Indications, technique for combining ablative laser resurfacing, chemical peels

Combining chemical peels with laser resurfacing for facial rejuvenation has proven to be a safe and effective treatment with long-term benefits. Greg S. Morganroth M.D., is clinical assistant professor of the department of dermatology at the University of California, San Francisco, and adjunct clinical assistant professor of the department of otolaryngology/head and neck surgery at Stanford University. He is also director of Morganroth Mohs and advanced dermatologic surgery fellowship in Mountainview, Calif., and offers his expert views and experiences in laser resurfacing, chemical peels and the combination of these two well-known and very effective facial rejuvenation techniques at the American College of Mohs Micrographic Surgery and Cutaneous Oncology meeting in Scottsdale, Ariz., this month.

Dr. Morganroth says that when choosing the technique for facial rejuvenation, it is paramount for the physician to be clear on what exactly he is trying to correct (texture, pigmentation, wrinkling), what procedures he is combining it with (undermined skin flaps are a contraindication for UltraPulse CO₂ laser resurfacing), the downtime and the degree of risk. The epidermis is the target tissue level when trying to correct pigment and texture, and the papillary and reticular dermis the target tissue when correcting wrinkles and scars.

In his practice, he says, pigmentation, texture and fine wrinkles can be successfully treated with TCA, UltraPulse CO₂ laser as well as the Fraxel laser. Deep wrinkles and acne scars can be improved with UltraPulse CO₂ laser and Fraxel and less so with single light to medium-depth TCA peels. Improvement in acne scars is possible with multiple, sequential medium-depth TCA peels spread four to six weeks apart.

Healing time for TCA peels is one to two weeks with low risks, one to 12 weeks with low risks for UltraPulse CO₂ laser, and only two to three days with very low risks for Fraxel. Additionally, wrinkles and acne scars require more than five or six treatments when using Fraxel laser, due to the fractional treatment of the skin with this device.

TCA chemical peels induce a keratocoagulation necrosis in the skin and are used for the face, neck, chest and arms, using only topical anesthetics. They result in few complications and patients enjoy a rapid recovery period with long-lasting effects for at least two years, and of all resurfacing procedures, they provide the best benefit-to-risk ratio.

Deep-depth chemical peels include phenol and carboxylic acid peels like Baker-Gordon or Litton's formulas, but can be accompanied by unwanted potential complications. These include atrophy, cardiac arrhythmias, laryngeal edema, toxic shock syndrome, hyper-, hypo-, or depigmentation and lines of demarcation.

Dr. Morganroth tries to avoid UltraPulse CO₂ laser resurfacing complications by tailoring energy and passes for a specific skin type, reducing energy, density and passes to well-known danger zones like the eyelids - using 150 mJ, density of 6, the jaw line - completing one pass at full energy (250 mJ to 300 mJ, density of 6), at the inferior border of the jawline and neck junction and feathering upward with additional passes, and avoiding the neck.

His techniques include feathering the laser into the hairline, ear and neck regions, thereby minimizing the lines of demarcation, and performing criss-cross and overlap patterns effecting an even skin injury, thereby eliminating geometric patterns after healing. He stressed that the cosmetic surgeon must peel first and only then laser into the peeled skin, and never peel into lasered skin. TCA applied into laser wounds will create scarring. He advised not to laser over skin flaps from concurrent facelifts, although laser resurfacing over skin-muscle flaps is fine (e.g., transconjunctival blepharoplasty and subperiosteal chin-jowl implants).