Cosmetic Facial Surgery

Chapter 12  •  Skin Resurfacing
533
E
F
G
H
E–F, Appearance 48 hours postpeel. G–H, Appearance 4 days postpeel.
FIGURE 12-29, cont’d
Continued

534
Chapter 12  •  Skin Resurfacing
I
J
I–J, Appearance 5 days postpeel, with the majority of dead skin exfoliated.
FIGURE 12-29, cont’d
A
B
C
D
FIGURE 12-30.  I prefer the Obagi Blue Peel for darker
skin types. Shown here are intrapeel images of African
American (A), Brazilian (B), Asian (C), and Hispanic
(D) patients.

Chapter 12  •  Skin Resurfacing
535
FIGURE 12-31.  With the Obagi Blue Peel, 30% trichloroacetic acid (TCA)
is mixed to the desired concentration with the Blue Peel base.
A
B
C
FIGURE 12-32.  The peel solution can be applied with a cosmetic sponge (A), cotton-tipped applicators (B), or surprisingly well
with gloved fingers (C).
A
C
B
FIGURE 12-33.  A, Results several minutes after a single coat of 20% Obagi Blue Peel; a light frost is noticeable. B, Several
minutes after a second coat of the same acid solution, with a deeper white frost—in this case the endpoint. C, 15 minutes
after the end of the procedure and removal of much of the blue base.

536
Chapter 12  •  Skin Resurfacing
A
B
C
FIGURE 12-34.  A significant amount of the blue base can be removed by washing with the included cleanser.
skin will have a bluish tint for several days. Much of the blue
base can be removed with the included cleanser that accompa-
nies the OBP kit (Figure 12-34).
Postpeel care is the same for the previously described
straight TCA peel. Patients apply a light coat of petroleum
jelly or Aquaphor until the peeling is complete and wash the
face twice a day with a hypoallergenic wash. Most patients
will begin to peel by day 3 or 4 and finish by day 6 or 7
(Figure 12-35).
Chemical peeling can also be used as an adjunct to laser skin
resurfacing, especially to blend in hairlines and treat the neck.
Figure 12-36 shows combination cases.
Case Presentations
Figures 12-37 to 12-45 show before-and-after chemical peel
patients treated by the author.
Chemical Peel Complications
Chemical peeling can be a very safe and effective procedure and
is very commonly requested in the cosmetic facial surgery
A
B
C
FIGURE 12-35.  Several patients with different ethnic skin during the peak of the peel phase. Some pigmentation may be initially
lost but will quickly return upon healing.
practice. Many patients do not completely understand the
effects of a chemical peel and must be educated as to what the
procedure entails and expected results. Not all skin types are
good candidates for chemical peel, and hypopigmentation and
hyperpigmentation do occur. Like all resurfacing procedures,
there can be a fine line between optimum treatment and over-
treatment resulting in complications. Choosing the right
patients has a lot to do with the results of a surgeon. Patients
with darker skin types can portend significant problems with
hyperpigmentation and hypopigmentation.
As I have said many times, successful chemical peeling is as
much art as science and requires significant experience to obtain
predictable results. Precise attention to creating a homogenous
frost and hence peel depth is critical to the end result (Figure
12-46). It is equally important to make sure that all regions are
symmetrically treated and blended into the hairline, or the
transition is noticeable (Figure 12-47).
Overcoverage or extending natural transition zones is just as
problematic as undercoverage. Not all chemical face peel patients
Text continued on page 545.

Chapter 12  •  Skin Resurfacing
537
A
B
FIGURE 12-36.  A, Patient treated with full-face CO2 laser resurfacing and a two-coat 20% plain trichloroacetic acid (TCA) peel
of the neck. B, Patient treated with a full-face 30% TCA chemical peel and periorbital CO2 laser resurfacing.
B
D
F
E
A
C
FIGURE 12-37.  Patient requested chemical peel for correction of spotty photodamage. A–C, Before treatment. D–F, One week
after medium-depth chemical peel with three coats of 30% trichloroacetic acid (TCA).
Continued

538
Chapter 12  •  Skin Resurfacing
G
I
J
H
Scan of same patient before (G–H) and after (I–J) illustrates significant clinical improvement of
photodamage.
FIGURE 12-37, cont’d.

Chapter 12  •  Skin Resurfacing
539
D
A
C
B
FIGURE 12-38.  An 18-year-old female presented for improvement of her freckles. She is shown intrapeel with white frost on a
pink background (A) and in the midpeeling process at day 5 (B). The patient before (C) and after (D) her papillary dermal 30%
trichloroacetic acid (TCA) peel.

A
C
B
D
F
E
G
I
H
J
L
K
FIGURE 12-39.  Female patient with severe pigmentation and melasma. She is shown before (A–C) and after (D–F) 30% tri-
chloroacetic acid (TCA) peel. UV photography of the patient before (G–I) and after (J–L) the peel illustrates degree of pigment
improvement. Periorbital darkness is from sunscreen.
540

Chapter 12  •  Skin Resurfacing
541
A
B
C
D
FIGURE 12-40.  A–B, Patient with moderate photodamage was treated with a medium-depth 30% trichloroacetic acid (TCA)
peel. C–D, Actual degree of pigment improvement is more noticeable with UV photography than clinical photographs. Showing
patients such evidence of improvement helps them realize the true effects of chemical peeling they might not otherwise
appreciate.

542
Chapter 12  •  Skin Resurfacing
A
B
C
D
FIGURE 12-41.  Patient before (A) and 2 weeks after (B) a two-coat 30% trichloroacetic acid (TCA) peel. C-D, The UV photog-
raphy further illustrates the improvement of her pigmentation.

Chapter 12  •  Skin Resurfacing
543
A
B
FIGURE 12-42.  This patient of Hispanic origin is
shown before (A) and 6 weeks after (B) three
coats of 20% Obagi Blue Peel. Although signifi-
cant improvement of her melasma is seen, the
patient will require eventual retreatment to con-
tinue the degree of improvement.
A
B
FIGURE 12-43.  African American female shown before (A) and after (B) an Obagi Blue Peel for perioral and generalized
pigmentation.
A
B
FIGURE 12-44.  African American female shown before (A) and after (B) a three-coat 15% Obagi Blue Peel, with good resolution
of her pigmentation and homogenization of her complexion.

544
Chapter 12  •  Skin Resurfacing
A
B
FIGURE 12-45.  Although most chemical peeling is performed as a full-face procedure, isolated pigmented lesions can be
improved with local application of 15% trichloroacetic acid (TCA) every several weeks.
A
B
FIGURE 12-46.  Patient with a trichloroacetic acid (TCA) peel was overtreated in some areas and undertreated in others. The
surgeon must be constantly aware of providing even coverage and waiting several minutes between coats to observe a
homogenous frost.
FIGURE 12-47.  Failure to pay attention to symmetric coverage or not extending into the hairline can leave noticeable differences
in skin color and texture. Patient shown 4 days after a trichloroacetic acid (TCA) peel with obvious undercoverage.

Chapter 12  •  Skin Resurfacing
545
rejuvenation, owing to inherent risks. As far as cosmetic surgery
has advanced, when it comes to facelift, lasers and peels, the
neck stands out against a rejuvenated face and a predictable and
safe treatment option will someday be a welcomed advance in
the art.
Learning the correlation between the quality of a frost, its
approximate depth, and the expected healing time is the crux
of predictable and safe chemical face peels. Undertreatment can
be corrected with future peels, but overtreatment can cause
delayed healing and burns (Figure 12-51).
Hyperpigmentation
Hyperpigmentation is also a frequent complication or, more
accurately, a sequela of skin resurfacing, both laser and chemical
peel. Although seen much less frequently with medium-depth
chemical peels (as compared to laser skin resurfacing), it is
always disconcerting to the patient. Since one of the main
factors that warrant a chemical peel is dyspigmentation, these
patients are already predisposed to pigmentary problems and
can be very reactive to any insult of the epidermis and dermis.
Properly performed prepeel conditioning can reduce the mela-
nocytic activity and is important to decrease postpeel hyperpig-
mentation. The judicious use of sunscreens and avoiding
sunlight are also important. Regardless of the succinct manage-
ment of the patient, postinflammatory hyperpigmentation
(PIH) will occur in some patients. Regardless of your explaining
this in the preprocedure consult process and having it on the
consent, patients are frequently upset when PIH appears. Clas-
sically, PIH will appear about 30 days post peel or laser as patchy
bronzing (Figure 12-52). Placing patients on hydroquinone 4%
and the judicious use of sunscreen will resolve most cases in
several weeks. It is important to warn patients of the possibility
of PIH at several opportunities before the peel. In cases of severe
overtreatment, hyperpigmentation can be permanent, but this
is rare with medium-depth peels.
undergo simultaneous neck peeling. If the neck is not peeled,
the transition must stop at the mandibular border so as not to
be noticeable (Figure 12-48). Landmarks can shift with a supine
patient, so the mandibular border should be marked in the
upright position before the case (Figure 12-49).
This chapter has mentioned the sensitivity of the neck skin
compared to facial skin. Delayed healing and severe scarring can
occur with overtreatment (Figure 12-50). It is very tempting to
aggressively treat the neck because it is a major area of concern
for many patients. Although some practitioners espouse predict-
able expertise with aggressive neck peeling, I would again
caution all peelers to reject the temptation of instant neck
A
B
FIGURE 12-48.  Lack of attention to a natural anatomic border endpoint is shown. This peel should have either stopped at the
mandibular border or extended to encompass the entire neck.
FIGURE 12-49.  Marking the mandibular border with the patient in the upright
position is important to achieve a hidden lower border for a face peel when
not treating the neck. Since soft tissue boundaries will change when the
patient is supine, it should always be done before the procedure.

546
Chapter 12  •  Skin Resurfacing
Laser Skin Resurfacing
As noted in the opening paragraphs of this chapter, prior to
the mid-1990s, dermabrasion and chemical peels were the
accepted means of skin resurfacing. Light and medium chemi-
cal peels could affect pigment problems and minor skin wrin-
kles. Deeper peels used for “skin leveling” to treat deeper
wrinkles, folds, and scars produced varied results and significant
complications. Dermabrasion, an art in itself, was not predict-
able or controllable in the hands of the average clinician, and
the spray of blood, serum, and tissue it produced made this
procedure especially hazardous in a time when concerns about
bloodborne diseases such as acquired immunodeficiency syn-
drome (AIDS) were on the rise. The cosmetic world required
a more controlled means of rejuvenating skin. Enter laser
technology.
Hypopigmentation
Permanent hypopigmentation is a rare complication with
medium-depth chemical peels but a common sequela of deep
phenol peels. Peeling darker skin types can induce relative
hypopigmentation (Figures 12-53 and 12-54). This condition
occurs when the face is lighter than the neck and surrounding
tissues and is not true hypopigmentation, which is a disorder of
melanocytes. With relative hypopigmentation, the peeled skin
will initially appear lighter but will usually return to normal
pigmentation over several months.
Chemical peeling smaller regions of pigmentation can be
useful, but the surgeon should be very cautious and not try to
push the result with a single procedure. It is much safer to
perform numerous conservative peels every several weeks to
avoid overtreatment (Figure 12-55).
A
B
C
FIGURE 12-50.  A-B, Normal neck healing responses to several coats of 15% trichloroacetic acid (TCA). C, An overtreated neck
after chemical peel that fortunately went on to heal normally but not without some sleepless nights for the patient and surgeon.
A
B
FIGURE 12-51.  Patient underwent a trichloroacetic acid (TCA) peel with an extra coat on the cheeks that resulted in delayed
healing. Although the areas healed normally, it could have been an unfortunate complication.

Chapter 12  •  Skin Resurfacing
547
ablation and collagen shrinkage and is used to treat scarring,
dyschromias, actinic cheilitis, rhytid effacement, keratoses,
benign lesions, precancerous lesions, intraepidermal malignan-
cies, and rhinophyma. Older technologies like dermabrasion
and chemical peel required “an experienced guess” at tissue
depth, but the CO2 laser is an instrument that precisely ablates
tissue each time: 50 to 150 microns of tissue with a zone of
thermal damage up to 100 microns. The chromophore for CO2
laser is tissue water and is also absorbed by surrounding vessels
and structures for unselective tissue destruction. This is different
for other lasers that have chromophores of melanin or hemo-
globin and are much more tissue-target specific. Early CO2
lasers were continuous wave, and it was more difficult to control
lateral tissue damage. With the advent of ultrapulsed lasers
Laser stands for “light amplification by stimulated emission
of radiation.” Laser technology in medicine existed decades
before it became popular, but problems existed with selectively
ablating unwanted tissue without damaging surrounding normal
tissue. With the improvement of technology and the under-
standing of light science and tissue response, lasers became a
versatile treatment option. The basic principle of laser therapy
is known as selective photothermolysis in which the chromophore
is targeted with a pulse duration that is shorter than the thermal
relaxation time, thus minimizing risks of unwanted surrounding
tissue damage.7 The carbon dioxide (CO2) laser (wavelength
10,600 nm) was initially developed for surgical excisions but
eventually became a very useful tool for skin rejuvenation and
surgical incisions (Figure 12-56). The CO2 laser provides tissue
FIGURE 12-52.  Patient 30 days after a medium-depth chemical
peel with the patchy hyperpigmented areas of postinflammatory
hyperpigmentation.
A
B
FIGURE 12-53.  Patient 14 days (A) and 90 days (B) after medium-depth Obagi Blue Peel. Her lightened pigmentation returned
to normal with no treatment.

548
Chapter 12  •  Skin Resurfacing
contemporary CO2 laser surgeons can offer safer and more
predictable treatments.
As with other technology, many types of lasers were intro-
duced to compete with CO2 technology. The erbium:YAG laser,
with a wavelength of 2940 nm, became popular in the mid-
1990s as a “safer and gentler” laser (Figure 12-57). This wave-
length has a 13-fold greater affinity for water, 70% of the skin’s
composition. The stated advantages included less ablation
depth, less thermal damage, faster healing, and decreased ery-
thema persistence. Although this laser grew quickly in popular-
ity after U.S. Food and Drug Administration (FDA) approval
in 1996, many of the same problems and complications associ-
ated with CO2 lasers appeared soon after. Although the
erbium:YAG laser is still popular with some clinicians, the CO2
laser is still the gold standard for skin rejuvenation, especially
skin tightening and rhytid effacement. I have used all the
popular resurfacing lasers, but the majority of this section will
deal with the Lumenis UltraPulse Encore CO2 laser (Lumenis
Inc., Santa Clara, CA). This machine with its versatile treatment
options has been the mainstay of my laser skin resurfacing and
blepharoplasty practice. This is not to say that other lasers
cannot work well in a practice, but the purpose of this text is
to relate my experiences in cosmetic facial surgery for safe and
effective results. Newer “light” and fractional lasers will be dis-
cussed later in this chapter.
The Lumenis Encore is a smaller-platform CO2 laser than
the original model (see Figure 12-57), with a peak output of 60
watts and 100 mJ, which equals 7 J/cm2. The laser comes with
a computerized pattern generator for skin resurfacing as well as
straight handpieces for lesion removal and tissue incision (Figure
12-58). Currently, several options are available, including a
curved laser wave guide for endoscopic brow and forehead lift
and a Deep FX computerized scanner for newer technology
deep fractionated treatments.
and computerized pattern generators, high peak powers and
short pulse duration were possible. Tissue vaporization was
maximized and thermal injury minimized.8 With the develop-
ment of this powerful new laser technology, pioneering skin
resurfacing techniques followed. Unfortunately, many lessons
were learned the hard way, and an onslaught of complications
occurred in the 1990s. Learning from the past, today’s
A
B
C
D
E
F
FIGURE 12-54.  A–C, Patient with significant noticeable relative hypopigmentation on the face after a medium-depth trichloroacetic
acid (TCA) peel. D–F, Six months after her peel. The hypopigmentation has improved, but she has also regained much of her
melasma. This patient gradually returned to her normal skin color, which took almost a full year. Eradicating pigmentary abnor-
malities in darker-skinned patients can be a true challenge, rarely accomplished in a single procedure in difficult cases.
FIGURE 12-55.  Patient was treated with 20% trichloroacetic acid (TCA) on
several occasions for a pigmented neck lesion. The lesion remained, but
the surrounding neck skin became hypopigmented, which lasted for years
before returning close to the baseline. This underlines the sensitivity of
neck procedures.

Chapter 12  •  Skin Resurfacing
549
penetration of acid, many practitioners do not precondition
laser patients.
Contraindications (especially for aggressive ablative proce-
dures) include the use of systemic isotretinoin (Accutane) within
1 year, problems with previous resurfacing (chemical peel or
dermabrasion), proclivity for keloid or hypertrophic scarring,
history of severe herpetic outbreak, or history of excessive lower
eyelid skin removal. The presence of autoimmune disorders
(e.g., vitiligo, psoriasis) can worsen or spread to the face. Patients
with collagen vascular diseases such as lupus or scleroderma may
have impaired healing mechanisms that could affect healing.
LSR is very effective for skin tightening and improving the
appearance of wrinkles. In my experience, the degree of both is
far superior to a single medium-depth chemical peel, but
Patient Selection
The same patient selection guidelines for chemical peels apply
to laser resurfacing (e.g., Fitzpatrick skin types). The best can-
didates are Fitzpatrick 1 and 2 patients. Fitzpatrick 3 is generally
the cutoff for aggressive skin resurfacing; types 4, 5, and 6 are
contraindicated for this technique. The same skin conditioning
can be used for laser skin resurfacing (LSR) patients, but whereas
preconditioning is critical for chemical peeling to allow even
Nd:YAG
1064 nm
CO2
10,600 nm
Pulsed dye
510 nm
Copper vapor
511 nm
Krypton
520-30 nm
KTP
532 nm
Frequency doubled
ND:YAG
532 nm
Krypton
568-577 nm
Argon tunable dye
577 nm
Copper vapor
578 nm
Pulsed dye
590 nm
Long-pulse dye
590 nm
Photoderm
550-900 nm
Ruby
694 nm
Alexandrite
755 nm
500
600
700
800
1,000
Wavelength (nm)
Visible light
Infrared
FIGURE 12-56.  CO2 laser and Erbium:YAG laser wavelengths are shown on the electromagnetic spectrum.
A
B
FIGURE 12-57.  The newer Lumenis Encore UltraPulse CO2 laser (A) is
a smaller-platform laser than the original Lumenis 5000C UltraPulse  
laser (B).
A
B
C
FIGURE 12-58.  The Lumenis Encore laser is shipped with a computer
pattern generator (A), a 0.2-mm incisional handpiece (B), and a 2-mm
spot handpiece for tissue ablation (C).

550
Chapter 12  •  Skin Resurfacing
bottom line for any surgeon is that concentrated laser light
damages tissue. It does not matter what the wavelength or
technology is, lasers burn tissue. Although LSR has been a huge
part of my practice since 1996, and my laser cases are among
my most impressive cosmetic outcomes, I must admit that the
majority of my sleepless nights have come from worrying about
LSR problems. It takes years of experience to master LSR, and
every practitioner should devote significant study, preceptor-
ships, and proctoring to learn the skill. Similar to chemical
peeling, performing less aggressive procedures on a long series
of patients is the best way to become competent and have
reproducible and safe results.
Laser Safety
Laser treatment can be very hazardous to the surgeon, staff, and
patient. Numerous hazards exist and must be accounted for
when using any laser. Any time a laser is used, windows in the
operating room must be covered, and a sign warning that a laser
is in use and naming the specific wavelength must be displayed
on the door (Figure 12-59). This is protection for anyone that
may wander into the room.
Eye protection for the specific wavelength used is paramount
for the surgeon, staff, and patient. The CO2 laser technically
does not require protective eye wear for the doctor and staff,
but it must be used in the event that the laser beam reflects into
the operator’s or staff’s eyes.
When using lasers on the face or performing LSR anywhere
near the eye, stainless steel corneal shields are an absolute req-
uisite; serious eye damage has occurred by inadvertent laser
contact (Figure 12-60). The placement of corneal shields is very
simple. Several drops of topical ophthalmic drops are instilled
in each eye, and the stainless steel polished corneal shields are
placed in the fornix of the lids with suction-cup holders (Figure
12-61). Some patients have larger or smaller palpebral apertures
that may require different-sized shields. Although some sur-
geons lubricate the shields with an ophthalmic ointment, I have
abandoned this practice because it seemed to produce more
irritation. At the end of the laser procedure, the shields are
removed, and the eyes are irrigated with sterile normal saline
(0.9% sodium chloride). In the event that swelling makes the
recovery with LSR is much more complex and will be discussed
in detail. When discussing LSR with potential patients, the
surgeon and patient must decide which type of CO2 laser treat-
ment is applicable to their degree of aging and recovery window.
Using the same laser, numerous types of treatments can be
performed, including ultralight fractional, light, medium, deep
fractional, and aggressive high energy, high density. Each type
of treatment has increasingly noticeable outcomes and recover-
ies. Aggressive CO2 resurfacing can entail a formidable recovery
process, and not all patients are up to that extreme.
For the purposes of this text, I will classify CO2 laser treat-
ments into the following categories and nomenclature:
• Ultralight fractional CO2 LSR. This is also referred to
as active FX and involves high-fluence, low-density
fractional treatment.
• Light CO2 LSR. Also referred to as CO2 Lite, this
involves
lower-fluence,
high-density,
single-pass
treatment.
• Medium CO2 LSR. This is my nomenclature and involves
high-fluence, high-density, single-pass treatment.
• Deep fractional LSR. Also called Deep FX, this involves
high-fluence, low-density, single-pass treatment with
increased tissue penetration depths. A doped erbium
wavelength is also used with the Fraxel Re:pair laser (Solta
Medical, Inc., Hayward, CA).
• Aggressive CO2 LSR. Also my nomenclature, this
involves high-fluence, high-density, multipass treatment
for severe photoaging.
Treatments are listed in increasing order of clinical result and
recovery time. An ultralight CO2 LSR may heal in 5 days, but
it produces minimal improvement. An aggressive high-power
multipass CO2 LSR can produce dramatic results but requires
almost 2 weeks of recovery, with another month of post-laser
sequelae. Younger patients with few wrinkles and small pigmen-
tary problems may benefit from a lighter laser, whereas older
patients with significant photodamage, dyschromias, and wrin-
kles will require high-power aggressive treatment for rejuvena-
tion. One of the keys to successful treatment is to pick the
proper patients and communicate a realistic expectation of
degree of improvement and recovery time.
The current onslaught of laser promotion for increased
results with decreased recovery marks how cosmetic science
progresses. The problem lies in the fact that laser manufacturers
and the media frequently distort the actual results and the
recovery periods required. This is a very confusing time for
novice laser surgeons; so many of the currently available frac-
tional lasers sound too good to be true. As laser manufacturer
competition has grown, many surgeons are offered lasers that
have downtimes of several days and results that are amazing.
Unfortunately, many times expectations exceed results. I have
numerous friends who have purchased “miracle” lasers that
purport maximum results with several days of downtime, only
to be extremely disappointed. Some surgeons were even told,
“You can’t hurt anyone with this laser”—which is a travesty. As
I write this text, numerous journal articles are beginning to
appear describing serious burns and scarring from fractional
laser treatment. Unfortunately, this is a replay from the 1990s
when the hard lessons of overtreatment were learned. The
FIGURE 12-59.  A danger sign is posted on the closed door of the operating
suite and must include the wavelength of the laser in use. Any personnel
entering the room must first have appropriate wavelength-specific protec-
tive eyewear.

Chapter 12  •  Skin Resurfacing
551
removal of a shield difficult, a wall suction hose tip can better
grip the shield for removal (Figure 12-62).
Inhalants are another potential laser hazard, and the smoke
plume must be controlled. Everyone in the room must wear a
face mask; dedicated fine-pore laser masks are preferable. These
masks are thicker and have extended coverage to protect person-
nel from laser smoke plume. A dedicated smoke evacuator is
also a necessity when using ablative lasers (Figure 12-63).
The CO2 laser beam is also an ignition source and must not
be used in the presence of confined oxygen, because operating
room fires can occur. This is especially important when working
around endotracheal tubes or nasal cannulas, which can readily
ignite (Figure 12-64). Besides the fire risk, the patient and their
airway can be severely burned. Any flammable material such as
FIGURE 12-60.  This infamous image has circulated the laser world as
an austere reminder of the danger of unprotected eyes during laser
treatment.
A
B
C
FIGURE 12-61.  Laser corneal shields are placed after instilling several drops of ophthalmic topical anesthetic in the eye (A), then
the lower end of the shield is inserted into the lower lid fornix (B) and sits on the globe, covering the entire cornea (C).
A
B
FIGURE 12-62.  In the event corneal shields are difficult to remove, the end of a wall-suction tubing can be used to better secure
the shield to remove it from the eye.

552
Chapter 12  •  Skin Resurfacing
a fractional treatment. Whereas standard laser treatment ablates
the entire skin surface to a given depth, the fractional CO2 has
spot sizes that are spaced so that microspaced columns of skin
are ablated, but normal skin is left between the treated areas
(Figures 12-65 and 12-66).
Another innovation by Lumenis is CoolScan technology.
Traditional CO2 laser scanners use high-density overlapping
patterns that lay down laser pulses in an orderly left-to-right
order. This does not allow heat to escape. CoolScan technology
lays down laser pulses in a random nonsequential pattern that
allows heat dissipation, which produces less lateral tissue damage
(Figure 12-67).
The ultralight fractional or Active FX treatment is a conserva-
tive laser procedure that can be performed with topical anesthe-
sia. This level of treatment is an epidermal treatment and does
not reach the papillary dermis. The advantage is that healing
occurs in 3 to 5 days. This level of laser treatment is moderately
effective for dyschromias and very fine lines and wrinkles. It is
beneficial for skin health and will produce a refreshed, smoother
skin surface. Although a single CO2 fractional treatment can
produce benefit, multiple treatments are more effective. I only
use this treatment rarely; most patients in my practice have
greater levels of skin damage or expect more dramatic results.
For patients who desire a mild to moderate improvement and
shorter downtime, this is an option. I primarily use fractional
CO2 laser for younger patients with busy schedules.
I also use fractional CO2 laser for treating the neck. As
stressed earlier, resurfacing the neck is a dangerous procedure
that can produce severe complications. For this reason, I never
use high-energy, high-density laser treatment on the neck, but
the Active FX treatment has proven very safe (Figure 12-68). A
single treatment does not produce significant results but does
produce a smoother-feeling skin surface. Repeated fractional
CO2 laser neck treatments can produce mild to moderate
improvement of dyschromias and photodamage.
For fractional CO2 facial treatment, two options exist. The
first is high-fluence 80- to100-mJ (5 to 7 J/cm2), with a low
paper or cloth drapes, hair, and plastic must also be kept out of
the path of the laser beam. Patients should never have hair spray
or hair gel on during ablative laser surgery.
CO2 Laser Treatment Options
Discussion of every laser treatment available is beyond the scope
of this chapter. Instead, we will focus on the mainstay of safe
and predictable procedures I have performed since 1996.
Ultralight Fractional CO2 Laser
Skin Resurfacing
The Lumenis UltraPulse Encore laser is capable of ultrapulsed
fractional CO2 LSR, also referred to as Active FX. The biggest
difference between this and conventional CO2 LSR is that it is
FIGURE 12-63.  A dedicated smoke evacuator is an absolute necessity
when performing ablative CO2 laser skin resurfacing.
FIGURE 12-64.  The CO2 laser is an ignition source and must be used very
cautiously around flammable gases, paper products, hair, and other flam-
mable objects. This oxygen cannula was ignited by a CO2 laser beam.
Normal CO2
Dense pattern with overlap
Fractional CO2
Sparse pattern no overlap
Fractional CO2 laser
Ablated columns of tissue separated by
intact bridges of untreated skin
Ablated column
Intact bridge
Heat in dermis
FIGURE 12-65.  Standard CO2 laser uses high-density overlapped spots
that ablate the entire skin surface. Fractional CO2 ablates small columns
of tissue but leaves intact bridges of untreated skin between the treated
columns. This “polka-dot” pattern leaves untreated skin, which heals much
quicker. (Courtesy Lumenis Ltd., Yokneam, Israel.)

Chapter 12  •  Skin Resurfacing
553
better benefit from conventional laser treatment and not frac-
tional treatment.
Although prophylactic antibiotics and antivirals are used
with most resurfacing procedures, many practitioners forgo this
with fractional laser treatment unless the patient has a contrib-
uting history of skin infections or herpetic outbreaks.
Superficial Fractional CO2 Laser Procedure
For patients desiring topical anesthesia only, they are asked to
first wash their face, and then the face is wiped with acetone or
alcohol. Next, a thick coat of topical anesthesia (BLT: 20%
benzocaine, 6% lidocaine, 4% tetracaine) is placed on the face,
and the patient left to sit for 1 hour (Figure 12-69). The face is
again washed and dried, and the treatment is begun. Local
anesthetic facial nerve blocks can also be used. Some patients
tolerate topical fractional treatment very well, while others
cannot tolerate it. The eyelids may or may not be treated; if they
are, corneal protection must be used.
As stated earlier, the treatment can be done at high fluence
with low density or lower fluence with high density. In my
experience, lower-fluence treatment will heal faster but have less
effect. Figure 12-70 shows a patient treated with a lower-energy
treatment of 60 mJ and a density of 3.
For higher-energy fractional CO2 treatment, discomfort and
healing are more challenging, but results are more significant
(Figure 12-71).
CO2 Lite Laser Skin Resurfacing
Fractional CO2 LSR produces the least effects, and I generally
only use it on young patients with minor photodamage or those
who cannot undertake a longer recovery. The CO2 Lite proce-
dure is the next step up in terms of result and recovery and is
much more utilized in my practice. This treatment consists of
density of 1 to 2 and a hertz setting of 15 to 20. The second
option is a lower 40- to 60-mJ, with a density of 3 to 4 and a
hertz rate of 100 to 400. I have had better results with the
higher-fluence treatment, but the patient experiences more dis-
comfort. With the lower hertz rate, the high-energy option takes
much longer to perform the procedure. Although I sometimes
perform these procedures with topical anesthesia only, I prefer
a short IV sedation; the entire procedure only takes 10 minutes.
Generally a single pass is performed with these procedures, but
multiple passes can be performed to increase the result. In my
opinion, if a patient needs this level of treatment, they would
A
B
FIGURE 12-66.  A, Standard CO2 laser uses high-density patterns with overlapping laser spots that ablate the entire skin surface.
B, Fractional CO2 laser resurfacing leaves intact bridges of untreated skin between the ablated columns of lasered skin.
Conventional Laser Scanners versus Lumenis CoolScan
Heat does not dissipate from
adjacent pulses within the scan
Heat is allowed to dissipate from
adjacent pulses within the scan
Traditional CO2
Uses sequential
scan sequence
CoolScan™
Nonsequential,
nonadjacent
scan sequence
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
1
9
3
19
8
20
5
15
12
16
17
11
2
6
4
7
13
18
10
14
FIGURE 12-67.  A, Conventional CO2 laser scanners use a sequential scan-
ning sequence for the laser spot, which lays down the laser spot coverage
in an orderly fashion and cannot dissipate heat. B, The CoolScan technol-
ogy, which lays down the laser spots in a randomized, nonsequential
fashion and allows heat dissipation, reducing unwanted tissue damage.
(Courtesy Lumenis Ltd., Yokneam, Israel.)

554
Chapter 12  •  Skin Resurfacing
been challenged, the community standard of care should dictate
usage.
Medium CO2 Laser Skin Resurfacing
As noted, I use my own system of names to explain the different
levels of LSR to patients, and it is not necessarily common
nomenclature. Medium CO2 LSR is a single-pass, nondébrided,
high-fluence laser treatment. This treatment is more aggressive
than the CO2 Lite procedure but less aggressive than traditional
multipass treatment. It takes about 8 or 9 days to heal and
probably reaches into the papillary dermis (Figure 12-75). Like
CO2 Lite, this treatment is effective for dyschromias and fine
a single nondébrided laser pass at medium fluence (3.5 J/cm2)
with a density of 6 (Figure 12-72). In my experience, this treat-
ment is very similar to a medium-depth chemical peel in healing
and results. The CO2 Lite procedure heals in about 7 days,
which means it is reaching the level of the papillary dermis
(Figures 12-73 and 12-74). Results are much more significant
than fractional CO2 treatments. Like a chemical peel, it is very
effective for common pigmentation and fine lines and wrinkles,
but it does little for deep wrinkles or significant lasting skin
tightening.
I prescribe antibiotics and antivirals for all CO2 Lite laser
patients and all aggressive laser treatments. Although this has
A
B
FIGURE 12-68.  Patient treated with traditional high-power CO2 facial laser skin resurfacing (LSR), and the neck was treated with
fractional CO2 LSR with a setting of 40 mJ and a density of 2. The density of the treated face and neck is obvious. Patient
with traditional facial and fractional neck treatment immediately post laser (A) and 6 days post laser (B).
A
B
FIGURE 12-69.  Topical anesthetic cream is placed on the face for 45 to 60 minutes before fractional CO2 laser skin resurfacing
(LSR) and removed with alcohol or acetone prior to treatment.

Chapter 12  •  Skin Resurfacing
555
The Fraxel re:store laser (Solta Medical Inc.) is a nonablative
laser and has also become a popular option for reduced-recovery
LSR (Figure 12-79). This platform utilizes a 1550-nm erbium-
doped fiber laser which produces microcolumn ablation using
a 15-mm handpiece and concomitant forced-air cooling.10 The
Fraxel re:store laser uses fluences of 8 to 16 J/cm2 at densities
of 125 to 250 microscopic thermal zones. Alster et al. state,
“These localized columns of thermally denatured collagen
stimulate collagen remodeling while leaving islands of intact
dermal and epidermal cells, which in turn leads to speedy
epithelial recovery, thereby minimizing downtime.”10
The more aggressive and deep-penetration fractional lasers
hold promise to advance LSR for improved results with decreased
downtime. Although this is an inviting combination, these
lasers have not achieved the gold standard results of conven-
tional aggressive, high-energy, multipass CO2 LSR. To achieve
significant results, the fractional laser treatments must be
repeated 3 to 5 times. To my mind, the decision to forgo a
conventional CO2 procedure with healing at 12 days for 3 to 5
treatments of fractional laser which require 3 to 5 days of recov-
ery each is not a huge advantage at this point. One hopes this
newer technology will progress, but at the time of this writing,
articles are beginning to appear reporting significant complica-
tions from fractional LSR.11,12 Unfortunately, these articles
mirror the hard-learned lessons of the 1990s and include lower
eyelid and neck burns. This calls into question the term safe
laser; as with automobiles, accidents happen, and the driver is
most frequently at fault.
Aggressive High-Energy Multipass CO2
Laser Skin Resurfacing
The CO2 laser has been one of the greatest advances in cos-
metic surgery science in the last century. For the first time,
it allowed precision ablation of skin at controlled and predict-
able depths. The biggest advantage of the CO2 laser is its ability
to efface rhytids, tighten skin, and make new collagen. The
biggest disadvantage is a formidable and extended recovery. In
addition, due largely to the misuse of this laser in its early days,
numerous complications have been associated with its use.
Since 1996, I have used this laser as my mainstay for facial
rejuvenation and scar treatment, and despite the blitz of “new”
lasers and laser technology, it remains my primary resurfacing
treatment.
Patient selection for traditional multipass resurfacing runs
the gamut of skin damage and age groups. Treatment can be
tailored by manipulating the energy and density of overlap, but
not all treatments are the same. I treat some patients with a
single pass (rarely) and others with two, three, or more passes,
again depending upon the degree of damage and skin type. I
only perform aggressive LSR on Fitzpatrick 1 to 3 skin types
and never use it on darker skin types. I have performed hun-
dreds of full-face laser cases. I feel that it is a predictable treat-
ment, and I have taken numerous steps to mitigate the infamous
CO2 laser recovery, which will be discussed later.
Aggressive CO2 Procedure
This treatment can yield dramatic improvement in the appear-
ance of photodamage, skin wrinkling, and scars, but it is not a
lines and wrinkles, but it produces a greater degree of skin
tightening than CO2 Lite. Medium CO2 treatment is not a
commonly performed procedure in my practice.
Deep Fractional Laser Skin Resurfacing
The Deep FX laser (Lumenis Inc.) is an ablative CO2 laser with
a spot size of 0.12 mm, which is much smaller than standard
lasers (Figures 12-76 and 12-77). The small spot size and the
ability to deliver high power (10 to 20 mJ) allow this laser to
penetrate much deeper into the skin (Figure 12-78). The abla-
tion depth relates to the energy level: a 10-mJ single pulse can
penetrate 230 microns, a 20-mJ pulse can penetrate three-
fourths of a millimeter. This drills deep into the dermis to a
depth of 450 microns, plus an additional 300 microns of lateral
thermal damage, for a total of 750 microns, which is well into
the reticular dermis (the ablative CO2 laser penetrates 100 to
300 microns). Unlike aggressive ablative treatment, since not all
the surface skin is disrupted and the penetration is deeper, the
results can be delayed. It is the nonablative nature of the laser
coupled with its depth of penetration that set deep fractional
LSR apart from traditional LSR. The main drive for this type
of treatment is significant clinical improvement of the skin, with
decreased healing time.9 Despite shorter healing time, however,
to date the degree of clinical improvement, in my experience
does not correlate with traditional high-energy, multipass abla-
tive CO2 LSR.
A
B
C
D
E
F
G
H
I
FIGURE 12-70.  Patient before (A–C), 3 days after fractional CO2 laser skin
resurfacing (LSR) (D–F), and 6 days after fractional CO2 LSR (G–I) with a
setting of 60 mJ and a density of 3.

556
Chapter 12  •  Skin Resurfacing
A
B
D
E
C
F
G
H
FIGURE 12-71.  A–C, Patient immediately after high-energy fractional CO2 laser skin resurfacing (LSR) performed under topical
anesthesia. Many patients could not tolerate this level of treatment with topical alone. D–E, Patient 72 hours post high-energy
fractional CO2 LSR. F–H, Five days after fractional CO2 LSR.

Chapter 12  •  Skin Resurfacing
557
I
J
L
K
Patient at 7 days (I–J) and 10 days (K–L) post high-
energy fractional CO2 LSR.
FIGURE 12-71, cont’d
FIGURE 12-72.  The control panel of the Lumenis Encore laser is shown in
the “CO2 Lite” setting with the laser settings.
A
B
FIGURE 12-73.  Patient immediately after CO2 Lite laser skin resurfacing (A) and the following day (B).
treatment applicable to every patient, given its formidable
recovery. The prospective patient must understand that the laser
will remove the entire epidermis and extend to the dermis in
aggressive treatments. They must understand that they will have
a second-degree burn and a raw face for the first 5 to 7 days,
and for the next week, their face will be very pink, but the
pinkness will resolve with time. Some patients will have ery-
thema resolution in 3 to 4 weeks, others may require 3 to 4
months. Females can readily cover the erythema with makeup,
but the condition is more problematic for males. Newly regener-
ated epidermis is fragile, reactive, and sensitive and can undergo
hyperpigmentation; patients must be ready for this as well.

558
Chapter 12  •  Skin Resurfacing
A
B
FIGURE 12-74.  A, A CO2 Lite patient on the fourth post-laser day. B, Another patient on the fifth post-laser day after CO2 Lite
laser skin resurfacing.
A
B
C
FIGURE 12-75.  Patient underwent medium CO2 laser skin resurfacing (LSR) with a single, nondébrided, high-energy (90 mJ)
pass. A, Immediately post LSR. B, 4 days post LSR. C, 9 days post LSR. The lower eyelids were treated with two passes at
the same settings and therefore are not healed.
FIGURE 12-76.  The Lumenis Deep FX handpiece.

Chapter 12  •  Skin Resurfacing
559
they are not good candidates. If a surgeon lives in Miami or a
tropical region, it is always summer. The treatment can still be
performed, but requiring patients to avoid the sun (and a higher
incidence of temporary hyperpigmentation) may complicate
recovery.
Finally, there is considerable wound treatment required in
the first weeks of aggressive LSR, and an unmotivated or non-
compliant patient can be a huge problem. All of this must be
covered in the LSR consent, including what the treatment is,
what the patient will look like and for how long, how the
patient’s compliance can improve outcome, and potential com-
plications. The need for multiple treatment sessions must also
be covered in the informed consent. For aggressive CO2 LSR,
the preoperative check list should include medical and anes-
thetic considerations, appropriate medications, skin care,
healing products, and sun protection. Pre-laser photographs
should be taken on all patients.
Immediately before the procedure, the transition zone or
endpoint of the laser extension is marked at the inferior border
of the mandible (see Figure 12-49). If the neck is to be treated
with fractional laser or simultaneous chemical peel, this is
marked as well. Any regions of deeper wrinkles or scars are also
marked with a surgical marker to alert the surgeon for more
aggressive treatment. Likewise, any regions that need lighter
treatment are also marked.
Bottom line for patient selection: Aggressive CO2 LSR is
not for timid or impatient patients. I actually tell my laser
patients that they will not like me for 5 or 6 days and probably
be sorry they agreed to the procedure, but in the end, they will
be very happy. The recovery process is not extremely painful,
but the swelling, oozing, and greasy face can wear patients
down.
Stressing the need for touchup procedures is also important,
as with any LSR procedure. The skin can only be safely treated
to a given extent at a single treatment. Patients with severe
wrinkling or scarring must understand that they will see
improvement but may require additional treatments (usually
not full-face) to obtain optimum results. I may perform a full-
face treatment and then 90 days later retreat the perioral or
periorbital regions or whatever areas that could be improved.
All acne or scar patients must realize that numerous treatments
are the norm, not the exception. Patients may begin with impos-
sible expectations because they’ve seen or heard inflated media
and marketing promises; they must get the truth from their
cosmetic facial surgeon. Underselling a recovery or overselling
a result is an excellent way for a surgeon to lose patients and
develop a reputation for being undependable.
Time of year can influence treatment. Laser and chemical
peel patients must avoid direct sunlight for at least a month. In
the summer, this is impossible for some patients, and therefore
Pre
6 Days
14 Days
24 Hours
FIGURE 12-77.  Deep FX laser resurfacing is an ablative, CO2
fractional treatment that does not burn the entire skin surface.
Compared to conventional CO2 laser treatment, the Deep FX
produces deeper dermal penetration, heals faster, and also
produces a dry wound. Patient is shown here before treatment
and 1 day, 6 days, and 14 days post Deep FX LSR.

560
Chapter 12  •  Skin Resurfacing
smaller spot size, so all the settings are different: 100 mJ on the
newer Encore machine is similar to 300 mJ on the first-gener-
ation 5000C machine. On the Encore, my most common
setting is 80 mJ with a density of 6. Although I occasionally use
higher power, 80 mJ has proven safe and effective for multiple-
pass laser treatment.
I do not treat aesthetic subunits without full-face coverage,
with the exception of the periorbital region—having thin skin
and being recessed, it does not stand out as much against unla-
sered skin. Some practitioners routinely treat subunits, and their
patients are frequently left with posttreatment white mustaches
or nasolabial-fold white lines due to changes in texture and
color. If I do get a request to treat significant perioral wrinkling
and photodamage, I will treat this aggressively but also treat the
remainder of the face with less aggressive or light laser to prevent
treated regions from standing out against untreated areas. If I
treat a patient with a full-face aggressive LSR and they return
in 90 days for a touchup, I will at that time laser subunits such
as the perioral region. This can be done because the initial full-
face procedure homogenized the skin color and texture.
It is important to have a diagram of the face in the medical
record and have the assistant document the areas treated as the
procedure progresses. This not only serves as part of the opera-
tive report but prevents inadvertent under- or overtreatment. It
is easy to lose track of the treated areas, and the surgeon can
mistakenly retreat a given area. When “laying down” the CPG
passes, I prefer a large square or circle pattern. It is important
not to overlap or underlap the edges of the pattern because this
will be apparent as a lattice or checkerboard pattern during
healing and can be permanent (Figure 12-80). In addition,
overlapping will cause increase treatment of the area and under
lapping will cause decreased treatment of the area.
The entire face is treated, and various anatomic components
with thicker or thinner skin require adjustment. I routinely
perform a total face single pass with 80 mJ and a density of 6.
Areas like the columella and alar bases, which don’t routinely
wrinkle are lasered to keep a homogenous skin color and texture.
I routinely laser the earlobes, which frequently do exhibit wrin-
kling. The lips can be lasered, but this is generally not performed
I only perform this level of laser resurfacing (as well as most
others) with IV sedation. Some practitioners utilize facial blocks
and oral medications, but a fully anesthetized patient makes for
a faster procedure and one that is much easier on both the
patient and the surgeon. All the common laser safety checks are
made, and the corneal eye shields are inserted as described
earlier.
In terms of laser settings, novice surgeons must be careful
when using “cookbook” settings published by manufacturers or
other operators. What works for one surgeon may lead to disas-
trous complications for another. Although recommended set-
tings may be reference points, they can vary dramatically from
company to company and are influenced by such variables as
power, spot size, degree of overlap, and pulse settings. In actual-
ity, there is no substitute for hands-on training, and surgeons
should slowly and carefully progress from light laser treatments
to more aggressive treatments. Insights gained in the firsthand
observation of intraoperative and post-laser effects are invalu-
able and requisite for safe and effective practice.
With the first-generation Lumenis ultrapulsed lasers (model
5000C), the aggressive settings were 60 watts with 300 mJ and
a computer pattern generator (CPG) density setting of 6 (30%
overlap). The newer Lumenis UltraPulse Encore laser has a
Active FX
1.3-mm spot size
Deep FX
0.12-mm spot size
DeepFXTM - Variable Density
• 120-m spot size • 5%-25% ablation
A
B
FIGURE 12-78.  A, Comparison of the depth of laser beam columns in rela-
tion to spot size. The active FX (ablative fractional ultrapulsed CO2) has a
larger spot size and remains in the superficial skin, whereas the much
smaller Deep FX spot size will penetrate deeper into the skin. B, Horizontal
and saggital sections of the Deep FX tissue penetration. (Courtesy Lumenis
Ltd., Yokneam, Israel.)
Fraxel® Laser Microscopic
Treatment Zones
Microscopic
treatment zone
Dermis
Epidermis
Laser
One pulse produces one micro
treatment zone
Columnar shape
Diameters are variable <250 m
1.5 width to depth aspect ratio
5%-70% total skin
coverage – each treatment
FIGURE 12-79.  Fraxel is a brand name of fractional laser resurfacing. The
small spot size laser beam ablates microcolumns deep into the dermis
and can be adjusted between 5% and 70% of total skin coverage.  
(Courtesy Solta Medical Inc., Hayward, CA.)

Chapter 12  •  Skin Resurfacing
561
In multipass LSR, the whole face is totally treated before
moving on to a second pass, which allows cooling of the skin
between passes. Immediate double laser firing on the same spot
(pulse stacking) is never performed, because it does not allow
the heat to dissipate and may cause deeper tissue damage than
intended and result in scarring.
Laser treatment dogma has always warned to débride the first
laser pass before applying a second pass of treatment to the skin
(Figure 12-84). Skin ablation results in the formation of a char
(eschar), and it was previously thought and proven in animal
studies that if a second pass was made over this char, it would
act as a heat sink and amplify the thermal damage to the deeper
tissues, causing increased tissue injury.12-23 Débriding the laser
char between passes has positive and negative consequences. For
the novice practitioner, it allows judgment of clinical endpoints
unless there are actinic changes; the power is lowered to 50 to
60 mJ, and the density is also lowered. The lower-eyelid skin is
treated with two passes of 80 mJ with a density of 6 in patients
with significant dermatochalasis. In younger patients without
significant eyelid skin changes, a single pass will suffice. The
upper lids are lasered with a single pass at 70 mJ and a density
of 5. Areas of other thin skin such as the temple and lateral
canthal regions of females with very thin skin are also lasered at
lower energy and/or density.
As the laser proceeds to the mandibular border, some sur-
geons utilize the same power and density settings as the rest of
the face. Other surgeons “feather” the result by progressively
decreasing power and density with the last several rows of passes
(Figures 12-81 and 12-82). On patients with severe neck
photodamage, I feather the mandibular border, or the demarca-
tion is significant. On those patients with neck skin similar in
color and texture to the facial skin, I pay less attention to
feathering.
When lasering over deep rhytids, it is helpful to stretch the
skin or use a tongue blade to elevate the corners of the mouth
so the laser beam can reach the base of the rhytids, otherwise
the deeper portions will be missed (Figure 12-83). It is also
important to extend the laser all the way to the hairline to
prevent a noticeable demarcation. Some surgeons apply TCA
chemical peeling solution into the hairline to further blend.
A
B
C
FIGURE 12-80.  Overlapping laser pattern edges (pulse stacking) can
produce deeper penetration relative to nonoverlapped areas and produce
a lattice pattern. The same pattern can occur from “underlapping” or
leaving small gaps between treated pattern squares. A, Intraoperative laser
overlapping; this pattern manifested throughout the healing (B) and recov-
ery process (C). Although this will usually resolve, it can be permanent.
3 passes
2 passes
1 passes
FIGURE 12-81.  A full-face treatment in which the upper face was treated
with three passes at 80 mJ and a density of 6. The next-to-last row from
the mandibular border was treated with two passes at 70 mJ with a
density of 5, and the final row at the mandibular border was treated with
a single pass at 70 mJ and a density of 5.
FIGURE 12-82.  Patient at 10 days post multipass, high-energy, high-den-
sity laser skin resurfacing with a progressive feathering to the mandibular
border, which will blend with the neck skin color and texture when fully
healed.

562
Chapter 12  •  Skin Resurfacing
A
B
FIGURE 12-83.  A, When lasering deep lines, wrinkles, or folds, the skin should be stretched so the laser can reach the base
of the wrinkle. B, A tongue blade used to elevate the corners of the mouth to provide the same type of elevation and
stretching.
FIGURE 12-84.  Most surgeons débride the laser char between passes, but
the char can be safely lasered over without débriding.
FIGURE 12-85.  The endpoint of aggressive CO2 laser resurfacing is a
chamois color of the skin. Patient was treated with two passes on the right
side (pink) and three passes on the left side, which shows the chamois
color and thus the endpoint of treatment. These signs cannot be seen
unless the laser char is wiped off between passes.
insofar as a chamois color is frequently described as the end-
point of aggressive CO2 LSR (Figure 12-85). This is difficult to
judge without débriding the char. There are, however, many
negative points when the char is débrided between passes. The
development of LSR was intended to capitalize on the precise
and predictable level of tissue ablation. Débriding the treated
tissue with a moist gauze pad further injures the skin, and in
effect, this added mechanical trauma negates the precise ability
to ablate tissue as originally intended with laser technology.
Added trauma complicates recovery, increases post-laser pain,
and increases the duration of post-laser erythema.
In 2008, I published the first human study showing that not
débriding laser char between laser passes does not increase
ablation depth. In this study, I performed split-face histologic
studies on high-energy, high-density, multipass CO2 LSR
patients. One side was débrided between all passes and after the
final pass, and the other was not débrided at all between passes24
(Figure 12-86). These patients were followed clinically and
histologically (Figures 12-87 and 12-88). The histologic analysis
showed no difference in the ablation depth when débriding or
not débriding. In addition, the undébrided eschar serves as a
biological dressing which is more comfortable than denuded
skin. Not abrading the raw skin with moist gauze also decreases
postoperative discomfort and erythema.
This study involved a more clinically qualitative observation
of erythema resolution and postoperative pain. Although this
method is less scientific, experienced and astute laser practitio-
ners have a “gestalt” and are aware of faster or slower post-laser
erythema resolution and pain. The nondébrided patients as a

Chapter 12  •  Skin Resurfacing
563
group had less post-laser discomfort, and their post-laser ery-
thema resolved significantly faster than the hundreds of full-face
laser patients treated by this author over the past decade (Figure
12-89). Admittedly this is qualitative opinion, but one that is
based on busy and diverse CO2 laser experience. Although dif-
ficult to quantify in this particular study, to ignore these positive
findings goes against the grain of observational clinical medicine
and surgery. The histologic portion of this study is more scien-
tific, but the qualitative portion can be construed as equally
relevant to other practitioners if repeatable in their practices.
Other qualitative observations were a greater acceptance of
aggressive laser resurfacing by the author, the staff, and the
patients. All patients also had fewer follow-up appointments for
dressing changes, wound care, and the like and were only seen
at 1 to 2 weeks post procedure. As mentioned previously, per-
forming multipass lasering without débriding allows a much
faster surgical procedure because the multiple time-consuming
steps of débriding the entire face (sometimes 3 to 4 times in a
single procedure) were eliminated. Finally, although a small
advantage, the messy strewing of débrided skin about the surgi-
cal site, floor, and patient is also eliminated in the non-
débriding technique.
Some surgeons feel that by lasering incisions prior to closing
them that the surgical scar will be improved. When performing
simultaneous LSR and blepharoplasty, it is sometimes difficult
to laser up to the suture line, because sutures can be burned or
melted. I have had excellent results with lasering all the way up
to and including the wound margin with the CO2 laser and
then closing the incision after the laser procedure is completed
(Figure 12-90).
Laser resurfacing with simultaneous facelift is a procedure
I have performed well over 100 times without significant
A
B
C
FIGURE 12-86.  A patient from my study24 is shown with three nondébrided high-energy (6 J/cm2), high-density (level 6) laser passes. The patient’s right
side was débrided between passes, and the patient’s left side was not. A, Pre laser. B, Immediately post laser. C, Six weeks post LSR.
A
B
D
C
FIGURE 12-87.  Patient with facial aging and actinic damage at preop
(A), immediately after laser with three high-density, (6 J/cm2, density 6)
nondébrided passes (B), 13 days after procedure (C), and 6 weeks after
laser (D). No débriding of laser char was performed between passes.

564
Chapter 12  •  Skin Resurfacing
2 Nondébrided passes
6 J/cm2 Density 6
2 Débrided passes
6 J/cm2 Density 6
Epidermal necrosis with retained
fragments of necrotic epidermis
with coagulation necrosis of the
superficial papillary dermis to a
depth of about 85 microns
Epidermal necrosis with
coagulation necrosis of the
superficial papillary dermis to
a depth of about 85 microns
FIGURE 12-88.  A, Histologic results of three aggressive laser passes
without débriding between passes. The depth of the thermal injury is
approximately 85 microns. B, Specimen from same patient using the
same laser and settings but with débriding after each pass. It is notable
that the average depth of tissue injury is almost exactly the same in
both specimens regardless of débriding or not.
FIGURE 12-89.  Patient was treated with two to three high-energy, high-
density CO2 laser passes without débriding and using open-wound care.
She is shown at 12 days with excellent and rapid healing. Forgoing the
abrasion of the denuded skin with moist gauze hastens healing in my
experience.
A
B
C
FIGURE 12-90.  A, Completed blepharoplasty with open incision. B, Eyelids
and wound margins treated with laser skin resurfacing. C, Blepharoplasty
sutures were placed after the lids were lasered. This seems to enhance
the final scar.
complication, but this should only be attempted by surgeons
with significant facelift and laser experience. The thin lipocuta-
neous facelift flap can easily be devitalized, and horrific conse-
quences can occur. When lasering facelift patients, I leave the
LSR for last. Prior to lasering, the extent of the facelift flaps are
marked (Figure 12-91, A). The central oval of the face is treated
at normal settings with multiple passes of 80 mJ and a density
of 6. The undermined lipocutaneous facelift flap is then care-
fully lasered (with great care not to overlap patterns) at 80 mJ
but with a reduced density of 4 (see Figure 12-91, B). The laser
flap is never débrided. The CO2 Lite setting of 3.5 J/cm2 can
also be safely used as a single pass over the undermined facelift
flap. Again, this is not a procedure for novice facelift or laser
surgeons.

Chapter 12  •  Skin Resurfacing
565
Blepharoplasty Incisions
Although not a resurfacing procedure, the Lumenis UltraPulse
Encore laser is indispensable in my blepharoplasty practice
(Figure 12-92). The 0.2-mm incisional handpiece provides liter-
ally bloodless surgery. When performing four-quadrant
A
B
FIGURE 12-91.  A, The limit of the undermined facelift flap is marked so
aggressive laser does not proceed over the flap. B, The central oval of
the face was treated with aggressive laser resurfacing and the undermined
flap just prior to light lasering.
A
B
C
FIGURE 12-92.  The CO2 laser 0.2-mm incisional handpiece allows incision and simultaneous hemostasis. Laser incision is shown
on the skin (A), orbicularis oculi muscle (B), and preaponeurotic fat (C).
blepharoplasty, we measure our blood loss on a cotton-tipped
applicator. This has simplified my procedure to the point where
the incision closure takes longer than the actual procedure. With
little
or
no bleeding, patients heal faster, bruise less, swell less, and have
less postoperative discomfort. The incisional laser handpiece
is used for upper blepharoplasty and lower transconjunctival
procedures.
Laser Treatment of Scars
Acne, surgical, and traumatic scar treatment are frequently
requested cosmetic facial procedures. The CO2 laser is one of
the few predictable and effective treatments for acne scarring in
particular. Acne patients frequently suffer from not only the
physical scarring but also the emotional issues that accompany
scarring. In the past, deep chemical peeling and dermabrasion
were the mainstay therapies for the treatment of acne scars. The
CO2 laser ushered in an entirely new paradigm for acne scar
treatment.
When discussing acne scar treatment with patients, it is
important for them to understand that their skin will never be
normal, and the goal is improvement, not eradication. Acne
scars manifest in numerous configurations (Figure 12-93).
Shallow depressions (also known as rolling scars) respond well
to generalized resurfacing with simultaneous edge reduction.
The goal is to level the skin surface to make the depressions less
noticeable. Hypertrophic scars also respond well because they
can be reduced. “Ice-pick” scars, which are narrow and deep,
A
B
Thin epidermis
Epidermis
Dermis
Subcutaneous
fat
Thin dermis
Fibrotic strands
tethering scar
Thickened scar tissue
replaces epidermis
C
D
E
F
FIGURE 12-93.  Acne scars present in numerous configurations, as shown
in this diagram. (From Arndt KA: Procedures in cosmetic dermatology scar
revision, Edinburgh, Saunders, 2006.)

566
Chapter 12  •  Skin Resurfacing
with elliptical incisions and close them with sutures (Figure
12-94). This will transform a depressed ice-pick scar into
a level straight-line scar which responds better to LSR. These
straight-line scars will be lasered with the full face 6 to 8 weeks
later.
Punch grafting prior to LSR is also a popular option with
some surgeons. This involves either removing the scar with a
biopsy punch and closing the incision, or elevating the “plug”
to the surface to reduce scar depth. I have not had positive
results with the elevation technique and if using a punch prefer
to stretch the margins with skin hooks and primarily close the
excision site (Figure 12-95). I prefer simple elliptical scalpel
excision for this type of treatment.
Most acne cases involve all scar configurations, so the basis
of treatment is to attempt to level high areas and stimulate col-
lagen around the depressions. This is known as shouldering the
scar. The laser is used to first reduce the periphery of the scar,
the shoulder around the depression. This leveling is apparent
after several circumferential passes around the lesion. Shoulder-
ing is performed on all the deeper scars first, then the entire face
is lasered with several passes. It is important to not overtreat
patients and remember that more skin can be removed, but it
is impossible to put it back. After two to three full-face passes,
I will return to the areas of deepest scarring and perform a
fourth or fifth pass on the individual lesions in appropriate
cases. Figure 12-96 illustrates such a case. The patient was
present more of a challenge for laser resurfacing and will not
improve to the degree of more shallow acne scars. “Boxcar” scars
also present a challenge due to the depth and precipitous edges.
Laser treatment of acne scars can be augmented by such proce-
dures as surgical excision, punch grafting, subcision, and inject-
able fillers. Acne scar treatment is rarely a single procedure and
more frequently requires numerous combination treatments
depending upon the severity.
Before treating acne scarring, the surgeon must make sure
the patient has not been on systemic retinoids (Accutane) for at
least a year. In addition, any active acne must be under control
before LSR.
The treatment of acne scarring is based upon the actual
configurations of the scars. The goal is to level hypertrophic
tissue and stimulate collagen at the base of the scar to assist in
filling the void. With shallow rolling scars, I generally perform
“standard” laser skin resurfacing with two to three passes over
the entire face. Most acne patients have thick, sebaceous skin
and can be aggressively treated. I frequently perform extra passes
(total of 4 or 5) over the regions of most severe scarring. All
these patients understand that the primary LSR will be full-face
treatment, and subsequent follow-up treatments can possibly
be confined to the areas of scarring without retreating the
entire face.
For patients with significant acne scars, I perform individual
scar excisions 8 weeks prior to the LSR. I excise individual lesions
A
B
D
C
FIGURE 12-94.  Deeper acne scars can be excised before laser resurfacing. A, Depressed acne scar. B, Scar excised with an
elliptical punch. C, Excised scar being undermined with iris scissors to facilitate closure. D, Sutured excision.

Chapter 12  •  Skin Resurfacing
567
A
B
C
FIGURE 12-95.  Acne scar being removed with a biopsy punch (A), base of the scar separated with scissors (B), and excision
sites closed with 6-0 nylon suture (C).
B
C
D
E
A
FIGURE 12-96.  Patient with acne scars. A, Individual scars were shouldered at the beginning of the case and then the entire
face treated with three high-energy, high-density passes of CO2 laser at 90 mJ and a density of 6. B–E, Another patient
returned for geometric excision of the deepest perioral scars. B shows the pre-excision photo, and C shows one excision site
with the geometric excision and the other excision site closed. Excision sites at 1 week (D) and 6 weeks (E) after a second
full-face laser skin resurfacing procedure.

568
Chapter 12  •  Skin Resurfacing
B
A
FIGURE 12-97.  An 18-gauge Nokor needle (circle in A) is used to tunnel between the depressed scar and the deeper tissue
adhesions. B, Multidirectional vectors used when releasing adhesions under depressed scars.
B
A
FIGURE 12-98.  A, Patient hit a deer while driving and was gored by a deer antler. B, The scar was treated with a single session
of laser skin resurfacing with three passes at 80 mJ and a density of 6. Most scars do not improve to this level with a single
laser treatment.
treated with aggressive LSR with good improvement, but the
severe perioral scars required combination treatment. After the
first LSR procedure, the patient returned for direct scar
excision.
Subcision is another means of treating depressed acne or
traumatic scars prior to LSR. This procedure involves using a
needle or blade to disrupt the fibrous adhesions between the
dermis and epidermis that contribute to the depression. When
these adhesions are cleaved, the potential space fills with blood
and can plump out the concavity. This may require several treat-
ments for full effect. I prefer using an 18-gauge Nokor needle
(B-D Inc., Franklin Lakes, NJ; Figure 12-97). This needle has
a solid tapered blade at the tip and is perfect for the delicate
cutting between the dermis and epidermis.
Laser Skin Resurfacing of Surgical
and Traumatic Scars
Postsurgical or traumatic scars are treated similar to acne scars.
Many scars will respond to several treatments of LSR, and the
shoulder of the scar can be reduced as with acne scars. These
scars may also be treated with geometric excision or subcision
before lasering. Although some scars can be successfully treated
with a single treatment, most will require several treatments.

Chapter 12  •  Skin Resurfacing
569
B
C
A
FIGURE 12-99.  A, Patient underwent trichophytic brow and forehead lift and had a suboptimal scar. She is shown immediately
after two passes of 80 mJ and a density of 6 (B) and 8 weeks post laser (C).
B
C
A
E
D
FIGURE 12-100.  Patient sustained a facial laceration earlier in life. A–C, Scar and geometric excision. Patient before (D) and
after (E) a single session of aggressive CO2 laser skin resurfacing.
Figures 12-98 and 12-99 show exceptional results from a single
treatment with aggressive LSR. Other scars require surgical
intervention prior to LSR (Figure 12-100).
Postlaser Care
I believe there is no other cosmetic facial surgery procedure that
requires the level of postop care ablative CO2 laser resurfacing
does. We are essentially creating second-degree burns, and
anyone who has ever completed a surgery rotation knows the
complexity of burn management.
Numerous open and closed wound techniques are available
for CO2 laser resurfacing and run the gamut of being as simple
as Crisco to as complex as platelet-rich plasma with total mem-
brane facial coverage. Since 1996, I have used all the popular

570
Chapter 12  •  Skin Resurfacing
cubes, soak four or five washcloths in the bowl, and to alternate
them on the face to keep the skin continuously chilled for the
first 24 to 48 hours. Patients are asked to gently wash their face
on the second day. This is easiest in the shower for the first time,
because the ointment and weeping serum begin to crust over
the first 48 hours. The patient is instructed to wash their face
with Cetaphil Gentle Cleanser (Figure 12-103) using their
fingers only and to blot (not wipe) the face with a clean towel.
Daily showering is a good means of keeping the hair and face
wound dressings, including closed membranes such as Flexan
and Silon. I believe these dressings allow slightly faster reepithe-
lialization and slightly reduce postoperative discomfort, but I
don’t feel the physical and emotional distress to the patient and
family are worth the small gains. I treated many patients with
a Silon membrane which was held in place by elastic gauze
(Figure 12-101). Although this worked well as a closed wound
healing system, the mummy appearance was a significant draw-
back. The patient and their family balked when shown this
dressing in the consult period, and many patients were scared
away. Since I do not débride between laser passes, the charred
skin serves as a biological dressing, and simply keeping a gener-
ous coat of petroleum jelly or Aquaphor on the skin has greatly
simplified the postoperative dressing. I have treated hundreds
of full-face LSR patients by this method, and there is very little
difference between this and the cumbersome closed dressings in
terms of comfort and wound healing.
With the open wound care technique, a generous amount of
petroleum jelly or Aquaphor is applied to the entire lasered area
and will be maintained for the first 5 to 7 days on a continuous
basis (Figure 12-102). Biafine (Ortho Neutrogena, Skillman,
NJ) is a prescription burn cream that has also proven to be an
excellent vehicle for open wound care. The only drawback is
aesthetic; Biafine is a white cream and has to be applied in a
thick coat.
Cold compresses are applied for the first 48 hours for swell-
ing and discomfort. The lasered skin can be sensitive, but the
level of postoperative pain is actually much less than expected
with a full-face second-degree burn. Patients are told that the
discomfort will be similar to sunburn and generally only neces-
sitate analgesics for the first 48 hours. Severe or extended pain
may indicate herpetic infection or another problem. I tell the
patients to take a large salad bowl, fill it with water and ice
B
A
FIGURE 12-101.  A Silastic transparent membrane (A) held in place with elastic gauze (B) promotes slightly faster healing but is
a cumbersome and unsightly situation for patient and family.
FIGURE 12-102.  Patient shown 24 hours after multipass, high-energy CO2
laser skin resurfacing with petroleum jelly open-wound care.

Chapter 12  •  Skin Resurfacing
571
is extremely sensitive, and patients must be careful to not inad-
vertently pick or scratch the healing surface. Some patients will
pick at the peeling skin or accidentally scratch themselves with
rings or bracelets while sleeping. All jewelry should be removed,
and if unconscious nocturnal scratching or picking continues,
patients may need to sleep with gloves or socks on their hands
(Figure 12-107).
As the skin reepithelializes, oozing will cease and the skin
will become very pink. This generally happens between post-
laser days 5 and 7 (Figure 12-108). The greasy ointments should
be discontinued as soon as possible because they clog pores. At
clean. The face is also washed a second time, usually in the
evening. The hands should be washed first, and the same product
and procedure is used. After washing, the petroleum jelly or
Aquaphor is reapplied. The ultimate goal is to keep a thin film
of ointment over the raw skin until reepithelialization takes
place, which is usually about 10 to 12 days for aggressive LSR.
Patients should be told in advance to use old pillowcases; the
ointment and serous drainage will necessitate frequent chang-
ing. Men are asked to not shave for 10 to 12 days.
Occasionally, some patients can experience significant post-
laser edema. Prednisone 60 mg once a day for 5 days will assist
with the resolution.
As healing progresses, the combination of dried ointment,
serum, and skin debris builds up yellowish crusts that are intimi-
dating to patients (Figure 12-104). I explain to them this is
“Nature’s Band-Aid” and is actually a protective layer during
healing. This exudate is especially thick on the lower eyelids,
which are usually the last region to heal. Much of this crust can
be débrided by regular face washing and soaks. A good skin soak
is gauze saturated with hydrogen peroxide, which will foam
away much of the debris (Figure 12-105). One tablespoon of
white vinegar mixed with a quart of water is also frequently
used. After the crusts are soaked, they can be lightly wiped away
with wet gauze or fingertips. Patients should understand that
the goal is to reduce the dried exudate, not eliminate it. If pin-
point bleeding occurs while removing crusts, they should be left
alone as the wound is still healing. It is this first 5 to 7 days of
recovery after aggressive laser that are most unpleasant and
require the most postoperative care.
Some patients are incapable of cleansing their own faces for
various reasons. Some don’t have the home support personnel
or understand the importance of meticulous wound care (Figure
12-106). These patients should be seen and cleansed by the
office personnel as much as necessary.
Patients should also remember that their immediate home
area needs to be a postsurgical environment, and contact with
pets, sick relatives, and so forth is contraindicated. Healing skin
FIGURE 12-103.  Cetaphil Gentle Skin Cleanser is an excellent cleansing
agent for laser skin resurfacing (LSR) patients. This product, Vaseline, and
Aquaphor represent the mainstays of my post LSR open-wound
treatment.
FIGURE 12-104.  Patient 48 hours after aggressive laser skin resurfacing.
She has not been compliant in early wound care and has extensive dried
exudate and ointment on her skin. This can be a nidus for infection and
should be kept to a minimum with washing and débriding soaks.
FIGURE 12-105.  Soaking exudative crusting with hydrogen peroxide before
face washing can keep the dried exudates to a minimum.

572
Chapter 12  •  Skin Resurfacing
to conceal their erythema. Special makeup formulations are
available with a green tint that readily masks the erythema
(Figure 12-111). The surgeon must be observant for any signs
of infection during this phase. LSR requires a significant com-
mitment to postop care and observation.
Sun avoidance for at least a month is an absolute requisite
for post-LSR patients (Figure 12-112). This prevents many
patients from having LSR in the summer. Similarly, anything
that would irritate the face, such as wind, should be avoided.
At the time of this writing, I have been experimenting with
a new wound care regimen that is said to greatly accelerate
reepithelialization and decrease pain and post-laser erythema.
Although I have only used it on 20 or so patients, to this point,
biO2 Cosmeceuticals International Oxy-Mist system (Harbor
City, CA) has lived up to its claims. The treatment consists of
this point, the patient switches from ointment-based wound
care to a hypoallergenic moisturizer such as Cetaphil moistur-
izer. The moisturizer should be applied liberally and frequently
to keep the skin hydrated. Dry, flaky skin indicates an under-
moisturized patient (Figure 12-109).
Some patients can develop a wheltlike irritation of the skin
which responds well to topical steroids such as clobetasol 0.05%
(Figure 12-110). This should not be used longer than 1 week
and should not be applied to unepithelialized skin. Diphen-
hydramine 50 mg is also effective for post-laser itching.
The second post-laser week becomes much easier as the skin
begins to epithelialize and the serous exudates stops. The
washing and moisturizer regimen continues throughout this
secondary healing phase. Between 10 and 14 days, most patients
should be totally reepithelialized and can begin using makeup
B
A
FIGURE 12-106.  Patient is an example of poor compliance of wound care. She is shown 5 days after laser skin resurfacing
(A) and immediately after soaks and débriding in the office with reapplication of Aquaphor (B).
A
B
FIGURE 12-107.  This patient is an admitted “picker” and has denuded her lasered skin and facelift incisions. This can be a
severe disorder in some patients, and they may require psychiatric intervention.

Chapter 12  •  Skin Resurfacing
573
accelerating reepithelialization.5 Immediately after LSR, the face
is misted with a light coating from the included nebulizer
(Figure 12-113). This is then repeated two to three times in the
early post-laser period and is a cooling, soothing, and comfort-
ing treatment for the patient. The remainder of the system
consists of a cleansing solution, a protective balm, and an aerosol
can of a soothing mist (Figure 12-114). I am impressed with
the results seen thus far (Figure 12-115). Having the patient
return to the office several times for the nebulizer misting is a
relative inconvenience, but the reduction of discomfort and
a nebulizer misting apparatus that attaches to a common E-type
portable oxygen tank. The mister nebulizes the Amino-Plex
medication, which consists of amino acids, peptides, nucleic
acid components (<10,000 D molecular weight), and micellized
vitamin E. The company has performed wound care studies for
wounds sustained by military personnel in the Iraq war and
claims that the Amino-Plex formulation plays a role in reversing
damaged cells to their normal state, increasing glucose and
oxygen transport utilization, providing conditions favorable to
collagen synthesis and healthy granulation tissue formation, and
Post laser erythema
1 week post laser
2 weeks post laser
3 weeks post laser
FIGURE 12-108.  Patient after multipass, high-energy CO2 laser skin resur-
facing (LSR).
FIGURE 12-109.  Patient illustrates an example of severely undermoisturized
and inflamed skin. Protecting the newly epithelialized skin with a barrier
ointment or moisturizer is paramount in post laser skin resurfacing skin
care.
FIGURE 12-110.  Newly reepithelialized skin can be very sensitive and reac-
tive. A short course of a potent topical steroid can increase comfort and
reduce inflammation.
FIGURE 12-111.  Special makeup is available to conceal post laser ery-
thema and may be necessary for several weeks after surgery.

574
Chapter 12  •  Skin Resurfacing
Complications of Facial CO2
Laser Resurfacing
Although advances in controlling the pulse width of the laser
beam and understanding the concept of thermal relaxation time
have led to a safe and effective new high-tech means of facial
rejuvenation, accidents and complications occur. As with most
new technologies, LSR was pushed to the limits by many dif-
ferent specialties, resulting in many great results but also many
untoward outcomes and lawsuits. Again, predictably for new
technology, the technique fell out of favor with many practi­
tioners but continues to be mainstream in the practices of other
surgeons, including this author.
The prolonged healing, possible complications, sequelae,
and intense postoperative care required made aggressive CO2
laser resurfacing less palatable for patients and surgeons. In
addition, the media, corporate, and consumer push for less
invasive resurfacing techniques kept CO2 LSR on the back
burner of many practices. Regardless of the technique of dam-
aging the skin, the skin reacts basically the same way in its
response to the insult. It is possible to undertreat with an abla-
tive CO2 laser to minimally damage the skin or overtreat with
a less invasive technology, but complications have much to do
with the level of damage to the skin. Having previously dis-
cussed the relative injury depth and healing times of resurfac-
ing, suffice it to say that almost any complication can occur
with almost any treatment. It also makes sense that the more
aggressive the treatment, the greater the chance of complica-
tions. Many of the conditions patients look at as complications
are actually sequelae. In a landmark article, Nanni and Alster
reviewed 500 cases of LSR and categorized them as listed in
Table 12-2.25 Whereas this table represents aggressive full-face
CO2 laser resurfacing, any or all of these problems can and do
occur with other common resurfacing modalities and other
“nonablative” procedures. Looking at the data,25 the level of
herpetic superinfection is exceedingly high compared to my
experience. The high percentage of contact dermatitis found in
this study might be reduced or eliminated by avoiding triple-
antibiotic preparations.
inflammation seems to provide incentive for the extra visits.
Figure 12-115 shows two patients who underwent two passes
of 80 mJ, density 6 LSR shown on post-laser day 6. The com-
bination of not débriding between passes and the use of the
Oxy-Mist and Amino-Plex (although small sample size) have
greatly reduced healing time, post-laser discomfort, and ery-
thema. This makes patient acceptance of aggressive CO2 LSR
much easier.
Case Presentations
Figures 12-116 to 12-142 illustrate various cases of cosmetic
facial CO2 LSR.
FIGURE 12-112.  Post laser skin resurfacing sun avoidance is paramount
for healthy healing and avoidance of complications. Patients are usually
very compliant in protecting their cosmetic surgery investment.
FIGURE 12-113.  The Oxy-Mist system treats the lasered skin with amino
acids, peptides, nucleic acids, and vitamin E and is purported to acceler-
ate wound healing.
FIGURE 12-114.  The biO2 Amino-Plex system utilizes a cleanser, a healing
balm, and a patient spray mister. The nebulizer misting treatments are per-
formed in the surgeon’s office.
Text continued on page 587.

Chapter 12  •  Skin Resurfacing
575
A
B
FIGURE 12-115.  Both of these patients are shown 6 days after two-plus nondébrided passes of CO2 laser skin resurfacing
(LSR) at 80 mJ and a density of 6. These patients were treated with the Amino-Plex and Oxy-Mist systems and are healing
faster than my normal aggressive CO2 LSR patients.
A
B
FIGURE 12-116.  Patient underwent blepharoplasty, facelift, and cheek implants. She was treated with three passes of aggressive
CO2 laser skin resurfacing on the central oval of the face and a single pass at 80 mJ and density of 4 over the undermined
facelift flaps.

576
Chapter 12  •  Skin Resurfacing
A
B
FIGURE 12-117.  Patient was treated with facelift and three passes of aggressive CO2 laser skin resurfacing over the central oval
of the face and a single pass of 80 mJ and a density of 4 over the undermined facelift flaps.
A
B
FIGURE 12-118.  Patient received a facelift and three passes of aggressive CO2 laser skin resurfacing over the central oval of
the face and a single pass of 80 mJ and a density of 4 over the undermined facelift flaps.

Chapter 12  •  Skin Resurfacing
577
A
B
FIGURE 12-119.  Patient treated with
three passes of aggressive CO2 laser
skin resurfacing at 80 mJ and a
density of 6.
A
B
FIGURE 12-120.  Patient treated with
three passes of aggressive CO2 laser
skin resurfacing at 80 mJ and a density
of 6.
A
B
FIGURE 12-121.  Patient treated with
three passes of aggressive CO2 laser
skin resurfacing at 80 mJ and a density
of 6.

A
B
FIGURE 12-122.  Patient treated with three passes of
aggressive CO2 laser skin resurfacing at 80 mJ and a
density of 6.
B
A
D
C
FIGURE 12-123.  A–B, Patient was treated with three passes of aggressive CO2 laser skin resurfacing at 80 mJ and a density
of 6. Note the amount of jowl improvement from laser only. C–D, A UV scan shows improvement of dyschromias.
578

Chapter 12  •  Skin Resurfacing
579
A
B
FIGURE 12-124.  Patient was treated with three passes of aggressive CO2 laser skin resurfacing at 80 mJ and a density of 6.
Note the improvement of both skin tightening and dyschromia.
A
B
FIGURE 12-125.  Patient was treated with three passes of 80 mJ and a density of 6. Significant improvement of perioral rhytids
is noted.
A
B
FIGURE 12-126.  Patient treated with three passes of 80 mJ and a density of 6. Although significant improvement of perioral
rhytids is noted, this patient will require additional perioral laser skin resurfacing to complete the result.

A
B
FIGURE 12-127.  Patient underwent upper and lower blepharoplasty with full-face multipass CO2 laser skin resurfacing with
excellent improvement of the periorbital skin.
B
A
D
C
FIGURE 12-128.  A–B, Patient underwent a single pass of CO2 Lite laser skin resurfacing at 3.5 J/cm2. The healing time is about
7 days. C–D, A UV scan illustrates excellent resolution of dyschromias with this single-pass treatment.
580

Chapter 12  •  Skin Resurfacing
581
A
B
FIGURE 12-129.  Patient with acne scar underwent three passes of 90 mJ and density 6 CO2 laser skin resurfacing, with addi-
tional passes on areas of most severe scarring. The CO2 laser remains the gold standard for rhytid and scar effacement.
A
B
FIGURE 12-130.  Patient with acne scar underwent direct excision of perioral laser scars, followed 8 weeks later with three passes
of 90 mJ and density 6 CO2 laser skin resurfacing with additional passes on the areas of most severe scarring.