Facial skin resurfacing using the carbon dioxide laser has become an increasingly popular procedure. Improvements in carbon dioxide laser technology have made the procedure simpler and more reliable. However, difficulties in the postoperative period can lead to patient morbidity and physician anxiety. Common problems such as prolonged erythema, hyperpigmentation, acne, milia, dermatitis, and infection can be controlled or avoided with proper postoperative care. Less common sequela such as hypertrophic scarring and prolonged healing are often a results of errors committed in the postoperative period. The authors have performed laser resurfacing in almost 2100 patients in the last 4 years. Changes in the postoperative regimen to include no pretreatment, use of semipermeable dressings, antiviral and antibacterial prophylaxis, and early treatment with sunscreens and bleaching agents have made for a smoother recovery with more predictable results.

Removal of periocular wrinkles is a common yet difficult problem. There are many techniques currently available, all of which have some drawbacks. With the advent of new generation ultrapulse carbon dioxide lasers, skin can now be resurfaced successfully with minimal risk and side effects. In our study of 36 patients we assessed the benefit of using ultrapulse carbon dioxide (CO 2) laser to resurface the periorbital skin in association with transconjunctival lower lid CO 2 laser blepharoplasty. We found that 36/36 (100%) patients had good to excellent results. The incidence of side effects was very low. We also found that 2/36 (5.6%) of patients developed mild clinically insignificant hypopigmentation and 1/36 (2.8%) developed mild scarring, which resolved with one injection of triamanalone 10 mg/ml. No patients had hyperpigmentation. In addition, 1/36 (2.8%) patients developed transient ectropion, which resolved spontaneously in 6 weeks. We conclude that ultrapulse CO 2 laser is an excellent method for treating periocular wrinkle lines and can be readily performed in conjunction with a transconjunctival lower lid blepharoplasty.

Laser skin resurfacing has become increasingly popular as a method of facial rejuvenation. Although carbon dioxide (CO2) laser resurfacing is extremely effective, there is considerable morbidity associated with this procedure. Erbium (Er):YAG lasers, like CO2 lasers, are highly absorbed by water, and are absorbed superficially in skin. In our study of 141 patients using the computerized scanning Er:YAG laser, we found that it was possible to precisely ablate skin with less thermal injury than the currently available scanning CO2 lasers. The scanning system allowed very precise and homogeneous skin ablation. It was possible to ablate epidermis and superficial dermis, although deeper resurfacing led to pinpoint bleeding. Furthermore, healing was more rapid than generally experienced using CO2 lasers. Erythema was less marked, and disappeared usually within 3-4 weeks. Histological studies confirmed the minimal degree of thermal injury, as was evident clinically. Fluences of at least 20 J/cm2 were necessary to produce new collagen formation.

Laser skin resurfacing has enjoyed great popularity in recent years with the introduction of computerized, pulsed carbon dioxide lasers. However, the morbidity and side effects of carbon dioxide lasers have stimulated a search for alternative methods of skin remodeling. The erbium:YAG laser can be successfully used for skin resurfacing, with lower morbidity than the carbon dioxide laser. In a series of 625 patients who had erbium:YAG resurfacing, the following conclusions were reached. (1) Long-term (> 6 months) improvement in wrinkles and acne scars required total fluences exceeding 20 J/cm2. Periocular wrinkles required total fluences of between 20 and 40 J/cm2, depending on the depth of the wrinkles and skin thickness. Perioral rhytids required total fluences of between 40 and 80 J/cm2, whereas the cheeks and forehead required total fluences of 30 to 60 J/cm2. (2) Deeper wrinkles were best treated with a combination of erbium and carbon dioxide lasers, which minimized the bleeding that occurs with deeper erbium resurfacing. The simultaneous combined erbium with carbon dioxide laser was particularly advantageous. (3) Complications were relatively uncommon using the scanning erbium laser, and most adverse effects occurred early in the series. Scarring occurred in 5 of the 625 patients (0.8 percent) and mostly resolved with intralesional steroids. Hyperpigmentation occurred in 21 of the 625 patients (3.4 percent) and was temporary in nature. Hypopigmentation, which became evident after 6 months, occurred in 25 of the 625 patients (4.0 percent) but was mild and not a significant cosmetic problem, except in one patient who developed scarring on the neck. Hypopigmentation seemed to be related to the depth of resurfacing. Four of the 625 patients (0.6 percent) developed temporary scleral show, but no patients had permanent ectropion. Eight of the 625 (1.3 percent) developed synechiae under the lower eyelid, which required minor correction.