Skin Resurfacing: Then and Now

NEW YORK, NY (October 4, 2002) — Aging, heredity, sun exposure and lifestyle can alter a person's skin, causing wrinkles and pigmentary changes such as blotchiness or brown spots. Today, there are a variety of surgical and nonsurgical ways to address these problems. Creams, lotions, peels, dermabrasion and lasers all play a role in the battle against aging skin. Over a million-and-a-half Americans had some type of skin resurfacing treatment in 2001, according to statistics from the American Society for Aesthetic Plastic Surgery (ASAPS). This number is expected to rise, as the results of available treatments improve and recovery times diminish.

Chemical peels, dermabrasion and laser skin resurfacing all achieve results in basically the same way. Layers of skin are removed and, as healing progresses, a new, healthier-looking skin emerges. What differentiates the various resurfacing methods is the way in which the skin's layers are removed. Peels involve the application of a chemical solution, dermabrasion utilizes a high-speed rotary wheel, and laser resurfacing uses a laser beam.

Skin resurfacing does not treat excessive skin laxity of the face and neck. It is not a substitute for, but can certainly complement, a facelift.

Skin Resurfacing: How have things changed?

Since the beginning of recorded history, people have tried to influence the aging process by using "potions" and creams to help their skin look its best. It has been said that Mark Antony conquered the lands of the Dead Sea so that Cleopatra could use the water, salt and mud for cosmetic purposes. Sea Buckthorn was used by the ancient Greeks to promote the healing of various skin conditions. The Egyptian queen Nefertiti is believed to have used Shea Butter to prevent wrinkles.

Today, many people use over-the-counter creams, lotions, and exfoliants to treat facial blemishes, smooth the skin, or encourage a healthy-looking glow. However, skin care has come a long way, and medically-supervised treatments using scientifically-based formulas and state-of-the-art technology are widely recognized as desirable for optimal skin beauty and health.

Skin Resurfacing: Where are we now?

In the early days of modern skin resurfacing, phenol was the only agent used for full-face application. Throughout the 1960s, 70s and 80s, phenol was the resurfacing modality of choice. A phenol peel still may be recommended for treating particularly rough and sun damaged skin. Phenol is a strong and effective chemical agent that reduces the appearance of wrinkles ranging from fine lines to deeper creases. It is particularly useful for minimizing the deep vertical lines that often form around the mouth as a result of aging or smoking. The disadvantage of phenol for spot peeling of limited areas is that it often has a significant bleaching effect. Although the traditional phenol peel may still be appropriate for some patients, it has largely been replaced by other milder peels, including newer variations of "buffered" phenol peels that have added ingredients to produce a gentler solution.

A trichloroacetic acid (TCA) peel is another treatment for wrinkles, pigmentary changes and blemishes. Unlike a phenol peel, patients can benefit from having TCA applied not only to 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, with lighter application, they can have less of a bleaching effect. 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 a cumulative effect, or TCA can be used to achieve a medium or even a deep peel, depending on the acid concentration and manner of application.

Light peels -- those containing alpha hydroxy acids (AHA's) such as glycolic acid -- can be used to give the skin a fresher, healthier appearance without downtime or the use of anesthetic. Repeated treatments can help to further improve skin texture. AHA peels can reduce the effects of aging and sun damage including wrinkling and brown spots, but usually not to the extent of deeper treatments.

Dermabrasion is another form of skin resurfacing utilized by plastic surgeons. This technique uses a small, rapidly spinning wheel with a texture similar to fine-grained sandpaper to abrade the skin, removing its upper layers. Dermabrasion sometimes is selected for the treatment of facial scars. It is effective in reducing the appearance of vertical wrinkles around the mouth that often cause lipstick "bleed." Patients with lighter skin types can expect minimal pigmentary change in the treated areas, whereas those with darker skin are at a higher risk for hyperpigmentation3 or hypopigmentation4.

Microdermabrasion is a relatively new resurfacing technique; it has only been available in the United States for a few years. With microdermabrasion, the depth of the skin injury is typically controlled so that it barely extends through the epidermis (outermost layer of skin). No anesthesia is required for the procedure, and the end point of the treatment is mild erythema.2 A true "lunch hour" procedure, patients can reapply make-up and return to work or other activities immediately.

Laser resurfacing is a commonly used technique for skin resurfacing. The effects of a laser are similar to the other procedures, except that the laser removes skin layers by vaporization rather than with chemicals or a sanding device. Skin characteristics such as thickness, texture and color influence whether a person is 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; the skin-tightening effect from laser-treatment in this area may not always be long-lasting.

The carbon dioxide (CO2) laser and the Erbium laser are commonly used for skin resurfacing procedures. While the CO2 laser has been used for some time and is highly accepted, the newer Erbium laser is also popular. The Erbium laser produces less thermal damage per impact, so wound healing and recovery time are more rapid. In experienced hands, the Erbium laser may achieve similar results to the CO2 laser with less risk of complications. As a result, there is an increasing utilization and acceptance of this device.

Despite the efficacy of ablative systems, the downtime during recovery may be too much for many patients. The desire for corrective procedures which minimize downtime has led to an increase in the popularity of nonablative5 systems. Current nonablative laser systems vary in the way they achieve results. Some heat the deep dermis while protecting the skin's surface with a spray coolant. Others may partially disrupt the superficial skin vessels causing a cellular response which promotes new collagen formation.

The nonablative or nonexfoliating laser rejuvenation of facial wrinkles is relatively new and requires additional investigation to evaluate its effectiveness. Studies are underway to further develop the devices and techniques. This modality may be particularly applicable for those individuals who are poor candidates for conventional laser resurfacing because of deeply pigmented skin, which places them at high risk for post-procedure pigmentation irregularities, or for those patients who have already undergone a laser resurfacing procedure. However, some plastic surgeons remain unimpressed by results obtained with the current generation of nonablative lasers.

Intense pulsed light (IPL) technology
is yet another skin resurfacing technology. With this technology, the energy source is not limited to a single wavelength, but modulated with filters. A series of sessions is necessary to provide a lasting benefit. IPL is effective in treating brown age spots, broken blood vessels, rosacia6, and flushing while improving skin texture and pore size. A smoother, brighter, more homogeneous skin appearance can be expected in the majority of patients who complete 5 to 6 treatments. Very limited downtime is involved -- usually just a few hours of redness. Patients with extremely sun damaged skin, however, may experience a few days of mild to moderate crusting; downtime is less with each successive treatment. Like nonablative lasers, the current IPL technology is still being evaluated, and some surgeons feel that it does not yet offer sufficient benefit.

Doctors are studying the effects of combining certain skin-resurfacing treatments for optimal results. For example, combining microdermabrasion and a trichloroacetic acid peel has been reported as an effective treatment for photodamaged skin, more severe acne scarring, and moderately deep wrinkles.

Many board-certified plastic surgeons are now offering nonsurgical skin care as part of their cosmetic surgery practice, offering patients the full range of options when it comes to choosing appropriate treatments.

Glossary of terms:

1. Dyschromia: A skin condition causing any abnormality in the color of the skin.
2. Erythema: A skin condition causing redness due to capillary dilation
3. Hyperpigmentation: A skin condition causing an excess of pigment.
4. Hypopigmentation: A skin condition causing a deficiency in pigment.
5. Nonablative: Nondestructive of outer tissue while stimulating collagen creation in thedermis
6. Rosacea: A skin condition causing dilated blood vessels, or flushing, and pustules on the nose and cheeks.

About ASAPS
The American Society for Aesthetic Plastic Surgery (ASAPS), is recognized as the world’s leading organization devoted entirely to aesthetic plastic surgery and cosmetic medicine of the face and body.  ASAPS is comprised of over 2,600 Plastic Surgeons; active members are certified by the American Board of Plastic Surgery (USA) or by the Royal College of Physicians and Surgeons of Canada and have extensive training in the complete spectrum of surgical and non-surgical aesthetic procedures. International active members are certified by equivalent boards of their respective countries. All members worldwide adhere to a strict Code of Ethics and must meet stringent membership requirements.

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