Laser Resurfacing

    Many of the oculoplastic surgical advances in the last 10 years have been technology-dependent. Refinements in our understanding and delivery of laser energy, combined with development of new lasers, have had a dramatically favorable impact on the art of cosmetic oculoplastic surgery. For the first time in the short history of the multiple subspecialties offering cosmetic procedures, there has been an interdisciplinary exchange of knowledge as each specialist offered a valued vantage-point that has contributed to improved patient results and satisfaction. This has been well illustrated by the introduction and refinement of laser technology and resurfacing procedures.

    The use of the C02 laser for surface vaporization began in 1987 as a treatment modality for localized cutaneous tumors and more diffuse dermal disease. The incidental finding of cosmetic benefit led to the initial report of cosmetic facial resurfacing in 1989.98 The initial use of a computer-assisted scanning device to achieve uniform and smooth depth vaporization was reported in 1987 by Brauner and Schifman." The technique was not initially successful, because of inadequate energy levels and a gaussian laser beam distribution.


    At about the same time, dermatologists began understanding the importance of laser tissue interaction and the theoretical thermal relaxation time of skin.

    Hobbs and colleagues described the use of super-pulsed laser and high-irradiation, short-duration pulses (1 ms) to minimize thermal damage. In 1989, David and Lask demonstrated histologic evidence of the cosmetic benefit that was being observed clinically. They showed reduction in atypical keratocytes and solar elastosis with a histologically normal epithelium 4 weeks after laser resurfacing.

    In the early 1990s, the medical laser industry responded by producing a variety of supcrpulsed, ultrapulsed, and scanning lasers with and without computer-generated pattern delivery systems. In 1994, Weinstein was the first to describe laser resurfacing of periocular wrinkles in the literature. At the 1994 American Academy of Ophthalmology annual meeting, many oculoplastic surgeons were skeptical as they viewed Sterling Baker's videos, live surgery, and postoperative patients. Since that time, cosmetic laser resurfacing has enjoyed immense popularity and is now widely accepted by the medical community and the public as a valued option for facial skin aesthetic improvement. It has been a significant advance in improving the appearance of periocular rhytids ('crow's feet') that are not solved with incisional surgery.

    Hibst and Kaufman worked with and recommended the erbium: YAG laser for cosmetic resurfacing. The erbium laser's shorter pulsed time, higher pulsed power, and increased laser light absorption in tissue water may make it more efficacious for surface ablation. Further clinical experience has shown that hybrid lasers which combine the advantages of both the thermal components of C02 lasers and the ablative effects of the erbium laser (such as the Sciton System) have reduced recovery time and complications, while improving patient outcomes.