Primary goal: Blunting of wrinkles by tightening within the dermal layer of the skin
Secondary goals: Alteration of skin texture, smoothing of uneven scars (dermabrasion), generation of new collagen
Special anatomy: The outermost layer of the skin is called the "epidermis", below which is located the "dermis".
Anesthesia: From none to mild oral sedation to nerve block by injection
Operative technique: Skin resurfacing is a non-surgical (although destructive) technique:
• Chemical Peel: Following skin preparation and cleansing, the selected chemical is applied using Q-tips.
• Laser resurfacing: The beam of the laser is directed over the tissue to be treated in one or a series of "passes".
Variations:
• Chemical Peel: Different chemicals may be used alone or in combination. The more destructive the chemical, the deeper the level of wounding and the more pronounced the fnal effect. Minimal chemical peeling may be accomplished using alpha hydroxy acids. Deeper peels are accomplished by using increasing concentrations of trichloroacetic acid ("TCA") or phenol. Since the depth of peeling with the more potent chemicals is not fully predictable, some practitioners taut their use of the laser, in which the delivery of "energy" is said to be more controlled. Any real advantage, however, seems to be over-emphasized by advertisers and laser manufacturers; using a laser does not guarantee a superior result.
• Laser resurfacing: Either the carbon dioxide (stronger) or erbium:YAG (weaker) lasers may be used, or the two may be used in combination. The doctor may "dial in" the amount of energy and depth of penetration by setting different laser beam parameters on the machine. Newer and less destructive (non-ablative) lasers cause less tissue damage but also less effect.
• Either localized areas (skin around the eyes, around the mouth, etc.) or the full face may be treated.
Advantages: Blepharoplasty surgery is designed to remove extra tissue and strengthen weakened structure. While canthal tendon reinforcement may blunt the appearance of wrinkling in the lower eyelid, skin creasing is due to damage within the skin rather than excess tissue and is thus not helped by "cutting surgery." Resurfacing procedures are designed to create a controlled "injury" into the dermis of the skin, which, in the process of healing, leads to a reduction in wrinkling. It is reasonable to expect about a 50-80% reduction in the depth of most deep wrinkles.
Limitations: If blepharoplasty is indicated in a patient for the removal of more than tiny amounts of excess eyelid skin and/or fat, attempting to avoid eyelid surgery by using heavy-handed laser or chemical resurfacing instead will not often yield a satisfactory result. Fine wrinkles such as those around the eyes often return rapidly once any swelling from the procedure has fully disappeared
Care and recovery: Except with the most mild of chemical peels, care and recovery is much more extensive and prolonged than for blepharoplasty alone (and usually more extensive than many patients expect). With deeper treatments, the face may appear truly "hideous" for several weeks and bad for months more. Redness and blotchy skin pigmentation may resolve only gradually and create a cosmetic problem for 6-18 months. After treatment, unprotected exposure to the outdoors must be avoided indefinitely.
Risks and complications: Complications include prolonged and extreme skin redness and tenderness, hyperpigmentation, permanent blotchy pigmentation, worsening of pre-existing acne, herpes and other types of infection, hypopigmentation, and scarring. More aggressive techniques may leave the "texture" of the skin with a somewhat waxy look. The phenol used in deep chemical peels is highly toxic. If the skin of the lower eyelid is excessively tightened by deep resurfacing, ectropion (eversion) or retraction (pulling down) of the lid may occur. While rare, severe injury to the cornea has been reported.
Comments: Resurfacing techniques tend to benefit "static" wrinkles rather than "dynamic" wrinkling caused by underlying muscular pull (for example, crowsfeet).
As with any "artistic" discipline, to obtain consistent results with skin resurfacing requires a good deal of doctor knowledge and a greater amount of experience.
Be aware that some eyelid specialists have now abandoned the laser in favor of TCA chemical peeling; treatment is not only easier, safer, less painful, and much less expensive, but the healing is relatively rapid and more predictable. While carbon dioxide laser resurfacing and deeper chemical peeling may work wonders on severely sun-damaged or aged skin, younger patients with more modest changes should carefully consider the downside of such aggressive treatments.
