Management of Aging Skin

Management of Aging Skin 26
Stephen W. Perkins | Heather H. Waters
Key Points
Combined resurfacing modalities tailored to skin type and location are more effective than a single
modality alone.
The ideal patient for skin resurfacing is the thin-skinned woman with a fair complexion and fine

rhytids.
Impairment of liver and/or kidney function could slow the excretion of phenol and increase the

likelihood of cardiac complications.
All patients should receive appropriate antiviral therapy to prevent and treat possible herpetic

outbreaks prior to skin resurfacing.
Retinoic acid increases the depth of chemical peels by decreasing the thickness of the stratum

corneum.
Fitzpatrick type III or higher should consider the use of 4% to 8% hydroquinone gel before and

after resurfacing to prevent hyperpigmentation.
Superficial peels extend to the papillary dermis, medium-depth peels extend to the upper reticular

dermis, and deep peels extend to the midreticular dermis.
Indications for medium-depth peel are moderate photoaging, actinic keratosis, pigmentary

dyschromia, mild acne scarring, and blending of other modalities.
Pigmentary changes are the most common complication of chemical peels.

Carbon dioxide or erbium:yttrium-aluminum-garnet laser is particularly good for treating perioral
vertical furrows, periocular crows feet, glabellar rhytids, diffuse acne scarring, and age spots.
Nonablative resurfacing usually requires multiple treatments to obtain the desired effect.

Multiple superficial peels do not equate to single moderate or deep peels.
A ging skin is one of the primary characteristics of the aging the epidermis with fibrous strands that consistently paralleled
face that must be addressed as a part of comprehensive facial the newly formed epidermis. Later, Kligman and colleagues3
rejuvenation. Proper skin care regimens can be started at an studied the skin taken from Baker and Gordons facelift patients
early age to decrease the amount of photoaging, dyschromias, who had chemical peels 18 months to 20 years earlier. First,
and superficial scarring that a person accumulates over time. they described histologic changes of nonpeeled skin; these
Even though these preventive measures are becoming more aging skin changes were typical of actinic exposure with a loss
commonplace, many patients still seek treatment of their aging of orderly differentiation in the epidermis and degeneration of
skin to reverse this process. This chapter focuses mainly on the elastic network, along with some mottled pigmentation and
the resurfacing techniques available to treat advanced skin lymphocytic infiltration. The amount of collagen was decreased,
damage. Chemical peels and laser ablative techniques have and disordered degeneration of the dermal fibers, a flattening
been proven to produce substantial results in a consistent of the dermal-epidermal junction, and multiple actinic kerato-
manner. We will also discuss the increased utilization of nonab- ses with atypia were evident. The number of melanocytes was
lative and fractionated ablative laser therapy. Additional topics, increased in this actinic skin, but they were unevenly distrib-
including dermabrasion and medical skin care regimens, will uted and contained variable amounts of melanin.
also be addressed. Each of these techniques alone can produce The skin of patients who had undergone a previous chemi-
predictable results in selected patients. However, it has been cal peel showed a new band of dermis 2 to 3mm thick just
our experience that combined modalities tailored to skin type beneath the epidermis and lying on top of the old elastotic
and location can be most effective.1 dermis. The epidermis had returned to orderly cellular differ-
entiation without irregularities or microscopic actinic kerato-
ses. Although an abundance of melanocytes were present and
CHEMICAL PEELS contained some fine, evenly distributed melanin granules,
impaired melanin synthesis with a generalized bleaching
HISTOLOGIC CHANGES OF AGING SKIN effect, or hypopigmentation, was apparent. Lentigines were not
The first scholarly report on phenol chemical peels was written seen. Furthermore, the epidermal-dermal matrix was com-
by Brown and colleagues.2 Brown described the histologic posed of thin, compact, parallel collagen bundles arranged
changes that were induced, including laminated collagen in horizontally in contrast to the usual wavy pattern. Elastotic
391
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392 PART III | FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY
fibers had actually regenerated, forming a network of fibers

TABLE 26-1. Fitzpatrick Sun-Reactive Skin Types
paralleling the new collagen. Finally, the lymphocytic infiltra-
tion was diminished compared with that of untreated skin. Type Description
Kligman and colleagues3 believed that the dermal reconstruc- I Fair-skinned, blue or hazel eyes, blond or red hair
tion lasted about 20 years based on their study. They further Always burns, never tans
concluded that chemical peel reduced the development of new II Fair-skinned; blond, red, or brown hair
neoplasms. The laying down of a band of new connective tissue Usually burns, tans less than average
can adequately account for the effacement of the wrinkles seen III Fair-skinned, largest group of U.S. citizens
clinically. The skin is smoother, fuller, and tighter. Stegman4 Sometimes burns mildly, tans about average
and Litton and colleagues5,6 showed the chemical peel solution
IV Still considered white skinned
penetrating deeper in the dermis of actinically damaged skin
Rarely burns, tans more than average and with ease
than in nonactinically damaged skin. Hayes and Stambaugh7
demonstrated that during the first 2 to 5 days of a chemical V Intermediate-colored skin (Asian, Latin, Indian)
peel, epidermal necrosis, edema, and homogenization are Brown skin
seen with the lymphocytic infiltration all the way into the reticu- VI Black skin
lar dermis.8 At 2 weeks, new collagen formation had begun. Never burns
Stegman,4 Alt,9 and Brody and Alt10 have illustrated that pen-
etration of phenol is deeper with occlusion than with non-
occlusion. According to Beeson and McCollough,11 this is photoaging and are best managed with a superficial peel in
apparently true but not necessarily desired. conjunction with a good medical skin care program. Patients
Litton and others6 agreed with Kligman and colleagues3 that in categories II and III are candidates for medium-depth peels
the rate of appearance with precancerous and early cancerous in addition to long-term medical therapy as with retinoids or
lesions of photoaged skin was decreased after a phenol chemi- alpha-hydroxy acids. Category IV photoaging patients are best
cal peel. treated with medium or deep chemical peels, ablative lasers, or
Brodland and Roenigk12 showed that trichloroacetic acid dermabrasion in conjunction with long-term medical skin care
(TCA) destroys the epidermis and upper dermis and further regimens.
showed that the new epidermis migrated from the cutaneous
adnexa beneath the destroyed tissue. This is similar to phenol
peel. Histologically, the atypical clones of keratinocytes are
THERAPEUTIC INDICATIONS
removed and replaced by normal epidermal cells. Several aesthetic and therapeutic indications exist for chemical
peels and resurfacing (Box 26-1), and todays facial plastic
PATIENT EVALUATION, CLASSIFICATION, surgeon must be aware of these to effectively rejuvenate aging
skin. Additionally, treating a patient based on his or her Fitz-
AND SELECTION patrick skin type and Glogau aging characteristics is essential
The process or technique of chemical peels, as well as other to select the best type and depth of facial resurfacing.
resurfacing modalities, is relatively easy to learn. However, it
takes a great deal of experience with many different types of
patients to learn the wide variation in skin types and how these
CONTRAINDICATIONS
respond to peel solutions.13 It also takes a great deal of experi- A few relative contraindications to chemical peels exist in addi-
ence to predict how each area of the face will respond to light tion to some absolute contraindications (Box 26-2). In the past,
or deep resurfacing in an individual patient and to influence a history of herpes simplex virus was a contraindication to
the method of application used. Careful selection of the appro- chemical peel.19 However, with the advent of antiviral drugs,
priate patients for resurfacing is the first and most important acyclovir or valacyclovir can be effectively used as a preventive
consideration. According to McCollough and Hillman,14 The or therapeutic intervention. Telangiectasias are relative contra-
ideal patient is a thin-skinned female with fair complexion and indications in that they become more apparent after chemi-
fine rhytids. cal peels or laser resurfacing. Confirmed malignant lesions
Fitzpatrick15 described types of actinically damaged skin in should not be treated with chemical peels, unless they are very
a range, from type I to type VI (Table 26-1). Brody16 stated that superficial basal cell carcinomas. Nevoid or nevus lesions may
Fitzpatrick types I through III patients are suitable for a chemi- become darker or actually stimulated to grow, and port wine
cal peel. He describes the ideal patient as a light-complected stains, hemangiomas, and neurofibromatoses are not effectively
person of Celtic or Northern European descent with skin type treated with chemical peels. Contraindications include the
I or II.17 presence of hepatorenal disease or cardiac disease (for phenol
The Glogau classification system18 was created in 1994 and peels) unless approved by an appropriate specialist. True docu-
provides an objective assessment of the degree of photoaging, mented allergies to an agent are obvious contraindications, and
categorizing the patients skin damage as mild, moderate, dressings should be latex free in sensitive patients. Patients who
advanced, or severe (groups I through IV, respectively; Table are unstable psychologically should not be treated with any
26-2). Patients in category I are often young with minimal resurfacing modality, particularly because the postoperative
TABLE 26-2. Glogau Classification of Photoaging Groups

Group I (Mild) Group II (Moderate) Group III (Advanced) Group IV (Severe)
Little wrinkling or scarring Early wrinkling; mild scarring Persistent wrinkling or moderate Wrinkling: photoaging,
acne scarring gravitational, and dynamic
No keratoses Sallow color with early Discoloration with telangiectasias Actinic keratoses with or without
actinic keratoses and actinic keratosis skin cancer or acne scars
28 to 35 years 35 to 50 years 50 to 65 years 60 to 75 years

26 | MANAGEMENT OF AGING SKIN 393
this is the only objective way that the surgeon can later deter-
Box 26-1. INDICATIONS FOR FACIAL RESURFACING
mine whether satisfactory results have been achieved. Standard
Aesthetic preoperative workup and medical clearance are obtained,
Fine facial rhytids depending on the patients preexisting health status. If a
Atrophic changes in skin caused by excessive sun exposure phenol chemical peel is to be used, special attention must be
Spotty or splotchy hyperpigmentation given to cardiac, liver, and kidney function in the preoperative
Multiple actinic and solar keratoses medical workup. Any impairment of liver or kidney function
Superficial acne scarring could slow the excretion of phenol and has the potential to
Melasma
increase the bloodstream concentration, which can lead to
Excessively wrinkled skin
After blepharoplasty or facelift cardiac irregularities or even death.
Therapeutic Prepeel Preparations
Multiple actinic, seborrheic, and solar pigmented keratoses Before any resurfacing procedure, steps must be taken to opti-
Superficial basal cell carcinomas
mize the patients final aesthetic outcome. The preoperative
Lentigo maligna lentigenes
Melasma (discoloration of skin caused by pregnancy) consultation is used to ensure that the patient is adequately
prepared for the day of the chemical peel. Considerations such
Data from McCollough EG, Hillman RA Jr: Symposium on the aging face. as a positive history of herpetic outbreaks should warrant appro-
Otolaryngol Clin North Am 1980;13:353; Farber GA, Collins PS, Scott MW: priate prophylaxis. In all patients who are undergoing a medium
Update on chemical peel. J Dermatol Surg Oncol 1984;10:559; and Litton C, or deep peel, with or without a preceding history of fever blis-
Sachowicz EH, Trinidad GP: Present day status of the chemical face peel.
ters, we have found that acyclovir at 800mg four times per
Aesthetic Plast Surg 1986;10:1.
day starting the day before the peel and continuing until reepi-
thelialization is complete is effective at preventing outbreaks.
care may require intense patient involvement, education, and To achieve optimal results, patients must adhere to a skin
understanding. care regimen in both the preoperative and postoperative
periods. Patients undergoing medium or deep chemical peels
CHEMICAL PEEL PROCEDURE are best pretreated with tretinoin on a nightly basis starting 2
to 4 weeks before the peel. The use of retinoic acid before
Patient Selection and Education chemical peels, dermabrasion, or laser resurfacing speeds epi-
Patients who request rejuvenation of aging skin via chemical dermal healing and enhances the effects of the procedure.
peels must have a realistic understanding of potential out- Retinoic acid also increases the depth of a chemical peel by
comes, limitations, and postoperative care. The preoperative decreasing the thickness of the stratum corneum. Its use is
consultation should include a discussion of the patients expec- restricted during the postoperative period until reepithelializa-
tations and motivation to participate in postoperative care. The tion is complete and maturation of the skin has occurred. This
patient must have a clear understanding of the postoperative takes approximately 3 months.
discomfort, appearance, and care that will follow. He or she In darker-skinned individuals (Fitzpatrick type III or
must understand that preexisting large pores will remain greater), the use of 4% to 8% hydroquinone gel in the preop-
unchanged, and that telangiectasias may appear to be more erative and postoperative periods may reduce the incidence of
prominent. Informed consent about the risks and benefits is hyperpigmentation. It is also necessary to use hydroquinone
essential. At the end of the consultation, high-quality photo- when peeling for the treatment of pigmentary dyschromia
graphic documentation is obtained and should be standardized (melasma) in patients of any skin type. Hydroquinone blocks
using reproducible measures. Acne scarring is notoriously the enzyme tyrosinase from developing melanin precursors for
underdemonstrated or overdemonstrated, depending on the the production of new pigment in the epidermis during the
lighting or flash used; therefore the clinician should adjust the healing phase.
setup to accurately reflect the patients true skin appearance; All patients undergoing medium to deep facial resurfacing
procedures must minimize sun exposure in the postoperative
period. This is even more important in patients taking estro-
Box 26-2. BRODYS CONTRAINDICATIONS TO gens and in those with preexisting pigmentary disturbances.
CHEMICAL PEELS Wearing sunblock with a sun protection factor (SPF) of 30 or
greater is recommended during the first 9 to 12 months after
Relative
a peel.
Darker skin type (Fitzpatrick IV, V, and VI)
Keloid formation by history
History of herpes infections CHEMICAL PEEL AGENTS
Cardiac abnormalities Superficial Peels
History of previous facial irradiation
Marked quantity of vellous hair present Depending on the surgical goal, the appropriate agent is
Unrealistic patient expectations selected for each individual patient. Histologically, superficial
Physical inability to perform quality postoperative care peels extend down into the level of the stratum granulosum
Telangiectasias and papillary dermis. Such depth is good for treating mild
Anticipation of inadequate photoprotection because of job, vocation, or photoaging (Glogau I and II), melasma, comedonal acne, and
recreation postinflammatory erythema. Multiple peels are usually required
Absolute for a maximal result, ranging from six to eight peels on a weekly
Significant hepatorenal disease basis or every other week. A nice refreshing of the skin is
Human immunodeficiency viruspositive patient achieved; however, multiple superficial peels do not equate to
Significant immunosuppression (hypogammaglobulinemia) the results of a medium or deep chemical peel.
Emotional instability or mental illness Several chemical agents fall into the superficial peel cate-
Ehlers-Danlos syndrome
Scleroderma or collagen vascular diseases
gory. These agents include low concentrations of glycolic acid;
Isotretinoin treatment within the previous 6 to 12 months 10% to 20% TCA; Jessners solution (resorcinol, 14g; salicylic
acid, 14g; lactic acid, 14mL; ethanol, 100mL); tretinoin;

5-fluorouracil; and salicylic acid, a -hydroxy acid. The depth

of the peel achieved with each of the above agents varies
depending on the concentration of agent used, the duration
of the application, and the number of times the agent is
applied. During application, there may be a mild stinging fol-
lowed by a level 1 frosting, defined as the appearance of ery-
thema and streaky whitening on the surface.18 Regular washing
with a mild cleanser and the use of routine moisturizers and
sunscreens is all that is needed after the procedure. Superficial
peels usually cause mild erythema and desquamation, with a
healing time that varies from 1 to 4 days, depending on the
strength of the chemical agent.
Medium-Depth Chemical Peels
A medium-depth peel is one in which the injury extends
through the epidermis to the upper reticular dermis. In the
past, 50% TCA was the standard medium-depth peeling agent,
but it has been abandoned with time because of a high rate of
complications that include pigmentary changes and scarring. FIGURE 26-1. Chemical peel equipment tray.
Currently, a combination of agents or modalities is used for
medium-depth resurfacing. The most common agents include
a combination of 35% TCA with Jessners solution, 70% glycolic The patients face is vigorously scrubbed with acetone using
acid, or carbon dioxide (CO2) laser. Phenol 88% by itself will 2 2 gauze pads folded on a hemostat. Thorough degreasing is
give a medium-depth peel. The senior author (S.W.P.) prefers necessary for even penetration of the peeling solution, and
to use phenol 88% for chemical exfoliation of the lower eyelid, uneven or splotchy peels are typically caused by residual oils on
because it produces more consistent results than CO2 laser the stratum corneum from inadequate degreasing.
resurfacing without the temporary lower eyelidtightening A tray of all the required material should be available,
effect. Current indications for medium-depth chemical peels including cotton pads and gauze (Fig. 26-1), and once ade-
include moderate photoaging (Glogau II), actinic keratoses, quate preparation and cleansing of the skin has been com-
pigmentary dyschromia, mild acne scarring, and blending of pleted, these are used to apply the Jessners solution evenly. On
other resurfacing modalities (i.e., deep peels or lasers). application, a faint frosting appears within 1 minute within a
Monheit20 has demonstrated the use of Jessners solution background of mild erythema. The frosting is much less obvious
before the application of TCA as a synergistic combination. than that seen when using TCA, and this portion of the peel is
Jessners solution effectively destroys the epidermal barrier by not uncomfortable for the patient.
breaking up individual keratinocytes, allowing deeper and more After the Jessners solution has dried, 35% TCA is evenly
even penetration of the 35% TCA. This technique is useful for applied using cotton pads or swabs. The amount of TCA deliv-
the improvement of mild to moderate photoaging. Risk of ered to the skin surface is dependent on the number of applica-
pigmentary or textural complications is minimal, and this com- tions, the degree of saturation (volume of solution), the amount
bination softens fine rhytids and freshens sallow, atrophic skin. of pressure applied to the skin, and contact time with the peel
Collagen remodeling and thickening occur over a 3- to 4-month solution. Larger areasincluding the forehead, bilateral
period, with continued improvement in rhytid effacement and cheeks, nose, and chinare treated first with cotton pad appli-
texture quality of aging skin. Deep furrows, however, are not cators. Then, using cotton swabs, the perioral area and eyelids
eliminated with this medium-depth combination alone. The are treated, coming within 1 to 2mm of the lower eyelid
Jessners solution plus 35% TCA combination has been as effec- margin. An assistant should always be on standby with sterile
tive as topical 5-fluorouracil chemotherapy in removing grossly eye wash for irrigation in the event the surgeon inadvertently
visible and clinically undetectable actinic keratoses, with less spills any peel solution into the eye. The white frost should
morbidity and the positive effect of antiaging. This combination appear within 30 seconds to 2 minutes after application of the
of agents is also used to blend resurfacing procedures with the TCA peel (Figs. 26-2 and 26-3). Before retreating an area,
surrounding skin. For example, patients who have undergone however, the clinician should wait at least 3 to 4 minutes to
dermabrasion, CO2 laser resurfacing, or deep chemical peels ensure that the frosting has reached its peak before determin-
in an isolated region (e.g., perioral or periorbital area) may ing asymmetry. Additional applications can then be added with
develop a sharp line of demarcation or hypopigmentation caution, because the depth of the peel and the potential com-
when compared with nontreated skin. In these instances, use of plications are proportional to the volume of chemical applied.
Jessners solution plus 35% TCA on the surrounding non- The white frosting seen after a peel indicates the process of
treated skin helps blend the treated area into its surroundings. keratocoagulation, the completion of the chemical reaction. A
level II or III frosting is a sufficient end point for a medium-
Technique: Medium-Depth Chemical Peels. The medium- depth peel. Level II frosting is defined as a white-coat frosting
depth peel using Jessners solution plus 35% TCA is performed with a background of erythema. Level III frosting is a solid white
with the patient under intravenous (IV) sedation as necessary enamel frosting with no background of erythema, indicative of
as an isolated procedure. The burning sensation is typically penetration into the reticular dermis; such level III peeling
short lived; therefore short-acting drugs are sufficient. From 5 should be limited to areas of thicker skin and heavy actinic
to 15mg of diazepam plus 1 to 2mg of hydromorphone hydro- damage. Sensitive areas such as thin eyelid skin and bony prom-
chloride is typically sufficient. Nonsteroidal antiinflammatory inences, which have a high propensity for scarring, should be
drugs or aspirin can also be given within the first 24 hours to limited to a level II frosting.18
relieve pain and inflammation. A fan to cool the patient is also An immediate burning sensation is felt with the application
helpful. of the TCA peel, but this begins to dissipate with the onset of
The skin must first be cleansed of all residual oils, debris, frosting and is typically resolved by the time of discharge. Cool
and excess stratum corneum before the application of any peels. saline compresses offer symptomatic relief for a peeled area

FIGURE 26-2. Medium-depth 35% trichloroacetic acid chemical peel; FIGURE 26-3. Medium-depth 35% trichloroacetic acid chemical peel;
treatment of perioral area. treatment of periocular area.
and are used over the entire face after completion of a peel, improvement of collagen thickness progressing over a 6- to
whereupon a brawny, dusky erythema progresses over the first 13-month period (Figs. 26-4 and 26-5).11
12 hours. Mild to moderate edema soon follows and can be The medium-depth peel is a widely accepted resurfacing
severe over the thin eyelid skin and forehead regions. As the modality that has a broad range of applications for the man-
edema begins to resolve, dark crusts appear that peel off during agement of aging skin. If the measures and precautions
the subsequent 5 to 7 days to reveal a new, erythematous described here are followed, an excellent safety profile will be
epithelium. The redness soon fades to a pink color that resem- maintained.
bles a sunburn and can typically be camouflaged with makeup
by the tenth day after the peel. A formal makeover with a Deep Chemical Peels
makeup artist within the aesthetics department is a valuable Resurfacing techniques that penetrate or wound the midreticu-
experience for the patient once he or she has reepithelialized lar dermis are classified as deep chemical peels. Patients with
on day 10. The patient can begin using sunscreens as tolerated, Glogau group III or IV photodamage may require deep chemi-
although at least 3 months should be allowed to pass before the cal peeling. The classic chemical compound is the Bakers solu-
patient resumes regular aesthetic skin care services such as tion that consists of 3mL phenol 88%, 8 drops Septisol, 3 drops
superficial chemical peels or microdermabrasion; cleansing croton oil, and 2mL distilled water.21 This depth can also be
facials can begin as early as 4 to 6 weeks after the peel. Repeat achieved with a 50% or greater TCA peel; however, the high
medium-depth chemical peel should not be performed for at risk of scarring and pigmentation problems have resulted in a
least 1 year; several studies have demonstrated microscopic trend away from these concentrations.
A B
FIGURE 26-4. Medium-depth chemical peel. A, Pretreatment. B, Posttreatment.

A B
FIGURE 26-5. Medium-depth chemical peel. A, Pretreatment. B, Posttreatment.
Phenol is carbolic acid, an aromatic benzene-ring hydrocar- Langsdon24 involves more cleansing of the skin and application
bon formed from coal tar.6,14,22 At concentrations greater than of more peel solution. This enhances the efficacy of the solu-
80%, carbolic acid is a keratocoagulant that precipitates the tion without penetrating as deeply as in the occluded peel. Both
surface protein, thus preventing further penetration of the peel methods are reliable resurfacing tools for the rejuvenation of
solution. Phenol produces an extremely rapid denaturization advanced photoaging and severely photoaged skin.
and irreversible coagulation.5 Further penetration of the
phenol is prevented when the keratin protein binds to the Patient Selection. Patient selection is crucial with deep chemi-
phenol, creating large molecules that cannot penetrate further. cal peeling, and patients must be informed and willing to
McCollough and Hillman14 state that if the concentration of undergo a greater degree of morbidity and risk the higher
phenol is less than 50%, it becomes keratolytic and interrupts potential for textural changes and pigmentary disturbances.
sulfur bridges in the keratin layer and can then produce deeper Patients must accept the possibility that they will always need
penetration and more destruction than desired. Therefore as to wear makeup and use protective sunscreen.
the concentration of phenol is decreased, the depth and there- Phenol itself is cardiotoxic and undergoes both hepatic and
fore the wounding of tissue becomes more severe. renal elimination. Standard preoperative workup must include
The croton oil included in the formula is composed of glyc- a complete blood cell count; liver function tests; serum urea
erides of several acids and can be very irritating to the skin. nitrogen, creatinine, and electrolyte determinations; and a
Because of its inflammatory characteristics, it induces more baseline electrocardiogram. Any patient who has a history of
collagen formation.6,14 Recent studies have demonstrated that cardiac arrhythmias or who is taking medications that are
croton oil is the key ingredient to create the significant depth potentially arrhythmia precipitating may not be a good candi-
of wounding.23 Some surgeons vary the depth of the Bakers date for Bakers phenol peeling. Additionally, patients with
solution peeling by using one, two, or three drops of croton oil. poor renal or hepatic function are poor candidates.
Soap in the solution acts as a surfactant to reduce surface
tension and enhance the penetration of the waxes and choles- Technique: Deep Chemical Peel. Patient preparation and edu-
terol esters of phenol. Septisol (hexachlorophene and alcohol) cation before a deep chemical peel procedure are important.
is a partial astringent that helps remove the stratum corneum Preoperative prescriptions should be given at the time of sched-
and plays the role of a surfactant. The addition of distilled water uling. Preoperative antibiotics such as cephalexin (500mg
produces the desired concentration of phenol between 50% twice daily) are started 24 hours before the procedure and are
and 60%. The mixture of ingredients is freshly prepared and continued for 1 week. Patients are offered a sedative to help
must be stirred vigorously before application because of its them sleep the night before the procedure, and they are also
poor miscibility. given 5mg of diazepam by mouth 1 to 2 hours before the peel.
The two main variations in deep chemical peeling with All makeupincluding mascara, eyeliner, eye shadow, and
Bakers phenol solution are occluded and nonoccluded. Occlu- lipstickis to be removed before arrival at the surgery facility.
sion of the peeling solution with tape increases its penetration The face is washed twice with Septisol and is rinsed thor-
and creates injury to the midreticular dermis. Classically, this oughly after each washing; pHisoHex and pHisoDerm should
occluded technique has been used for deeply lined, weather- not be used because they leave a residue on the skin24 that may
beaten faces, but it should only be used by the experienced interfere with the penetration of the phenol. Brody and Alt10
surgeon because of the higher risk of complications such as believe in treating the skin with retinoic acids immediately
delayed healing, prolonged erythema, and late hypopigmenta- before the peel to stimulate skin healing and to remove more
tion. The unoccluded technique as modified by McCollough and of the stratum corneum. This, however, only pertains to a

medium-depth chemical peel and should not be used before a and hypertension. After this, central nervous system depression
Bakers solution chemical peel. occurs with rapidly ensuing respiratory failure, hypotension,
A deep Bakers solution peel is a time-consuming procedure and cardiac arrhythmias. Cardiac signs of toxicity develop, start-
that must be performed in a properly suited facility. The patient ing with tachycardia, followed by premature ventricular con-
is given a preoperative sedative (diazepam), antinausea medica- tractions and then atrial fibrillation.25 In Grosss study,25 the
tion (promethazine), and a prokinetic agent (metoclopramide). average time from application of phenol to the onset of arrhyth-
An IV line is introduced, and approximately 500 to 1000mL of mias was 17.5 minutes, and most patients had 50% of the face
Ringers lactate solution is administered. The patient is then covered at one time; to prevent such toxicity, volume loading
moved to the operative or procedure room, where full cardio- with IV fluids before, during, and after phenol peeling enhances
vascular monitoring is commenced that includes checks of excretion in patients with normal liver and renal function.
blood pressure and oxygen saturation. The patient is given a Many authors, including Botta and colleagues,26 recommend
narcotic medication to offset the burning sensation, typically 1 maintaining a fluid load to force diuresis with 20mg of furose-
or 2mg of hydromorphone hydrochloride. Additional mid- mide given 10 minutes before the application of phenol. Con-
azolam, usually 1 to 2mg, is given for sedation and as an troversies exist over the use of plasma expanders (i.e., colloids);
amnestic agent at this time. Sensory nerve blocks are then therefore phenol should be avoided in patients with renal
administered with injections of bupivacaine 0.05% with disease, because they may not excrete it rapidly enough to avoid
1:200,000 epinephrine solution. The regional blocks include direct cardiac toxicity. Waiting as long as 20 to 30 minutes
the supraorbital, infraorbital, incisive foramen, and mental between treatment of each area and not peeling more than
nerves as well as infiltration of the lower eyelids and preauricu- 50% of the face at one time minimizes the risk of phenol toxic-
lar area. This spares the patient the typical 4 to 6 hours of ity in most patients. Postoperative cardiac monitoring is neces-
postoperative burning discomfort. An additional liter of saline sary for a minimum of 30 minutes after the procedure, and
is given over the course of the procedure. personnel trained in advanced cardiac life support must be
The face is divided into five aesthetic subunits that include immediately available in the recovery unit.
the forehead, perioral region, bilateral cheeks, nose, and peri-
orbital region. First, thorough scrubbing with acetone-soaked Postoperative Care Routine. Postoperative care includes
2-by-2inch gauze is applied to each region. Bakers solution is administration of an analgesic, such as oxycodone or hydroco-
then applied with a cotton-tipped applicator to each region done, and acetaminophen. Patients should minimize activity
with feathering performed at the periphery of the peeled area, and rest until the next mornings office visit. Cool compresses
especially in the regions of the hairline and jawline, and overlap can be applied in addition to Aquaphor ointment (Beiersdorf,
of regions by 5mm. A minimum of 15 minutes should elapse Wilton, CT) or petroleum jelly. The patient will need assistance
between the treatment of each cosmetic area, totaling 60 to 90 and is not allowed to drive or perform self-care the day of the
minutes for the entire procedure. This allows for the renal peel. A postoperative instruction booklet is given to the patient
clearance of phenol from the circulatory system. Death from that discusses the expectations of marked edema, moderate
arrhythmia has been reported when phenol was applied to the temperature elevation to 99F to 100F, occasional nausea, and
full face in a short period of time. Frosting occurs rapidly; moderate discomfort. The morning after surgery, the patient is
therefore less solution is used compared with TCA peels. The instructed to wash or rinse the face without soap using tepid
solution should be applied in the direction of relaxed skin tap water; this is done five or six times per day, followed by the
tension lines. A prominent white frost should be obtained application of Aquaphor in an icing on cake fashion. Alter-
immediately on application of the solution in each area, which nately, Eucerin cream or bacitracin ointment can be applied;
rapidly changes to a zone of intense erythema that extends 1 however, antibiotic sensitivity may develop with time. The
to 2cm beyond the area treated with solution. It is therefore patient is given 10mg of dexamethasone by IV intraoperatively
important to peel across this band of erythema when peeling and methylprednisolone postoperatively to reduce swelling.
the next region to avoid skipping areas. The patient is encouraged to take 1000 to 2000mg/day of
When peeling the perioral area, the clinician must apply the vitamin C, as well as a multivitamin, and to continue the anti-
phenol solution with a slanted-cut wooden applicator so that biotic prophylaxis for 4 to 5 days postoperatively.
the solution reaches the bottom of each individual rhytid. The The patient is asked to return to the office on the third
lip is then stretched to spread out the rhytids while the solution postoperative day to assure the physician that the wound is
is applied with a very wet cotton-tipped applicator. A white frost being cleaned as instructed. At this time the physician has the
should be obtained that is carried 2 to 3mm across the vermil- opportunity to intervene early if the wound has been neglected,
ion border. When treating the lower eyelid, it is important to or if superficial infection has become a problem, such as with
use a semidry applicator rolled once across the skin. The lower Pseudomonas, which can create a deeper injury. The patient
eyelids need to be treated to within 1 to 2mm of the ciliary often requires further education regarding the importance of
margin. On the upper eyelid, the clinician must be judicious his or her involvement in removing the desquamating skin and
about treating below the supratarsal fold, and most surgeons crust. The patient is reevaluated in 3 to 4 days to observe the
do not breach this boundary. amount of wound healing and residual crusting. After 7 to 10
Application of the peeling agent creates an immediate days, the patient can begin to apply makeup if epithelialization
burning sensation that lasts for 15 to 20 seconds and then is complete. A makeup artist should be available, and camou-
resolves. After 20 minutes, the pain returns and lasts from 6 to flage techniques should be provided to instruct the patient how
8 hours and then typically resolves. The combination of bupi- to cover the pink/red areas. To neutralize the red areas, a mint
vacaine nerve blocks and narcotics usually makes the procedure green base is generally used before the foundation is applied.
well tolerated by the patient. Additionally, a brand name hypoallergenic moisturizer is rec-
ommended for use once or twice daily.
Phenol Toxicity. Phenol is essentially toxic to all cells. It is The use of sunscreens and sun avoidance is critically impor-
absorbed through the skin into the bloodstream and therefore tant. Sunscreen with an SPF of 30 or greater is advised. The
must be excreted rapidly. The cardiac, hepatic, and renal patient is not allowed any direct sun exposure for 6 weeks and
systems are all affected by toxic doses of phenol (between 8 and is told to minimize sun exposure for up to 6 months.
15g for adults). Systemic toxicity is first suggested by central To reduce the possibility of hyperpigmentation, estrogens
nervous system stimulation, including tremors, hyperreflexia, should be withheld 4 weeks before the peel and for at least 6

to 8 weeks postoperatively. As the erythema is fading, pigmenta- healing; 6) milia; 7) skin pore prominence; 8) increased promi-
tion abnormalities are possible, and estrogen may increase the nence of telangiectasias; and 9) darkening and growth of pre-
risk of this abnormality. existing nevi.
At our facility, mometasone furoate 1% is recommended for Pigmentation changes are by far the most common phe-
2 or 3 weeks after reepithelialization to decrease the erythema nomena seen with chemical peels, and these predominantly
and the hypersensitivity that is common. The patient often occur as hypopigmentation. These areas are most obvious in
complains of intense pruritus during the early recovery period, transition zones between peeled and nonpeeled areas, which
and steroid cream (2.5% pramoxine hydrochloride and hydro- can be minimized with the feathering technique described
cortisone) with an antipruritic agent can be helpful. During the earlier. Splotchy pigmentation can either be hypopigmentation
day, the patient may benefit from a nonsedating antihistamine or hyperpigmentation and is increased with exposure to sun or
such as desloratadine or fexofenadine and may require hydroxy- with the use of systemic estrogens. This sequela is most com-
zine or diphenhydramine at night to decrease the sensation of monly seen during the first 3 months of healing. Brody16 notes
itching. Hypnotics such as temazepam or zolpidem tartrate may that pigmentary changes rarely occur in Fitzpatrick type I and
be necessary for sleep. II patients, but in types III and IV, lines of demarcation are
Although some surgeons begin the administration of retinoic frequently prominent. In Fitzpatrick types V and VI, hyperpig-
acid as soon as epithelialization has occurred, we prefer to wait mentation usually develops that may resolve over 18 to 24
at least 3 months after the peel before giving the patient retinoic months; however, most surgeons will not peel this population
acid (tretinoin), and we then use it only if the patient desires it. (Asian, Latin, or Indian) because of the risk of irregular color-
The patient returns for an office visit at 2 weeks and again ation postoperatively. Retinoic acid 0.1% and hydroquinone
6 weeks later for evaluation of the early development of 4% mixed with triamcinolone 0.1% should be applied at the
splotchy hyperpigmentation. Collins27 recommends the use of onset of early hyperpigmentation and should be continued for
hydroquinone gel almost routinely for 2 to 4 months as a pro- 2 to 3 months after the peel.
phylactic regimen against this condition, especially in darker- Persistent rhytids, or wrinkles, are relatively common after
skinned persons, those with Fitzpatrick type III or higher skin. peeling, especially if they were prominent before the peel.
If splotchy pigmentation develops, a combination of retinoic McCollough and Brody believe that waiting 3 to 6 months is
acid, hydroquinone, and triamcinolone may provide improve- appropriate before repeating a chemical peel. We often touch
ment. The patient is seen again at 3-month, 6-month, and up rhytids of the vermilion border and perioral area with derm-
1-year visits postoperatively, and photographs are taken at each abrasion between 3 and 6 months. Repeeling rhytids before the
session (Fig. 26-6). 2-month mark can result in severe hypopigmentation and sub-
epithelial hypertrophic scarring, and prolonged erythema
should be expected with early repeeling.
CHEMICAL PEEL COMPLICATIONS Complications of chemical peels include but are not limited
It is important to recognize the expected sequelae, as opposed to 1) skin infection with organisms such as herpes simplex
to true complications, that accompany healing with chemical virus, Pseudomonas, staphylococci and streptococci, and Candida;
peels. The sequelae of chemical face peeling include 1) pig- 2) lower eyelid ectropion; 3) cardiac arrhythmias; 4) renal
mentary changes, such as hyperpigmentation, hypopigmenta- failure; 5) laryngeal edema28; 6) toxic shock syndrome29;
tion, and depigmentation (rarely, and in isolated areas); 7) facial scarring; and 8) poor patient-physician relationship.
2) persistence of rhytids; 3) prolonged erythema; 4) persistent Infections are uncommon, but herpetic breakouts can
texture changes in the skin; 5) hypertrophic subepidermal almost be expected if appropriate antiviral prophylaxis is not
A B
FIGURE 26-6. Deep-depth chemical peel. A, Pretreatment. B, Posttreatment.

given (e.g., acyclovir 800mg orally four times daily starting 2 PATIENT SELECTION AND
to 3 days before the peel). For patients with a strong history of
herpetic outbreaks, at least 2 weeks of antiviral therapy should
CONSULTATION
be administered after the peel. For patients who do undergo a Facial scars and skin lesions can be improved but not entirely
herpetic outbreak despite prophylaxis, we have found that acy- eliminated by dermabrasion techniques. The treatment of
clovir dosed at 4g/day is most expedient at clearing the infec- rhytids and photodamage may improve only by 50% to 80%,
tion. Superficial infection with Pseudomonas, Staphylococcus, or especially in the perioral region. Similarly, bad acne scars are
Streptococcus organisms is rare and can usually be attributed to expected to improve by only 30% to 40% or less. This point
poor postoperative wound care. Candida infections can occur, must be stressed during the initial patient consultation for both
which delays epithelialization; these should be treated with patient and physician satisfaction. The patient must accept a
topical nystatin cream. Prolonged use of ointments after chemi- 10- to 14-day healing time with a relatively intense postoperative
cal peel may promote folliculitis and acne, especially in patients wound-care regimen. The patient should be educated on the
with a prior history, and these conditions may become second- amount of anticipated drainage, swelling, discomfort, and
arily infected with Staphylococcus or Streptococcus species and bruising and should be advised that a period of prolonged
should be treated with the appropriate oral antibiotic in addi- erythema will ensue that can last up to 8 to 12 weeks. The risks
tion to topical clindamycin phosphate gel. and benefits should be covered during the consultation period
In summary, chemical peels are an effective and extremely with a witnessed informed consent form signed. Preoperative
satisfactory procedure with which every facial plastic surgeon and postoperative photographs are very important for docu-
should be familiar. Careful patient selection and education are mentation, although acne scarring may be difficult to photo-
crucial to both the patients final result and his or her satisfac- graph without proper lighting techniques.
tion. Learning the chemical peel technique is only a small part Careful patient selection is important to the final outcome
of the overall process; postoperative care and close patient of dermabrasion resurfacing. Patients with a history of prior
follow-up are equally important. Understanding these princi- skin resurfacing tend to have a less dramatic result with derm-
ples and knowing how to treat the sequelae or complications abrasion and are at a slightly higher risk of hypopigmentation
of chemical peels allows the surgeon and patient to achieve a and complications. A minimum of 12 months is recommended
satisfactory result in facial skin rejuvenation in addition to before a second dermabrasion procedure to allow for maximal
establishing a positive long-term relationship. improvement of scars and completion of the healing process.
Scars or wrinkles on the neck should not be treated with derm-
abrasion, because of the high risk of hypertrophic scarring and
DERMABRASION depigmentation caused by a significant decrease in adnexal
Facial dermabrasion is an effective technique in skilled hands. structures and a much thinner dermis.
It dates back to 1905, when Kronmayer30 used rotating burrs Patients with a history of acne should be under complete
for removal of various skin lesions, and it was modernized in medical control before any dermabrasion resurfacing tech-
the late 1940s by Kurtin31 with the development of the wire niques. The use of isotretinoin within a 6-month period is a
brush technique. Although discussed here for the management contraindication to dermabrasion because of the increased risk
of aging skin, dermabrasion is most commonly used for the of scarring, because this medicine decreases the number of
treatment of facial scars induced by acne, trauma, varicella, or pilosebaceous units required for adequate healing.32-34 Some
surgery in addition to removal of superficial skin lesions. dermatologists recommend waiting a full year after the end of
However, dermabrasion is a time-tested technique for the isotretinoin administration before facial resurfacing. Derm-
removal of wrinkles, especially in the difficult-to-treat perioral abrasion is also contraindicated in patients with deficient
and vermilion regions. healing capacities, collagen vascular disorders, or a personal
Dermabrasion is a mechanical method that uses abrasive history of keloids.
surfaces to remove the epidermis and create a wound in the
papillary or reticular dermis. This subsequently causes the stim-
ulation of type I and III collagen and brings about the forma-
EQUIPMENT
tion of a fresh new layer of skin. An excellent cosmetic Equipment for dermabrasion techniques varies from handheld
improvement is seen, and the collagen continues to thicken manual units to sterile sandpaper to high-speed machines.
over a 12- to 18-month period, further enhancing a youthful Modern electrical dermabrasion machines are compact and
appearance. Sun-damaged cells, superficial scars, and prema- easy to use, and they generate rotational speeds of up to
lignant lesions are removed and replaced by the epithelializa- 33,000rpm. The hand piece accepts various tips that allow
tion process, which enhances the final aesthetic outcome. site- and lesion-specific treatment for the patient (Fig. 26-7).
A B
FIGURE 26-7. A, Electrical dermabrasion machine. B, Various tips for use with electrical dermabrasion hand piece.

Additionally, the rotation of direction is reversible, making the

approach to anatomic sites safer and enabling access for either
a right- or left-handed surgeon.
Dermabrasion is performed with either a wire brush,
diamond fraise, or serrated wheel placed into the hand piece.
The wire brush attachment is a wheel with rigid stainless steel
wires that protrude from its circumference. The wire brush is
very efficient at tissue removal and often achieves the desired
depth with only one pass. It therefore has a narrow margin of
error and is preferred by more experienced surgeons. The
microlacerations created by the wire brush are believed to
improve the final result of the procedure, because the papillary
or outer reticular dermis is wounded, and therefore subsequent
collagen formation is stimulated. The skin surface must be
frozen when using the wire brush to achieve efficient abrasion
and to maintain the surface topography. This technique also
decreases the risk of gouging the skin; in addition, free margins
of the lip must be approached with care, because it is easy to
catch the margin and create an intraoral tear. FIGURE 26-8. Proper technique for use of a dermabrasion hand piece.
The diamond fraise attachment consists of wheels or cones
studded with diamond chips of various degrees of coarseness. dependent areas to avoid pooling of blood in the upcoming
The coarser the unit, the deeper the skin penetration achieved; region. In the perioral areas, special care must be given to
the finer diamond fraises are used more as a polishing or holding the lip taut and keeping the direction of rotation away
blending tool. Although the diamond fraise is the safest and from the mouth to avoid significant laceration (Fig. 26-9). The
easiest dermabrasion unit to use, it is also the slowest. The use operator must always stay parallel to the skins surface when
of the diamond wheel/burr also requires little or no cryogen performing dermabrasion, which should be carried out in
spray, which is unique among the dermabrasion attachments. facial units and carried to, but not across, the jawline, hairline,
and orbital rims. Untreated areas are then peeled with the
appropriate chemical agents, such as Jessners solution plus
TECHNIQUE 35% TCA or phenol 88% to the lower eyelids. This allows for
Dermabrasion at our facility can be performed with the patient better blending of pigmentation and avoids discrete areas of
under IV sedation or under twilight anesthesia as an isolated hypopigmentation. The neck should never be dermabraded
procedure. The patient receives 10 to 20mg of diazepam orally because of the high risk of scarring and pigmentation difficul-
before the procedure. Cardiovascular monitoring is used, and ties (Fig. 26-10).
the patient is administered 3mg of midazolam and 1mg of
hydromorphone hydrochloride before regional blocks. The
local blocks are performed with bupivacaine 0.25% and epi-
POSTOPERATIVE CARE
nephrine 1:200,000 and include the supraorbital, infraorbital, The regional nerve blocks given during the onset of the derm-
and mental foramen for full-face dermabrasion. This tech- abrasion procedure typically last for 6 to 8 hours, and a narcotic
nique, in conjunction with the use of a refrigerant spray (e.g., is prescribed to control delayed pain. Wet gauze is applied to
Frigiderm), allows for a pain-free experience for most patients. the dermabraded regions immediately after the procedure for
The face or region of concern is treated in 1- or 2-inch about 5 minutes, and after this, most bleeding has usually sub-
square segments. These areas are blocked off by a 4-inch square sided. Xeroform gauze is applied topically to all areas of derm-
gauze pad before application of the refrigerant spray to prevent abrasion and is allowed to dry overnight before moisturization
inhalation or ocular injury. Once the skin has been chilled, a and lubrication are begun. Using tepid water or saline-soaked
10- to 12-second period of dermabrasion is allowed before gauze, the clinician cleanses the sites of dermabrasion of all
further freezing is required. Overzealous use of the refrigerant serum and crusting all the way down to the visible gauze fibers,
spray should be avoided, because tissue damage and focal skin
necrosis is possible. The dermabrasion hand piece should be
held firmly and pulled only in a plane perpendicular to the
plane of rotation (Fig. 26-8). The clinician should avoid rotary
or back-and-forth motions, because this may increase the risk
of gouging the skin and causing deeper injury. Use of the wire
brush requires minimal pressure, because the steel wires cause
numerous microlacerations, whereas the diamond fraise
requires significantly more pressure. Adequate depth of treat-
ment is determined by observing the skin surface: stripping off
the epidermis reveals a slightly gray papillary dermis; in the
midpapillary dermis, multiple small punctate bleeding points
are seen and represent the dermal capillary loops. The border
between the papillary and reticular dermis is marked by a
slightly yellow color, which signifies the sebaceous gland lobules.
As the midreticular dermis is approached, larger but fewer
bleeding points appear, and the surface becomes coarser. Care
must be taken when proceeding deeper than this, because the
risk of scarring significantly increases.
It is best to begin the dermabrasion process centrally, near FIGURE 26-9. Proper technique for performing dermabrasion in the peri-
the nose, and to work outward toward the cheeks; begin in the oral area.

A B
FIGURE 26-10. Perioral dermabrasion. A, Preoperative view. B, Postoperative view.
and a fresh coat of Aquaphor or bacitracin is applied topically results. Studies have shown that dermabraded skin in the peri-
four to six times daily. Alternatively, if Silon (Bio Med Sciences, oral region has identical cosmetic results when compared with
Allentown PA) was applied, it would be removed on the third results with CO2 laser but heals in half of the time with less
postoperative day, at which point lubrication would begin. The postoperative erythema and morbidity.37,38 Additionally, derm-
administration of a methylprednisolone dose pack is usually abrasion for lip rhytids tends to be more effective and predict-
started on the day of the procedure, and the patient continues able as a single treatment compared with use of a CO2 laser or
to take antibiotic and antiviral prescriptions that started on chemical peel. Therefore an understanding of and an ability to
preoperative day 1. When epithelialization begins, the Xero- perform dermabrasion techniques should be in the armamen-
form gauze starts to separate and can be trimmed progressively. tarium of all facial plastic surgeons, because it serves as an
Complete reepithelialization has occurred by the seventh to the excellent and diverse tool for facial resurfacing.
tenth day, and a session with a makeup artist is provided for the
patient to teach him or her more about camouflage techniques.
Strict adherence to sun avoidance or the use of sunscreen with
LASER RESURFACING
an SPF of 30 or greater is discussed with the patient, because Laser skin resurfacing has become increasingly popular over
serious pigmentation problems can be caused by early sun the past several years and is an important modality in rejuvena-
exposure. Patients with prolonged erythema are treated with tion of the aging face. Many surgeons have turned to laser
1% mometasone furoate cream topically twice a day. Patients resurfacing instead of dermabrasion to ameliorate the higher
with signs of hyperpigmentation or known melasma are given risk of infection with bloodborne pathogens when performing
topical hydroquinone 4% or 8% to be applied nightly. Most dermabrasion. The primary lasers used for facial resurfacing
patients can return to work by day 7 to day 10 postoperatively are the pulsed carbon dioxide (CO2) and erbium:yttrium-
with a light covering of makeup; however, cosmetics should be aluminum-garnet (Er:YAG) lasers. The practice of combining
avoided before complete reepithelialization, because contact these lasers is also gaining popularity.39 Laser resurfacing can
dermatitis and further infection may follow. also be combined with the use of chemical peels or dermabra-
sion when clinically indicated. Additionally, laser skin resurfac-
ing is commonly combined with other surgical procedures such
COMPLICATIONS as endoscopic browlifts, facelifts, and transconjunctival blepha-
Acne outbreaks are a common complication of dermabrasion, roplasty. The physician should become aware of the unique
especially in patients with a previous history. The breakouts can properties of these resurfacing lasers to best treat patients
be minimized with the preoperative use of tetracycline in high- aging skin needs.
risk patients. Active breakouts respond to tetracycline plus
topical clindamycin phosphate gel. Other common complica-
tions include milia formation at the site of dermabrasion. This
CARBON DIOXIDE LASER
can be avoided or treated with the use of tretinoin therapy. The Energy of the pulsed CO2 laser is produced in the 10,600-nm
use of a sloughing pad or sponge (Buf-Puf; 3M, Maplewood, spectrum. Approximate tissue ablation of the CO2 laser depends
MN) to lightly abrade the surface of these lesions is helpful. on the amount of energy (fluence) delivered, typically between
Deep pore cleansing facials and extractions are also helpful and 50m and 300m, although depths have been reported up to
can be performed by an aesthetician. Prolonged erythema 1500m. A characteristic pattern of thermal necrosis and
beyond 4 weeks should be treated with a topical steroid such thermal conduction damage is apparent between 30m and
as 1% mometasone furoate to avoid pigmentary problems or 50m away from the zone of ablation.
scarring. Subepithelial hyperplasia should be injected with tri- The pulsed CO2 laser is considered to be the gold standard
amcinolone steroid to avoid potential scarring. Another uncom- in laser resurfacing, and its utility has improved considerably
mon complication is postoperative infection. The most common the past 20 years.40 It is particularly good for treating mild to
microorganisms include Staphylococcus aureus, herpes simplex moderate rhytids in the perioral area, crows feet in the peri-
virus, and Candida species.35 The prompt use of the appropriate ocular region, glabellar rhytids, and diffuse actinic damage,
antibiotic, antiviral, or antifungal agent should be sufficient for aging spots, and dyschromias. Although excellent results have
treatment, and often poor cleansing is the culprit for infection. been seen with full ablative resurfacing, techniques in frac-
Additionally, some hypopigmentation is seen quite often after tional ablation have shown remarkable results, with less risk of
dermabrasion.36 hypopigmentation, prolonged erythema, or social downtime.
Dermabrasion is therefore a long-standing, reliable method A variety of pulsed CO2 lasers are available (Fig. 26-11). The
for rejuvenation of aging skin with predictable and reproduc- laser energy is delivered through a flexible wave-guide hand
ible results. The equipment is inexpensive and simple to piece to the targeted area in a geometric pattern that varies in
operate; however, technique is very important to obtain the best size and is easily adjustable. The UltraPulse Encore CO2 laser

FIGURE 26-12. Intraoperative use of carbon dioxide laser.
necrosis occurs. Therefore, the clinician can overlap pulses by

10%, which must be avoided when using the CO2 laser second-
ary to thermal damage.
Because tissue damage is less severe, the classic pigmentary
changes involved in CO2 laser surgery are not seen; however, a
useful depth indicator when using the Er:YAG laser is pinpoint
bleeding, which occurs at the level of the papillary dermis. This
high-powered laser transforms the superficial skin into particu-
late matter; therefore a smoke evacuator and laser masks that
FIGURE 26-11. Pulsed carbon dioxide laser. filter 0.1-m particles are recommended in addition to laser
eyewear.
As with CO2 lasers, multiple options are also available for
(Lumenis [formerly Coherent], Santa Clara, CA) has a ran- Er:YAG resurfacing lasers. The Sciton Joule (Sciton, Palo Alto,
domization pattern feature, known as cool scan, that prevents CA) combines both ablative and fractional laser technologies
the postage-stamped marking on the patients skin. The oper- (ProFractional) (Fig. 26-13). This tunable resurfacing laser
ator selects the energy density and power in millijoules to deter- allows the user to adjust the depth of ablation from 4 to
mine the depth of tissue ablation, and the microprocessor 200 microns per pass. If coagulation is desired, subablative
calculates the peak power in watts based on the settings and laser energy is delivered in a train of pulses that heat the tissue
the spot size delivered. Standard settings for a patient undergo- to a selectable depth without vaporizing it (Fig. 26-14). The
ing initial full-face resurfacing for moderate aging and photo- addition of the ProFractional component utilizes either a
damage ranges from 80 to 90 mJ and a density of 4 or 5; the 250- or 430-m spot size and offers a range of treatment den
largest rectangular spot size at our facility ranges from 46 to 60 sities from 1.5% to 30% coverage with the ability to add
W. For a second pass over regions with more photoaging, the
unit is typically set at 20 mJ less than the first pass and at a
density setting of 4. The deeper passes are used to treat the
base of the furrow of the brow, using the principle of dermal
remodeling with subsequent collagen thickening. The edges of
the wound are also blended with the edges of nondamaged
skin, giving a more uniform appearance after healing (Fig.
26-12). Depending on the depth of treatment required, the
clinician can pass superficially to the upper papillary dermis, to
the upper reticular dermis, or to the deepest recommended
midreticular level. However, care must be given when treating
the thin eyelid skin, and most operators recommend only one
pass in this region.
ERBIUM:YTTRIUM-ALUMINUM-GARNET
LASER
The Er:YAG laser emits infrared light with a wavelength of
2940nm, far closer to the peak of the absorption spectrum of
water than the 10,600-nm wavelength of the CO2 laser. As a
result, erbium laser light is absorbed more efficiently by cutane-
ous tissue than is CO2 light. The laser penetration depth is
between 2 and 5m, instead of 20 to 30m, and it leaves a far
narrower zone of residual thermal damage. The technique of
facial resurfacing using the Er:YAG laser is similar to that of the
CO2 laser, except that with less tissue interaction, no coagulative FIGURE 26-13. Sciton laser.

deep ablation can also be combined with superficial complete

ablation during the same treatment. This combination allows
for the complete removal of superficial keratosis and dys-
chromias, while the fractionated columns stimulate collagen
production and improve the appearance of fine lines and
wrinkles.
COMPARISON OF CARBON
DIOXIDE AND ERBIUM:YTTRIUM-
ALUMINUM-GARNET LASERS
In addition to differences in their ablation depths, the two
lasers produce different kinds of tissue effects. The CO2 lasers
effect is primarily photothermal, whereas the erbium lasers
effect is primarily photomechanical. The thermal effects of the
CO2 laser leave a relatively wide zone of coagulative necrosis,
FIGURE 26-14. Example of Sciton ablation resurfacing; blending of wound which results in highly effective hemostasis, and they produce
edges. immediately visible collagen shrinkage of up to 25% during
irradiation. In contrast, as a result of less extensive thermal
depth-selectable tissue coagulation for enhanced collagen diffusion, the erbium laser causes less coagulative necrosis,
remodeling. The ProFractional component is able to vaporize which permits more bleeding to occur intraoperatively, and
any depth of tissue from 25 to 1500m per pass with extreme collagen shrinkage is much less. Some authors recommend the
precision (Fig. 26-15). combined use of the CO2 laser with the Er:YAG laser for
optimum postoperative healing: the first pass is performed
using the CO2 laser for primary resurfacing, and the Er:YAG
FRACTIONATED DEVICES laser is then used to clean up the zone of thermal necrosis,
In the past few years, more advanced delivery methods for the which would otherwise turn into persistent erythema; the favor-
CO2 and Er:YAG lasers have become popular. Fractionated ably heated deeper dermis remains, and the fibroblasts have
devices such as the ActiveFX and DeepFX (UltraPulse Encore been stimulated to secrete neocollagen.43 Usually two to three
CO2; Lumenis Aesthetic, Dreieich, Germany), Fraxel Repair passes are required using the Er:YAG laser with this technique.
CO2 (Solta Medical, Hayward, CA), and Sciton Joule are The study by Utley and colleagues44 showed that one pass with
showing excellent clinical results similar to the traditional com- the Er:YAG laser penetrated 20m, whereas one pass with the
plete ablative laser devices. Fractional technology allows for CO2 laser penetrated 62.5m.
only a small fraction of the skin surface to be treated using a
pattern of microscopic pulsed laser columns. The untreated
skin can then promote improved healing times and reduced
POSTOPERATIVE LASER CARE
risks of hypopigmentation and prolonged erythema. Some A postlaser occlusive dressing (silicone-based Silon) may be
authors have shown good results even in patients with Fitzpat- used for the first 3 to 4 days. The use of an occlusive dressing
rick skin types IV and V without postinflammatory hyperpig- is less painful for the patient, prevents crusting seen with the
mentation.41 The pulsed CO2 laser column can penetrate exudative phase, and promotes moist reepithelialization (Fig.
deeper into the dermis than the traditional methods, which 26-16). Once this dressing is removed on postoperative day 4,
allows for improved collagen remodeling.42 the patient is instructed about wound care. If an occlusive dress-
Fractionated laser devices use a scanner to apply a fractional ing is not used, the cleansing regimen is begun immediately
pattern of laser columns onto the skin. Adjustments are easily postoperatively and includes cleansing the entire face (or resur-
made in regard to the energy density, density of treated to faced region) with saline and a 4-inch square gauze pad four
untreated skin, and time between pulses. This affects the depth to five times daily down to pink, healing skin; this is followed
of treatment into the dermis and the total percentage of abla- by a generous layer of Aquaphor. If required, dilute acetic acid
tion and allows for improved thermal dissipation. Fractional soaks are used beginning on postoperative day 1 for increased
removal of serum exudates. Additionally, appropriate antibac-
terial agents (e.g., bacitracin ointment) or antifungal agents are
used if clinically indicated, which is typically a sign of inade-
quate cleansing. Once reepithelialization has occurred, by day
7 to 10, a makeup session with an aesthetician or makeup artist
should be offered to teach important camouflage techniques
during the period of postoperative erythema. A good water-
proof sunscreen with an SPF of 30 or greater is recommended
for a minimum of 6 to 12 months postoperatively to minimize
discoloration issues and to maximize healing (Figs. 26-17
through 26-20).
Postoperative laser complications are the same as discussed
in terms of chemical peel procedures, and therefore frequent
and meticulous postoperative visits and patient evaluation
cannot be overemphasized. Additionally, hot spots often seen
with laser treatment will benefit from hydrocolloid occlusive
dressings during the early healing periods. These should be
changed every 24 to 72 hours until reepithelialization has
FIGURE 26-15. Example of Sciton fractionated resurfacing; perioral area. occurred.

A B
FIGURE 26-16. Postlaser occlusive (Silon) dressing. A, Frontal view. B, Lateral view.
A B
FIGURE 26-17. Carbon dioxide laser resurfacing. A, Preoperative view. B, Postoperative view.

A B
FIGURE 26-18. Carbon dioxide laser resurfacing. A, Preoperative view. B, Postoperative view.
A B
FIGURE 26-19. Sciton laser resurfacing. A, Preoperative view. B, Postoperative view.

A B
FIGURE 26-20. Sciton laser resurfacing. A, Preoperative view. B, Postoperative view.
In general, facial resurfacing using the CO2 laser requires a performed by the aesthetician under topical or local anesthetic
longer downtime of 7 to 10 days with prolonged erythema for to depths of 20 to 50 and 350m, respectively. Patients are able
up to 3 to 4 months, compared with the Er:YAG laser, which to return to work within 3 days, and erythema is easily camou-
tends to involve a healing time of 4 to 5 days with short-lived flaged with makeup. Treatments are repeated two to four times
erythema. However, the CO2 laser produces a true skin- at intervals of 6 to 8 weeks to achieve the desired result. Super-
tightening result with improved elasticity, rhytid removal, and ficial rhytids, scarring, keratosis, and dyschromias may all be
long-term results compared with the Er:YAG laser.44 Although successfully addressed via these modalities.
the pulsed CO2 laser and Er:YAG laser are the most popular
ablative resurfacing lasers currently available, technology is
rapidly advancing, so the operator must stay current with such
NONABLATIVE FACIAL RESURFACING
advances to be competitive. Additionally, nonablative resurfac- As technology improves, new devices are being introduced to
ing lasers and technologies are gaining more popularity and the marketplace at a stunning pace as options for nonablative
may surpass conventional laser use because of the minimal facial rejuvenation. Nonablative laser resurfacing refers to the
downtime and postlaser care required for the patient. However, techniques that avoid damage to the epidermis while treating
to date, none of these lasers is able to treat significant rhytids the dermis to produce the desired resurfacing effect. Ablative
and photoaging, even with a series of four to six treatments. resurfacing (previously discussed) requires destruction of the
epidermis and thus requires a substantial period of healing and
AESTHETICIANS ROLE IN THE regrowth. This presents patients with long downtimes and
necessitates extensive skin care before reepithelialization. Ery-
MANAGEMENT OF AGING SKIN thema and edema can persist for several weeks, depending on
The role of the aesthetician in facial rejuvenation and skin care the depth of resurfacing involved. Different types of nonabla-
is rapidly expanding. The aesthetician has numerous options tive, intense pulsed light, and fractionated lasers are shown in
and skills available that do not require sedation or direct physi- Table 26-3.45
cian supervision to improve skin quality. Such interventions Radiofrequency energy has also found a role in promoting
include: new collagen formation in the dermis while reducing epider-
Nonablative resurfacing mal damage. The effect is to induce thermal damage of the
Microlaser resurfacing dermis by elevating temperatures to 65C to 75C (149F to
Fractional resurfacing 167F), thereby causing collagen to denature. The resultant
Microdermabrasion healing process is thought to create skin contracture and neo-
Superficial chemical peels collagen growth.
Medical skin care regimens Each laser discussed has its unique characteristic that is
marketed for skin rejuvenation. No one technique has been
shown to be superior, and a wide variety of treatment settings,
ABLATIVE LASER RESURFACING methods, and outcome measures are possible. Although none
Whereas ablative resurfacing performed by a trained physician has been shown to be as predictable or effective as the ablative
under sedation provides excellent textural and pigmentary techniques, they can all be used as alternatives for patients who
results, superficial resurfacing completed by the aesthetician are unwilling to accept the long, intensive recovery times
can provide effective rejuvenation with decreased downtime. required for resurfacing. Typically, multiple treatments are
Microlaser peels, as well as fractionated treatments, can be required for improved rhytid removal and skin texture quality,

TABLE 26-3. Lasers Used for Nonablative Facial Resurfacing

Laser Type (Wavelength) Target Molecule Depth of Penetration Properties
Pulsed-dye (585 to 595nm) Oxyhemoglobin Dermal vasculature Collagen remodeling, dyschromias
KTP (532nm) Oxyhemoglobin Dermal vasculature Collagen remodeling, dyschromias
Q-switched Nd:YAG (1060nm) Water Papillary and reticular Collagen remodeling and selective
dermis thermal injury
1320-nm Nd:YAG Water Papillary dermis Epidermal protection by cryogen cooling
Er:glass (1540nm) Water 0.4 to 2mm Low melanin absorption
1450-nm diode Water 500m Epidermal cooling by cryogen spray
Intense pulsed light (500 to Various Papillary and reticular Noncoherent light; treats lentigenes,
1200nm) dermis telangiectasias, tattoos
Fractional photolysis (1500nm) Water 400 to 700m Microscopic grids of injury
Er, erbium; KTP, potassium titanyl phosphate; Nd, neodymium; YAG, yttrium-aluminum-garnet.
From Kim KH, Geronemus RG: Nonablative laser and light therapies for skin rejuvenation. Arch Facial Plast Surg 2004;6:398-409.
usually over a 4- to 12-week interval. Advantages of the nonabla- After each microdermabrasion session, the patient should
tive techniques include avoiding the potential complications of expect several hours of increased pinkness or redness and sen-
deeper peels and lasers, which include hypopigmentation, pro- sitivity to the skin; with deeper treatments, this may last for days.
longed erythema, and hypertrophic scarring. The disadvan- With the stratum corneum disrupted, the skin requires more
tages of these new technologies are mostly in the long-term moisturization and sun protection. A sunblock with zinc oxide,
results. Many investigators feel that the nonablative devices titanium oxide, or an SPF of 30 or greater is recommended for
show modest improvement in wrinkles at best, which is likely a the first week after each treatment. Patients note increased skin
result of collagen homogenization. This clinical improvement tightness for the first 12 to 24 hours with a corresponding
requires 3 to 6 months to appreciate, and such results are often decrease in fine wrinkles. Some peeling of the skin may be
short lived.46 With further clinical trials and improving technol- noted 48 to 96 hours after a treatment session; this can be
ogy, however, these less invasive alternatives to facial rejuvena- reduced or avoided with the use of a strong moisturizer. Makeup
tion may predominate in the future. can be reapplied within minutes of a treatment, and medical
skin care programs can be resumed within 48 hours.
MICRODERMABRASION
Microdermabrasion is a popular noninvasive technique per-
SUPERFICIAL CHEMICAL PEELS
formed by aestheticians for facial rejuvenation. The term for Although medium and deep chemical peels require a physi-
this procedure is actually a misnomer, because the controlled cians expertise and patient sedation, lighter chemical peels can
injury created by this process is actually to the epidermis. be performed by the aesthetician as an excellent skin mainte-
Microdermabrasion uses the abrasive action of small-particle nance program. These treatments are often combined with
microcrystalsaluminum oxide, sodium chloride, or sodium other techniques, such as microdermabrasion, for improved
bicarbonateto wound the epidermis, coupled with suction to efficacy. The following are common superficial peels used rou-
remove any skin debris. An inflammatory response is stimulated tinely for skin rejuvenation and maintenance:
within the epidermis and results in the formation of a new Glycolic acid 20% to 70%
stratum corneum within 3 to 5 days. Some authors believe that TCA 10% to 30%
repeated microdermabrasion treatments not only increase the Resorcinol 20% to 30%
thickness of the outer epidermis after a 6-week period, but they Jessners solution
may also even stimulate fibroblasts and new collagen deposition Alpha-hydroxy acid
in the superficial papillary dermis.47 Retinoic acid
Typically, a series of treatments are required to achieve the Enzymatic peels
desired resurfacing results (6 to 10 treatments), followed by a Superficial peels effectively slough the outer epidermis
maintenance program every 4 to 6 weeks. The patients skin (stratum corneum) and thus improve skin texture by produc-
surface will feel smoother, and a firmer texture is reported. ing a thicker epidermal layer. Additionally, superficial skin
Microdermabrasion is best used for epidermal conditions that lesions and dyschromias are treated by these peels. Precautions
include fine rhytids, dyschromia, superficial scarring (e.g., to avoid sun exposure should be taken for at least 72 hours
acne), and actinic keratosis. Microdermabrasion techniques after a peel, and patients with sensitive skin should avoid
are best complemented with a daily medical skin care program. hydroxy acid and retinoid products for 24 to 48 hours after the
As the process histologically removes the stratum corneum, procedure.
the penetration of the topical medications is enhanced, yield-
ing a more desired outcome. Patient satisfaction is typically
good after a full series of microdermabrasion treatments,
MEDICAL SKIN CARE REGIMENS
because discomfort is minimal with little need for recovery or Antiaging and wrinkle cream products have flooded the
downtime. market over the past few years, often accompanied by false
Contraindications to microdermabrasion treatments are promises regarding potential facial rejuvenation outcomes.
relative but should include open herpetic lesions, bleeding The majority of these products have not been approved by the
disorders, active inflammatory rosacea, open wounds or sores, U.S. Food and Drug Administration, nor are they supported
vascular lesions, warty growths, or sunburned skin. Although with clinical prospective trials. It is therefore imperative that
active acne regions can be covered individually with tape, wide- clinicians recommend medical skin care maintenance pro-
spread active acne should be viewed as a contraindication. grams that are both safe and effective.

Retinoids are derivatives of vitamin A and are most com-

monly prescribed as tretinoin, which has been proven effective
SUMMARY
through numerous double-blind studies for treating mild to The management of aging skin is a very important topic in
moderate photodamaged skin. Available tretinoin products todays society, and facial plastic surgeons play a predominant
include Renova, Retin A, MicroRetin A, and Avita. Daily appli- role. It is imperative to remain current with the latest technolo-
cation of these topical creams has been shown to improve fine gies, because the patients expectations and knowledge base are
wrinkling, surface roughness, hyperpigmentation, and sallow- rapidly increasing in the Internet age. Physicians should main-
ness48 over a 6- to 12-month period. Tazarotene cream, a treti- tain a diverse repertoire of options in their armamentarium for
noin receptor derivative, has been shown to improve fine the management of aging skin, and patient selection and edu-
wrinkling, mottled hyperpigmentation, lentigines, elastosis, cation will ultimately provide the best clinical outcome and
pore size, irregular depigmentation, tactile roughness, and patient satisfaction.
coarse rhytids in a 12-month multicenter randomized trial.49
Tretinoin induces type I procollagen formation, thickens the For a complete list of references, see expertconsult.com.
epidermis, reduces melanin content, increases glycosaminogly-
cans, and stimulates angiogenesis, giving a rosy appearance
to the skin. Histologically, tretinoin-treated skin is more stable SUGGESTED READINGS
because of increased anchoring fibrils and decreased activity of Baker TJ, Gordon HL, editors: Chemical face peeling. In Surgical reju-
collagenase enzyme. Tretinoin can also reduce ultraviolet- venation of the face, St Louis, 1986, MosbyYear Book.
induced collagen destruction and therefore helps prevent pho- Brodland DG, Roenigk RK: Trichloracetic acid chemexfoliation (chem-
todamage.50 Adverse effects include mild to moderate dryness, ical peel) for extensive premalignant actinic damage of the face and
skin irritation, peeling, and photosensitivity; therefore protec- scalp. Mayo Clin Proc 63:887, 1988.
Brody HJ, Hailey CW: Medium-depth chemical peeling. J Dermatol Surg
tion from sun exposure is important. Oncol 12:1268, 1989.
Alpha-hydroxy acids have long been used in skin care prod- Collins PS: Trichloracetic acid peels revisited. J Dermatol Surg Oncol
ucts and have a proven level of safety as adjunctive therapy in 15:933, 1989.
photodamaged skin, melasma, hyperpigmentation, acne, and Fitzpatrick TB: The validity and practicality of sun-reactive skin types
rosacea. Although their exact mechanism of action is unknown, I-VI. Arch Dermatol 124:869, 1988.
alpha-hydroxy acids function by thinning the stratum corneum, Goldberg DJ: Nonablative dermal remodeling: does it really work? Arch
promoting epidermolysis, dispersing basal layer melanin, and Dermatol 138:13661368, 2002.
increasing collagen synthesis within the dermis.51 Alpha-hydroxy Hetter GP: An examination of the phenol-croton oil peel: part 1. Dis-
acids are often used in combination with retinoids and other secting the formula. Plast Reconstr Surg 105:227, 2000.
Kim KH, Geronemus RG: Nonablative laser and light therapies for skin
antioxidants for maximum clinical benefit. rejuvenation. Arch Facial Plast Surg 6:398409, 2004.
Beta-hydroxy acids contain salicylic acid and have similar Kligman AM, Baker TJ, Gordon HL: Long-term histologic follow-up of
properties to alpha-hydroxy acids. Beta-hydroxy acids are also phenol peels. Plast Reconstr Surg 75:652, 1985.
antiinflammatory in nature and are often less irritating than Niechajev I, Ljungqvist A: Perioral dermabrasion: clinical and experi-
their alpha counterparts. mental studies. Aesthetic Plast Surg 16:11, 1992.
N6-furfuryladenine (Kinerase; ICN Pharmaceuticals, Costa Perkins SW, Castellano R: Use of combined modality for maximal resur-
Mesa, CA) is a plant growth factor that is good for patients with facing. Facial Plast Surg Clin North Am 12:323337, 2004.
very sensitive skin who cannot tolerate retinoids and alpha- Rappaport MJ, Kramer F: Exacerbation of facial herpes simplex after
hydroxy acids. In a large, 6-month uncontrolled study, use of phenol face peels. J Dermatol Surg Oncol 10:57, 1984.
Spira M: Treatment of acne scarring by combined dermabrasion and
N6-furfuryladenine led to a significant reduction in skin rough- chemical peel. Plast Reconstr Surg 60:38, 1977.
ness (63%) and to smaller reductions in hyperpigmentation Spira M, Gerow FJ, Hardy SB: Complications of chemical face peeling.
(32%) and fine wrinkles (17%).49 However, further double- Plast Reconstr Surg 54:397, 1974.
blind studies are warranted. Stagnone JJ: Chemical peeling and dermabrasion. In Epstein E, Epstein
Numerous antiaging products are being investigated, and E, Jr, editors: Skin surgery, Philadelphia, 1987, WB Saunders.
considerable interest has been given to antioxidants such as Tung RC, Bergfeld WF, Vidimos AT, et al: Alpha-hydroxy acidbased
vitamins C and E applied topically to protect or reverse photo- cosmetic procedures: guidelines for patient management. Am J Clin
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prooxidant that caused oxidative DNA damage; however, the Utley DS, Koch RJ, Egbert BM: Histologic analysis of the thermal effect
on epidermal and dermal structures following treatment with the
use of vitamin C esters has been promising in terms of effec- superpulsed CO2 laser and the erbium:YAG laser: an in vivo model.
tively reducing photodamage. Further investigation and trials Lasers Surg Med 24:93102, 1999.
are warranted in the realm of topical antiinflammatory, antioxi- Weiss JS, Ellis CN, Headington JT, et al: Topical tretinoid improves
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26 | MANAGEMENT OF AGING SKIN 408.e1
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Management of Aging Skin

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Management of Aging Skin 26

Stephen W. Perkins | Heather H. Waters

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fibers had actually regenerated, forming a network of fibers

TABLE 26-2. Glogau Classification of Photoaging Groups

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5-fluorouracil; and salicylic acid, a -hydroxy acid. The depth

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Additionally, the rotation of direction is reversible, making the

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FIGURE 26-12. Intraoperative use of carbon dioxide laser.

necrosis occurs. Therefore, the clinician can overlap pulses by

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deep ablation can also be combined with superficial complete

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TABLE 26-3. Lasers Used for Nonablative Facial Resurfacing

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Retinoids are derivatives of vitamin A and are most com-

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