Lasers in Plastic Surgery

Laser skin resurfacing is a procedure that uses light beams to treat facial scars, wrinkles and blemishes. This technique is also known as a laser peel, laser vaporization or lasabrasion. Laser devices send short, concentrated pulsating beams of light at irregular skin. This removes unwanted, damaged skin in a very precise manner one layer at a time. This targeted approach means there are fewer problems with hypopigmentation especially when used for acne scar removal. Newer laser technologies give your plastic surgeon a new level of control in laser surfacing, permitting extreme precision, especially in delicate areas.

For many years CO2 lasers have been used to treat various skin conditions. It works by vaporizing superficial, damaged skin cells. A newer generation of CO2 lasers has the power to deliver very short pulsed light energy (called ultrapulsed) or continuous light beams. This type of laser precisely removes thin layers of skin with minimal damage to your surrounding tissue.

How does it work?

The laser beam used in laser resurfacing will remove the outer layer of skin, called the epidermis. It  simultaneously heats the underlying skin, called the dermis. This action works to stimulate growth of new collagen fibres. As the treated area heals, the new skin that forms is smoother and firmer.

Preparation of laser treatment for skin resurfacing

Laser skin resurfacing is usually done on an outpatient basis and typically takes between 30 minutes and 2 hours depending upon the treated areas.

Laser skin resurfacing can be painful. The skin may be numb with topical anaesthetics. Occasionally, sedative may be prescribed to alleviate anxiety if necessary. Prior to laser skin resurfacing, the face will be thoroughly cleaned and eye protection will be given before commencement of the treatment.

Special considerations

Skin that is treated with laser resurfacing may react in different ways. But most of the time, it will feel like a mild sunburn. There may be some redness and swelling. Occasionally itching or stinging sensation may persist for a few days after the procedure.

Depending on the treatment, some patients may present with severe sunburn. The skin will be raw, oozing and may even blister. A yellow liquid may ooze from treated areas to form a crust. These crusts should not be scratched or picked as they can cause scarring. Usually, about five days to a week after laser skin resurfacing, these crusts will become dry and peel off. It is possible that the skin may stay red or pink for up to several months after laser skin resurfacing. The treated areas may also be extra sensitive to sunlight for up to a year. Some people who have laser resurfacing may see an immediate difference in the treated skin. That will continue to improve for up to a year. While the effects of laser resurfacing can last for many years, the normal aging process means that wrinkles and expression lines will reoccur. Repeated laser resurfacing may be necessary from time to time to achieve optimum result.

To achieve an optimum result, follow these steps as part of your recovery

• Clean the treated areas two to five times a day with saline solution or mild facial cleanser as directed by your plastic surgeon
• Apply protective skin care treatments that are recommended to help your skin heal
• After healing, you’ll need to use sunscreen, particularly one that’s formulated for the sensitive, rejuvenated skin on your face. It is very important to use sunscreen at all times to prevent hyperpigmentation
• Use a liberal amount of moisturizer each day on your new skin to keep it moist

You can expect the treated area to peel. After that, the new, rejuvenated skin will be pink, but it will gradually lighten over two to three months. It may take up to several weeks or months for the pinkness to go away. It is very important to protect your skin from excessive sun light during this time of healing. Redness tends to last longer on individuals with very fair skin.

Tips for an easier recovery

• Elevate your head with an extra pillow at night
• Use an ice pack during the first day or two to ease swelling and discomfort
• Stop smoking. Tobacco smoke will complicate the healing process
• Camouflage the pink or red skin after laser skin resurfacing with make up
• Efforts should be made to minimize sun exposure and use sunscreen liberally every day.

Complications of laser skin resurfacing include

• Acne flares – Your plastic surgeon will recommend a treatment regimen
• Bacterial infection – If this occurs, antibiotic is prescribed prior to the surgery and afterward
• Cold sore reactivation – This may occur if you have laser resurfacing around your mouth. Be sure to tell you doctor about your history of cold sores (herpes). You can prevent the reactivation by taking an antiviral medication before and after the procedure
• Hyperpigmentation – It is possible for the treated area can become darker in tone. Your physician may recommend a bleaching solution. More rarely, you may have hypopigmentation, a lightening of the skin tone
• Milia – These small white bumps may appear during healing. They can be removed with gentle cleansing using a washcloth
• Prolonged redness – For some people, the redness just takes longer to disappear
• Scarring – This is rare, but possible
• Swelling – If you are having laser skin resurfacing around your eyes, your doctor may prescribe oral steroids to manage this swelling

Contraindications for laser skin resurfacing

It may not be the best choice if you have:

• Active acne
• Very dark skin
• Deep wrinkles
• Excessive or sagging skin

Patients with darker skin tones have a greater risk of healing with darker pigmentation (hyperpigmentation). This may be minimized by use of a bleaching agent after laser skin resurfacing as well.

Laser treatment for pigmented conditions have been widely used with variable success in conditions such as Becker’s nevus, cafe-au-lait macules, Nevus of Ota, nevocellular nevi, lentigines, tattoos, melasma, and post-inflammatory hyperpigmentation (PIH).

How does it work?

The principle of selective photothermolysis is based on highly specific targeting on different tissue components namely the pigmented cells. In other words, when the laser light is absorbed by the melanin or pigment cells within the skin, it will cause over heating of the cells resulting in cellular destruction. These damaged pigment cells will eventually be removed naturally by our immune cells. The pigment appears to darken as the pigmented cells are lifted to the surface and in some cases forming a very light scab. This is then naturally shed after a few days one to two weeks and the pigmentation underneath is removed or lightened.

Preparation of laser treatment for pigmented conditions

• Discussion about patients’ expectations and desired outcome
• Medical conditions, drug allergies and previous treatment history
• Strict sun avoidance
• Topical depigmenting agents: before and after treatment
• Test spots (for Q-switched lasers)
• Appropriate eye protection, eye shields, universal precautions

Laser treatment for pigmented conditions can sometimes be painful. Prior to the procedure, the skin can be numbed with topical anaesthetic cream.

Special considerations

After the laser treatment, there may be some swelling and skin redness for several days. Antibiotic ointments or moisturizing cream may be used to facilitate healing process. It is important for the patient to follow all the post-laser treatment instructions, particularly regular usage of sunblock and avoiding sun exposure. The full impact of the laser may not be apparent for a month or two, especially with vascular deformities. Additional treatment sessions will not be scheduled until the healing process for a particular treatment is complete.

Other considerations include:

• If the long wavelength is used for deep pigment problems, immediate reddening occurs at the treatment sites and fades over 24-48 hours.
• If the short wavelength is used for superficial pigment problems, the treated area may be bruised for 10-14 days. Crusting and/or slight bleeding may occur.
• There may be swelling of the treated skin for two to three days.
• There is always the possibility of unwanted changes in skin colour after the treatment, either slightly darker or lighter.
• The treated skin will be sensitive to the sun rays after treatment. Therefore sun screen (with SPF 50 and above) should be used regularly after treatments

Tips for a speedy recovery

• Apply protective skin care treatments that are recommended to promote skin healing and rejuvenation
• After healing, diligent use of sunscreen is very important to prevent hyperpigmentation
• Use a liberal amount of moisturizer each day on your new skin to keep it moist

Complications of laser treatment for pigmented conditions include

• Discomfort at treated sites
• Swelling
• Erythema
• Purpura
• Pigmentary alterations (hyperpigmentation or hypopigmentation)
• Blister or crust formation
• Acne formation
• Milia
• Folliculitis
• Flaring of cold sore
• Delay healing or scar formation
• Allergic reaction

The presence of unwanted hair continues to plague many individuals for whom traditional methods of hair removal remain unsatisfactory. Old methods of removing unwanted hair include shaving, waxing, chemical depilation, and electrolysis, all of which have temporary results. The invention of photothermolysis and the development of various laser systems with many ranges of wavelengths have made effective hair removal possible.

There has been an explosive increase in the use of lasers for hair removal since the first lasers were approved in 1996. Since then, numerous advances in laser hair removal, which use melanin as a chromophore, have been made. Laser hair removal is commonly used to remove unwanted hair on the face, neck, armpits, chest, back, genital area, arms, legs, fingers, toes and feet.

How does it work?

Laser hair removal is accomplished through follicular unit destruction. The ability to remove hair without damaging the surrounding skin is based on selective photothermolysis—the theory that at a particular wavelength, pulse duration, and fluence, thermal injury is confined to a target that contains a light-absorbing molecule called a chromophore.

Laser-assisted hair removal is the most efficient method of long-term hair removal currently available. Several hair removal systems have been shown to be effective in this setting: the ruby laser (694 nm), the alexandrite laser (755 nm), the diode laser (800 nm), an intense pulsed light source (590 to 1200 nm), and the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser (1064 nm), with or without the application of carbon suspension. Both the long-pulsed alexandrite and the long-pulsed diode laser systems are effective in the treatment of unwanted hair, and they are more effective than the Nd:YAG laser. The parameters used with each laser system vary considerably.

Preparation of laser for hair removal

• Avoid tanning and using sunless tanners for at least a month to prepare for laser hair removal
• Refrain from plucking or waxing
• Hair should not be bleached
• Usually one or two days before the appointment, shave the area that will be treated as instructed during the pre-treatment consultation. The hair follicles should be visible, but it can be more painful if longer hair is present during the laser hair removal
• Clean the skin at the treatment site before the procedure

Special considerations

After the treatment, redness and swelling may persist for the first few hours. If skin reaction appears immediately after laser hair removal, steroid cream can be applied to the affected area. Hairs do not fall out immediately, but will be shed over a period of days to weeks. This may look like continued hair growth. The repeated treatments are usually necessary because hair growth and loss naturally occur in a cycle, and laser treatment works best with hair follicles in the new-growth stage.

Results vary significantly and are difficult to predict. Most people experience hair removal that lasts several months, and it might last for years, but laser hair removal doesn’t guarantee permanent hair removal. When hair regrows, it’s usually finer and lighter in color. Maintenance laser treatments are usually recommended for long-term hair reduction.

Tips for a speedy recovery

• Initial discomfort can be reduced by application of ice or cold packs to numb the treated area
• Reduce redness or swelling at treated areas with appropriate skin care products
• Protect the treated area from sun light with sun screen (SPF 50 and above)
• Avoid exposing treated skin to heat sources until it has entirely healed. Hot water, saunas, and steam rooms should all be skipped for a minimum of 48 hours after the treatment
• Avoid strenuous exercise for at least 48 hours after treatment.Raising the body’s temperature through exercise can also irritate the treated area
• Clean the treated area with a mild cleanser
• Select skin care products such as moisturizer suitable for sensitive skin
• Avoid makeup and harsh skin products

Complications of laser treatment for hair removal

The most common complications of laser hair removal include:

• Skin irritation – Temporary discomfort, redness and swelling are possible after laser hair removal. Any signs and symptoms typically disappear within several hours.
• Pigment changes – Laser hair removal might darken or lighten the affected skin, usually temporarily. Skin lightening primarily affects those who don’t avoid sun exposure before or after treatment and those who have darker skin.

Rarely, laser hair removal can cause blistering, crusting, scarring or other changes in skin texture. Other rare side effects include graying of treated hair or excessive hair growth around treated areas, particularly on darker skin.