Rhett Drugge, M.D. | Cosmetic Procedures | Laser Resurfacing with Erbium Yag

Author:
Philip S.H. Hughes, M.D.
Diplomate, American Board of Dermatology
San Antonio, Texas

The Erbium:YAG laser (Continuum Biomedical, Dublin, CA), emitting in the infrared at the 2.94 micron peak of the water absorption spectrum, produces minimal residual thermal damage (2 microns at 4.2 joules/sq.cm.) compared to superpulsed C02 lasers (greater than 100 microns). This means there is less pain (procedures can be done with no anesthesia or topical EMLA), faster healing, and faster resolution of erythema with the Erbium:YAG laser compared to the carbon dioxide laser. Specifically, facial resurfacing procedures with the Erbium:YAG laser re-epithelialize in 5 days and erythema generally resolves in 5 days! Using a fluence of around 5 joules/sq.cm. the Erbium:YAG laser penetrates 25-30 microns per pulse. The first pulse is intraepidermal. After the second pulse the epidermis is ablated and the upper papillary dermis is entered.

Extrinsic photoaging produces rhytids, actinic keratoses, and solar elastosis, all of which are effectively treated with the Erbium:YAG laser.

Intrinsic aging (producing the sagging skin of blepharochalasia or the jowling of dermatochalasia), infraorbital fat pads or deep wrinkling from muscular contraction are not appropriate candidates for Erbium:YAG resurfacing.

Do not use ablative methods (including Erbium:YAG resurfacing) for melasma or postinflammatory hyperpigmentation. These procedures frequently exacerbate the problem.

Epidermal tumors (such as actinic keratosis, seborrheic keratosis, lentigo, verruca vulgaris, molluscum contagiosum, achrocordon, leukoplakia), selective elevated dermal tumors (like syringoma ,sebaceous hyperplasia, xanthelasma, cherry angioma, dermal nevus, steatocystoma multiplex), rhinophyma and superficial basal cell epithelioma may all be ablated with the Erbium:YAG laser. (Be sure to consider the need for histopathology before using an ablative procedure on a tumor.)

Scars, such as acne scars (deep pitted scars should be punch-stitched and resurfaced 6 weeks later), varicella scars, traumatic scars and surgical scars (ideal resurfacing time is 4-6 weeks post-op) are all improved with the Erbium:YAG laser. Hypertrophic scars or keloids (especially if followed by 585 nm pulse dye laser treatment or intralesional corticosteroid injections) are candidates for Erbium:YAG ablation. Mature “spread” scars may be de-epithelialized with the Erbium:YAG laser and then treated with the 585 NM pulsed dye laser.

Furthermore, an experimental use of the Erbium:YAG is upper epidermal ablation to enhance the penetration of topical drugs.

Although controversial, from a medical legal standpoint alone, wait 6 months after Accutane before a resurfacing procedure. Avoid patients with keloids or vitiligo. With ectropion, don't do eyelid work. Because of the presumed hazard of the laser plume, don't use the laser in the presence of HIV.

At 5-10 herz with a 5 mm spot size, a dry cotton ball will burst into flame. At atmospheric oxygen, the following have not flamed: cotton balls soaked in 70% isopropanol, cotton drapes, paper drapes, human hair.

Use pre-op sedatives or minor tranquilizers and oral analgesia. I use Valium 10-15 mgm and two Tylenol #3 with codeine (may substitute 2 Vicodin tablets) 1 hour before resurfacing.

Apply EMLA cream to defatted skin (scrub with soap and water, wipe with 70% iosopropanol). Apply a thick "white" layer and occlude with Saran wrap. Lightly tape in place with paper tape. Keep the patient lying down so that the Saran wrap doesn't slide down. Consider doing this in your office properly, so it works!

With multiple passes, the procedure is moderately unpleasant but tolerable. In over 400 consecutive cases, I have not needed or used infiltration anesthesia, nerve blocks, or IV sedation.

There are three supplemental topical anesthetic modalities that may be employed during a resurfacing procedure. One, after I pass with the Erbium:YAG laser, EMLA may be applied; wait 60 seconds and effective deeper anesthesia is obtained. Don't try this after more than 1 pass as it will sting severely. Second, after any number of passes, squirt a pH-neutralized solution of 10 parts 1% lidocaine with epinephrine and 1 part 8.4% sodium bicarbonate onto the skin between passes, wait 60 seconds, and obtain analgesia. Wipe dry before proceeding with resurfacing, because the aqueous solution will absorb the laser energy. Third, 5% Xylocaine ointment ("plain," nonflavored) is effective and causes minimal discomfort when applied.

No anesthesia is required for removal of isolated lesions or small scar resurfacing. Biophysics

The Erbium:YAG fires almost silently. The "pop" with each pulse is from the supersonic ejection of tissue. The higher the fluence, the louder the "pop." Note the build-up of "cotton candy" on the handpiece. With higher fluence, there is a minimal insignificant increase in residual thermal damage. There is greater ablation per pulse and slightly prolonged healing time and erythema with higher fluence. The ablation threshold is about 1.5 joules/sq.cm. for human skin.

Using one of my child's old deciduous tooth, one pulse with the Erbium:YAG laser permanently etched the tooth, even with saliva on it.

The 5mm spot size produces a columnated beam. The 2mm and the 3.5mm handpieces produce a focused beam, the diameter gets larger and the power (joules/sq.cm.) lessens as the distance is increased beyond the “guide.” With the 2mm spot size, at 6 inches or so from the skin there is almost no power delivered to the skin target (the power is below the ablation threshold of the skin). This is because the beam diverges. (It is not due to water vapor in the air, as water vapor, in contrast to liquid water, is essentially transparent to 2.94 micron wavelength light.)

In general, start all resurfacing patients on Retin A and LacHydrin 1 month before the procedure. This speeds up re-epithelialization and probably lessens the incidence of postinflammatory hyperpigmentation. In darker skin types, I will sometimes add a topical hydroquinone product to the regimen, again to lessen the likelihood of postinflammatory hyperpigmentation. Recommend sunscreens.

All patients are started on an oral anti-herpes simplex medication the morning of the procedure. My current favorite is Valtrex.

Use eye and tooth protection for the patient. The operator and assistant need laser-safe eyewear and facial masks. Due to presumed hazards of the laser plume, use a smoke evacuator.

For isolated lesions, use the 2 mm (at 175 mj) or 3.5 mm handpiece (at 450 mj) to ablate epidermal lesions. With macular epidermal lesions, 2-4 passes will produce visible ablation below the basement membrane to the pinkish upper papillary dermis. With experience, this endpoint is readily recognized.

Elevated dermal tumors (syringomas, sebaceous hyperplasia) are ablated until they are flush with the epidermis.

On a few occasions, I have treated hypertrophic actinic keratoses, superficial squamous cell carcinoma or superficial basal cell carcinoma by a technique of repeated Erbium:YAG vaporization followed by rubbing with a gauze, reminiscent of “electrodessication and curettage.”

Leukoplakia of the lower lip (after a shave biopsy result is back) is treated with 4-6 passes with the 5mm handpiece at 935 mj at 5 herz.

For resurfacing larger areas (rhytids, scars), use the 5mm handpiece (935 mj) at 5 herz around the eyelids, glabella, nose and mouth. Speed up to 10 herz for the cheeks and forehead. No wiping of treated tissue is required; the tissue is literally ejected in tiny fragments at supersonic speeds, producing the "popping" sound.

I do 3-4 passes for the lower eyelids, 7-9 passes for the glabella and peri-oral areas, and5-7 passes everywhere else on the face. If needed, I will use a 2 mm handpiece (at 175mj) after the above passes for selective "sculpting" of the shoulders of acne or varicella scars. I gently pull the wrinkled skin while resurfacing, thus enhancing the ablation of the shoulders and valleys of rhytids.

When resurfacing, after 2 passes (when the upper papillary dermis is entered), I can't determine depth, so I count the number of passes. Because there is very little residual thermal damage (10 microns or less) with the Erbium:YAG laser at the fluences used, there is no color change as deeper dermal areas are entered. Focal bleeding or wrinkle or scar ablation are other end-points.

By the way, the apparent wrinkle or scar ablation seen immediately is temporary. The defects reappear after a few minutes, suggesting that the temporary ablation is really dehydration of tissue.

Bleeding is not a problem with resurfacing. Sometimes, when ablating isolated lesions, bleeding will occur. This can be stopped with pressure or 35% aqueous aluminum chloride solution. Aluminum chloride solution delays wound healing, so use it only if needed.

A "combined" technique is used for non-erythematous mature "spread" or hypertrophic scars (typically pre-auricular and post-auricular spread scars following a facelift) consisting of 3 passes with the Erbium:YAG laser (5mm spot size at 935 mj) followed with 585 NM pulsed dye laser treatment (10 mm spot size at 3.0 to 3.4 joules/sq.cm.) Focal sculpting passes may be made with the Erbium:YAG (2mm spot size at 175 mj) to elevated areas prior to the pulsed dye surgery.

For individual lesions, occlude with Aquaphor Healing Ointment and a bandage daily. Clean with shower water. Avoid hydrogen peroxide, as this delays wound healing.

Immediately after resurfacing of larger areas, cover the treated area with AquaphorHealing Ointment. Compress the treated area 3x daily with a solution of 1 tsp. Betadinesolution (not cleanser) in 1 cup of water. Then cover with Aquaphor Healing Ointment. Shower water is OK. On the 4th day, clean with Cetaphil Cleansing Lotion and apply the Aquaphor afterwards until healed. Avoid topical antibiotics due to the high incidence of allergic contact dermatitis following resurfacing.

For cheek resurfacing (where there is less movement), I like Spenco 2nd Skin or Vigilon held in place with Flexinet the first 24 hours. On the 2nd day, start the above compresses and ointment.

I do not routinely prescribe oral or topical antibiotics or antifungals.

Edema is generally not a significant problem following Erbium:YAG resurfacing; however, sometimes after full facial or eyelid resurfacing, I will use p.o. prednisone 20 mgm. immediately post-op and another 20 mgm. h.s. to lessen edema.

Restart Retin A and LacHydrin on the 10th day. Use sunscreens.

Following a period of dermal remodeling, touch-up resurfacing may be done 6 to 8 weeks later.

Facial resurfacing consistently re-epithelializes in 5 days and erythema generally resolves in five days.

Dorsal hand and forearm lesions will epithelialize in 7-9 days if occluded, 14 days if not occluded. Erythema lasts about 30 days.

Leukoplakia of the entire lower lip responds to Erbium:YAG ablation and heals in 3 weeks without scarring.

Postinflammatory hyperpigmentation is rare, particularly with the use of Retin A and occasionally hydroquinone preoperatively.

In 400 individual cases. I have had I case of culture-proven bacterial pyoderma (staph. aureus) which responded to Zithromax treatment. There have been several cases of persistent erythema (greater than 4 weeks); one followed a severe wind and sunburn 5 days after resurfacing multiple facial actinic keratoses. Several patients have developed a superficial folliculitis (acneiform eruption) primarily in adjacent areas, perhaps due to Aquaphor occlusion. One patient, suffering from acne excoriee' (neurotic excoriations), excoriated an Erbium:YAG resurfaced postsurgical scar 2 weeks after resurfacing (the scar was secondary to excision of a deep scar produced by self-induced excoriation). An identical scar on the other side of her chin, healed uneventfully following resurfacing.

Several cases of Polysporin dermatitis occurred. Three weeks after resurfacing pen-orbital rhytids, one patient developed transient (3 days) pinpoint purpura of the treated eyelids and lateral canthal area. There was one erythematous flat scar at the site of a facial actinic keratosis ablated 2 months earlier.

I have had one case of herpes labialis post-resurfacing, despite the patient taking Valtrex 500 mgm b.i.d. x 7 days starting the morning of the procedure

If there is a problem, consider herpes simplex, bacterial pyoderma, candidiasis and allergic contact dermatitis. If the KOH exam is negative, pending bacterial and fungal cultures, start Zithromax. Do open patch tests to Aquaphor and Betadine solution (apply twice daily for 2 days to dime-size areas on the forearm).

As mentioned, postinflammatory hyperpigmentation is rare.

With Erbium:YAG laser resurfacing there is an immediate and persistent 4% contraction of the skin followed by a 13% contraction which then develops over a 2-3 week period. This contraction persisted during a 11 week period in one study (Philip Hughes, submitted for publication).

Epidermal lesions ablated with the Erbium:YAG laser healed without scarring or prolonged erythema, except as mentioned under "complications."

Ablation of sebaceous hyperplasia produces "practically perfect" results. And never before has there been a successfiil method for syringoma ablation.

In general, rhytids and acne scars resulted in 50% improvement following Erbium:YAG resurfacing. With rhytids, improvement was usually observed 3 weeks post-op. Importantly, acne scars continue to improve for many months following resurfacing. Specifically, in evaluating my series of rhytids resurfaced with the Erbium:YAG laser, 45% of results were "excellent," 42% “good,” 3% “fair,” and 10% "unknown" (too soon to evaluate). In rating acne scar improvement following Erbium:YAO resurfacing, 22% were rated "excellent," 33% "good," 33% "fair," and 11 % "unknown (too soon to evaluate).

Varicella scars were dramatically improved, 75% improvement occurring with 1 treatment.

Comparing liquid nitrogen cryosurgery to Erbium:YAG ablation of individual tumors, patients prefer the laser. It is less painful during the procedure and heals faster.

Patients who have experienced 35% combined TCA peels, dermabrasion, and Erbium:YAG resurfacing (I have several who have experienced all three), find the laser resurfacing the least unpleasant, both during the procedure and postoperatively.

Following ErbiumYAG resurfacing of one area of the face, it is common for patients to comment during post-op visits about other facial areas that they want treated. Patients commonly refer friends and relatives for Erbium:YAG resurfacing.

One common misconception is that the Erbium:YAG laser does not ablate deeply. In fact, the laser ablates 25-30 microns of tissue per pulse. For example, after 7 passes, about 200 microns are vaporized. There is still minimal residual thermal damage (3 microns) below this 200 micron ablation.

Another controversy or misconception is whether or not deep thermal damage is required for permanent collagen shrinkage. This appears unimportant, since with Erbium:YAG resurfacing, I have mentioned there is immediate and persistent 4 % cutaneous contraction. Then after 1 -2 weeks a 13% tightening occurs which persists through a 11 week observation period.