protection for the patient and all operating room personnel is required. The patient’s eye protection should be made of metal to prevent corneal injury.⁴

General anesthetic should be induced with a laser-safe endotracheal tube, and, if this is not accessible, the endotracheal tube should be wrapped with moist gauze or aluminum foil.⁴ Supplemental oxygen (fraction of inspired oxygen >21%) should be avoided during laser use, and, if it is required, oxygen should be stopped 1 minute before treatment. Moist towels should be placed at the periphery of the treatment area to reduce the risk of drape ignition. (See Video 2 [online], which displays safety measures and laser settings.)

Video 2. Safety measures and laser settings. Video 2 from “Laser Resurfacing: Safety and Technique”.

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TECHNIQUE

The face is prepared using betadine. Profile dual-mode Erbium:YAG laser (Sciton, Inc., Palo Alto, Calif.) is set to an ablative depth of 100 microns. The treatment is performed using a systematic approach with 2 passes and 50% overlap in each facial zone.¹ (See Video 1 [online], which displays preoperative facial analysis.) “Paprika” bleeding represents injury to the papillary dermis and indicates treatment endpoint. Blending along the mandibular border is achieved by passing the laser at an oblique angle.¹ Areas with deeper rhytides, namely perioral and forehead, may warrant a third pass. (See Video 3 [online], which displays the Erbium:YAG laser technique.)

Video 3. Erbium:YAG laser technique. Video 3 from “Laser Resurfacing: Safety and Technique”.

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POSTOPERATIVE CARE

Immediately following laser treatment, Stratamed (Stratpharma AG, Basel, Switzerland), a silicone-based ointment, is applied and continued for 24 hours. This is followed by Alastin (ALASTIN Skincare, Carlsbad, Calif.) application, which facilitates wound healing and is reapplied daily for 7 days. Patients are discharged home but have frequent follow-up monitoring for potential, albeit rare, complications including hyper/hypopigmentation, skin necrosis, skin sloughing, prolonged erythema, and infection.¹ Methylprednisolone taper and cephalexin 500 mg 4 times daily for 4 doses are started on postoperative day 1. (See Video 4 [online], which details postoperative care).

Video 4. Post-operative care. Video 4 from “Laser Resurfacing: Safety and Technique”.

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