Facial Resurfacing: Peels and Lasers

History

Physical Examination

• A full examination of the face and neck should be performed, and the skin should be carefully assessed for texture, rhytids, pigmentary changes, acne lesions, open wounds, and scars.

• Pigmented skin lesions must be examined, and suspicious lesions should be biopsied. Facial resurfacing is not a treatment for skin cancer.

• Photodamaged skin must be differentiated from skin or muscle laxity and loss or descent of adipose tissue. The former is an indication for facial resurfacing; the latter are indications for surgery or injectable fillers.

• The degree of photodamage should be assessed and classified according to the Glogau scale ( Table 159.2 ).

  TABLE 159.2

  Glogau Skin Types

  Glogau Type	Degree of Photoaging	Description of Changes	Patient Age	Makeup
  I	Mild	Mild pigmentary changes No keratosis Minimal or no wrinkles	20s	Minimal to none
  II	Moderate	Early solar lentigines Rare keratosis, mainly palpable Wrinkles seen only with facial expression	30–40s	Wears some foundation
  III	Advanced	Obvious dyschromia and telangiectasias Moderate actinic keratoses Wrinkles seen at rest	50s	Always wears heavy foundation
  IV	Severe	Sallow (yellow–gray color) Keratoses, skin cancer, severe actinic changes Wrinkles throughout, little normal skin	60–70s	Can’t wear makeup due to cakes and cracks

• The patient’s baseline skin pigment and response to UV exposure should be assessed and classified according to the Fitzpatrick scale ( Table 159.1 ).

• A lower eyelid “snap test” should be performed to assess for lower eyelid skin elasticity and recoil. Pull the lower eyelid skin inferiorly and release. If the skin does not return to its starting position within 3 seconds, laser resurfacing should not be performed in the area of the lower eyelid due to risk of postprocedure ectropion.

Imaging

• Radiographic imaging is not indicated in patients desiring facial resurfacing. However, pre- and posttreatment photodocumentation are essential.

• Lighting and patient positioning should be standardized and consistent between pre- and posttreatment photos.

• The five standard views are frontal, right and left lateral, and right and left oblique. Close-up photos should also be obtained of lesions or areas to be specifically targeted.

Indications

• General indications for facial resurfacing are: photodamaged or thick, rough skin, hyperpigmentation, dilated pores, acne, and acne scarring.

• Factors influencing the choice of resurfacing agent include: degree of photoaging, skin Fitzpatrick type, comorbidities, and willingness for postprocedure downtime.

• Superficial chemical peels are appropriate for mild to moderate photoaging (Glogau types I and II). Patients with more severe photoaging (Glogau types III and IV) are unlikely to see significant benefit.

• Superficial peels may be used in all Fitzpatrick skin types.

• Medium and deep chemical peels may provide benefit to patients with advanced photoaging; however, recovery period and risks are higher than with superficial peels, and laser resurfacing may be a better option.

• Medium and deep chemical peels are contraindicated in patients with higher Fitzpatrick skin types due to the high risk of pigmentary complications.

• Nonablative laser resurfacing is appropriate for mild to moderate photoaging and rhytids (Glogau types I to III).

• Nonablative lasers have the advantage of limited postprocedure downtime, with the tradeoff of modest results. A series of treatments is usually necessary to see significant results.

• Fractionation increases depth of penetration and improves results; the tradeoff is increased healing time and increased risk of complications.

• Fractional nonablative lasers can be used in all skin types but should be used with caution in patients with darker skin types (Fitzpatrick IV to VI).

• Ablative laser resurfacing is indicated for patients with lower Fitzpatrick skin types (I to III) and more advanced photoaging, including static rhytids (Glogau IV). Patients must accept significant recovery downtime from this procedure.

• Fitzpatrick skin types IV to VI are not candidates for ablative laser resurfacing due to a high risk of pigmentary complications in these patients.

Contraindications

• Uncontrolled medical illness

• Bleeding disorder or anticoagulant use

• Active herpes simplex or other infection

• Open wound in the treatment area

• Damage to adnexal structures in the dermis that are responsible for regeneration of the epithelium, such as use of Isotretinoin (Accutane) within the preceding 6 to 12 months or a history of radiation treatment or burns to the face

• Medium to deep facial resurfacing in treatment area in the past 6 to 12 months

• Recent heavy sun exposure

• History of keloid or hypertrophic scarring

• Impaired wound healing

• Skin malignancy in the treatment area

• Pregnancy or nursing

• Body dysmorphic disorder or unrealistic patient expectations

• Allergy to chemical peel ingredients

• Ectropion is a contraindication to lower lid laser resurfacing.

• Tattoos in the treatment area are a contraindication to laser resurfacing, as a burn may occur in the skin under the tattoo.

Preoperative Preparation

• A standard skin preparation regimen should be initiated 6 weeks prior to skin resurfacing procedures

• Broad-spectrum sunscreen of SPF 30 and sun avoidance for 1 month prior to the treatment

• Topical retinoid should be started 6 weeks prior to chemical peeling. Preprocedure treatment with topical retinoids has been demonstrated to decrease time to reepithelialization following chemical peels.

• Retinoid use also helps to modify the epithelium to a uniform thickness, which is helpful in achieving a standardized peeling depth. Retinoid use has not been shown to be beneficial prior to laser resurfacing.

• Topical hydroquinone should be started 1 month prior to the procedure for patients with a history of hyperpigmentation or a high Fitzpatrick type.

• Antiviral prophylaxis should be started two days prior to the procedure and continued for 3 to 5 days following the procedure.

• Patch testing of chemical peels may be performed.

• All retinoid or AHA products should be stopped 2 weeks prior to the procedure to decrease skin irritation.

• Anticoagulant medications and supplements should be discontinued 2 weeks prior to the procedure. However, it is advisable to forgo facial resurfacing rather than to stop anticoagulant medications that are medically indicated.

Anesthesia

• Superficial chemical peels do not require anesthesia during the procedure.

• Nonfractional nonablative lasers often have built-in skin cooling that is sufficient for pain control for these procedures.

• Fractional nonablative laser treatments usually require a topical anesthetic. Cold-air cooling may also be beneficial. Regional nerve blocks may be used if necessary.

• Deeper peels and ablative laser resurfacing will require increased pain control. Options include strong topical agents, nerve blocks, anxiolytics, and/or narcotics. In certain cases, IV sedation or general anesthesia may be necessary.

Positioning

• For chemical peeling, the patient should be reclining with the head elevated 45 degrees. Head elevation helps to prevent pooling of the peel solution in dependent areas of the face.

• For laser treatments, the patient may be reclined in the treatment chair or lie flat in the supine position on the treatment table.

Perioperative Prophylaxis

• The risk of bacterial infection is low, and no antibacterial prophylaxis is indicated.

• Prophylaxis for HSV 1 and 2 should be given starting 2 days prior to the procedure.

• Because the rate of latent HSV infection is so high (up to 90% in some studies), many providers provide prophylaxis regardless of prior infection history.