James J. Romano, MD
There has been an upward trend in the use of CO2 lasers for skin resurfacing over the last five years, mostly due to their distinct technological advantages over other methods in removing wrinkles and pigmentation. CO2 laser manufacturers who mass-market them to physicians; higher overhead due to the CO2 laser purchase or lease; media publicity; and the need to be “on the cutting edge” can all be credited with increasing their usage. However, many patients, physicians, and skincare specialists have become less and less enthusiastic about laser resurfacing because of the pain, prolonged redness, potential complications, downtime, and intense care required. In addition, there is growing concern that CO2 lasers are being over utilized for treatment of conditions that can be handled successfully by other less invasive modalities.
The Consultation Process
CO2 lasers provide controllable and predictable technology for the treatment of textural wrinkles and irregular pigmentation. It is important to be aware of treatment alternatives for clients who are interested in learning about other options. I present the available spectrum of treatment alternatives to every patient interested in removing wrinkles or pigmentation. The chosen procedure depends mostly on how complete a result is desired, and to a lesser extent how much “downtime” this person’s schedule can tolerate. Other factors taken into consideration include individual compliance, clinical skin condition, level of patience, pain threshold, and how long the individual can stand to be treated. This spectrum begins with treatments from skincare specialists; if necessary, increasingly aggressive treatments are available exclusively through a physician’s office. Treatments often graduate from one setting to the next, and overlap enough so the client has the opportunity to take advantage of both.
I begin by having every patient fill out an extensive skin history form that includes the information necessary for my referring estheticians to provide the best care possible. Upon examination and discussion with the patient, I determine which wrinkles and spots to focus on for treatment. I also ask if “softening” the spots or wrinkles would be satisfactory, or if a more dramatic and complete result is desired.
I am careful to evaluate and classify wrinkles in terms of textural, dynamic, or furrows. The fine, medium, or deep textural wrinkles in the dermis of the skin respond well to surface treatments. Dynamic wrinkles in the dermis of the skin are byproducts of muscle activity, and can be softened but not completely removed. Hanging, loose excess skin—such as in the jowls—or furrows—which sometimes appear in the nasolabial area—are more related to the underlying anatomy and are better treated surgically by a facelift.
In analyzing pigmentation, I am careful to evaluate the patient’s expectations, motivations, and degree of compliance. Pigmentation changes can be spotty or diffuse, deep or superficial. Some pigmentations are genetically programmed, such as freckles. Most pigmentation can be improved—in some cases, completely removed. An electric UVB black-light examination in the skincare salon or spa can help assess the depth and predictability of surface treatments on skin-pigment improvement.
The Role of the Esthetician
I always start with and emphasize the importance of skincare and esthetic services, including glycolic peels. The esthetician’s role in the care and education of clients undergoing surgical procedures should not be underestimated. Skincare specialists are already familiar with and play a huge and growing role in the treatment of plastic-surgical and laser patients.
The glycolic peel was introduced and gained momentum and popularity in the 1880s through what was known as lay peelers, or beautifiers. These esthetic pioneers then taught this procedure to dermatologists years later. As peeling became more aggressive and deeper, physicians gradually took over most of this practice, as complications related to these procedures began to arise.
Today’s estheticians often assist with the pre- and post-treatment of clients undergoing plastic surgery and laser resurfacing and are fully aware of procedural complications. In fact, estheticians play a vital role in educating and preparing clients for the surgical procedures, and physicians depend on the estheticians’ help. From its most basic start of cleansing, toning, exfoliating, and moisturizing, excellent and aggressive skincare is vital to pre- and post-op care. Professional skincare treatments are excellent preparation for the next aggressive stage of any skin resurfacing intervention.
In addition, I emphasize sun avoidance to all clients. The majority of the wrinkle lines and pigmentation problems physicians treat are the result of photodamage. Studies have shown that complete avoidance of sun over the course of years can help reverse some of the damaged skin. Since complete avoidance is not practical, when outside, sunblock always should be worn.
Light (superficial) epidermal peeling with glycolic peels or a slightly deeper Jessner’s solution also can be done by the esthetician under the direction of a physician. Glycolic peels should be presented as a program with frequent intervals in the beginning, increasing the duration and concentration of glycolic acid as tolerated with each visit until a stable endpoint of improvement is reached. Then a maintenance program should begin.
The next step-up alternative is a physician-supervised, very aggressive skin-bleaching program using Retin-A*, glycolics, and hydroquinone. The program is fully customizable, and should be individualized for each patient. There essentially is no downtime, it is easy to use, and it provides very predictable results. It works best for patients concerned with pigmentation, but also works well to help soften wrinkles and improve skin texture. I use it as a preparation on laser and facial cosmetic surgery patients with an overwhelmingly high degree of satisfaction. This treatment is used as a supplement to the products and services offered by my referring estheticians, so there is no conflict whatsoever.
The next alternative offered in my office is the medium-depth peel; I use a low-concentration (15 to 30 percent) of TCA. This is an excellent “refresher” minimal downtime peel that can be repeated frequently for cumulative benefits. It also works well for non-facial areas such as the chest, hands, and arms. I use this to feather the edges of demarcation along and into the neck when using deeper treatments to the face, such as laser or a phenol peel. I suggest this as a “jump-start” to patients on a bleaching program. It also is an excellent stand-alone treatment for such things as the fine wrinkles of lower eyelids. I offer this as a “weekend peel.” At first, it looks like a deep-brown sunburn, and comes off like snakeskin. It will help to increase the amount of improvement in pigmentation and soften wrinkle lines. If performed on a Thursday, the patient can be back to work on Friday, have the skin literally peel on Saturday and Sunday, and have it mostly done peeling by Monday or Tuesday. I always inform patients who want to have this procedure done that a one-time isolated treatment is simply not enough.
Dermabrasion is still a very viable alternative that I continue to offer to my patients. It heals faster than the laser, and can be used on small or localized areas where wrinkles are not too deep. It also works well with acne. There is less post-op redness and swelling, and clients quickly see results.
Many physicians continue to prefer and offer phenol peels over the laser because it often is more effective for coarse, deep wrinkles. Hypopigmentation is still an unavoidable byproduct of any phenol peel. Non-resurfacing treatments are preferred in some cases, depending on the anatomy of the problem. In these cases collagen, fat grafting, synthetic filler materials, or surgery may be indicated.
Know the Options
Never underestimate the important role the skincare specialist plays in client education, especially with the CO2 laser resurfacing procedure. Your awareness and client education may be the first step in identifying and preventing complications. There are many modalities available for the treatment of wrinkles and pigmentation that can be employed before, or even instead of, laser resurfacing. Your client may depend on you to educate them on these alternatives.