Ablative Laser Resurfacing (Laser treatment)

Overview of Ablative Laser Resurfacing

Ablative laser skin resurfacing is a process that removes the outer layers of the skin to reduce visible signs of aging caused by sun damage. It can also be used for treating scars, actinic keratoses (rough, scaly patches on the skin), seborrheic keratoses (non-cancerous skin growths), and facial wrinkles.

This treatment uses lasers that precisely generate heat in the outer layers of skin, which is based on a process known as selective thermolysis. The laser rays are absorbed by the two main color-causing substances in the skin called melanin and water. This absorption process triggers heat, which destroys the tissue it contacts, making way for new and healthier skin to grow.

Laser skin resurfacing technology has seen significant improvements since the 1980s when continuous-wave carbon dioxide (CO2) lasers began to be used. Later, the introduction of pulsed CO2 lasers and a different kind of laser called erbium-doped yttrium aluminum garnet (Er:YAG) laser improved the precision of the treatment. These lasers allowed doctors to better control the depth of the treatment, making it safer and reducing risk of side effects.

Another significant advancement came in the early 2000s with the development of fractional lasers. These lasers treat only a specific portion of the skin using narrow, microscopic columns of light, resulting in less skin damage, fewer side effects, and similar therapeutic outcomes compared to non-fractional lasers.

Based on the specific condition of the skin, the technician may choose to use a particular type of ablative laser (like CO2 or Er:YAG) with different modes of operation (fractional or non-fractional) to achieve the desired results. The aim is always to minimize risk of complications such as scarring, persistent redness, and discoloration of skin.

In summary, ablative lasers are a safe and effective method for skin resurfacing when used appropriately.

Anatomy and Physiology of Ablative Laser Resurfacing

The skin is the largest organ of the body. It has different layers: the epidermis (the outer layer), the dermis (middle layer), and the hypodermis (innermost layer). Here’s a little detail about each:

The epidermis is the skin’s topmost layer and is made up of cells. It consists of several sub-layers:

1. Stratum basale, with its column-shaped cells that divide and move upward to be shed off from the skin.
2. Stratum spinosum, with its 8 to 10 layers of uniquely-shaped cells that have bridges connecting them to each other, turning into a spiny appearance under a microscope.
3. Stratum granulosum, where cells are packed with tiny bodies of protein keratohyalin and lipid compounds that begin hardening to become part of our skin.
4. Stratum lucidum, a layer of flat cells that is packed tightly and often missing in thin skin around eyelids. It mostly appears in areas with thick skin like the palms of our hands or the soles of our feet.
5. Stratum corneum is the final and most superficial layer that consists of dead skin cells that are being continually shed and replaced.

Next, we have the dermis, which is thicker than the epidermis and filled with blood vessels. It is divided into two sub-layers:

1. The reticular layer – This deeper layer has a web-like structure and is rich in collagen and elastin. It is attached to the muscles and contains sensory receptors, hair follicles, and skin glands.
2. The papillary layer – This upper layer contains thin collagen and elastin fibers and loose connective tissues. The dermal papillae contribute to the formation of fingerprints.

The hypodermis, or subcutaneous layer, lies beneath the dermis and contains loose fibrous and fatty tissues. Although it is not strictly part of the skin, it provides the skin’s main blood supply and nerves.

If you’re considering ablative laser therapy, it is vital to understand the basics of a laser. The most common ablative laser treatments come from CO2 or Er:YAG lasers, which are divided into non-fractionated and fractionated. Non-fractionated lasers treat the whole area of skin, whereas fractionated lasers target specific sections of skin, reducing risks and speeding up recovery. Ablative lasers destroy tissue and are considered aggressive with more noticeable results than non-ablative lasers, which are less invasive and only slightly improve the skin’s appearance.

Laser light emits particles of light (photons) at a particular wavelength, which the target tissue absorbs. The goal is to deliver enough penetration and energy to the target tissues while minimizing heat transfer to nearby structures.

The deeper penetration of laser light corresponds with the longer wavelengths. Lasers like CO2 and Er:YAG are absorbed by the water in the skin, causing vaporization of the skin’s top layer and preventing the light energy from going deeper into the skin. However, there might still be some damage due to the penetration of energy, but it is believed to stimulate skin tightening by shrinking and remodeling collagen.

CO2 lasers have been used for skin rejuvenation because they release energy absorbed by water, which works well for cutting and reshaping the skin. Lasers like these can help smooth out fine facial wrinkles. CO2 laser treatment often needs local anesthesia with extra sedatives and possible pain relief medication. After the treatment, redness might linger for two weeks or even several months for more aggressive treatments.

Why do People Need Ablative Laser Resurfacing

Ablative laser resurfacing is a medical process that uses lasers to improve the appearance of skin or treat minor facial flaws. This is often used if you have certain skin conditions or issues. These might include:

– Photoaging: This is skin damage caused by prolonged exposure to the sun’s harmful ultraviolet (UV) rays.

– Facial wrinkles: Lines or folds that appear on the face as a result of aging.

– Acne scars: Scars left behind from severe acne incidents.

– Surgical or traumatic scars: Marks left behind after a surgery or injury.

– Actinic keratoses: Rough, scaly patches on the skin caused by excessive sun exposure.

– Seborrheic keratoses: These are benign (non-cancerous) skin growths that usually occur on the chest or back.

– Warts: Small, hard growths on the skin caused by a virus.

– Moles and other nevi: Small spots on the skin that are usually brown or black.

– Xanthelasma: Yellowish patches that develop on the skin, usually around the eyes.

– Skin tags: Small, soft pieces of skin that stick out on a thin stalk.

– Rhinophyma: A skin disorder characterized by a large, red, bumpy nose.

– Sebaceous hyperplasia: A common, benign condition of the sebaceous glands.

– Pyogenic granuloma: A small, often red, bump that quickly grows on the skin.

– Neurofibroma: A type of benign (non-cancerous) tumor that forms in the nervous system.

– Angiofibroma: A small, benign growth that consists of blood vessels and connective tissue.

– Actinic cheilitis: A lip inflammation caused by long-term sunlight exposure.

– Keloids: An overgrowth of scar tissue that occurs where skin has healed after an injury.

When a Person Should Avoid Ablative Laser Resurfacing

There are certain situations or health conditions that might mean you shouldn’t have a type of skin treatment called ablative laser resurfacing. These include:

If your skin is a certain type – Fitzpatrick skin types IV-VI. This is a scale that measures skin color and its reaction to sun exposure, with types IV-VI being darker skin types. People with these skin types are more likely to have changes in skin color after the treatment.

If you have a history of developing thick, oversized scars called keloids.

If you’ve recently been treated with a medicine called isotretinoin, often used for severe acne. Typically, you’re advised to stop this medication for 6 to 12 months before having skin treatments.

If you have a condition where the lower eyelid droops away from the eye, it’s called ectropion, especially when thinking about treating skin below the eyes.

If you have skin diseases like morphea or scleroderma, both conditions that cause hard and tight skin.

If you’ve previously had radiation therapy, which can slow down the skin’s healing process.

If you have certain skin conditions like vitiligo, lichen planus, and psoriasis, these conditions either change the color of your skin or cause patches of dry, itchy skin. These aren’t absolute rules but rather factors your doctor might want to consider.

If you currently have an active herpes outbreak or any ongoing skin infections in the area that is supposed to get the laser treatment. For this, the process should be delayed until your skin clears up.

If you’re frequently exposed to ultraviolet light, like sunlight that can damage the skin.

If you’ve recently had a chemical skin peel. Depending on how deep the peel was, you might need to wait anywhere from six weeks to six months before considering this laser skin treatment.

Equipment used for Ablative Laser Resurfacing

Anesthesia is one of the core aspects of medical procedures. For laser treatments that break down (‘ablate’) the skin, doctors may use local anesthetics, which numb the area they’re applied to. What type of anesthesia they use typically depends on two main factors: how well the patient can handle pain and the expertise of the person operating the laser. If the plan is to treat the entire face, the doctor might use numbing techniques that target the nerves specifically responsible for the sensation in the face.

One way of providing topical anesthesia is to use a cream called EMLA. This is made up of two substances that together act as local anesthetics. The cream is put on the skin under a dressing to keep it in place, with the amount applied being around 2mg per square centimeter of skin. Usually, the cream stays on for between 45 to 60 minutes, and only gets taken off right before the procedure begins.

For these laser procedures, doctors will typically use either ‘CO2 lasers’ or ‘Er:YAG lasers’. These lasers can be operated in two different modes: ‘fractional’, which treats only certain parts of the skin, or ‘non-fractional’, which treats the entire area.

Protecting the eyes during a laser procedure is very important. Wet gauze or a protective shield covers the patient’s eyes. The healthcare team also needs to protect their eyes, so they’ll wear safety glasses that provide protection from the particular wavelength of laser light they’re working with.

The use of laser-safe instruments is also crucial. This includes having a fire extinguisher and wet towels ready to act fast in case of a fire. Additionally, water or saline (saltwater) solutions are needed.

There are other factors to consider too. Laser protocols and settings should be checked before the procedure starts. All healthcare staff should wear gloves, masks, and caps for protection. A 5% povidone-iodine solution is generally used for cleaning the skin and reducing the chance of infection. Alcohol is usually avoided because it can catch fire.

Who is needed to perform Ablative Laser Resurfacing?

Everyone who works with the laser tool used for removing certain parts of tissues should be well trained in how to use it safely. This includes a technician or a nurse. This medical professional’s role is to help the main person operating the laser. They clean the skin area to be treated and prepare the numbing cream that we apply to numb the pain. They are also in charge of operating the laser and noting down any anesthesia data and changes in your health condition.

Preparing for Ablative Laser Resurfacing

Before starting laser treatment to remove any unwanted marks or scars on your skin, your doctor will first need to understand your medical history and give you a full physical examination. This is an essential step to make sure that you’re a good candidate for this type of treatment.
For example, some people might not be suitable for laser treatment if they have a history of forming overgrown scars (keloids), have recently taken a drug called isotretinoin, or if they have specific skin conditions or have had radiation therapy.
Before the treatment begins, you and your doctor will talk about the risks and what you can expect from the treatment. It is also a practice to take photographs of the area to be treated, from different angles, both with a smile and a straight face. This helps in examining the effectiveness of the treatment.
Your doctor might suggest you take antiviral medicines to reduce the risk of a facial herpes infection coming back. Usually, you would start taking these pills the day before or on the morning of your laser treatment and would continue to take them for several days afterward.
A skin cream called tretinoin might be applied to your skin before the laser treatment, which helps your skin to heal more rapidly after the procedure.
There’s an ongoing debate among doctors about whether to give preventative drug treatments for bacterial and fungal infections before laser treatment. Therefore, this isn’t routinely suggested to every patient.

How is Ablative Laser Resurfacing performed

There is a lack of well-structured studies comparing the different settings of two types of lasers used for skin treatments – CO2 and Er:YAG. The ways in which these lasers are used can vary greatly and depend on things like the doctor’s preferences, what the patient wants, and the devices available. So, it’s up to the reader to decide which laser and procedure best suits their skills and the patient’s expected results. This article won’t go into detail about the various settings used for both types of lasers, but will highlight some common features of laser skin treatments.

Here’s a general process of what laser skin treatments usually look like:

1. The patient is informed about the procedure, its purpose, expected results, recovery process, and potential risks.
2. The patient is given antiviral and possibly antibacterial medicine to prevent infections.
3. The patient is positioned on their back for treating the face and chest. To target the sides of the face and neck, the patient may be asked to lie on their side.
4. Both the patient and healthcare staff are given eye protection and other protective wear suitable for laser treatments.
5. The target area is cleaned with a 5% povidone-iodine solution. Alcohol-based solutions are avoided since they can catch fire.
6. Anesthesia is administered. This could be general anesthesia, nerve blocks, or topical anesthesia. Additionally, cooling the area during the process can make the patient feel more comfortable.
7. The laser is operated by pressing a foot pedal, and the laser tool is held at a 90-degree angle to the target area. The doctor will then treat different areas on the face sequentially. The treatment can cause temporary swelling, crust formation, oozing, and light bleeding, which can be gently cleaned using a water-soaked sterile gauze.

The desired end result of the treatment is to reveal a layer of skin that has a yellowish color, indicating that the optimal layer of skin has been reached. If this level isn’t achieved, the results may not be as noticeable. If the treatment goes further than this level, it could cause scarring. This skin layer also usually shows minor bleeding after about a minute.

After the procedure:

1. Frozen compresses and persistent ointment are applied. The face must stay always moist until the crust formation ceases. The initial application of these is done in the recovery room.
2. Patients should use sun protection of at least SPF 30 and avoid direct sun exposure, especially at midday, to reduce chances of skin darkening. Wearing wide-brimmed hats is also beneficial.
3. Swelling and skin shedding can be managed with cool compresses, head elevation, cleansing with saline or water, ointment (preferably over topical antibiotics), and sealed dressings. If the swelling is severe, systemic steroids like prednisone may be considered.
4. Redness can be managed with mild steroids, tretinoin, and hydroquinone in a cream base. Make-up with green tints is helpful to reduce the appearance of redness.
5. Any sudden acne can be managed with regular acne treatments.
6. A sudden skin irritation can usually be managed with topical steroids and oral doxycycline, a type of antibiotic.
7. For any infections, treatment varies depending on the source (viral, bacterial, fungal) and can be managed with antiviral, bacterial, or antifungal medications.
8. Patients can use topical steroids and oral antihistamines as necessary to manage itching.

Possible Complications of Ablative Laser Resurfacing

Ablative laser resurfacing is a treatment that’s known to be safe and effective. It’s generally a low-risk procedure that most people are satisfied with.

However, it’s important to note that like with all laser treatments, there can be complications. These types of treatments include full-field and fractional lasers. Fractional laser resurfacing tends to result in less severe and less frequent complications. Some issues that might occur after this type of treatment include:

• Constant redness in the skin (persistent erythema)
• Changes in skin color, either becoming too dark (hyperpigmentation) or too light (hypopigmentation)
• Infections caused by viruses, bacteria, or fungi
• Scarring
• Acne-like breakouts (acneiform eruptions)
• Small, white bumps on the skin, somewhat similar to whiteheads (milia)
• Ectropion, a condition where the lower eyelid turns outwards

Despite these potential side effects, this treatment is generally well-received and provides satisfactory results.

What Else Should I Know About Ablative Laser Resurfacing?

Ablative laser resurfacing is a way to improve the look of skin that has been damaged by sun exposure, scarring, and minor skin lesions. The main types of lasers used for this type of treatment are the CO2 and Er:YAG lasers. The amount of energy used by the laser can be adjusted to suit a person’s specific needs. This can include things like how much they want their skin’s appearance to change, how long they’re willing to spend recovering from the treatment, and unique factors such as their skin color and any history of scarring.

There are different kinds of ablative laser treatments. Full field lasers treat the entire surface of the skin, while fractional lasers treat only a portion of the skin at a time. Fractional lasers are generally less intense, which can make recovery quicker and easier, while still providing significant improvements to the skin.

In summary, ablative laser therapy is a key way that cosmetic doctors can make the face look younger and fresher without the need for surgery.