ASAPS Update: Skin Resurfacing Procedure

Scars, skin pigmentation, wrinkles and “crow’s feet” around your eyes can make you look tired and old. To improve your skin and look younger, board certified plastic surgeon Dr. Mark Pinsky recommends laser skin resurfacing procedures or combination of skin care treatments.

ASAPS Update: Skin Resurfacing Procedure

Aging, sun exposure, heredity and lifestyle factors including nutrition, alcohol consumption and smoking all may contribute to facial wrinkling.

Pigmentary changes of the skin, such as blotchiness or brown spots, may also occur with age or as a result of birth control pills, pregnancy or genetic factors. Prior acne may have made the surface of your skin uneven. These problems, as well as certain other skin conditions, may be improved by skin resurfacing.

As you consider skin resurfacing, regardless of technique employed, skin resurfacing is a controlled injury to your skin. As your skin heals, the goal is form “good” scar tissue; the risk is forming “bad” scar tissue.

Your Personal Consultation

During the consultation, you may be asked to look in a mirror and point out the specific areas of your face that you would like to see improved. This will help your surgeon to understand your expectations and determine whether they realistically can be achieved.

Am I a good candidate for skin resurfacing?

You may be a good candidate for skin resurfacing if you have one or more of the following conditions:

• wrinkled or sun-damaged facial skin
• vertical wrinkles around your mouth, such as those that cause lipstick “bleed”
• “crow’s feet” lines around your eyes and perhaps some skin laxity in your lower eyelid area
• fine wrinkling of your upper eyelids
• brown spots or blotchy skin coloring
• certain precancerous skin growths
• acne or chicken pox scars
• superficial facial scars from a past injury

Patients may have their skin resurfaced at almost any age. You may have certain characteristics that make you a better candidate for one technique rather than another, or your surgeon may have a preference based on his or her personal experience with the different methods.

The amount of time you can allow for recovery also may be an important factor in selecting a particular resurfacing method or determining the extent of treatment. All resurfacing techniques can be performed to varying depths.

A more superficial treatment will require less healing time, but you may need to have the procedure repeated more than once to achieve the same results as a deeper treatment. If you are having aesthetic (cosmetic) surgery, such as a facelift or eyelid surgery, you may be able to have a skin resurfacing procedure performed at the same time.

How will my plastic surgeon evaluate me for skin resurfacing?

Your plastic surgeon will carefully examine your skin to determine which resurfacing technique, or combination of treatments, will provide you with the best results. Your skin type, the severity of any sun damage, the extent of uneven pigmentation and the depth of skin imperfections will be evaluated. Fine lines, coarse wrinkling or deep acne scarring each may require a different approach to treatment.

You should come to the consultation prepared to discuss your medical history. This will include information about any medical conditions, drug allergies, medical treatments you have received, previous surgeries, and medications that you currently take. Be sure to tell your plastic surgeon if you have ever had x-ray treatments of your facial skin such as those used in the treatment of acne or if you have had a prior chemical peeling procedure. Current or past use of AccutaneT, as well as Retin-A, and other topical skin preparations, must be reported to your surgeon. For your safety, it is important that you provide complete information.

Skin Resurfacing Techniques

Resurfacing options are reviewed below. All achieve results in basically the same way. Parts of your skin are injured, as the healing process progresses; a new, healthier-looking skin emerges. What differentiates the various resurfacing methods is the way in which the skin’s layers are injured. Chemical peels involve the application of a caustic solution, dermabrasion utilizes high-speed rotary wheel, and laser resurfacing uses a laser beam.

Will my insurance help cover the cost of skin resurfacing?

Skin resurfacing procedures usually are not covered by insurance. Occasionally, however, if the resurfacing is being performed to treat precancerous skin conditions or improves certain types of scars, insurance coverage may be available. Your plastic surgeon’s office will explain how you can find out from your insurance company if a particular procedure will be covered.

Chemical Peel

Peels use differing formulas of chemicals to treat your skin. Mild chemicals (like glycolic acid) create very superficial changes, but more irritating chemicals (such as phenol) can cause more profound changes in your skin. As the potential for dramatic change increases, so does the potential risk of undesirable change, such as permanent skin lightening or scarring.

How is a chemical peel performed?

A chemical peel solution may be applied to your entire face or just to certain regions, such as the crow’s feet area around your eyes or the vertical wrinkles around your mouth. Your surgeon decides how long to leave the solution on your face by carefully observing any changes in the appearance of your skin. With certain types of chemical peels, the solution may be “neutralized” after an appropriate amount of time has elapsed.

Types of chemical peels

The different types of chemical peels vary according to their specific ingredients and their strength. The depth of their peeling action may also be determined by factors such as how long they remain on the skin and whether they are applied lightly or rubbed more vigorously onto the skin.

Glycolic (AHA) Peel: Generally, the most superficial peels are those using alpha hydroxy acids (AHAs) such as glycolic acid. Sometimes just a single treatment with an AHA peel will give your skin a fresher, healthier appearance and a radiant glow. Repeated treatments can help to further improve the texture of your skin. AHA peels can reduce the effects of aging and sun damage including fine wrinkling and brown spots. Your surgeon will recommend a maintenance program using AHA products that you can apply at home on a regular basis.

An AHA peel is performed in your plastic surgeon’s office. No anesthesia or sedation is needed, and you will only feel a tingling or mild stinging sensation when the solution is applied to your face. Immediately after the procedure, you generally will be able to wear makeup, and you can drive yourself home or back to work.

TCA Peel: A trichloracetic acid (TCA) peel is often used for the treatment of wrinkles, pigmentary changes and skin blemishes. Many patients can benefit from having TCA applied not only on the face but also on the neck and other parts of the body that have been exposed to the sun. For spot peeling of limited areas such as around the mouth or eyes, TCA formulas are often preferred because they have less bleaching effect than solutions containing phenol, another popular peeling agent. For the same reason, some surgeons have found TCA to be effective in treating darker-skinned patients.

Milder TCA peels can be repeated frequently in order to achieve cumulative effects, or TCA can be used to achieve a medium or even a deep peel, depending on the acid concentration and manner of application.

Phenol Peel: A phenol peel is sometimes recommended for treating particularly rough and sun-damaged facial skin. Phenol is effective in reducing the appearance of wrinkles ranging from fine lines to deeper creases. It can correct pigmentary problems including blotchiness or age-related brown spots and may be used in the treatment of precancerous skin conditions.

Phenol is particularly useful for minimizing the vertical lines that often form around the mouth as a result of aging. The disadvantage of phenol for spot peeling of limited areas is that it often has a significant bleaching effect. After your skin has been treated with phenol, you may need to wear makeup in order for the treated portions of your skin to more closely match the skin color of the surrounding areas. Unlike TCA peels, phenol cannot be used on your neck or other parts of your body. Certain variations in the phenol peel formula, creating a “buffered” or milder solution, may allow for greater flexibility in its use.

Dermabrasion

Dermabrasion creates an injury similar to skinning your knee. It uses a small, rapidly spinning wheel with a roughened surface similar to fine-grained sandpaper to abrade the skin, removing its upper layers. This injury heals the same as when you skin your knee.

This resurfacing procedure sometimes is selected for the treatment of facial scars such as those caused by acne and often is performed on the cheeks or the entire face. Dermabrasion, like the deeper chemical peels, is very effective in reducing the appearance of vertical wrinkles around the mouth that often cause lipstick “bleed”. It can be used on a small area of skin and on patients with somewhat darker complexions. The treated area usually will blend with the surrounding skin so that there is little if any noticeable difference in the pigmentation.

How is dermabrasion performed?

Dermabrasion will require some form of anesthesia. Small areas may require only local anesthesia, but larger areas may benefit from sedation, as well. Post-dermabrasion treatment is similar to treating a burn. Your plastic surgeon will prescribe your individual care based on experience, the area treated, depth of dermabrasion, and your skin type.

Laser resurfacing

There are two forms of laser resurfacing. In the first form, laser resurfacing creates a uniform injury to your skin, similar to deeper chemical peel or dermabrasion. In the second form, the laser “drills” tiny holes into deeper layers of your skin, or “fractional resurfacing.”

Many surgeons feel the first form of laser treatment gives greater control for the depth of injury than seen with dermabrasion or chemical peel. In fractional resurfacing, the majority of the skin surface is not injured. Your skin then tightens by “connecting the dots,” where your collagen contracts between the tiny laser holes. The benefit of fractional treatment is less surface injury. The risk is that there is a greater depth of injury. If there is a complication healing, there is a risk of undesirable scar.

Like the other resurfacing methods, the laser is effective in treating wrinkles, blotchiness or age spots, and scars from acne or other causes. It can be used on the entire face or specific areas. Certain other characteristics of your skin, such as its thickness and texture, may influence whether you are a good candidate for laser resurfacing. Some patients may benefit from the laser’s mild “tightening” effect on the skin, particularly in the lower eyelid area where the skin often becomes somewhat loose as a result of aging.

How is laser resurfacing performed?

Laser resurfacing requires anesthesia. Depending on the laser treatment chosen and the area treated, local anesthesia may be adequate. For larger areas, sedation or general anesthesia may be recommended. Recovery will depend on the technique and depth of treatment you require.

Understanding Risks

Every year, many thousands of patients undergo successful skin resurfacing procedures, experience no major problems and are pleased with the results. Anyone considering treatment, however, should be aware of both the benefits and risks.

I understand that every medical procedure has risks, but how will I learn more so that I can make an informed decision?

The subject of risks and potential complications of skin resurfacing is best discussed on a personal basis between you and your plastic surgeon, or with a staff member in your surgeon’s office.

Skin resurfacing procedures are generally safe when performed by an experienced board-certified plastic surgeon. The various resurfacing techniques discussed in this brochure have similar types of risks, although there are some differences. For example, infection or abnormal healing are infrequent but may occur with any of the treatments.

If you are prone to skin disorders, including allergic reactions or herpes (cold sores), skin resurfacing can cause eruptions of these conditions. Even an AHA peel, which is the most superficial of the resurfacing techniques, may occasionally produce temporary minor skin irritation. Tiny whiteheads may develop on the skin following some procedures. These usually disappear with use of a mildly abrasive cleanser, but occasionally may require removal by your surgeon or a staff member in your surgeon’s office.

Some individuals have a tendency to form raised or thickened scars, and this may be unpredictable. Medications are available to treat such complications, but in rare cases some degree of scarring may be permanent. While the bleaching effect of a phenol peel is to be expected, other types of peels, dermabrasion and laser skin resurfacing sometimes may produce unanticipated color changes or skin blotchiness.

Following all resurfacing treatments, it is important that you avoid direct or indirect exposure to the sun until all the redness or pinkness of your skin has subsided. Even after that, it is advisable for you to protect your skin by regular use of a sunblock and, whenever possible, a wide-brimmed hat. This is particularly important if you have had a phenol peel which eliminates your skin’s ability to tan. If the area around your eyes has been treated, you should wear good quality sunglasses when outdoors. After some types of skin resurfacing treatments, you may need to be careful about exposing your skin to chlorinated water.

You can minimize certain risks and help to maintain the results of your skin resurfacing treatment by following the instructions of your plastic surgeon.

Your Resurfacing Treatment

How should I prepare for skin resurfacing?

Prior to a deeper chemical peel, laser resurfacing, or less often, dermabrasion, your plastic surgeon may place you on a pretreatment program during which you will apply special creams, lotions or gels to your skin for a few weeks or longer. You may also be given certain oral medications that you should begin taking prior to your treatment. Your surgeon will provide you with additional instructions.

Your skin resurfacing treatment may be performed in your plastic surgeon’s office, a free-standing ambulatory facility or a hospital. You should arrange for someone to drive you home after the procedure and probably assist you for a day or two.

What will happen immediately before and after the treatment?

Medications will be administered for your comfort prior to the treatment. Frequently, local anesthesia alone or combined with intravenous sedation is used for patients undergoing skin resurfacing procedures. Sometimes, general anesthesia may be desired.

When the treatment is completed, your resurfaced skin may be covered with petroleum jelly or other protective ointment. In some cases, dressings, tape or a bandage may be applied.

How will I look and feel initially?

Deeper chemical peels, dermabrasion or laser skin resurfacing will produce redness and swelling to varying degrees. Depending on the post-treatment regimen selected by your plastic surgeon, a scab may or may not form over the treated area. You will be advised about cleansing your skin, as well as if and when you should apply any ointments. In the case of men who have undergone resurfacing procedures, shaving must be delayed for a while. It is essential that you follow your plastic surgeon’s instructions and avoid doing anything that might interrupt the healing process.

About seven to ten days after your skin resurfacing procedure, a new skin will have begun to form. After the initial redness subsides, your skin may be pink for several weeks to months. Camouflage makeup usually can be used within a couple of weeks, but your plastic surgeon will advise you.

Results of Skin Resurfacing

Because of the persistence of skin pinkness following many types of resurfacing procedures, it may take months before you can fully appreciate your new look. Most patients feel that the results are definitely worth waiting for and, in the case of deeper treatments, the benefits are relatively long-lasting. Superficial resurfacing procedures, such as light chemical peels, may need to be repeated periodically in order to maintain their benefits.

Your skin will, of course, continue to age. Also the type of wrinkles caused by movement of your facial muscles will eventually reappear. Some wrinkles may recur sooner than others, depending on their location as well as the type and extent of your resurfacing treatment. Despite this, you can expect that improvements in skin quality and texture achieved by resurfacing will make your complexion appear younger and fresher for many years to come.

When can I resume my normal activities?

Depending on the type and depth of your skin resurfacing, straining, bending and lifting should be avoided during the early period following your procedure. For deeper resurfacing, you should be able to return to work within a week or two, less for superficial peels such as glycolic acid.

Maintaining a Relationship with Your Plastic Surgeon

You will return to your plastic surgeon’s office for follow-up care at prescribed intervals, at which time your progress will be evaluated. Your surgeon will encourage you to schedule routine mammographic evaluations at the frequency recommended for your age group.

Please remember that the relationship with your plastic surgeon does not end when you leave the operating room. If you have questions or concerns during your recovery, or need additional information at a later time, you should contact your surgeon.