Periorbital Laser Resurfacing

Key Points

•Lasers are an excellent nonsurgical treatment option for periorbital rhytids and lower lid laxity.

•Four categories of resurfacing lasers exist: traditional

ablative lasers (CO2 and erbium laser), traditional nonablative lasers (Cool Touch, N-lite), fractionated nonablative lasers, and fractionated ablative lasers.

•Fractionated lasers are less effective for periorbital treatment of lower lid laxity and deep rhytids as compared

with the traditional ablative Ultrapulsated CO2 and erbium lasers.

•Proper pretreatment of skin with hydroquinone and Retin-A is essential for avoidance of adverse effects with all laser technologies.

•The results of ablative resurfacing are immediate, improve with time, and are long lasting.

•The incidence of ablative laser complications such as dyschromia is greater with extreme skin types: Fitzpatrick I and V–VI.

•Laser resurfacing can be an extremely useful adjunct to blepharoplasty and other lower lid rejuvenation techniques in the periorbital region.

23.1Introduction

Lower lid rejuvenation remains one of the more challenging problems in cosmetic surgery. Other chapters in this book have elegantly discussed multiple surgical approaches to addressing lower lid laxity and pseudoherniation of orbital fat. The surgical management of deeper lower lid rhytids and

D.G. Hamilton (*)

Private Practice, Dermatologist and Assistant Clinical Professor, David Geffen School of Medicine at UCLA,

Beverly Hills, CA, USA e-mail: dgh@ucla.edu

fine lines remains elusive. Although, aggressive skin care regimen and chemical peels can improve the appearance of fine lines, periorbital laser skin resurfacing is still the gold standard for attaining excellent long-term improvement of this very difficult problem.

23.2History

Laser technologies for resurfacing procedures fall into four basic categories in chronological order of their development: 1. Traditional ablative lasers (Ultrapulsated CO2; Erbium)

2. Traditional nonablative lasers (Cool Touch; N-Lite)

3. Fractionated nonablative lasers (Relient’s Fraxel SR750,

1500 (Re:store): Cynosure’s Affirm 1440/1320; Palomar Lux)

4. Fractionated ablative lasers (Fraxel Re:pair CO2; Affirm CO2; Palomar Lux 2940 erbium: Lumenis CO2: Cutera Pearl)

The traditional ablative lasers were introduced in the mid-1990, with great enthusiasm, for full and segmental facial resurfacing. CO2 was the first ablative laser introduced to the market. Erbium ablative laser technology was later introduced as a “less invasive” option. They were both shown to be efficacious for the treatment of wrinkles and scars, with Ultrapulsated CO2 being more efficacious in improving lower lid laxity. Clinical improvements with these traditional ablative lasers were shown to continue for 5 years. Despite the significant aesthetic improvements with traditional ablative lasers, the prolonged recuperation time with significant erythema reduced overall patient acceptance. As a result, multiple technologies subsequently came to market in an attempt to achieve similar results with reduced downtime.

The search for a no-downtime procedure to resurface the face resulted in the development of the second category of lasers (traditional nonablative lasers) such as Cool Touch and

N-lite. Unfortunately, the pendulum swung significantly with this category of lasers. Although, downtime and side-effects were generally inconsequential, these lasers were significantly less effective in effacing lower lid rhytids.

Fractionated nonablative lasers were a major advance in laser skin resurfacing appearing in 2004 with the production of Reliant’s Fraxel 750 developed under contract by Wellman Laboratories at Harvard Medical School. Other fractionated nonablative lasers soon followed. Treatment with these types of lasers resulted in minimal downtime and an extremely low incidence of dyschromia, allowing use on all skin types. Efficacy with acne scars, fine rhytids, and overall skin texture has been significant with this category; however, improving deeper (nondynamic) rhytids as well as lower lid laxity has been limited. To improve the treatment of static rhytids, a second generation of ablative, fractionated lasers using the CO2 and Erbium technologies has since been developed. These fractionated lasers offered some of the advantages of the traditional CO2 and Erbium lasers with slightly less downtime as well as lower risk of dyschromia.

23.3Use of Resurfacing Lasers for Periorbital Resurfacing

Periorbital cosmetic concerns generally involve anatomic changes, cutaneous laxity, and rhytids. Anatomical changes typically include true or pseudoherniation of orbital fat, tissue deflation, sagging, and loss of eyelid tone. Correction of these concerns is addressed elsewhere in this book.

Periorbital rhtyids are primarily a result of photodamage, loss of elasticity, and dynamic expression (facial animation). These issues need to be addressed with appropriate treatments such as chemodenervation, skin care, sun protection as well chemical and laser resurfacing. Skin resurfacing results are more predictable with the use of lasers than chemical peels. All laser categories will produce improvement but the most substantial improvement comes from the use of traditional ablative CO2 and erbium lasers.

Surgery is the optimal treatment for cutaneous laxity of the upper eyelids. For the lower lids, however, lid tightening can also be addressed with lasers. While traditional surgical approaches can remove excess skin, they do not alter the quality of remaining skin. Ultrapulsated CO2 laser skin resurfacing not only enhances the quality of rhytids, it can additionally improve skin laxity and may be the treatment of choice for the appropriate skin type. The clinical skin tightening produced by the traditional CO2 is immediate and long lasting. Erbium laser with appropriate treatment protocol can achieve similar improvements in deep rhytids as Ultrapulsated CO2 laser but falls short in causing skin tightening. The ablative fractionated CO2 and Erbium lasers will produce some skin contraction but not enough to justify their use for this purpose.

23.4Traditional Ablative Laser Resurfacing

Although erbium lasers were first introduced as a less invasive option to CO2 lasers, both technologies are effective for periorbital rhytids. The downtime and complication rates are also similar for both lasers at settings that garner the same aesthetic outcome. Typically, erbium laser will require additional passes to achieve the rhytid results of CO2. The main difference between the two technologies is that the CO2 application is more efficacious in tightening the lower eyelid skin.

The potential complications with ablative laser resurfacing include dyschromia (hyperpigmentation, hypopigmentation), prolonged edema/erythema, hypertrophic and atrophic scarring. Tables 23.1–23.3 summarize the preoperative evaluation for appropriate patient selection. Each patient must first be clearly classified into the Fitzpatrick skin classification, which has an excellent correlation with laser candidacy and potential complications. Absolute contraindications include active infectious disease, oral retinoids, connective tissue disorder, propensity for keloid formations, suspicion for cutaneous malignancy, and pregnancy. Relative contraindications

Table 23.2 Pretreatment analysis for ablative CO2 and erbium laser procedures

•Oral retinoids

•Suspicion for cutaneous malignancy

Table 23.3 Pretreatment medications for ablative CO2 and erbium laser procedures

Skin preparation: Hydroquinone (in the morning) and Retin-A (at night) are initiated one month prior to the procedure

Antibiotics: Cefuroxime 250 mg BID starting 12 h before procedure through evening after

Antiherpetic: Valacyclovir 500 g BID starting 3 days before procedure through postoperative day 4

Pain medications: Extra Strength Tylenol for mild to moderate pain; Tylenol with codeine for severe pain

Sleeping pills: Dalmane 15 mg

Specifications and technology information were taken from the following websites

Lumenis aesthetic: http://www.aesthetic.lumenis.com/ultrapulse

UltraPulse specifications data sheet: http://www.aesthetic.lumenis. com/pdf/UltraPulse_Encore_datasheet.pdf

Cynosure affirm specs: http://www.cynosure.com/products/affirm/ specs.php

Fraxel.com: http://www.fraxel.com/physicians.cfm

Fraxel laser skin treatments and resurfacing procedures: http://www. fraxel.com/Fraxel-Lasers-Compare-Technology/

include immune compromise status, poor lid distraction test, Fitzpatrick skin type I (hypopigmentation), and V–VI skin (hyperpigmentation). Patients with darker skin complexion are at a higher risk of hyperpigmentation. As a result, individuals with Fitzpatrick skin type V and VI require significant diligence in pretreatment protocol including one month of daily application of 0.025% trentinoin cream and 4% hydroquinone. Patients should be made aware that hyperpigmentation is treatable in most individuals. On the contrary, skin types I and II are at a higher risk of developing hypopigmentation with ablative lasers. Hypopigmentation, unlike hyperpigmentation,

has no great solution and can be a serious complication. As a result, patients with very light complexion must be approached with extreme caution.

23.5Technical Considerations: Ablative Ultrapulsated CO2 Laser Resurfacing

Patients are instructed to avoid sun 2 weeks prior to the procedure and are pretreated for one month with daily application of 0.025% trentinoin cream and 4% hydroquinone. Oral prophylaxis with antibiotics and antiviral medication is also recommended. Infraorbital and supraorbital nerve blocks are administered using 2% xylocaine with epinephrine 10 min prior to beginning the procedure. Tetracaine ophthalmic drops are administered prior to beginning the procedure.

The CO2 laser is performed on Hibiclens or alcohol prepped skin. With the Lumenis Ultrapulse CO2 laser (Lumenis Inc., Santa Clara, CA), a setting of 300 mJ at a fluence of 5 J/cm2 is used with a rectangular pattern. All personnel should wear laser-specific protective goggles. The upper lid and brows are typically treated at the same time as the lower lids. A laser safe Jaeger lid plate (or similar type protective shield) is inserted under the lids as a protective measure after application of lacrilube ophthalmic ointment. This specific Jaeger lid plate has a dull surface, removing its capacity to dangerously reflect the laser beam. The contralateral eye is covered closed with water-soaked gauze.

The white char created by the first pass is removed using wet gauze and the face is dried again. The first pass generally removes about 80–100 mm of tissue reaching the superficial dermis. Pinpoint bleeding may begin depending upon the area of the face. The first pass is merely a facilitator for the second and/or third pass when collagen remodeling and substantial long-term benefits can be achieved. On the second pass, the aesthetic benefit of the laser is observed with the ablation of the shoulders of the wrinkles and collagen contraction. Even though further beneficial effects may be achieved by a third pass, many experienced laser surgeons avoid further treatment with the eyelids. Third passes, if performed, should be done in a “spot” fashion. One wants to avoid the development of a grayish hue, which indicates imminent penetration of subcutaneous fat. Airborne debris is evacuated throughout the procedure with a vacuum device handled by an assistant. After a final removal of char, refrigerated plain Aquaphor is applied. Vigilon Primary Wound Dressing (Bard Medical, Covington, GA) may be used as an alternative for 24–48 h. Unlike other parts of the face, Wound dressing is fairly difficult to keep around the eyes. Figure 23.1 illustrates a typical outcome for crow’s feet with ablative laser resurfacing.

23.6Posttreatment Care for Ablative CO2 and Erbium Laser

Pain following the skin treatment is usually mild to moderate and can often be controlled by Extra Strength Tylenol. The patients are encouraged to apply cold compress continuously on the day of procedure until bedtime and 20 min per hour the day following the procedure. The head should be elevated between 30 and 45° for 4–5 days after the procedure. The patients can take a bath or shampoo their hair.

The treated area should be soaked for 10–15 min (4–6 times a day) with a mixture of 1 teaspoon of white vinegar in one 8 oz cup of cool water using a fine sponge or wash cloth. The skin should be kept lubricated with aquaphor in between soaks to prevent crusts and scabs. Dead skin or scabs should not be picked, rubbed, or removed by the patient as this may increase the risk of scarring. There should be no vigorous or strenuous activity which would raise the blood pressure or pulse for 2 weeks.

There may be considerable swelling, some bruising, and mild discomfort for up to a week following the procedure. There may be oozing of a pinkish/yellow serous fluid for the first several days following the procedure. The skin will be very smooth and quite reddish/pink in color in the first few weeks. The redness may last as long as 8–12 weeks before gradually fading.

Reepithelization starts immediately after laser resurfacing. The epidermis continues to thicken for several weeks; however, the region can be treated like normal skin about a week after the treatment. Although the area remains sensitive to wind and potential irritants for weeks, make-up and concealers can be applied at the 1-week time period. Sunscreen should be applied after 3 weeks and excessive sun exposure should be avoided.

23.7Fractionated Laser Resurfacing

Although fractionated laser resurfacing can be an excellent option for dyschromia and photodamage in the periorbital region; this technology has yet to produce the superior

results of the Ultrapulsated CO2 technology for lower lid laxity. Although the postoperative erythema does not have as long duration as traditional ablative lasers, the perioperative management and complication profile for ablative fractionated lasers is very similar to erbium and Ultrapulsated CO2 technology. The techniques for ablative fractionated laser will depend on the device type and therefore should be optimized with the help of the manufacturer and their representatives.

Nonablative fractional lasers have a lower risk profile and significantly decreased recovery time as compared with their ablative counterparts. Specifically, they have minimal downtime and an extremely low incidence of dyschromia, allowing use on all skin types. These class of lasers, however, require multiple treatments to achieve the desired outcome. In the following section, we will focus on the treatment protocol and postoperative management of Fraxel SR750, one of the most commonly used nonablative fractional lasers. Most light-based devices in this category will require a similar treatment algorithm.

23.8Technical Considerations: Nonablative Fractionated Laser

Contraindications for fractionated lasers are similar to other lasers which include active use of oral retinoid, predisposition to keloid formation, or excessive scarring as well as lesions suspicious for malignancy. Prior to the procedure, the patients are pretreated with hydroquinone and Retin-A for one month and encouraged to stop 5 days prior to treatment. The area is prepped 30 min to 1 h in advance with a high potency topical betacaine anesthetic. After the topical anesthetic is removed, Opti-Guide Blue is applied followed by a low potency topical anesthetic that allows the treatment tip to navigate easily. The dye (not used with the SR1500) serves to enhance contrast for the optical mouse. Eight nonoverlapping passes are performed with a density of 250 Mtz/cm2