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Lasers, Skin Resurfacing, and Hair Restoration


Key Points

  • 1.

    Skin resurfacing modalities and methods of action

    • Chemical peels: caustic injury

    • Dermabrasion: mechanical injury

    • Laser: thermal injury

  • 2.

    Different types of chemical peels

    • Superficial chemical peels (epidermis): TCA 10% to 30%, Jessner’s solution, glycolic acid 40% to 70%, and salicylic acid 5% to 15%

    • Medium chemical peels (superficial dermis): TCA 35% to 40%, combination of 35% TCA with other agents and phenol 88%

    • Deep chemical peels (deep dermis): TCA 50% and the Baker-Gordon phenol peel

  • 3.

    Contraindications of skin resurfacing

    • Facelift surgery, medium or deep chemical peel, or laser resurfacing in the previous 6 months

    • For non-fractionated fully ablative lasers and dermabrasion: Isotretinoin use within 6 months

    • Active herpes simplex virus infection

    • Active skin disorders

  • 4.

    Ablative lasers

    • CO 2 laser (10,600 nm) targets water

    • Erbium-YAG laser (2940 nanometers) targets water

  • 5.

    Nonablative lasers

    • Vascular lasers: pulsed KTP (532 nanometers) and pulsed dye (585 nanometers) target hemoglobin

    • Infrared laser: Nd-YAG (1064 nanometers)

    • Intense pulsed light: IPL (550–1200 nanometers) laser targets melanin and hemoglobin

Pearls

  • 1.

    The most important consideration prior to skin resurfacing is proper patient selection, especially with respect to the Fitzpatrick skin type (types I and II are the best candidates).

  • 2.

    The Baker-Gordon formula’s (phenol 88%, croton oil, septisol, and distilled water) depth of penetration is more dependent on the croton oil than on the concentration of phenol.

  • 3.

    Pigmentary changes can result from any skin resurfacing modality (chemical peels, lasers, or dermabrasion). Hyperpigmentation tends to occur sooner and can be successfully treated with topical steroid therapy, while hypopigmentation tends to be a delayed phenomenon and is often permanent.

  • 4.

    Ablative lasers cause vaporization of tissue and are comparable for resurfacing to medium and deep chemical peels and dermabrasion.

  • 5.

    Phenol chemical peels are associated with cardiac toxicity and should be applied to individual facial subunits at 15-minute intervals to limit systemic absorption.

  • 6.

    Follicular unit transplantation refers to the transfer of individual follicular units of hair (groups of one to four hairs). When evaluating the patient for hair restoration, the patient’s age, medical history, family pattern of hair loss, and amount of donor area on the posterior scalp need to be determined.

  • 7.

    Know the Norwood classification for androgenic alopecia.

Questions

Skin Resurfacing

1

Describe age-related changes of the skin.

The skin changes seen with aging include thinning of the dermis and epidermis, effacement of the epidermal-dermal junction (most consistent change), thinning of the subcutaneous fat, and loss of organization of elastic fibers and collagen. These changes contribute to increased skin laxity and wrinkling of the aged face.

2

Describe the Fitzpatrick skin type classification system.

The Fitzpatrick skin type classifies the degree of skin pigmentation and the ability to tan. Skin is graded from I to VI and predicts sun sensitivity, susceptibility to photodamage, and ability for melanogenesis ( Table 63.1 ). It also provides important information related to risk factors for complications during skin resurfacing procedures. Types III through VI have a higher risk of pigmentary dyschromia (hypo- or hyperpigmentation) after skin resurfacing procedures.

Table 63.1
Fitzpatrick Skin Classification System
SKIN TYPE SKIN COLOR SUN REACTION
I White or freckled Always burns
II White Usually burns
III White to olive Sometimes burns
IV Brown Rarely burns
V Dark brown Very rarely burns
VI Black Never burns

3

What are the different methods of skin resurfacing and how do they promote rejuvenation?

The different methods are chemical peels, dermabrasion, and laser resurfacing. Superficial resurfacing (microdermabrasion and superficial chemical peels) exfoliates the epidermis only and stimulates regeneration and thickening of the epidermis. Medium and deep resurfacing (medium and deep chemical peels, dermabrasion, and lasers) penetrate into the superficial and deep dermis, inducing collagen production.

4

What are the main indications for chemical peels and dermabrasion?

Photodamage, fine wrinkles, pigmentary dyschromia, and acne scars.

5

What are the agents used for superficial chemical peels?

Superficial chemical peels (epidermis) can be prepared using 10% to 30% trichloroacetic acid (TCA), Jessner’s solution (resorcinol, salicylic acid, lactic acid, and ethanol), glycolic acid 40% to 70% solution, and salicylic acid 5% to 15% solution.

6

What are the agents used for medium-depth chemical peels?

The medium-depth peel (papillary dermis) agents are trichloroacetic acid (TCA) 35% to 40% solution, a combination of 35% TCA with other agents (35% TCA + solid CO 2 , 35% TCA + Jessner’s solution, 35% TCA + 70% glycolic acid), and phenol 88% solution.

7

What are the agents used for deep chemical peels?

The deep chemical peel (reticular dermis) agents are trichloroacetic acid (TCA) 50% and the Baker-Gordon phenol peel (phenol 88%, croton oil, septisol, and distilled water). The addition of croton oil, an epidermolytic agent, increases the penetration of phenol into the dermis.

8

What are the limitations associated with the use of phenol?

Phenol is associated with cardiotoxicity (mostly premature ventricular contractions), hepatotoxicity, and nephrotoxicity. Phenol application requires intravenous hydration and cardiac monitoring for the development of arrhythmias. Facial subunits should be treated at 15-minute intervals to avoid toxicity.

9

Describe the complications related to chemical peels.

Complications associated with chemical peel resurfacing include milia formation (the most common complication of all resurfacing procedures), hyper- or hypopigmentation, scar formation, allergic or irritant dermatitis, bacterial or fungal (most commonly Candida ) infection, and reactivation of herpes simplex virus (which could lead to scarring).

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