This next article in the series of “Trends in Oculoplastic Surgery” will follow the non-surgical discussion and focus on laser resurfacing devices. This is an area of oculoplastic surgery that is constantly changing as new innovations arise. These devices aim to rejuvenate the skin by decreasing wrinkles and improving the tone of the skin, but can also be used for reduction of scar tissue and contractures.
Know Your Lasers
Lasers that resurface the skin have been around since the 1980’s and include CO2 and erbium lasers, which were traditionally fully ablative. These lasers fall on the infrared spectrum of the wavelength curve where water is the main chromophore.
The pulse and single-pass CO2 and Er:YAG lasers effectively rejuvenate the facial skin, but were associated with a long recovery time and significant side effects, such as hyperpigmentation, hypopigmentation, dermatitis and infection.
To avoid these issues, non-ablative lasers were created between 2003 and 2005. These lasers create columns of thermal heating called microscopic treatment zones (MTZs) and keep the stratum corneum intact. The surrounding uninjured tissue promotes migration of keratinocytes, promoting quicker healing and reducing adverse effects. The downtime is minimal with only mild erythema post-procedure, but efficacy is limited.
To bridge the gap between fully ablative and fractional non-ablative lasers, fractional ablative lasers were developed. These lasers provided good results with low downtime and low risks. Wavelengths included 10,600nm (CO2), 2940nm (Er:YAG), and 2790nm (YSGG). Fractional ablative lasers vaporize the epidermis and create channels that ablate down into the dermis, creating thermal injury and dermal remodeling through stimulation of collagen.
CO2 lasers extend to greater dermal depths. They create more tissue contraction and thermally induced dermal coagulation. Erbium lasers have the highest affinity for water and are absorbed 12 to 18 times more efficiently by water containing cutaneous tissue than CO2. The majority of the energy is taken up by heating water so there is less scatter and nonspecific heating. They create less thermal necrosis than CO2, but result in less hypopigmentation and less recovery time. Erbium is less effective in coagulating dermal capillaries, so there is a bit more bleeding involved during these procedures.
Other lasers close to the erbium wavelength include 2790 nm (YSGG) and 2780nm. These lasers have half the water absorption coefficient as erbium so create more thermal damage.
Laser Resurfacing Prep
Laser resurfacing is indicated for the treatment of wrinkles and photoaging and can be effective in blending scars. Contraindications include pregnancy, isotretinoin use in the previous year, infectious disease, connective tissue disease, immunocompromised patients and any medical condition that may affect wound healing.
It is important before any device use to consult thoroughly with the patient and discuss goals of treatment. Get a medical history and skin type the patient. Have the patient avoid direct sunlight for seven days prior to treatment. Obtain photographs and set the patient’s expectations.
For ablative lasers, have the patient start antiviral medication one day prior to treatment and continue for five days after. Antivirals can include acyclovir, valacyclovir, and famciclovir.
Ideally patients should stop blood thinners two weeks prior to the procedure to minimize bleeding. If the patient is a darker skin type, consider pre and post treating with tyrosinase inhibitors to help prevent pigmentation problems. Anesthesia should be applied topically and can also be given through the IV for sedation. Rarely people use tumescent anesthesia or nerve blocks. Before treatment, choose the appropriate goggles for the patient and everyone else in the room.
If the procedure is going to be performed on the eyelid proper, it may be best to use corneal shields, as long as there is not contraindication, such as recent trauma or surgery on the cornea. Corneal shields come in stainless steel or methylmethacrylate. Steel can be gas or steam autoclaved and are buffed and electropolished so won’t conduct heat. Plastic (methylmethacrylate) shields can be gas autoclaved, but there is a small risk of thermal conduction if the laser beam comes into contact with the shield. If only resurfacing on the face, external shields can be used.
For the provider and everyone else in the room, choose the goggles based on which wavelength the eyewear protects against. This wavelength will be printed or engraved on the glasses and will have the optical density, which indicates the protective properties of the eyewear.
During & Post-Procedure
Treatment areas with adnexal structures (pilosebaceous units and sweat glands) have greater success because there is a reservoir of epithelial cells that migrate to form new epidermis. This is the reason why patients on isotretinoin should not be treated with laser.
Choose settings depending on what needs to be treated. For deeper lines and wrinkles, energy settings and depth may need to be increased. Take caution when treating off the face, such as on the neck, chest, arms and hands. Also, if treating the lower lids, take note of whether the patient has pre-existing lower lid laxity because significant contraction of the skin can cause ectropion
If using ablative laser, a smoke evacuator should be used in addition to a Zimmer cooler because the thermal destruction of tissue creates a smoke by-product with toxic gases and vapors, dead and live cells, blood fragments and even viruses. If not evacuated, this plume can cause ocular and upper respiratory irritation, which can carry a mutagenic potential.
After the procedure, cold compresses can help minimize discomfort. Patients should expect to have burning, erythema, edema, some oozing and crusting if ablative. Have the patient avoid sun exposure for seven to 10 days. After an ablative procedure, a bland ointment, such as Vaseline, should be applied, as wounds heal more quickly in a moist environment. Also, vinegar soaks help as an antiseptic and debriding agent. Vinegar is effective against pseudomonas and gram negative bacteria. Mix one teaspoon of vinegar with one pint of water to form ¼ percent of acetic acid.
It is extremely important to have a helpful, knowledgeable and available staff to take calls in case patients have concerns. Patients can resume skin care and makeup after full epithelialization, but should avoid any topical products during the healing phase to avoid a contact dermatitis.
One of the more recent advances in laser technology is the use for scar revision. These lasers can be combined with topical medications, such as 5 Fluorouracil and triamcinolone to prevent fibrosis and poly-l-lactic acid to promote neocollagenesis, all of which can improve contractures, burn scars, surgical scars and acne scars.