Skin Resurfacing

Author Credentials 

Myriam Loyo, MD
Assistant Professor
Division of Facial Plastic & Reconstructive Surgery
Department of Otolaryngology–Head & Neck Surgery
Oregon Health & Science University
Portland, OR

Deniz Gerecci, MD
Resident 
Division of Facial Plastic & Reconstructive Surgery
Department of Otolaryngology–Head & Neck Surgery
Oregon Health & Science University
Portland, OR

Module Summary

The skin undergoes many changes with aging and sun damage. Many options are available for skin rejuvenation, including the use of laser, light therapy, radiofrequency, ultrasound, dermabrasion, chemical peels, and dermaceuticals. This outline describes the anatomy, pathophysiology, basic science, clinical applications, and clinical pearls of various skin re-surfacing techniques. Pre-treatment considerations and recognition and management of complications are also reviewed. 

Module Learning Objectives 

After completing this module, the physician will be able to: 

  1. Review the anatomy of the skin. 
  2. Describe the skin changes that occur with aging and photoaging.
  3. Explain the basic science of lasers and light therapy. 
  4. Describe the difference between ablative and non-ablative technologies. 
  5. Review the Glogau photoaging classification and Fitzpatrick skin type classification.
  6. Explain the concept of dermabrasion. 
  7. Describe chemical peels by depth: Superficial, Medium, and Deep.
  8. List “dermaceuticals” topical skin care products available to treat skin damage. 
  9. Explain the relevant pre and post-procedural care for skin rejuvenation techniques. 
  10. Recognize and understand the management of complications from skin rejuvenation techniques.

Embryology

Learning Objectives 

Know the embryological origin of each skin layer

  • Epidermis
  • Dermis 

Anatomy

Learning Objectives 

Understand the anatomy of skin:

  • Epidermis
  • Dermal-Epidermal Junction 
  • Dermis
References 
  1. Massa ST and Walen S. Chapter 2: Skin Anatomy and Wound Healing. In: Desai SC, ed. Facial Plastic and Reconstructive Surgery: Clinical Reference Guide. 1st ed. San Diego, CA: Plural; 2016: 3-14. 
  2. Owusu JA. Chapter 12: Scar revision and dermabrasion. In: Wong BJF, Arnold MG, Boeckmann JO, eds.  Facial Plastic and Reconstructive Surgery: A Comprehensive Study Guide. 1st ed. Middletown, DE: Springer; 2016: 145-151.

Pathogenesis

Learning Objectives 
  • Know the skin changes that occur due to aging 
  • Know the skin changes that occur due to photo aging 
References 
  1. Hadlock T, Lindsay R, Cheney M. Chapter 34: Facial Plastic Surgery. In: Lee KJ, ed. Essential Otolaryngology: Head & Neck Surgery.10th ed. Flushing, NY: McGraw-Hill; 2012: 744-768.  

Basic Science

Learning Objectives 
  1. Understand the basic science of re-epithelialization
  2. Understand the basic science of lasers
  3. Know the properties of commonly used lasers for skin resurfacing including wavelengths and chromophores 
    • Visible light vs infrared    
    • Crystalline media
    • Diode lasers
    • Gas lasers
    • Liquid lasers
  4. Understand the concept of fractional laser therapy
  5. Understand the basic science of non-laser light therapy
  6. Understand the difference between ablative and non-ablative technologies for skin rejuvenation 
References 
  1. Husain Z, Husain Q, Alster TS. Chapter 20: Skin Rejuvenation: Lasers, Peels, and Dermabrasion. In: Desai SC, ed. Facial Plastic and Reconstructive Surgery: Clinical Reference Guide. 1st ed. San Diego, CA: Plural; 2016:187-196. 
  2. Arnold MG, Wong BJF. Chapter 21: Nonablative Facial Skin Rejuvenation. In: Papel ID, Frodel JL, Holt GR, Larrabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York, NY: Thieme; 2016: 246--255.
  3. Loyo M. Chapter 25: Lasers in Aesthetic Surgery. In: Wong BJF, Arnold MG, Booeckmann JO, eds.  Facial Plastic and Reconstructive Surgery: A Comprehensive Study Guide. 1st ed. Middletown, DE: Springer; 2016: 307-313.
  4. Carniol PJ, Hamilton MM, Harirchian S. Chapter 20: Ablative Laser Facial Skin Rejuvenation. In: Papel ID, Frodel JL, Holt GR, Larrabee WF, Nachlas NE, Park SS< Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York, NY: Thieme; 2016: 235-245.
  5. Ries R, Wright HV. Chapter 6: Lasers in Facial Plastic Surgery. In: Papel ID, Frodel JL, Holt GR, Larrabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York, NY: Thieme; 2016: 

Patient Evaluation

Learning Objectives 
  • Know the classification systems used in patient selection and analysis and how they correspond with risk stratification 
  1. Fitzpatrick Classification
  2. Glogau Classification 
  • Know pertinent medical conditions that may be a contraindication to resurfacing
References 
  1. Lieberman DM. Chapter 21: Chemical peels. In: Wong BJF, Arnold MG, Boeckmann JO, eds.  Facial Plastic and Reconstructive Surgery: A Comprehensive Study Guide. 1st ed. Middletown, DE: Springer; 2016: 255-264.
  2. Been MJ, Harmuych BM, Mangat DS. Chapter 19: Dermabrasion, Chemical Peels, and Dermaceuticals. In: Papel ID, Frodel JL, Holt GR, Larrabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th.

Treatment

Learning Objectives 
  1. Understand the treatments available for skin rejuvenation 
    • Lasers (ablative vs non-ablative) 
    • Light devices (IPL or BBL)
    • Radiofrequency devices 
    • Ultrasound
    • Microneedling
  2. Be familiar with dermabrasion 
  3. Understand Chemical Peels
    • Know depth of penetration and how it relates to skin resurfacing treatments 
      • Nanopeels
      • Micropeels
      • Deep resurfacing
    • Know the types of peels available by depth and the solutions used to make them  
      • Superficial
      • Medium 
      • Deep
References 
  1. Lieberman DM. Chapter 21: Chemical peels. In: Wong BJF, Arnold MG, Boeckmann JO, eds.  Facial Plastic and Reconstructive Surgery: A Comprehensive Study Guide. 1st ed. Middletown, DE: Springer; 2016: 255-264.
  2. Arnold MG, Wong BJF. Chapter 21: Nonablative Facial Skin Rejuvenation. In: Papel ID, Frodel JL, Holt GR, Larrabee WF, Nachlas NE, Park SS,  Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York, NY: Thieme;2016: 246-255.
  3. Been MJ, Harmuych BM, Mangat DS. Chapter 19: Dermabrasion, Chemical Peels, and Dermaceuticals. In: Papel ID, Frodel JL, Holt GR, Larrabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York, NY: Thieme;2016: 223-234.
  4. Ramaut L, Hoeksema H, Pirayesh A, Stillaert F, Monstrey S. Microneedling: Where do we stand now? A systematic review of the literature. J Plast Reconstr Aesthet Surg. 2018; 71(1): 1-14. 

Medical Therapies

Learning Objectives 

Understand the mechanism of action and indications of dermaceuticals for skin rejuvenation   

  • Hydroquinone
  • Kojic acid
  • Ascorbic Acid (Topical Vitamin C) 
  • Retinoids (Vitamin A derivatives) 
References 
  1. Been MJ, Harmuych BM, Mangat DS. Chapter 19: Dermabrasion, Chemical Peels, and Dermaceuticals. In: Papel ID, Frodel JL, Holt GR, Larrabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York, NY: Thieme; 2016: 223-234.
  2. Lieberman DM. Chapter 21: Chemical peels. In: Wong BJF, Arnold MG, Boeckmann JO, eds.  Facial Plastic and Reconstructive Surgery: A Comprehensive Study Guide. 1st ed. Middletown, DE: Springer; 2016: 255-264.

Rehabilitation

Learning Objectives 
  1. Be familiar with pre-treatment considerations for skin rejuvenation techniques  
  2. Be familiar with post-procedural care after the above procedures 
     
References 
  1. Lieberman DM. Chapter 21: Chemical peels. In: Wong BJF, Arnold MG, Boeckmann JO, eds.  Facial Plastic and Reconstructive Surgery: A Comprehensive Study Guide. 1st ed. Middletown, DE: Springer; 2016: 255-264.
  2. Loyo M. Chapter 25: Lasers in Aesthetic Surgery. In: Wong BJF, Arnold MG, Boeckmann JO, eds.  Facial Plastic and Reconstructive Surgery: A Comprehensive Study Guide. 1st ed. Middletown, DE: Springer; 2016: 307-313.
  3. Carniol PJ, Hamilton MM, Harirchian S. Chapter 20: Ablative Laser Facial Skin Rejuvenation. In: Papel ID, Frodel JL, Holt GR, Larrabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed.

Case Studies

  1. 50-year-old female with photoaging Glogau III and Fitzpatrick V skin type classification seeking skin rejuvenation. She asks about laser resurfacing and is prepared to take down time in exchange for faster improvement 
    • Higher risk of dyspigmentation due to Fitzpatrick level with chemical peels, dermabrasion and chemical peels
    • Use hydroquinone in  preparation to interventions to prevent PIH
  2. 30-year-old female with acne ice pick and box car scarring seeking skin rejuvenation and improvement in her scars. She finished Accutane for the second time 4 months ago. 
    • Need to wait 1 year due to risk of atypical scarring prior to resurfacing
    • Would need deep laser ablation to reach the depth scars
    • Would need antiviral prophylaxis and wound care 
  3. 40-year old female with Glogau type I photoaging interested in treating facial dyschromias and fine rhytids with minimal recovery time 
    • Could offer superficial peel, non-ablative laser, light therapy
    • Counsel that in exchange for minimal down time there may be less significant treatment effect and she may require repeated treatments 
References 
  1. Been MJ, Harmuych BM, Mangat DS. Chapter 19: Dermabrasion, Chemical Peels, and Dermaceuticals. In: Papel ID, Frodel JL, Holt GR, Larrabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York, NY: Thieme; 2016: 223-234.
  2. Carniol PJ, Hamilton MM, Harirchian S. Chapter 20: Ablative Laser Facial Skin Rejuvenation. In: Papel ID, Frodel JL, Holt GR, Larrabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York, NY: Thieme; 2016: 235-245.

Complications

Learning Objectives 
  1. Understand the complications associated with skin rejuvenation techniques 
    • Persistent erythema
    • Post-inflammatory hyperpigmentation (PIH) 
    • Hypopigmentation 
    • Scarring
    • Infection 
    • Ocular complications
  2. Be familiar with complications specific to a particular modality
    • Dermabrasion
    • Chemical Peels
  3. Know how to recognize and treat post-procedural infections
    • Bacterial
    • Viral
    • Fungal 

Review

Review Questions 
  1. Name the categories of Fitzpatrick skin and Glogau photoaging classification systems. 
  2. What are the three properties of laser that make it unique? 
  3. What is the fundamental difference between laser and light therapy? 
  4. What is the difference between ablative and non-ablative therapies? 
  5. What is the difference between full field resurfacing and fractionated laser? 
  6. What are the wavelengths, chromophores, and uses for the CO2 and Er:Yag lasers? 
  7. What skin layers are targeted with superficial, medium, and deep chemical peels? 
  8. What medications for prophylaxis would you provide to a patient undergoing a deep chemical peel? 
  9. What is the mechanism of action for hydroquinone? 
  10. What treatments are available to a patient with post-inflammatory hyperpigmentation?  
Resources 

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  1. Otolaryngology Patient Scenarios (OPS):