according to Brian S. Biesman, MD.
Dr. Brian Biesman
“When performing laser skin resurfacing, our goal is to match the degree of injury to the needs of the patient we’re treating,” Dr. Biesman, an oculofacial plastic surgeon who practices in Nashville, Tenn., said during a virtual course on laser and aesthetic skin therapy.
“If we’re treating a 35-year-old with minimal photoaging, we don’t need to use full-field resurfacing. By the same token, a 60-year-old who’s never had anything but sun exposure is not going to do well with nonablative fractional resurfacing or other modalities that produce only modest changes,” he noted. “Full ablative resurfacing is a useful tool that can be used to treat a variety of patients. We can tailor each treatment to the individual patient. We can simply dial the energy up or down and adjust the density.”
Full-field laser ablation removes the epidermis as well as a part of the dermis, and the degree of dermal injury varies depending on the relative aggressiveness of the treatment. “We can treat very superficially in the dermis or we can do deep dermal treatments,” he said at the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine.
“The residual thermal injury will vary to some degree, depending on our treatment parameters. It does cause immediate collagen contracture. It also stimulates a process of neocollagenesis.”
Two main lasers used for full-field treatments are the erbium:YAG laser and the CO2 laser at wavelengths of 2,940 nm and 10,600 nm, respectively. “The erbium:YAG is far more highly absorbed by water, by a factor of about 13,” he said. “But both of these wavelengths can be used successfully as long as you understand the physics behind them.”
The short-pulsed erbium:YAG laser ablates effectively, producing about a 10 mcm zone of thermal injury. “That’s not going to induce much by the way of remodeling, but it will be effective in removing tissue from the superficial layers of the skin,” said Dr. Biesman, who is a past president of the American Society for Laser Medicine and Surgery. “There’s also an absorption peak for collagen, so if you’re treating a scar, this laser can be highly effective.”
The CO2 laser creates more residual thermal injury during full-field resurfacing, compared with the short-pulsed erbium:YAG laser. The long-pulsed erbium:YAG laser can be used in both short- and long-pulsed modes and is more ablative than the CO2 laser when used in short-pulsed mode. When used in long-pulse mode, it makes it possible to produce results “very similar to CO2 in terms of the thermal injury profile,” he said. “It’s a versatile device. So, the CO2 in its native mode produces more thermal injury, while the erbium:YAG laser is more ablative. Both can be used effectively for facial skin rejuvenation.”
Full-field laser resurfacing requires local infiltration with lidocaine 1% or 2% with epinephrine or general anesthesia. “This is not a treatment that you can do comfortably under topical anesthesia, even if you’re using cold air unless you are doing treatments essentially confined to the epidermis and superficial dermis,” Dr. Biesman said. “When working around the eyes or on the face you need to use ocular protection with metal ocular shields. There’s no two ways about it. There is no scenario in which you’re doing an ablative resurfacing around the eye where you don’t use metal corneal shields.”
Energy and density levels can be fine-tuned in order to optimize treatment. For deep rhytides in the perioral region or on the forehead or lateral cheeks, clinicians may choose to treat at a higher density, while rhytides located in other areas may respond well to treatments at a lower density. Relative danger zones include the eyelids in general, especially the medial lower eyelid, as well as the upper lip. “These are the areas that are most prone to developing scarring,” he said.
For the upper eyelids, Dr. Biesman treats from the lashes to the upper brow. “It’s important to protect the lashes and treat from the lower-lid margin all the way down to the orbital rim. I debride relatively aggressively. I want to debride all the eschar created by the first pass and come back with a second pass. I sometimes will decrease the density on the second pass, depending on the type of tissue response that I see. If I see a dramatic response on the second pass I will definitely decrease the density.” He uses Aquaphor to protect the eyebrows. “It’s difficult to do that on the lashes. For the lashes, I usually use a wet tongue blade and keep the lid on stretch as I do my treatments.”
Dr. Biesman recommends feathering to blend full-field treatments with the neck. This means bringing treatments below the mandible. “There are times when we want to conservatively treat the neck,” he said. “The neck does not recover nearly as well after ablative resurfacing as the face does due to the fact that there’s probably about 90% fewer sebaceous glands and hair follicles in the neck relative to the face.”
In Dr. Biesman’s opinion, the important perioperative preparation is counseling the patient, including setting realistic expectations and devising a plan for wound care. “They can expect 7-10 days to heal, depending on the area we’re treating and the relative aggressiveness of the planned treatment,” he said. For patients with a history of herpes simplex virus type 1, he recommends antiviral treatment prior to the procedure. “If you do encounter a herpetic infection postoperatively, you may not see typical clinical signs of blistering as the epidermis has been removed.”
Dr. Biesman uses both antiviral and antibiotic prophylaxis prior to full-field treatments. “The literature by and large says that antibiotic/antiviral prophylaxis is not required prior to full-face ablation,” he said. “The reason I choose to is that I have had some issues with community-acquired MRSA infections. Because it’s so ubiquitous these days, I typically do prescribe an agent that gives good MRSA coverage.”
As for wound care, the literature differs on open versus closed techniques. Dr. Biesman favors using Aquaphor for the first week or so and seeing patients back on posttreatment day 2, “who by that time are usually beyond the inflammatory phase of wound healing,” he said. “A lot of the initial oozing has stopped by then. We clean that off any dried exudate in the office very carefully. We debride gently with warm-water soaks and I like to use PRP [platelet-rich plasma]. There is literature to support the role of PRP in wound healing.”
Even in the most experienced hands, complications can occur from full-field laser resurfacing, including bacterial, viral, or fungal infections. Other potential complications include persistent erythema, hypopigmentation, hyperpigmentation, scarring, and ectropion. “Knowledge of treatment parameters, endpoints, and wound healing is required for safe and successful outcomes,” Dr. Biesman said.
He reported having no relevant disclosures related to his presentation.