Skin Resurfacing–the Overhaul

When you are seeing more advanced changes and look in the mirror and think "I really don't care for these changes," it's time to move on to some of the moderate to advanced dermatology in-office resurfacing procedures. You are in this category of moderate to advanced changes if you are seeing one or more of the following changes: etched lines(lines that don't totally go away when you stretch the skin), enlarged pores, loss of elasticity, the irregular bumpy slightly yellowish sallow surface that dermatologists call elastosis, and more pronounced brown spots, and worsening of old acne scars.

When you are seeing more advanced changes and look in the mirror and think “I really don’t care for these changes,” it’s time to move on to some of the moderate to advanced dermatology in-office resurfacing procedures. You are in this category of moderate to advanced changes if you are seeing one or more of the following changes: etched lines(lines that don’t totally go away when you stretch the skin), enlarged pores, loss of elasticity, the irregular bumpy slightly yellowish sallow surface that dermatologists call elastosis, and more pronounced brown spots, and worsening of old acne scars.

Options are:

Deep Chemical Peels

Traditional Dermabrasion

Laser Resurfacing

Deep Chemical Peels

Deep chemical peels have been around for a long time. They include high strength Trichloroacetic Acid (TCA, and Phenol peels. Both will penetrate deep enough into the skin to treat at the level at which deep etched wrinkles and acne scars reside, and that is how they treat deep etched lines and acne scars. The problem that is also the drawback, that they penetrate deep enough into the skin to cause scarring. Because they are applied by hand, by a physician, they are dependent on the thickness of the skin, the preparation of the skin before the procedure and the amount of acid applied. And even in the hands of a skilled physician who has performed many deep chemical peels, there is an inherent unpredictability with the depth that the acid will penetrate. Because of this, the risk of side effects such as permanent pigmentation changes, and scarring are greater than with laser resurfacing. Also sometimes they actually cause enlarged pores. Phenol peels always cause permanent loss of pigment so that the skin turns snow white. This is acceptable if your skin type is extremely fair, but not if you have any significant natural pigment. Both require general anesthesia.

I did a fair amount of deep chemical peels under anesthesia early in my career, but have abandoned them in favor of laser resurfacing. I will say that Phenol peels remove etched lines above the upper lip more completely than any other treatment, by replacing the skin and wrinkles with what is essentially a sheet of white scar. But this requires a patient with very fair skin, and the patient will be required to wear makeup every day forever to cover the fairly marked difference in color between treated and untreated skin.

Traditional Dermabrasion

Traditional dermabrasion (not to be confused with microdermabrasion), involves using an electric medical sanding tool to sand off the skin. It is used most often for deep acne scars. The problem again is that the depth of the treatment is dependent on the skin thickness, and the skill of the physician doing the procedure. Deep acne scars are from acne cysts that occur deep enough in the skin to cause a scar. Traditional dermabrasion is performed at the level of skin where scars form. That is why traditional dermabrasion replaces acne scars with a sheet of new scar. The skin never really looks or feels normal.

Laser Resurfacing

Laser resurfacing is divided into ablative and non ablative depending on whether the surface layer of the skin is removed with treatment (ablative) or not (non-ablative). It is also divided into fractional and non-fractional.

The first skin resurfacing lasers in the 90’s were ablative and non-fractional CO2 lasers. Non-fractional ablative lasers only required one treatment but usually required general anesthesia. Patients looked like they belonged in a burn unit for 2-3 weeks, were red and sensitive for months. Although not known in the first few years of use, some patients developed permanent loss of pigment in the treated skin several years after treatment. Additionally the risk of scarring, though less than deep chemical peels and traditional dermabrasion was unacceptably high. I also did many ablative non-fractional CO2 laser treatments in the 90’s but like most physicians switched to fractional laser resurfacing when it became available.

Fractional laser resurfacing was developed to address some of these problems. Fractional means that only a fraction of the skin is treated at a time by creating thousands of tiny treated channels in the skin surrounded by untreated skin. This allows safer treatment with much less risk of scarring and permanent pigment change, but requires more than one treatment to achieve best results. Fractional lasers are either ablative (destroys the top layer of skin) or non-ablative (does not). Fraxel was the first laser to utilize the fractional technology. Fractional laser resurfacing creates microscopic “wounds” within targeted areas beneath the outer layer of skin. The natural healing process produces collagen and healthy skin cells.

The original fractional laser resurfacing treatment Fraxel, is now Fraxel:restore, and is non-ablative. Fraxel:repair is a more recent development and is ablative. Ablative lasers require less treatments, but each treatment has a longer recovery time. Ablative lasers also may require general anesthesia. Non-ablative lasers may be safely used on the neck, chest, forearms and hands. Ablative lasers carry a risk of scarring in these areas.

We use Fraxel:restore as our patients prefer more treatments with less downtime and less discomfort with each treatment. They also don’t want general anesthesia which ablative procedures may require. In the last few years, many new resurfacing lasers have emerged. All have their pros and cons, but there are now multiple choices, and each physician usually has a personal preference.

Laser resurfacing treats mild to moderate wrinkles, surface irregularities, blotchy pigment, acne scarring, large pores, and stretch marks. Skin is smoother, less wrinkled and more refined with smaller pore size.

Next: How to know which skin resurfacing treatment is right for you.