Technique of carbon dioxide laser resurfacing

Facelift Without Surgery

An alternative approach to perioral rhytides

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Pre-operative skin preparation may be necessary in certain patients. Prophylactic anti-virals, i.e. Zovirax and oral antibiotics are frequently used and started 24 hours pre-operatively. If limited areas are being resurfaced, i.e. periocular or perioral regions only, then local anaesthesia, either infiltrative or regional nerve blocks, with or without intravenous sedation is used. Full face resurfacing is best undertaken using local anaesthesia and sedation or general anaesthesia.

Laser safety precautions must always be observed which include protection of areas not being treated with wet swabs and/or protective eye shields. Anaesthetic equipment if used, must be protected using silver foil around the exposed endotracheal tube and connection and all theatre staff, including the surgeon, must wear protective goggles.

Techniques for resurfacing vary greatly from one surgeon to the next but all adhere to certain basic tenets. The skin thickness varies considerably over different parts of the face with the periocular skin being the thinnest and skin over the cheek and chin the thickest. In order to achieve a similar improvement in each area more laser treatment or resculpting is necessary with the thickest tissues.

The skin is thoroughly cleansed with saline and dried. The area of treatment is outlined and any deep wrinkles individually marked. The laser pattern and power are set, the laser tested and treatment commenced. The initial treatment centres on the individual wrinkles or scars outlined, with treatment to the shoulders or elevated areas adjacent to the deeper wrinkle or scar. The ablated debris is removed with saline soaked gauze swabs. Confluent laser passes are then made over the entire region or regions to be treated, taking care to avoid significant overlap of the laser pattern. The number of passes with the laser is dependent on the region of skin treated and the laser characteristics. Usually 1-2 passes are all that is required when treating periocular skin whilst 2-4 passes may be necessary in areas of thicker skin such as the forehead, cheeks or chin. All desiccated tissue must be carefully wiped away with saline swabs after each pass (Figure 8.6). Assessment of the depth of treatment is facilitated by recognised colour changes occurring in the tissues.

Complete epithelial removal results in a pinkish appearance; treatment to the papillary dermal layer correlates with a yellow/orange coloration whilst deeper reticular dermal ablation is characterised by a chamois leather or white appearance. Treatment should stop at this latter stage as deeper laser treatment may well lead to hypertrophic scarring.

It is important to avoid a frank demarcation line between areas of treated and untreated facial skin. This is facilitated by feathering or blending of the adjacent areas whereby laser treatment using reduced power and wider spacing is undertaken.

Post operatively it is essential to keep the treated area moist or covered at all times until re-epithelialisation has occurred which is usually complete within five to seven days. Many techniques have been described ranging from regular applications of aqueous cream and cleansing through to custom designed dressings.

After re-epithelialisation it is again important to keep the treated area moist. Most patients elect to use a combined moisturising concealer preparation until the erythematous phase of the treatment (lasting anything up to three months from the time of laser treatment) has settled. It is essential that the patient treats the newly resurfaced skin very carefully, rather like a baby's skin. Direct sunlight must be

Figure 8.6 laser.

Periocular laser resurfacing with CO2

Figure 8.6 laser.

Periocular laser resurfacing with CO2

avoided and a sunblock preparation always used when outdoors, ideally long term.

Most post operative problems, assuming that laser treatment has been appropriately undertaken, result from poor skin care. Redness or erythema is to be expected and may take up to three months or more to settle. Hyper- or rarely hypo-pigmentation can occasionally occur. The former can be managed with topical skin bleaching agents or steroid preparations but there is relatively little that can be offered for hypo-pigmentation.

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