Laser Skin Resurfacing (LSR)
In 1964 an exciting step was taken in skin rejuvenation. The carbon dioxide laser became available for treating skin damage, acne scars, and the wrinkles and discolorations of aging and sun exposure. It very quickly became popular with dermatologists.
Laser Skin Resurfacing (LSR)
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One of the problems in the early days of laser skin treatments was the high rate of scar formation. But modern procedures have all but eliminated this risk, after the fruitful testing and experimenting of the past 40 or so years.
Now we have many choices for improving our skin. Laser resurfacing can:
- Tighten and smooth the eyelid skin
- Reduce crow’s feet
- Reduce and flatten scars
- Reduce or remove keloid and hypertrophic scars (raised and red scars)
- Smooth frown lines and fine wrinkles on the cheeks and upper lip
- Remove warts and skin cancers
- Remove vascular lesions such as hemangiomas (little benign tumors made of blood vessels) and capillary malformations (e.g., port wine stains)
- Remove pigmented lesions such as freckles and birthmarks
- Treat rhinophyma (enlarged oil glands on the nose)
Laser resurfacing is also known as lasabrasion, laser vaporization, and laser peel. It can make you look ten or even twenty years younger, and last for about ten years. We continue to age, but laser skin resurfacing can certainly set the clock back effectively.
Other resurfacing treatments
There have been other ways of improving our skin’s appearance and texture, such as dermabrasion and chemical peels. These treatments use the same property of skin that laser treatments use, which is that:
When the skin surface is scuffed off or removed somehow, the skin will react
by growing new, tighter cells, and these cells will rise to the top
skin layer that we see, giving a new, more youthful look.
See "Structure of our Skin" below.
However, dermabrasion and chemical peels are less precise treatments than laser resurfacing, and have become less popular as laser treatments have gained in popularity. A laser’s depth of penetration can be very precisely controlled, which makes the treatment more customized and more predictable compared to dermabrasion and chemical peels.
What is a laser?
Although we use laser as a word now, it was originally the acronym for Light Amplification by Stimulated Emission of Radiation.
Quick view of how lasers are made.
All lasers are man-made lights, each made for a specific purpose. They’re made such that their light is emitted in an organized fashion, rather than randomly as happens in ordinary lights. A classroom or pocket laser pointer illustrates this well.
To make a laser, basically, you need an optical cavity containing two mirrors, with a “lasing medium” in between. Lasers are classified according to what sort of lasing medium they require. A lasing medium can be:
- A gas – as in the CO2 laser used for skin resurfacing, or argon or krypton. It can also be a mix of gases, such as the mixture of active and inert gases used to make excimer lasers.
- Something in a “solid state” – such as ruby, which creates a ruby laser, or neodymium:yttrium-aluminium-garnet which makes the Nd:YAG laser often used for skin rejuvenation.
- A liquid – such as a dye, which is used to make the pulsed dye lasers, also popular for skin rejuvenation.
When the electrons in this lasing medium are first stimulated and then allowed to relax, they release light photons of a specific vibration, much the way a stove hotplate glows red when it’s hot.
One of the mirrors reflects light towards the second mirror, and the second one reflects, but also allows some light to pass through it, and this light is the laser beam. Each lasing medium produces a laser of a specific wavelength, that is, of a specific color. They can be visible colors, infrared (higher wavelength than red) or ultraviolet (lower wavelength than violet).
Characteristics of a laser.
Lasers all have some features in common that distinguish them from other sorts of lights and make them so effective in skin rejuvenation:
- Lasers are directional – they focus very exactly and powerfully, unlike incandescent bulbs or automobile headlights, which send their light waves out in a scattered fashion. Lasers can focus on a point too small for us to see, and this is what gives them microscopic precision.
- Lasers are monochromatic – they contain only one color, unlike our familiar white light which contains all colors. They can also be outside our range of visible colors, as with infrared and ultraviolet lasers. Having only one vibration level, lasers are powerful, as their light moves in unison, in organized waves.
All lasers release some heat, but the amount varies in a wide spectrum, from hot lasers that can cut through a block of steel by melting it, to cool ultraviolet lasers. In skin treatment, if necessary, this heat can be suctioned away, or cooled in various ways so that we don’t feel it.
Structure of our skin
Our skin is our largest organ. It has several crucial functions, as it protects us from the elements, prevents fluid loss, and with the help of the sun, creates vitamin D, essential for strong bones. It also helps keep our body temperature steady.
Three layers of the skin.
The epidermis – the top layer, which has 5 sub-layers. In the lowest of these, cells are constantly dividing and moving upwards to the next layers. As they progress, they flatten and acquire more keratin (a protein, also found in our hair), which helps to strengthen them. They also contain melanin, a pigment which gives us our individual skin color. When they reach the top level, they die and are sloughed off. Ablative resurfacing lasers remove the entire epidermis.
The dermis – the middle layer, where the proteins exist which make our skin strong and elastic. In this layer too are the hair follicles, tiny muscles, veins and arteries, oil and sweat glands, and nerve endings. The upper part of the dermis is known as the papillary dermis, and this is targeted by the non-ablative lasers.
The hypodermis – the lowest layer, containing fat for insulation and as part of the energy we store in fat. There are also larger blood vessels here, more nerves and hair follicles, and the roots of the oil (sebaceous) glands. No resurfacing laser penetrates to this depth.
Collagen and Elastin
Collagen is a tough, fibrous protein that’s the main part of our bones, and of connective tissue, e.g., tendons, ligaments, and cartilage, and a big ingredient in skin. Our skin is continually regenerating itself, and when collagen gets too old, new collagen is formed.
It’s collagen that contributes most to the strength of our skin. As we age, collagen gradually degrades, even the newly-formed collagen.
Elastin is the protein, also in the dermis, which allows our skin to stretch. Collagen and elastin form a network with each other, and as we age, their network loosens and disconnects in places. This creates tiny sunken areas on the skin that we call fine lines or wrinkles.
Two types of lasers for skin resurfacing
Ablative – these lasers ablate (remove) the top layer of the skin (the epidermis) and heat the next layer down, the papillary dermis. This stimulates our skin to re-grow, to heal itself, and in that process it becomes more smooth and even.
Non-ablative – these lasers bypass the top layer of skin, leaving it intact, and treat the papillary dermis beneath. Again, this stimulates the skin to heal itself by re-growing, becoming smoother. Healing time is short, as the top layer of skin isn’t affected.
How lasers work on skin
Lasers work on a microscopic level, which is possible because of how very precisely they can focus. Your surgeon can control exactly how deeply the laser will penetrate the skin, and can adjust that depth as needed. The laser beams are applied to the skin in a series of passes over the treated area, planned according to your specific needs, and the properties of the specific laser used. An experienced plastic surgeon will make the right number of passes in the exact right areas, so that there’ll be no border line showing where treatment stopped.
The goal is to destroy the targeted cells (those of the discoloration, wart, wrinkle etc.) without hurting the surrounding skin, and thus to stimulate the skin to replace the destroyed cells with new, tighter cells.
Three kinds of ablative lasers used for skin resurfacing
Carbon dioxide (CO2) – which is infrared and pulsed, and removes more tissue per pass than the Er:YAG laser. It’s named for its lasing medium, carbon dioxide, which makes it a gas laser.
Erbium:YAG (Er:YAG) – which is also pulsed, but a lower wavelength than the CO2 laser, and removes less tissue per pass. It was first used in the U.S. in 1996 for cutting bones Erbium is an element that was first discovered in Sweden, along with another element called yttrium. YAG stands for yttrium-aluminum-garnet, which is the lasing medium of this laser. It’s a solid-state laser.
The long-pulsed erbium:YAG – which is a variation on the above er:YAG laser, manufactured for medical use such that it’s pulses are longer, about 10 milliseconds, as opposed to less than one millisecond. It’s used for treating large, deeply seated scars.
How ablative lasers work
An ablative laser used to modify human tissue, whether it’s skin, gum tissue, tooth enamel, the cornea of the eye, or any other kind of tissue, basically does it by evaporating microscopic amounts of tissue according to the doctor’s treatment plan and knowledge of how to direct the laser. Human tissue contains a lot of water and the directed laser selectively evaporates the water, along with the cells containing it.
Ablative lasers remove wrinkles by removing the surface layer where they’re visible, including the skin around each wrinkle. This removes both the raised edges of the wrinkle and its sunken interior part. Since the laser seals off the remaining tissue, it minimizes or eliminates any bleeding.
The skin’s response
In response to this removal of part of itself, the skin tightens up the collagen it still has in the papillary dermis. These tightened forms are then the templates from which new collagen is made. Elastin is also replaced with a tighter form, so together the collagen and elastin can form a new network that’s more organized and in a parallel configuration. This leads to the smoother, more youthful appearance of the skin.
Immediately afterwards, there’ll be some redness, tenderness and swelling, and there’ll be a couple of weeks’ recovery period while the skin regrows. This is a longer recovery period than required after treatment by a non-ablative laser.
The pulsed CO2 laser.
The product name is UltraPulse CO2 Laser. This laser light is absorbed by the water that’s in and between the cells in our skin. The surgeon will apply it in several passes over the treated area, removing a little less tissue with each successive pass.
Since the CO2 laser can cause some burning if not properly controlled, exposure to the laser has to be very short, and it’s been found that a pulse of less than one millisecond does the best job of:
- Evaporating tissue;
- Sealing the remaining tissue; and
- Not damaging any neighboring tissue.
In between each millisecond there’s a pause long enough for the skin to cool down before it’s treated again. This is what’s meant by a “pulsed” laser.
The CO2 laser does well with fine and moderate wrinkles, acne scars, some other scars caused by surgery or an accident, sun damage, enlarged oil glands, baggy eyelids, and other specific skin conditions. It’s seldom used for resurfacing the neck or hands, as there’s a greater risk of scarring on these areas. Recovery time is usually a couple of weeks.
The pulsed er:YAG laser
This laser is often used in combination with the CO2 laser. It works more superficially and its beam is absorbed directly by collagen and other proteins in the skin, rather than by the water in and between cells. This type of absorption is more efficient than that of the CO2 laser. Since those proteins contain water, the laser heat is absorbed easily and doesn’t damage our skin.
When the Er:YAG laser is used after the CO2 laser, any small burns are reduced, and healing is speeded up. Because it has a more delicate touch than the CO2 laser, it’s preferred for treatment of skin around the eyes, and for resurfacing the skin on our hands and neck.
When the Er:YAG laser is used, you’ll hear a popping sound. Why? When the laser’s energy is absorbed by the skin proteins, those proteins are immediately desiccated, or dried; in fact they’re cooked, and are instantly ejected from the skin at a supersonic speed. This creates the popping sounds, like miniature sonic booms. These amounts of skin tissue are so minute, and the laser’s penetration of the skin is so shallow that no harm is caused. The recovery period is typically 5 to 7 days.
The long-pulsed erbium:YAG laser
This laser was developed to be an intermediate treatment between the CO2 Laser and the pulsed er:YAG laser. It’s effective for facial redness, broken capillaries, and vascular lesions such as hemangiomas.
Both the CO2 laser and the er:YAG laser have been effective for treating keloid and hypertrophic scars, which are famously difficult to treat. Their vaporizing action has become a good alternative to traditional surgery. The pulsed dye laser (PDL) has also had success, reducing the redness and stiffness of the scar.
How non-ablative lasers work
Non-ablative laser skin resurfacing is also known as photorejuvenation. The important fact about how non-ablative lasers do skin resurfacing is that:
They bypass the epithelium
In other words, they don’t remove the actual wrinkle, as ablative lasers do, but work on the next layer down, the papillary dermis, where they heat the cells called fibroblasts, which create new collagen.
How do they manage to heat the dermis but not the epidermis? They come with a cooling device: a spray of air or gas such as CO2 that cools the epithelium.
Immediately afterwards, the skin will be a little pink and swollen, but not weeping, since the top layer was left intact. You can go back to work and daily activities the next day and perhaps use a little makeup to camouflage the pinkness.
Am I a candidate?
There are two general considerations that might disqualify you.
If you scar easily from burns, cuts or abrasions – since a laser resurfacing treatment is a type of burn, this would not be a good idea. If you have a tendency to get keloid or hypertrophic scars (extra red, stiff, and raised scars, which never do shrink and fade without further treatment), then you’d want to avoid laser resurfacing.
If your ethnicity gives you darker skin – if you have an African, Mediterranean, or Middle-Eastern background, for instance, the laser could make your skin coloring uneven. There could be areas of too little or too much pigmentation, which would be permanent.
The ideal candidate would have elastic skin, not too oily, and a white European background.
But we’re all individuals, and many of us have mixed backgrounds. The best way to discover if you’re a good candidate for laser skin resurfacing would be to consult an experienced cosmetic surgeon. Some lasers do a better job with darker skin than others. Not every surgeon possesses every laser, or has experience treating people with your exact type of skin. So don’t be discouraged if someone tells you you’re not a candidate. Keep asking.
Bear in mind too, that the best cosmetic surgeons are the most careful in choosing their patients. They would not want to treat you inappropriately, against your best interests, just for the sake of adding another patient to their list.
Choosing a good cosmetic surgeon
- Collect some names first. You can do an internet search (Google, Yahoo, MSN etc.), and/or ask friends and relatives, or just look in this cosmetic surgery directory.
- Look at the various websites, where you should get a good idea of what treatments are offered, in what sort of environment.
- Choose a short list of possibilities by eliminating any who don’t have membership in one or more professional societies. You want a laser surgeon who’s in good standing with his peers, up-to-date on research and patient safety, and enthusiastic enough about his work to maintain these memberships. These professional societies accept only board-certified surgeons. Examples would be:
The American Society of Plastic Surgeons (ASPS)
The American Association of Plastic Surgeons (AAPS)
The American Society of Aesthetic Plastic Surgery (ASAPS)
What does board-certified mean?
In the field of medicine, there are national boards for each medical specialty, which set professional standards by offering extended education and certification. The American Board of Plastic Surgery (ABPS) does this for plastic surgeons. To be a board-certified cosmetic (plastic) surgeon, a doctor must complete a fellowship program and pass strict oral and written examinations. The ASPS was founded in 1931 and is the biggest plastic surgery organization worldwide.
Using your short list, call to set up initial consultations with each one. A good plastic surgeon will give you time to ask your questions, explain what you want, what considerations might bother you, etc. Be sure to get answers you can understand.
Ask lots of questions, especially about the specific procedure(s) you want to have. Ask how many times this surgeon has done it, and whether those patients were of your age, sex, skin type etc. How long does it take? What does it cost? What are the risks? Will there be any medications?
Ask about the cosmetic surgeon’s hospital privileges. What hospitals allow the surgeon to do what procedures? Hospitals monitor their doctors’ qualifications.
Feel free to quickly write down the answers.
Be frank with the surgeon
When asked about your background and medical history, give full details, even if it seems only remotely related. You want your plastic surgeon to know everything necessary to give you the best treatment possible. So answer all questions fully, whether about allergies, past medical treatments, any history of herpes, cold sores or other skin conditions, smoking history, or family history.
Ask if there are some before-and-after photos you can study. Usually a website will have these, and there might also be printed photos in the office.
When you feel satisfied enough with one of these cosmetic surgeons, you can go ahead and schedule your surgery. If you’ll be having a treatment that uses an ablative laser, you might want to prepare for your recovery period.
Preparing for recovery
This will be about two weeks, during which time your skin will be dressed and protected as it heals. To avoid having to leave your home, you could get groceries ahead of time, and set up a comfortable space to spend the days, with books, CDs, TV program, pillows etc.
The ablative laser procedure
At your initial consultation, your goals, the procedure’s risks and benefits, and the surgeon’s suggestions will be discussed. The exact treatment areas will be decided upon.
- You’ll be given instructions about how to prepare, such as medications to avoid.
- You’ll also be advised as to how to care for yourself afterwards, and this will be given to you in writing too.
- You might be asked to get a physical and have some routine blood work done.
There’ll be a pre-operative visit, when you may be asked to give more details about yourself, and will be able to ask more questions. Photos may be taken, to be your “Before” photos.
- You’ll be given a prescription for an antibiotic to prevent infection
- You might be given prescriptions for pain medication or anti-inflammatory medication, depending on the circumstances
- You and your laser surgeon can discuss sedatives and anesthesia, and decide on a plan
The procedure itself can last just a few minutes, or as long as an hour or more, depending on how great an area is being treated, and how deeply.
When the laser work is finished, your cosmetic surgeon will cover the treated areas with an antibiotic burn cream and perhaps some other protective tissue. Sometimes that tissue will be absorbable and won’t need removing.
Over that there’ll be gauze bandages to absorb any fluid seeping from the skin.
Chitosan may be used to protect the treated skin. This is a special burn bandage made from cotton and a substance extracted from crustacean shells (crabs, shrimp, lobsters), called chitin. It has antibacterial properties and is slowly absorbed by the body and excreted.
You’ll be taken to a recovery room while the anesthetic wears off, and where you’ll be monitored until permission is given for you to go home.
The length of your recovery time depends on how deeply your treatment penetrated. About two weeks is typical, but it could be longer. There’ll probably be a follow-up visit the next day, and another one a little later.
- Take the antibiotic and pain medication as instructed.
- Take your temperature every day and if it rises, call your surgeon.
- You can use icepacks to bring down the swelling, but avoid wetting your skin. This is especially beneficial in the first two days.
- You’ll need to keep bandages over the area for up to a week, while the skin is still weeping. Your laser surgeon will remove them at a follow-up visit.
- After the bandages are off, crustiness will form over the area. Don’t mess with it, as you could cause scarring. Apply moisturizers frequently.
- Be sure and use a sunblock if you go outdoors. Do this beyond the 2 weeks or so of initial healing, as your skin will be fragile in its new growth, and you won’t want to undo the improvement you’ve just had.
- After the 2 weeks you can start wearing makeup. There’ll still be some pinkness and there are some camouflaging cosmetics you can buy at the local pharmacy.
- Itching and increased sensitivity can last several months.
Risks of laser skin resurfacing
Since this is a fairly new procedure, there are no long-term results known yet. Most risks are associated with having been a poor candidate in the first place, or with giving yourself poor care afterwards:
- Uneven pigmentation in people with darker colored skin
- Flare-ups of herpes simplex in people who have previously suffered from it
- Scarring in people who typically have difficulty with scarring
- Infection if the antibiotics are not taken as instructed, or if the skin is given poor care after the laser treatment
Combining with other cosmetic surgeries
Laser skin resurfacing can be done in conjunction with a variety of other cosmetic surgery procedures, as part of an overall makeover. This would be something to ask your cosmetic surgeon in the initial consultation. Such combined treatments are highly customized, and your surgeon could make suggestions after he had listened to your goals, examined your skin carefully, and studied your medical history.
Laser skin resurfacing can be combined with such treatments as:
- Rhinoplasty (nose recontouring)
- Blepharoplasty (eyelid surgery)
- Any facial implants
For more details, and to learn more about how laser skin resurfacing can benefit you personally, contact an experienced cosmetic surgeon.