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DEEP SURGICAL SKIN RESURFACING

SOME INFORMATION FOR OUR PATIENTS ABOUT CHEMICAL, LASER, OR ABRASIVE SKIN RESURFACING
(CHEMICAL PEEL, LASER RESURFACING AND DERMABRASION)
INTRODUCTION

CHEMICAL PEEL, LASER RESURFACING AND DERMABRASION of the skin are terms used to describe procedures which remove or modify outer layers of skin in order to improve or eliminate areas which may be finely wrinkled, inelastic, excessively pigmented, scarred or rough. Chemical peels, laser skin resurfacing, and dermabrasion all achieve results in basically the same way. Layers of skin are removed and as the healing process progresses, a new, healthier looking skin emerges. What differentiates the various resurfacing methods is the way in which the skin’s layers are removed. Chemical peels involve the application of a caustic solution, laser resurfacing uses a focused beam of laser light energy, and dermabrasion utilizes a high-speed rotary wheel. In general, the stronger the solution applied, the deeper its penetration and therefore the more significant the result. Treatment depth with laser resurfacing and dermabrasion must also be precisely controlled. Problems or complications following skin resurfacing are related to these same depth of treatment factors and must be controlled by comprehensive preoperative preparation of the skin, a precise surgical procedure, and controlled postoperative wound healing.

Skin resurfacing is most useful for: 1) finely wrinkled skin due to aging and accumulated photo damage; 2) certain types of pigmentation irregularities; 3) certain types of minor scar irregularities; 4) as an additional modality to maximize the results of other cosmetic facial procedures such as face lift, brow lift or eyelid surgery. When excessive laxity or looseness of the skin is present, surgical procedures to remove the laxity should be done either before or after skin resurfacing for best results.

Aging, sun exposure, heredity and lifestyle factors including nutrition, alcohol consumption, and smoking all may contribute to facial wrinkling. Pigmentary changes of the skin such as blotchiness or brown spots may also occur with age or as a result of birth control pills, pregnancy, or genetic factors. Prior acne may have made the surface of the skin uneven. These problems, as well as certain other skin conditions may be improved by skin resurfacing.

Surgical skin resurfacing can be performed to various depths within the epidermal (outer skin layer) and dermal (deeper) skin layers. Superficial treatment removes any or all of the epidermis down to the basal cell layer or to the level of the dermal-epidermal junction. Medium depth treatment destroys or removes tissues down to the level of the papillary dermis. Deep treatment destroys or removes tissue down to the level of the reticular dermis.

The epidermal layer of skin contains pigment cells (cells which darken the skin in response to ultraviolet radiation from the sun). In the skin resurfacing process, removal of some or most of these cells to achieve
the desired smoother result also produces lightening of the skin color in that area. Since the pigment cells no longer block sun rays effectively, protection from the sun following the procedure using sunscreens and other types of shields, including shading, is extremely important. Avoiding direct sun exposure during the most intense times during the middle of the day is also strongly advised. Hence, a major consideration when considering skin resurfacing is that some protection is mandatory in exchange for achieving a more youthful or smoother appearing skin. In women, this is more easily achieved since make-up is applied as a routine, and sunscreen is readily applied either along with or within currently used cosmetics. Males need to apply sunscreen or blocks as a learned daily routine.

Since the areas treated by skin resurfacing are usually lightened in color compared to other areas, the fair-skinned patient will show less contrast between the treated and non-treated areas as compared to darker or olive skinned individuals. Certain skin types may be better suited to one type of resurfacing procedure versus another.

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CHEMICAL PEEL SKIN RESURFACING PROCEDURES
Chemical peel consists of the application of a chemical solution, usually an acid, to the skin of the face or body. A chemical peel can be superficial, medium depth, or deep in terms of the levels of the epidermis and dermis treated. The goal of the chemical peel is to make the skin look smoother with a more regular color, but still leave the skin looking as natural as possible. Chemical peel is most commonly performed for cosmetic reasons. It may also however remove precancerous skin growths.

Alpha-Hydroxy Acids (AHAs), such as glycolic, lactic or fruit acids are the mildest of the chemical peel formulas and produce light peels. These types of peels can provide smoother, brighter looking skin with just a few superficial treatments and very little, if any, down time. These lighter peels are considered more complexion peels. They make the skin look brighter and fresher by stimulating exfoliation (cell turnover) and therefore must be repeated at varying intervals to maintain the effect. Repeated treatments can help to further improve the texture and overall health of the skin. They can also reduce the effects of aging and sun damage, including fine wrinkling and pigment irregularities. A topical skin maintenance program along with regular chemical peels is mandatory to achieve and maintain optimal results in terms of skin appearance and skin health. The advantage of light peels is that they minimally disrupt your schedule and you can look reasonably normal within a few hours or days. Make-up can be worn the same day and you can easily go back to work the same day.

For patient’s who have deeper or more severe problems, a medium depth chemical peel may need to be performed with trichlorocetic acid, TCA for short. Fine surface wrinkles, superficial blemishes, and pigment problems are commonly treated with TCA. The Obagi Blue Peel and the Biomedic Pigment Peel Plus are medium depth chemical peels typical of this type of treatment. Specially trained and medically supervised paramedical estheticians perform both superficial and medium depth chemical peels in my practice.

Deep chemical peels can also be performed with TCA or a powerful acid called phenol. My preference however, is to use laser resurfacing for deep skin treatments as I feel that this process is more precise, controlled, and predictable than deep chemical peeling with other agents. There clearly is a place however, for deep chemical peels in certain situations. Localized moderate depth wrinkles around the mouth for instance, can be treated with Phenol or a deep TCA peel at the time of other surgical rejuvenation procedures. Clearly, the lightening of skin pigment following deeper treatments becomes a more significant issue, and localized treatments do tend to have more visible differences in pigment and more contrast in the transition areas between treated and non-treated skin.

When the chemical peeling solution is applied to the skin, it penetrates through the epidermis (outer layer of skin) and partially and variably through the dermis (deeper skin layer) depending on the depth of the treatment. As the healing progresses, the skin is left smoother, healthier, and more youthful than before the treatment.

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LASER RESURFACING
In laser resurfacing, sometimes called “laser peel”, an erbium:YAG or carbon dioxide (CO2) laser is used to remove areas of damaged or wrinkled skin, layer by layer. The procedure is most commonly used to minimize the appearance of fine and medium depth wrinkles, skin roughness, and pigment irregularities. However, it is also effective in treating facial scars caused by injury or accident, and scars caused by acne. Laser resurfacing may be performed on the whole face or in specific regions such as the vertical lines around the mouth. Often, the procedure is done in conjunction with other cosmetic procedures, such as a face lift or eyelid surgery. Men and women of all ages may benefit from laser resurfacing. The best results from the procedure are typically seen in individuals with fair, healthy, non-oily skin.

Laser skin resurfacing is most effective for eliminating wrinkles, and skin damage caused by photo aging. Overall improvement that can be anticipated with a single treatment is approximately 50-70%. Laser resurfacing does not remove deep furrows. These lines come from decades of contracting muscles of the face to form smiles, frowns, and raised or knitted eyebrows. Laser resurfacing can tighten skin to some degree, especially the thinner skin of the upper and lower eyelids, but does not replace face lifting procedures.

It will not completely remove all facial flaws or prevent aging. Lines that occur as a result of natural movements of the face including smiling, squinting, blinking, talking, and chewing will inevitably recur.

Maintenance of the results from laser resurfacing is mandatory for best overall longevity. Maintenance includes an aggressive topical skin rejuvenation program including topical Retin-A, light alpha-hydroxy acid peels, sunscreen of the appropriate strength to prevent further sun damage as well as adherence to basic skin care principles including cleansing and moisturizing.

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DERMABRASION
Dermabrasion or dermaplaning helps to refinish the skin’s top layers through a method of controlled surgical scraping. The treatment softens the sharp edges of surface irregularities, giving the skin a smoother appearance. Dermabrasion is most often used to improve the look of facial skin left scarred by accidents, acne or previous surgery, or to smooth out fine facial wrinkles such as those around the mouth.

Dermabrasion uses a small, rapidly spinning wheel with a roughened surface similar to fine-grained sandpaper to abrade the skin, removing its upper layers. The procedure involves “sanding” the affected area to give it a more even texture. The technique does not change the underlying scar tissue itself, it makes the scars less visible by making the surface more uniform. Several procedures may be required to obtain the optimal result, although a single dermabrasion treatment may very well produce a very substantial improvement.

Care following dermabrasion treatment of the skin is similar to other skin resurfacing procedures, including chemical peels and laser resurfacing.

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AT YOUR INITIAL CONSULTATION
At the time of your initial consultation, we will review the information furnished for your reading and education prior to the consultation with me. Your past medical history will be reviewed and then a exam will be performed.

I will discuss with you which of your goals skin resurfacing may or may not meet, and which resurfacing procedure would best suit your needs. You should arrive at the consultation prepared to provide complete information about previous surgical procedures including cosmetic facial peels or dermabrasion, any abnormal skin conditions, medications that you are taking or have taken, skin allergies, and acne or facial injuries that you have sustained, as these may influence the overall outcome of your surgery.

In this consultation, I would expect you to be frank in discussing your expectations with me. Do not hesitate to ask any questions that you may have. I will be equally frank with you, explaining the factors that could influence the procedure and the results.

I cannot make the decision for you regarding whether to undergo surgery or not. I can only advise you regarding the surgical options and anticipated outcomes I would expect for you based upon your individual anatomy, desires, and realistic expectations. I will define goals in a surgical plan at this initial consultation. Follow up appointments will include time to ask further questions or reviewing the procedure so that you are comfortable with its nature and implications. I will educate you and define the operative scenarios and choices available to you, but you must make the final decision regarding undergoing the surgical procedure.

When a decision is made to proceed with surgery, preoperative photographs will be taken. These photographs are essential to the planning, execution and follow-up of your procedure and are maintained as a portion of your medical record.

Surgical fees for the procedure will be discussed with you. They depend upon the nature and the extent of the procedure being performed. All fees for cosmetic surgeries are payable in advance and include the cost of surgery as well as all postoperative follow up care. Additional fees are required for the surgical facility and anesthesia care, and will be collected on the day of your preoperative visit at the surgery center.

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BEFORE YOUR SKIN RESURFACING PROCEDURE
My office manager will make all arrangements regarding scheduling your surgery and will give you specific
instructions, then reconfirm these with you by telephone and letter. Since my schedule and your desires
must be coordinated with the surgical facility and anesthesia schedules, please allow my personnel a reasonable amount of time to make these arrangements. We will make every attempt to accommodate your requests.

Before any skin resurfacing procedures can be performed, the skin must be evaluated and classified. The results of this analysis determine your preconditioning treatment. IV Seasons Skin Care Clinic offers a variety of products specifically prepared to meet those needs. These range from a short series of glycolic acid peels and home care products, to a faster course of skin preparation that would include Retin-A or Renova and may be paired with a skin bleaching agent. All of this pretreatment depends upon your skin type. In order to gain optimal results from your skin resurfacing procedure, this initial preconditioning phase is mandatory.

Before skin resurfacing procedures, you must avoid sun exposure for at least 6 weeks prior to the surgery. Tan or sunburned skin may absorb laser light unpredictably or allow differential penetration of chemical peel solutions before they reach their target. I prescribe a topical Retin-A product for at least 6 weeks prior to the procedure, as Retin-A speeds the turnover of epidermal skin cells. It will prepare the skin for faster, more efficient healing and allow for more predictable results with less risk.

No aspirin or medications containing aspirin should be taken for at least 2 weeks prior to surgery, as they interfere with normal blood clotting. Tylenol or Ibuprofen may be substituted instead. If in doubt regarding the medications that you are taking, check the label carefully, or check with us.

Nicotine causes constriction of blood vessels, and can impair circulation to tissues following any surgical procedure, especially those of the skin. Smoking should be discontinued prior to the procedure for a minimum of 2 weeks. You should cease smoking for a minimum of 4 weeks following the procedure.

Good general health is mandatory for a problem free and predictable recovery from any surgical procedure. Wellness and good general health result from proper diet, regular exercise and appropriately timed medical evaluations focused on preventative medicine. Good nutrition, vitamin and herbal supplements, as well as adherence to holistic health principles are important concepts in maintaining wellness. Certain supplements, although generally beneficial, may have adverse effects during surgery. Please advise us about all your medications and supplements, so we may advise you regarding their safety in regards to your surgical procedure.

Arrange for someone to drive you home at the appropriate time following your procedure, and arrange for someone to stay with you the night of surgery.
Do not eat or drink anything for 8 hours before surgery.
Wear comfortable, loose fitting clothes that do not have to be pulled over your head.

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YOUR SKIN RESURFACING PROCEDURE
Skin resurfacing procedures may be carried out under local or general anesthesia depending upon the size and the location of the area to be treated. Small areas can be treated with local anesthesia and IV sedation. Full face resurfacing requires general anesthesia. If a chemical peel is being performed, the solutions are freshly and precisely mixed immediately prior to application and very carefully and evenly applied to the treated areas. With laser resurfacing, the amount of energy used and the number of passes utilized in treating the skin is dependent upon the depth necessary to address your specific areas of concern.

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AFTER YOUR SKIN RESURFACING PROCEDURE
When you arrive home following your procedure, make yourself comfortable in a chair, on a sofa, or in bed with your head comfortably elevated. You will be given very specific instructions regarding care of your skin in this early postoperative phase.

Patients often find their appearance scary at first. Treated areas look and feel as though they have been burned. They will be red and raw, and the skin will blister and ooze a clear or yellow fluid for 7-10 days, depending on the depth of the treatment. During the first week or so, the skin must be cleaned and dressings changed several times a day to stop dry scabs from forming, reducing the chance of infection, and promoting efficient skin re-growth. Skin resurfacing procedures can activate a Herpes virus infection in susceptible individuals, so an anti-viral drug is prescribed for everyone with a history of cold sores. Antibiotics are also given to reduce risk of bacterial infections.

Discomfort following the procedure is most significant the first few hours and decreases rapidly thereafter. Have all your medication prescriptions filled prior to the day of your surgical procedure. Understand the reasons for taking them and the directions for frequency of use. You will need to take all of your antibiotics and antivirals in the pre and postoperative period as directed.

The preconditioning skin treatments that you have undergone were in preparation for efficient healing in this immediate postoperative period. In the first 3 weeks, your skin will be bright pink to red in color. The redness is a positive sign that the healing process is progressing and a new layer of collagen is being laid down. You can safely apply make-up as a concealer after approximately 10-14 days and we will help you with this process. Depending upon how you feel, you may be able to return to work at 2-3 weeks. You will also feel much more comfortable.

After approximately 4 weeks, the redness will begin to fade significantly and you will begin to appreciate your improved appearance. It is important to remember that the redness will fade gradually. Although the color will continue to diminish with every passing week, some pinkness may remain for 4–6 months. You will not see the final results from your skin resurfacing procedure for 4–6 months. Please do not judge your results too soon as these change dramatically as your healing progresses.

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LIMITATIONS, RISKS and POSSIBLE COMPLICATIONS of SKIN RESURFACING
In any surgical procedure, there are factors such as the patient’s individual healing characteristics, which are not totally under our control. Untoward effects or complications are very unusual, and I will discuss them with you, not to alarm you, but to thoroughly inform you and to aid your decision regarding surgery. Since some factors in the surgical setting are outside of our control, I can give no absolute guarantees as to the results of your surgery.

The skin resurfacing process lightens the skin, but the exact degree of lightening or pigmentation may vary from area to area, and depends mainly on the depth of treatment and the type of skin treated. Areas with different degrees of pigmentation usually become more even over a period of weeks to months. Very occasionally, “touch-up” treatments to certain areas may be required.

Hypertrophic or excess scarring occurs extremely rarely, but is possible. If you have a history of forming unsatisfactory scars in any areas in the past, I must certainly be made aware of this.
Any nevi or moles which are present in an area to be treated may darken significantly following the procedure. When these are present, we will often recommend excision or removal of the moles either
before or after the procedure.

Telangiectasias are small “spider-like” blood vessels which when present in the area to be treated, may appear more prominent following the procedure as the skin is lightened.

Prominence of skin pores may be slightly more apparent following the procedure, especially if you have prominent pores preoperatively.

A line of demarcation between the treated and untreated areas will always be present. During the skin resurfacing treatment, we will make every attempt to “feather” or blend these treated areas so that this line is as inconspicuous as possible.

Any change in your appearance affects your perception of self-image and requires an adjustment period of days to weeks. It is normal to have mild feelings of doubt or low mood during this period in the first one to three weeks following surgery. These feelings are then rapidly replaced by positive feelings as healing progresses and you adjust to your improved appearance.

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CONCLUSION
Resurfacing procedures are extremely useful and effective in improving or eliminating fine wrinkling and other skin abnormalities as previously described. The newly regenerated skin has a much smoother, more youthful appearance and retains this improvement long-term if maintained properly.
During your office consultation, additional or more detailed information regarding all of the areas mentioned in this information sheet will be provided you, as well as an opportunity for you to ask in-depth questions. Please review this information carefully and write down any questions you may have.

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