What Are the Optimal Techniques for Skin Rejuvenation?

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The subtle improvements in skin texture and wrinkling after nonablative laser treatment are preferred by many patients to the more obvious improvements after ablative laser resurfacing, because the nonablative laser treatment has a lower risk of complications, shorter recovery time, and less disruption of regular activities. In 1993, the first highenergy resurfacing carbon dioxide lasers became available for skin resurfacing. These carbon dioxide resurfacing lasers effectively treat facial rhytids and actinic changes. They are used to ablate the epidermis and partially ablate the dermis, removing skin changes due to photoaging. They stimulate neocollagen formation and tissue tightening, resulting in long-term skin texture and wrinkle improvement. These and subsequent resurfacing lasers have continued to use high fluence (power density) coupled with a short pulse duration or a scanning mechanism to achieve similar improvement. These lasers, classified as ablative because they remove epidermis and some dermis, rapidly vaporize the skin’s surface with relatively minimal adjacent tissue injury. They differ significantly from the prior surgical carbon dioxide lasers, which used lower fluence and either continuous or interrupted laser energy. Their significantly longer dwell time caused greater tissue trauma and a greater adjacent zone of thermal necrosis. As surgeons gained experience with carbon dioxide lasers by 1995, they also noticed the typical long recovery time (prolonged erythema) and associated complications. At that time, one of us initiated a technique alteration to decrease the risks of carbon dioxide laser resurfacing and reduce recovery time. Laser surgeons had been advised to resurface down into the reticular dermis until a uniform chamois appearance was achieved. Using the new technique, resurfacing was continued only down to the necessary depth to treat the condition or until a chamois appearance occurred. Surgeons were still cautioned not to resurface after the chamois appearance was present, even if the condition was not completely eradicated. This revised technique reduced the incidence of postresurfacing scarring and delayed hypopigmentation and eased postresurfacing recovery. Within a year, this new technique was adopted by many practitioners. By 1998, the erbium:YAG laser was also being used for resurfacing. Comprehensive publications on laser skin rejuvenation provided information about both types of lasers. The erbium laser is effective for treating milder rhytids and photoaging. Compared with carbon dioxide resurfacing lasers, it causes less adjacent thermal injury and has a shorter recovery time and less neocollagen formation. Recovery time after resurfacing with the short-pulse-duration erbium laser is influenced by resurfacing depth and the particular laser and technique used. Significantly less collagen contracture occurs than after carbon dioxide laser resurfacing. Paul J. Carniol, MD Brad A. Greene, MD