Skin resurfacing employs a variety of techniques to change the surface texture and appearance of the skin. Common skin resurfacing techniques include chemical peels, dermabrasion, and laser resurfacing.
Skin resurfacing procedures may be performed for cosmetic reasons, such as diminishing the appearance of wrinkles around the mouth or eyes. They may also be used as a medical treatment, such as removing large numbers of certain precancerous lesions called actinic keratoses. Physicians sometimes combine techniques, using dermabrasion or laser resurfacing on some areas of the face, while performing a chemical peel on other areas.
As the popularity of skin resurfacing techniques has increased, many unqualified or inexperienced providers have entered the field. Patients should choose their provider with the same degree of care they take for any other medical procedure. Complications of skin resurfacing techniques can be serious, including severe infection and scarring.
Patient's with active herpesvirus infections are not good candidates for resurfacing procedures. Persons who tend to scar easily may also experience poor results. Patients who have recently used the oral acne medication isotretinoin (Accutane) may be at higher risk of scarring following skin resurfacing.
Chemical peels employ a variety of caustic chemicals to selectively destroy several layers of skin. The peeling solutions are "painted on," area-by-area, to ensure that the entire face is treated. After the skin heals, discoloration, wrinkles, and other surface irregularities are often eliminated.
Chemical peels are divided into three types: superficial, medium-depth, and deep. The type of peel depends on the strength of the chemical used, and on how deeply it penetrates. Superficial peels are used for fine wrinkles, sun damage, acne, and rosacea. The medium-depth peel is used for more obvious wrinkles and sun damage, as well as for precancerous lesions like actinic keratoses. Deep peels are used for the most severe wrinkling and sun damage.
Dermabrasion uses an abrasive tool to selectively remove layers of skin. Some physicians use a handheld motorized tool with a small wire brush or diamond-impregnated grinding wheel at the end. Other physicians prefer to abrade the skin by hand with an abrasive pad or other instrument. Acne scarring is one of the prime uses for dermabrasion. It also can be used to treat wrinkling, remove surgical scars, and obliterate tattoos.
Laser resurfacing is the most recently developed technique for skin resurfacing. Specially designed, pulsed CO2 lasers can vaporize skin layer-by-layer, causing minimal damage to other skin tissue. Special scanning devices move the laser light across the skin in predetermined patterns, ensuring proper exposure. Wrinkling around the eyes, mouth, and cheeks are the primary uses for laser resurfacing. Smile lines or those associated with other facial muscles tend to reappear after laser resurfacing. Laser resurfacing appears to achieve its best results as a spot treatment; patients expecting complete elimination of their wrinkles will not be satisfied.
Preparation for the chemical peel begins several weeks before the actual procedure. To promote turnover of skin cells, patients use a mild glycolic acid lotion or cream in the morning, and the acne cream tretinoin in the evening. They also use hydroquinone cream, a bleaching product that helps prevent later discoloration. To prevent reappearance of a herpes simplex virus infection, antiviral medicine is started a few days before the procedure and continues until the skin has healed.
Patients arrive for the procedure wearing no makeup. The physician "degreases" the patient's face using alcohol or another cleanser. Some degree of pain accompanies all types of peels. For a superficial peel, use of a hand held fan to cool the face during the procedure is often sufficient. For medium-depth peels, the patient may take a sedative or aspirin. During the procedure, cold compresses and a handheld fan can also reduce pain. Deep peels can be extremely painful. Some physicians prefer general anesthesia, but local anesthetics combined with intravenous sedatives are frequently sufficient to control pain.
Dermabrasion does not require much preparation. It is usually performed under local anesthesia, although some physicians use intravenous sedation or general anesthesia. The physician begins by marking the areas to be treated and then chilling them with ice packs. In order to stiffen the skin, a spray refrigerant is applied to the area, which also helps control pain. Some physicians prefer to inject the area with a solution of saline and local anesthetic, which also leaves the skin's surface more solid. Since dermabrasion can cause quite a bit of bleeding, physicians and their assistants will wear gloves, gowns, and masks to protect themselves from possible blood-transmitted infection.
Antiviral medications should be started several days before the procedure. Laser resurfacing is performed under local anesthesia. An oral sedative may also be taken. The patient's eyes must be shielded, and the area surrounding the face should be shielded with wet drapes or crumpled foil to catch stray beams of laser light. The physician will mark the areas to be treated before beginning the procedure.
Within a day or so following a superficial peel, the skin will turn faint pink or brown. Over the next few days, dead skin will peel away. Patients will be instructed to wash their skin frequently with a mild cleanser and cool water, then apply an ointment to the skin to keep it moist. After a medium-depth peel, the skin turns deep red or brown, and crusts may form. Care is similar to that following a superficial peel. Redness may persist for a week or more. Deep-peeled skin will turn brown and crusty. There may also be swelling and some oozing of fluid. Frequent washing and ointments are favored over dressings. The skin typically heals in about two weeks, but redness may persist.
Following the procedure, an ointment may be applied, and the wound will be covered with a dressing and mask. Patients with a history of herpesvirus infections will begin taking an antiviral medication to prevent a recurrence. After 24 hours, the dressing is removed, and ointment is reapplied to keep the wound moist. Patients are encouraged to wash their face with plain water and reapply ointment every few hours. This relieves itching and pain and helps remove oozing fluid and other matter. Patients may require a pain medication. A steroid medication may be taken during the first few days to reduce swelling. The skin will take a week or more to heal, but may remain very red.
The skin should be kept moist following laser resurfacing. This promotes more rapid healing and reduces the risk of infection. Some physicians favor application of ointments only to the skin; others prefer the use of dressings. In either case, care of the skin is similar to that given following a chemical peel. The face is washed with plain water to remove ooze, and an ointment is reapplied. Healing will take approximately two weeks. Pain medications and a steroid to reduce swelling may also be taken.
All resurfacing procedures can lead to infection and scarring. It is also possible that skin coloration will be altered, or that redness of the skin will be prolonged for many months. Some of the peeling agents used in deep chemical peels can affect the function of the heart.
Depending on the resurfacing techniques selected, it is possible to improve the appearance of skin damaged by sun, age, or disease in many people. Skin resurfacing techniques address only the surface of the skin; procedures such as face-lift surgery or blepharoplasty may be needed to repair other age-related skin changes. All resurfacing procedures are accompanied by some pain, redness, and skin color changes. These may persist for several months following the procedure, but they usually resolve over time.
As noted above, resurfacing procedures can reactivate herpesvirus infections or lead to new, sometimes serious infections. All resurfacing techniques intentionally create skin wounds, creating the possibility for scarring. Abnormal results such as these can be minimized with use of antiviral medications prior to the procedure and good wound care afterward. Selection of an experienced, reputable provider also is key.
American Society for Dermatologic Surgery. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-9830. 〈http://www.asdsnet.org〉.
American Society for Laser Medicine and Surgery. 2404 Stewart Square, Wausau, WI 54401.(715) 845-9283. http://www.aslms.org.
American Society of Plastic and Reconstructive Surgeons. 44 E. Algonquin Rd., Arlington Heights, IL 60005. (847) 228-9900. http://www.plasticsurgery.org.
Actinic keratosis — A crusty, scaly skin lesion, caused by exposure to the sun, which can transform into skin cancer.
Herpesviruses — A family of viruses responsible for cold sores, chicken pox, and genital herpes.
Isotretinoin — A powerful vitamin A derivative used in the treatment of acne. It can promote scarring after skin resurfacing procedures.