Ablativelasertherapyof Skin: J. Kevin Duplechain

A b l a t i v e L a s e r Th e r a p y o f
Skin
J. Kevin Duplechain, MD
KEYWORDS
Ablative laser therapy Thermal relaxation time of skin Fully ablative resurfacing
Fractional resurfacing Carbon dioxide resurfacing Chromophore
KEY POINTS
Skin rejuvenation continues to be one of the most popular requested cosmetic procedures.
Ablative lasers vaporize the tissue, removing all or part of the skin surface in the treatment area. The
damaged skin undergoes healing processes and is replaced with healthy tissue.
The most common indications for both full-field and fractional laser resurfacing are superficial dys-
chromias, dermatoheliosis, textural anomalies, superficial to deep rhytids, acne scars, and surgical
scars.
Using treatment parameters that combine depth of injury, energy of ablation, and density can pro-
vide safe and reliable treatments and consistent outcomes.
Treatment should be tailored according to each patient’s specific needs, skin characteristics, and
treatment area.
Video content accompanies this article at http://www.facialplastic.theclinics.com.
INTRODUCTION energy level applied. At the time of its introduction

into clinical use, resurfacing using the CO2 laser
Ablative laser skin resurfacing is used for removing required high operator skill due to pulse width and
superficial dermal layers of the skin to reduce cuta- power constraints. Continuous-wave devices could
neous signs of photoaging as well as for treatment either be used at high power, which caused less
of facial wrinkles, acne and surgical scars, trau- thermal damage but vaporization depth was diffi-
matic scars, and numerous types of superficial cult to control due to the need to sweep over the
skin lesions, and to enhance the effects of facial skin swiftly and uniformly, or at low power, which
plastic surgery, such as facelift and blepharoplasty. helped control penetration depth but could cause
excessive thermal damage. As a result, the extent
History of the Development of Ablative Lasers
of tissue destruction was unpredictable and was
for Skin Therapy
associated with unacceptable risks of impaired
Continuous-wave carbon dioxide (CO2) lasers for wound healing and scarring.1–3
skin resurfacing were introduced in the 1980s, gain- In an attempt to minimize complications, short-
ing popularity and often replacing chemical peels pulse laser devices were developed, which
and dermabrasion. The 10,600-nm CO2 laser wave- exposed the tissue to less than 1 msec of laser en-
length is absorbed by its primary chromophore, wa- ergy at a time, allowing tissue ablation with limited
facialplastic.theclinics.com
ter, which is heated, vaporizing the tissue and residual thermal damage of approximately 75 to
removing the entire skin surface in the treatment 100 mm. Despite excellent improvement of wrinkle
area. The depth of injury is determined by the appearance and skin laxity tightening within a
Division of Facial Plastic Surgery, Department of Otolaryngology, Tulane Medical School, 1103 Kaliste Saloom
Road, Suite 300, Lafayette, 70508, LA, USA
E-mail address: [email protected]
Facial Plast Surg Clin N Am 31 (2023) 463–473

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464 Duplechain
short period of time, this technology was associ- treatments were required and the clinical response
ated with significant downtime as well as long- was more limited compared with full-field ablative
term hypopigmentation in a large proportion of resurfacing.11,13
patients.4 As ablative lasers vaporize tissue, their effect is
The erbium-doped yttrium aluminum garnet more “destructive” with longer downtime and re-
(Er:YAG) laser, which delivers energy at 2940 nm covery compared with nonablative lasers that
was introduced at the turn of the century. As leave the skin intact. Nevertheless, they result in
2940 nm is at the peak of water absorption, vapor- better improvements when treating severe facial
ization is the primary mode of action, whereas wrinkles, dyspigmentation, and textural skin.
coagulation is minimal and diffusion of heat to sur- Depending on the indication, the technician may
rounding tissue is greatly reduced, lowering the choose to use a specific ablative laser (eg, CO2
risk of scarring and damage to pilosebaceous or Er:YAG) with a multitude of different settings,
units.5 The delivered energy density (fluence) of including fractional versus nonfractional, to achieve
the Er:YAG laser is linearly correlated with the the desired result and, more importantly, minimize
depth of tissue ablated, with 3 to 4 mm of tissue laser-associated complications such as scarring,
removed per J/cm2; thus, multiple passes can be persistent erythema, and dyspigmentation.
used to produce deeper tissue removal without
additive residual thermal injury. As a result, the
Patient Selection
recovery time to full epithelialization after deep
full-field Er:YAG laser resurfacing is 7 to 10 days Careful patient selection and knowledge of poten-
followed by 3 to 6 weeks of erythema. Compara- tial complications are essential for achieving
tive studies have shown that the combined depth consistent results. The initial consultation should
of ablation and coagulation determined the length begin with an evaluation of the patient’s ethnicity,
of recovery following the use of Er:YAG lasers.6,7 skin type, and degree of photodamage. Darker
Variable or long-pulse Er:YAG lasers enable con- skin types (IV–VI) have increased epidermal
trolling the amount of residual thermal injury pro- melanin, larger and more widely distributed mela-
duced for a given amount of tissue removal. nosomes, and reactive fibroblasts,14which result
Comparison of Er:YAG to CO2 resurfacing showed in a tendency for hyperpigmentation in response
more long-term wound contraction and fibroplasia to light stimuli or trauma.15 The characteristics of
with CO2 treatments.8 photoaging differ by ethnicity. For example, photo-
Additional advances in skin resurfacing tech- aging in Asian individuals is characterized by
niques occurred with the introduction of fractional pigmentary alterations, lentigines, and seborrheic
photothermolysis technology, whereby the laser keratoses rather than fine lines and deep rhytids
beam is manipulated through a diffractive lens, observed in Caucasian individuals.16,17
creating multiple microscopic laser beams. Each Understanding patients’ expectations in an
microscopic laser energy beam creates small esthetic treatment is crucial. For example, ablative
columns (< 400 mm in diameter) of thermal damage, laser resurfacing may be used for improving tone,
called microscopic thermal zones (MTZs), whose texture, and wrinkles but it is not a substitute for a
penetration depth is proportional to the laser en- facelift or a necklift. During the initial consult, the
ergy emitted. Fractionating the pulsed ablative treating physician should discuss healing times
laser energy that covers only a fraction of the and the return to social and work-related activities.
treated area (approximately 5%–30%) enables These timelines will affect the type and intensity of
rapid reepithelialization from the undamaged, adja- the treatment rendered.
cent epidermis separating the MTZs, facilitating The most common indications for both full-field
repair and remodeling of the epidermis and and fractional laser resurfacing are superficial dys-
dermis.9 Histologically, the MTZ of ablative frac- chromias, dermatoheliosis, textural anomalies, su-
tionated laser comprise a central column of perficial to deep rhytids, acne scars, and surgical
stratum corneum, epidermal, and dermal ablation scars. Other conditions that may respond favor-
lined by a thin eschar and surrounded by an annular ably include rhinophyma, sebaceous hyperplasia,
coagulation zone (penumbra).10,11 In contrast to xanthelasma, syringomas, actinic cheilitis, and
full-field resurfacing whereby healing occurs from diffuse actinic keratoses. Dyschromias such as
deep structures only, healing following ablative melasma have been successfully treated with frac-
fractional photothermolysis occurs from adjacent tional resurfacing but results are not consistent.
structures as well as from deeper structures. This Better treatments for melasma currently exist,
less destructive technology further reduced the particularly with the advent and use of tranexamic
incidence of adverse events and increased the de- acid accompanied by nonablative neodymium-
gree of therapeutic control12; however, multiple doped YAG laser treatments.
Ablative Laser Therapy of Skin 465
Pretreatment Considerations chemical sunscreens.32,33 Topical skin bleachers/

lighteners, such as ascorbic, tranexamic, glycolic
Herpes simplex virus 1 reactivation may occur in
and kojic acids, and hydroquinone, may be used
patients undergoing ablative facial laser resurfac-
for treating hyperpigmentation after erythema has
ing and may delay healing and result in severe
subsided.22,34,35
scarring18; therefore, antivirals should be pre-
Thermal damage may cause localized immuno-
scribed to every patient.19–21
suppression that may lead to a secondary infec-
Ablative resurfacing can produce a myriad of
tion.36 The use of topical antibiotics to prevent
wounds from very superficial epidermal injuries to
infection during wound healing is limited by the risk
deeper dermal wounds. The extent of the wound
of contact dermatitis in laser-abraded skin.4,20,23,37
healing period and the final cosmetic outcome
Antivirals should continue to be used after
depend on the preoperative and post-resurfacing
the treatment to prevent herpes simplex virus 1
care regimes.22 Bacterial infection after laser skin
reactivation.19–21
resurfacing may affect healing by increasing the
I currently use a formulated perfluorodecalin
depth of the original wound and delaying reepitheli-
product which has been shown to accelerate
alization, consequently increasing the risk of persis-
wound healing and significantly reduce postproce-
tent erythema, dyschromias, and scarring.23
dure complications including persistent erythema,
Infections are sometimes noticeable only in the
acneiform eruptions, and delayed healing.38
second week after the procedure.24 Infectious
agents identified following laser resurfacing proced-
ures were similar to those reported for burn injuries, Treatment Parameters
including Pseudomonas aeruginosa, Staphylo-
When planning an ablative resurfacing treatment
coccus aureus, Staphylococcus epidermis, and
for any area of the body, three factors must be
Staphylococcus aureus.25,26 Prophylactic oral anti-
considered: energy used, density, and the pulsed
biotics should be prescribed to prevent secondary
duration of the laser. As skin depth differs
bacterial infection.23 Oral antibiotics should be
throughout the face and body, it is imperative to
started 1 day before the procedure and be continued
consider skin depth when selecting the appro-
until reepithelialization has been completed.20,21,24
priate energy level. New technology lasers, such
Although it is debated whether pretreatment
as the Lumenis Alpha UltraPulse, now provide
with topical bleaching agents, such as hydroqui-
depth of injury parameters as energy levels are
none cream, reduce the risk of post-inflammatory
selected. The density must also be adjusted ac-
hyperpigmentation after laser resurfacing,27,28
cording to the treatment area and the depth of
this has been shown in darker skin types, espe-
injury. Fully ablative treatments remove the entire
cially after laser resurfacing.28
surface area of the treated zone. The wound or
Patients who were exposed to the sun or
depth of injury can be very superficial, affecting
actively tanned should wait until the tan fades (2–
the epidermis only, or it can reach papillary or
4 weeks) before starting ablative laser therapy.29
reticular dermal elements. Deeper penetration
into the reticular dermis must be fractionated and
Posttreatment
should be reserved for facial treatments. Creating
Treatment with any ablative laser system involves an injury that extends into the reticular dermis in
a healing phase that usually lasts 5 to 10 days. non-facial areas has been shown to significantly
The lack of postablative laser treatment proto- increase the risk of scarring (Fig. 1). The pulsed
cols was responsible to some degree for the duration of the laser must also be considered.
demise of ablative CO2 use in the 1990s. Post- The thermal relaxation time (TRT) of skin is approx-
treatment care should be diligent and the physi- imately 8 msec.39 The ability to lase and success-
cian must be involved in all of its care aspects. fully ablate skin within the TRT significantly
Application of topical corticosteroids immedi- reduces the risk of additional coagulation, thereby
ately after ablative skin resurfacing treatment preventing the enlargement of the laser ablation
has been shown to effectively decrease post- wound, which essentially affects the density of
inflammatory hyperpigmentation, especially in indi- the rendered treatment. Longer pulsed lasers
viduals with dark skin types.30 The persistent use of that mimic the early scanner type devices are
corticosteroids may however significantly reduce known to create wounds with significantly longer
the expression of messenger RNA and significantly wound healing times and increased complica-
reduce the amount of collagen regeneration post- tions. The primary reason for this phenomenon is
procedure.31 Mineral sunblocks that contain tita- the time on tissue or pulse width.
nium dioxide or zinc oxide prevent potential I have been using the UltraPulse CO2 Laser Sys-
sensitization effects associated with the use of tem (Lumenis BE, Yokne’am, Israel) since 2008.
466 Duplechain
Perioral Treatment
The perioral area often requires a more aggressive
treatment. Because the epidermis and papillary
dermis in the perioral area approach a depth of
250 mm,42 higher energy settings may be safely
used. Commonly, a deep scanner is used at a den-
sity of 15% and energy of 17.5 mJ to reach a depth
of 600 mm. With this setting, two passes may be
safely performed. Once completed, the superficial
scanner may be used at 100 to 125 mJ with a den-
sity setting of 80%. This will essentially remove all
of the epidermal and some papillary dermal com-
ponents, resulting in a deeper injury consistent
Fig. 1. Penetration into the reticular dermis in non- with a second-degree burn. This more aggressive
facial areas has been shown to significantly increase treatment will require approximately 10 days to
the risk of scarring. The photo depicts a neck 7 days heal (Fig. 3).
after fractional erbium resurfacing.
Hand Rejuvenation
The settings described below reflect my experi-
ence with this device. Rejuvenation of the hands continues to be an inter-
est of many patients. Ablative laser treatment
Periorbital Treatment combined with a filler, such as fat or calcium
hydroxylapatite, can significantly improve the
Changes around the eyes are often among the first appearance of the hands. Typically, the dorsal
perceived signs of facial aging. Fractional CO2 area of the hands is prepared for a sterile injection
laser treatment is a useful noninvasive alternative technique. A small amount of local anesthesia is
to blepharoplasty for reestablishing a more youth- placed between the four knuckles. A 25-gauge
ful appearance. In addition, it is a valuable adjunct cannula is used for injecting the calcium hydroxyl-
to blepharoplasty to improve the textural changes apatite, whereas a 19 gauge cannula is used for
associated with aging. injecting fat. To provide additional comfort, a small
Common treatment parameters for this area amount of lidocaine is mixed with the fat before in-
include a fractionated treatment around the lateral jection. Once the injection is completed, the hands
canthal area at an injury depth of approximately are superficially lasered at a power setting of
550 mm using energy of 15 mJ and 20% density. 80 mJ and 50% density. The healing process usu-
The DeepFX scanner (Lumenis) is set to a density ally takes about 2 weeks, with few limitations. The
of 10%, and two passes are completed. Recent laser power settings typically cause minimal crust-
advances with a randomized deep mode have ing, and most patients find recovery simple.
demonstrated the ability to increase density to
approximately 20% in a single pass without signif-
Neck Rejuvenation
icant changes in healing. The area is then treated
with the superficial Active FX scanner (Lumenis) The aging neck is characterized by lipodystrophy,
at 80 mJ with a density of approximately 50%. platysmal bands, and jowls that extend into the
The laser must not be used to treat the area below neck.43 As jowls develop, the chin and jawline
the supratarsal fold on the eyelid. In addition, lose definition and horizontal and radial necklines
metal eye shields should be used in all cases of become more noticeable.44 Like the face, the
facial skin resurfacing. At these settings, the depth neck is subject to photodamage.45 Patients who
of injury using the superficial scanner reaches the seek facial rejuvenation often request a neck treat-
papillary dermis of the eyelid skin. Decreasing ment to ensure a homogenous and completely
the density has proven to minimize the risk of scar- rejuvenated face and neck.
ring or ectropion related to resurfacing.40,41 I have The use of CO2 laser for neck skin rejuvenation
found no occurrences of delayed healing or ectro- has been described in several studies.46–49 Re-
pion with these parameters. ports of scarring have raised concerns about
Treatment benefits include improvement or deep neck treatments.50,51
disappearance of mild to moderate rhytids, Before starting neck skin rejuvenation, it is
improved skin texture and tone, decreased pore crucial that the expectations of both the surgeon
size, and improvement and reduction in skin laxity and patient are aligned. It is important to under-
(Fig. 2) stand that aggressive deep neck treatments are
Fig. 2. A female patient (A) before and (B) 3 months after undergoing blepharoplasty and facelift with combined
deep and superficial CO2 resurfacing. Note the significant improvement in the quality of the skin.
not a replacement for neck and facelift surgery and skin adnexal structures; therefore, laser treatment
therefore should not be performed. Attempts to parameters must be modified significantly to
injure the platysma muscle to elevate and tighten safely treat this area. The skin above the first cer-
it should not be performed with an ablative laser. vical crease is more similar histologically to facial
The key components of the neck skin should be skin, and settings can be similar to those used
considered when planning treatment. Beyond the for treating facial skin along the jawline. During
first cervical crease, the neck skin is deplete of facelift and necklift surgery, the neck is treated to
Fig. 3. A 74-year-old patient (A) before and (B) 11 days after undergoing a facelift and fat grafting with com-
bined deep and superficial CO2 resurfacing. The early result at 11 days indicates acceptable healing times even
with combined therapy.
468 Duplechain
improve the overall skin texture, but additional patients reported that their hidradenitis suppura-
tightening is usually not performed. Completely tiva was inactive 12 months after the laser treat-
undermined neck skin may be treated safely with ment. Two patients still had active hidradenitis
ablative CO2 laser using the UltraPulse device at suppurativa at untreated sites adjacent to treated
an energy setting of 80 mJ, with a density of sites within the anatomical unit. One patient devel-
50% and a frequency of 250 Hz. oped discharging lesions at treated sites 3 months
after surgery. Further laser treatment at this site
was effective in achieving remission. Seven pa-
Treatment of Scars
tients were able to discontinue all systemic treat-
Ablative fractional CO2 laser is currently considered ments without relapse. Scar contracture not
the gold standard treatment for hypertrophic scar- restricting limb mobility was noted in two patients.
ring. The use of the CO2 laser for treatment of facial Hazen and Hazen56 reported on treatment of 61 pa-
acne scarring was reported in four studies. In a tients aged 21 to 73 years. Following treatment with
study on 25 patients aged 17 to 62 years, patients the CO2 laser, all patients healed with cosmetic and
demonstrated overall improvement of acne scar- comfort qualities deemed acceptable to excellent
ring with significantly greater degrees of improve- in all areas. There were no instances of reduced
ment in the forehead, perioral region, and medial range of motion. Follow-up after treatment noted
cheek compared with the temple and lateral cheek. an average of 4.1 years without disease recurrence
There were no cases of prolonged hyperpigmenta- in treated areas (range 1–17 years).
tion or erythema persisting beyond 3 months and Acikel and colleagues58 investigated the effec-
no long-term complications were reported.52 His- tiveness of CO2 laser resurfacing and thin skin
tologic examination of skin biopsy specimens grafting in camouflaging self-inflicted razor blade
from nine patients (age range, 25–41 years, Fitzpa- incision scars in the upper arm, forearm, and ante-
trick skin types I–IV) taken immediately after treat- rior chest of 16 white male patients aged 16 to
ment with the CO2 laser showed full-thickness 41 years. All of the procedures were successful,
loss of epidermis with formation of a homogeneous and the postoperative course was uneventful for
hypereosinophilic zone of thermal damage in the all of the patients. Skin graft donor sites healed
papillary dermis, extending focally into the reticular in 5 to 7 days. Hair growth through the skin graft
dermis. Skin biopsy specimens taken after was excellent, and normal hair patterns were
3 months showed a thick band of papillary dermal regained over the treatment sites. Eighty percent
fibrosis in skin treated with the CO2 laser.53 Vapor- of the existing hypertrophic scars were totally
ization depth and residual thermal damage resolved after the operation; 20% of hypertrophic
following use of the “superficial” or “deep” scan- scars showed a tendency to recur and responded
ning modes of the 40 W continuous-wave CO2 laser well to repetitive intralesional steroid injections
was similar in biopsies taken from 14 patients aged and silicone gel sheeting. Complications included
24 to 54 years with Fitzpatrick skin type I–IV.54 partial graft loss on the anterior chest caused by
Moderate to severe acne scars significantly inadequate immobilization was observed in one
improved following treatment with the CO2 laser patient and the wound reepithelialized spontane-
using a “double-layer” technique.55 Varying de- ously. Significant hyperpigmentation developed
grees of pain, erythema, edema, oozing of blood, in one patient who did not protect the grafted
and exudate were observed immediately after area from sunlight. Small inclusion cysts were
each treatment. Two cases (10%) of persistent er- observed in five patients in the early postoperative
ythema were reported which lasted for 2 to 3 days period, which were treated by opening the top of
and two cases (10%) of hyperpigmentation which the cyst and removing the contents.
lasted 3 to 5 days. Average downtime was 6 days. Du and colleagues59 reported apparent esthetic
The use of the CO2 laser was found to be a highly scar improvement following CO2 laser treatment
effective therapy for management of the persistent, before skin suture during scar revision surgery in
scarred, and sinus tract lesions of hidradenitis sup- 10 patients aged 22 to 47 years with Fitzpatrick
purativa.56,57 Madan and colleagues57 reported on skin types III–IV. Erythema was resolved within
CO2 laser treatment of recalcitrant hidradenitis 3 months in all of the cases. No cases of perma-
suppurativa in nine patients aged 27 to 52 years nent hyperpigmentation, hypopigmentation, or
who had failed to improve on medical and other scar hyperplasia were observed.
surgical treatments. Mean wound healing time Zhang and colleagues60 compared the out-
was 2 weeks (range 1–4). Good clinical results, evi- comes of treatment of fresh surgical scars longer
denced by absence of active discharging lesions at than 2 cm in the neck and face with CO2 laser to
the treatment sites, were seen in seven patients the outcomes of untreated surgical scars. All 18
with no recurrence at 12-month of follow-up. Six patients in the treatment group had significant
improvements in their surgical scars after the laser ablation. Treatment parameters are typically 90 to
therapy. Assessments from both patients and phy- 100 mJ with 70% to 80% density. The neck is
sicians were highly consistent. The overall effec- commonly treated as using energy of 70 to 80 mJ
tive rate was 100%, with excellent responses in with 50% density.
16 patients (88.9%) and good responses in two The simultaneous treatment of facelift and abla-
patients (11.1%). The most significant improve- tive laser skin rejuvenation significantly improves
ments were color, vascularity, and hardness, the final results of facial rejuvenation. Patients
which all reached statistically significant differ- are extremely satisfied with the adjunctive proced-
ences before and after the treatment. Untreated ure, and do not find the healing time of 1 week a
scars improved statistically significant less than significant issue. The UltraPulse device used by
the CO2-treated scars. the author possesses a coherent beam. Coupled
with the ultra-short pulse duration, a painting tech-
Combined Surgical and Ablative CO2 Laser nique is used to reach the desired density without
Treatments as an Adjunct to Facelift creating any stamping or true delineation of lased
and non-lased skin. The attached video demon-
The ability to safely resurface skin during facelift
strates this technique (Video 1)
surgery is a key component of successful facial
rejuvenation. For many years, it was considered un- Case study 1
safe to perform laser skin ablation on undermined A 54-year-old patient had extensive weight loss
skin during facelift/necklift. The procedures were over 18 months and chose to have facial rejuvena-
commonly staged, and patients were treated later, tion. She was interested in having a natural look
after the facelift had healed, or areas of undermined and wanted to see some improvement in her photo-
skin were not treated. Chemical peels were often aged skin. She underwent an endoscopic brow lift,
used in the perioral area, but not elsewhere. I per- upper and lower lid blepharoplasty, and a deep-
formed 35% trichloroacetic acid peels during face- plane facelift. Fat grafting was also performed as
lift surgery for some time, and although no scarring well as a full face and neck CO2 resurfacing proced-
occurred, the results were inconsistent probably ure. CO2 treatment settings were 100 mJ at a den-
due to being cautious not to over penetrate the sity of 80% and a frequency of 250 Hz (Fig. 4).
skin with the peeling solution. With the advent of
more precise ablative laser technology, I began to Case study 2
use laser resurfacing in patients undergoing face- A 52-year-old patient with extensive sun exposure
lifts in 2008. The results of combined skin rejuvena- was seen in consultation for facial rejuvenation.
tion and facelift were dramatic, as the "canvas" had Her extensive sun exposure and long history of
been completely rejuvenated as well. Currently, smoking presented several concerns regarding
deep plan facelift is performed in my practice, but treatment, including the simultaneous use of laser
I do elevate a skin flap of approximately 5 to 6 cm resurfacing during a surgical procedure. The patient
before entering the deep plane. The areas over underwent an endoscopic brow lift, facelift, upper
the deep plane and the more superficial skin-only and lower blepharoplasty, fat grafting, and full
flap are lased using the same settings. I have not face and neck laser resurfacing with the CO2 laser
encountered skin loss in these areas with over (settings: energy 90 mJ, 90% density, frequency
1500 cases of combined facelift and laser skin 250 Hz, depth of injury approximately 80 mm).
Fig. 4. Frontal view before (A) and 1 month after surgery (B). Lateral view before (C) and 1 month after surgery (D).
470 Duplechain
Fig. 5. Frontal view before (A) and 3 months after surgery (B). Lateral view before (C) and 3 months after surgery (D).
Although her face healed without complications, eschar was removed, a second pass was per-
she did have a small amount of skin loss in the post- formed at 80 mJ, 50% density, and 250 Hz (Fig. 6).
auricular area which was not lased (Fig. 5).
DISCUSSION
Case study 3 Ablative laser skin resurfacing is a very powerful
A 74-year-old patient requested to treat her treatment of patients who desire an improvement
smoker’s lines in the perioral area. She also in the quality of their skin. As a stand-alone proced-
requested complete facial rejuvenation, including ure, it can significantly improve fine wrinkles,
an endoscopic brow lift, facelift, upper and lower pigmentation issues, and actinic keratosis. When
blepharoplasty, and full-face skin resurfacing. used in conjunction with deep fractional resurfacing,
The perioral area was treated with 125 mJ, 100% volumetric reduction may occur, which can reduce
density, and a frequency of 250 Hz. Once the the general surface area of the treatment area
Fig. 6. Frontal view before (A) and 3 months after surgery (B).
and decrease the apparent laxity. When used in DISCLOSURE

conjunction with a surgical procedure such as face-
lift, skin rejuvenation includes additional tightening J.K. Duplechain is a member of the Speakers’ bu-
and collagen restoration along with a completely reau of Lumenis and Apyx Medical and reports
fresh "canvas.” These outcomes provide a signifi- ownership of Cutagenesis stock options.
cant benefit and joy to the patient’s experience.
Skin resurfacing relies on the laser device to SUPPLEMENTARY DATA
provide safe ablation and coagulation in a finite Supplementary data related to this article can be
period to prevent overheating and over-ablation found online at https://doi.org/10.1016/j.fsc.2023.
or coagulation. Longer duration treatments 05.002.
outside the TRT of skin account for unsuspected
complications such as burns or an extremely REFERENCES
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Video content accompanies this article at http://www.facialplastic.theclinics.com.

INTRODUCTION energy level applied. At the time of its introduction

Facial Plast Surg Clin N Am 31 (2023) 463–473

Pretreatment Considerations chemical sunscreens.32,33 Topical skin bleachers/

and decrease the apparent laxity. When used in DISCLOSURE

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