April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Volume 143, Number 1 • Perioral Rhytide Correction Assessment

into the reticular dermis, the operator encounters larger individual bleeding points, as the vascular network in the skin is more scattered. Ideally, the best endpoint is complete resolution of the wrinkle before midreticular bleeding is seen. In that case, excellent results can be expected, and the operator can remain well within the safety window. Both carbon dioxide and erbium can give amazing results, and data have shown that when ensuring similar depth of penetration and energy there is no difference in results long term. 19 How- ever, the erbium provides a more controlled and uniform depth of ablation. Modifying erbium is extremely precise, with tissue removal control to just a few microns. 20 This allows for superficial peels of 5 to 20 μ m, and aggressive resurfacing treating some wrinkles to a depth of 800 μ m. This allows the erbium laser surgeon complete mas- tery over a variety of both superficial and deeper skin pathologic conditions. In addition, erbium has been shown to be associated with significantly lower rates of hypopigmentation, less residual tis- sue damage, and shorter duration of erythema. 21 This article supports this fact, even with deeper depths of erbium injury. In the event that lines of demarcation from treated to nontreated sites are encountered, they can be improved with fractional laser treatments along the line edge. If there are hypopigmented areas that occur, ablative fractional resurfac- ing followed by immediate Bimatoprost solution (Latisse; Allergan, Inc., Irvine, Calif.) can be helpful. Another option is medical tattooing, in a decreasingly pigmented fashion to eliminate sharp demarcation; the least invasive but more time-consuming choice would be daily make-up application until pigmentation returns to baseline. There are limitations to our study. Although every patient had perioral resurfacing, many had other facial rejuvenation procedures, includ- ing face lift, brow lift, and blepharoplasty, which could theoretically impact evaluation scores. However, we restricted all photographic analysis to the perioral area alone; thus, judges did not see a full-face view that could bias them. In addition, there was no significant difference in the scores for those patients having isolated laser treatment and laser treatment with concomitant rejuvena- tion procedures. The study also suffers from its retrospective nature. However, historically in our practice, patients with poor results or who are unhappy are more prone to coming back, whereas satisfied patients often skip follow-up appointments and photographs, which would eliminate them from

Fig. 7. Patient with debris 2 days after laser resurfacing.

Fig. 8. Same patient as in Figure 7 after débridement.

modalities can lead to a wide range of compli- cations. However, for individuals with minimal experience in facial resurfacing, we would argue that the erbium laser is an extremely safe tool for novices and experts alike. The endpoints for chemical peels and carbon dioxide lasers are an indirect reading of skin color or “crepiness,” whereas erbium endpoints are direct, much like dermabrasion. The advantage of erbium over dermabrasion is that the skin is seen at all times and there is no mechanical movement to tear thin, sun-damaged skin. A peel can be difficult for the novice to per- form safely, leading to a peel that is too superficial and does not provide the desired result or is too deep, causing a complication. The endpoints for laser resurfacing are more objective and direct. 18 As the laser depth enters the superficial papillary der- mis, a pinpoint bleeding pattern occurs that is easily identified by the operator. As the depth increases

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