Fast Healing after LaserSkin ResurfacingThe Minimal MechanicalTrauma Technique

LAURENCE DAVID, MDJAVIER RUIZ-ESPARZA, MD

BACKGROUND. Laser resurfacing is rapidly becoming a widelyused method of skin ablation for cosmetic improvement. Thetechnique with which the instrument is used can make the dif-ference between obtaining the desired result with a benign post-operative period and one with unnecessary complications.OBjEcrivE. This paper describes a technique that maximizes thebenefits while minimizes the risks in using this highly advancedinstrument.METHODS. We have limited the areas where multiple passes aredone to areas that have rhytides: for the rest of the skin a singlepass is done and the final carbonized eschar is not removed.RESULTS. Faster healing and less complications. Shorter opera-tive and anesthesia times. Greater patient acceptance and satis-factory cosmetic results.CONCLUSIONS. This technique provides a safer, faster, and sat-isfactory cosmetic results with a much smaller possibility of thecomplications seen with conventional methods. © 1997 by theAmerican Society for Dermatologic Surgeiy, Inc. Dermatol Surg1997:23:359-361.

Carbon dioxide laser skin ablation is a predictableand reproducible method of ablating the skinand should have equally predictable outcomes.

To accomplish this, laser resurfacing must be the resultof highly precise optical-thermal coagulation only. Un-fortunately, few operators keep this basic premise inmind and the technique is often contaminated by var}'-ing degrees of mechanical dermabrasion rather thanpure laser ablation.' Persisting erythema, texturalchanges in the skin, and outright visible scarring maythen be seen. These undesirable results were commonlyassociated with mechanical dermabrasion and are alsopossible after laser resurfacing if part of the skin abla-tion carried out in these patients is also mechanical. Wepropose in this paper to reflect on key aspects of thetechnique that will maximize the promised advantagesof using this novel, luminic, noncontact, highly predict-able ablation instrument.

Materials and MethodsIn our patients, chronic actinic damage, rhytides, and acnescarring were the most common reason for resurfacing. Thistechnique was used in all patients regardless of age or sex.Patients were directed to wash their face with an antibacterialsoap the day before and the morning of the procedure. Incontrast to other published articles'-^ no other skin prepara-tion on the part of the patient was required. Tretinoin wasavoided.-' Laser resurfacing was carried out under IV seda-tion. An Ultrapulse laser (5000c; Coherent, Inc., Palo Alto, CA)was used. Rhytides and/or scars were treated first using the3-mm collimated handpiece. On rhytides, the shoulders arelased with one to three passes while the valleys receive onlyone pass. Carbonized material is carefully removed with acotton applicator soaked in normal saline or hydrogen perox-ide after each pass. This is very important since carbonizedmaterial heats up quickly and does lose heat slowly. That canbe a source of unwanted thermal damage to the dermis. Thewalls and the floor of acne scars are treated similarly with twoto three passes for the walls and one pass for the floor. Whenthe operator is happy with the amount of sculpting and lev-eling of the wrinkles and scars being treated, then he treats theintervening skin, which has only shallow, diffuse actinic dam-age, with one pass only, using the computerized pattern gen-erator (CPG)* at 300 ml with a density of 1-2 for eyelids and3-4 for the rest of facial skin. The resulting whitish carbonizedtissue is not removed since only one pass is needed here. Adressing is then applied.

ResultsWe observed that healing time is considerably shorterwhen the skin heals after laser injury alone, than ifhealing from friction and shearing caused by indiscrim-inate rubbing has to take place. Our results comparedfavorably with those published by other authors sincerhytides and scars are treated much in the same way(Figures 1-3). We feel that potential complications suchas scarring, textural changes, prolonged erythema, andinordinate pain can also be diminished by this tech-nique since much of the nonspecific mechanical damageto tissue is eliminated.

From the Institute of laser and Cosmetic Surgery (LD), Hermosa Beach,California: and the Department of Dermatology (JR-E), University of Cali-fornia, San Diego, California.

Address correspondence and reprint requests to: Javier Ruiz-Esparza.MD, 477 N. El Camirio Real C-300, Enciiiitas, CA 91024.

DiscussionChemical ablation of the skin has many variables: man-ufacturer of the chemical, shelf-life and age of com-

© 3997 by the American Society for Dermatologic Surgery, Inc. • Published by Eisevier Science Inc. 359

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Dermatol Surg1997 ;23:359-361

Figure 1. A) Preoperative view of lips treated with MMTT; B)10 months post-op.

pound, manner of application (ie, fully soaked vs halfsoaked gauze, pressure during application, prior prep-aration of the skin being treated by defatting agents,nature of skin in question, sebaceous vs thin skin, etc).Each one of this variables may influence the outcome.

Dermabrasion by diamond fraise mechanical derm-abrader or one with wire brush are highly technique-sensitive and results vary widely depending on the skilland experience of the treating physician. Carbon diox-ide laser ablation provides the clinician with a techni-cally advanced instrument capable of reliably ablating50-70 |Lim of skin depth per pass.' Tissue is destroyedwithout scarring.^ But, the purported advantages of us-ing such a high-tech instrument for ablation of facialskin for cosmetic reasons are compromised if part of theablation is done by vigorously rubbing the skin with asponge or cheese cloth piece of gauze while removingcarbonized material. Some operators rub hard enoughto literally cause surface bleeding, again and again, ifmultiple passes are done. Multiple passes over the en-tire face are common practice.' This is no other thanmechanical dermabrasion with the abrasive surface of

Figure 2. A) A lateral view of a patient before undergoingMMTT: B) 1 month later.

the gauze used for rubbing and carries with it the in-herent potential complications of conventional derm-abrasion. The advantage of the high-tech instrument isthen defeated. When treating the skin between the rhyt-ides we must remember that the actinic damage is lim-ited to the epidermis and upper papillary dermis, andone pass will suffice to create thermal necrosis andsloughing of a shallow layer but one that will includethe tissue we are trying to ablate.

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Figure 3. A) Another patient before MMTT: B) 1 month post-op.

We found that avoiding the use of Tretinoin pre- andpostoperatively decreases the length of postoperativeerythema to 1-2 weeks in the majority of cases. We are

in agreement with other authors'̂ '* in that the degree oferythema directly correlates with the number of passesdone on a specific area.

To perform several passes may also increase the riskof scarring.' Doing only one pass over the entire faceminimizes postoperative erythema. Another point thatwe found helpful in our patients and differs from otherauthors'' is to deal with the rhytides first, before anypasses are done. By removing the undesired surfaceirregularities in wrinkles and/or scars first, the contourand full tridimensional elevation and shape is not al-tered as it would be if a general all-inclusive pass orseveral passes are done first. Hydroquinone is recom-mended after 1 week in patients with freckling and inpatients with Fitzpatrick's skin types III to V, and is tobe continued for at least 6 months along with a wide-spectrum sunscreen with a high SPF. Preoperatively,Acyclovir for 1 day and 4 days after the procedure isgiven to prevent an unwanted herpetic episode.*

Conclusions

Resurfacing by laser offers distinct advantages as a pre-cise instrument of tissue ablation. In order to realizesuch advantages, an effort should be made to avoid theabrasive action of gauze scrubbing between laserpasses.

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