Er:YAG Laser Resurfacing Using Combined Ablation and Coagulation Modes

BACKGROUND: The two main laser types used in resurfacing, the CO2 and the Er:YAG lasers, have their supporters and detractors, and each system has clear advantages and disadvantages. OBJECTIVE: The Er:YAG laser can be used in the usual efficient ablative mode, followed by reprogramming to achieve nonablative deeper dermal coagulation associated with the CO2 laser, thereby achieving the main advantages of both laser types. PATIENTS AND METHODS: Twenty-three female patients, ages 42-72 yrs, skin types I-IV, were treated. The epidermis was first removed in the ablative settings in a single pass with 50% overlap. The Er:YAG laser was reprogrammed for the subablative mode, and several passes produced controlled residual thermal damage (RTD) without further ablation. RESULTS: At 2 months postresurfacing the results were assessed. Thirteen patients were rated "very good," eight as "good," and two as "fair." CONCLUSION: The dual mode Er:YAG laser can first be used in the ablative mode to remove the epidermis with minimal RTD, following which, in the subablative mode, the same laser induces a controlled layer of dermal RTD, stimulating the dermis to achieve collagenesis and collagen remodeling and giving good long-term results.     

Laser Skin Resurfacing of the Face with a Combined CO2/Er:YAG Laser

BACKGROUND: A combined, dual-wavelength CO2/Er:YAG laser system having the ability to deliver both clean ablation of skin with the erbium wavelength and a simultaneous deeper penetrating subablative thermal pulse of CO2 was developed for full-face resurfacing. The CO2 component can be pulsed from 1 to 100 msec at a power of 1-10 W with the Er:YAG component pulsed at 350 microsec at 1.7 J/cm2 through either a computer pattern generator with 3 mm diameter spot size or through a noncollimated spot ranging from 0.2 to 8 mm in diameter. Our previous study using this laser on the neck using a 4-8 mm diameter spot with Er:YAG fluence at 1.7 J and the CO2 at 5 W with a 50 msec pulse at a frequency of 10 Hz showed a higher degree of overall patient satisfaction, as well as improvement in skin texture and skin color, compared to patients treated with an Er:YAG laser alone. OBJECTIVE: This study evaluated the CO2/Er:YAG laser treatment modality in facial resurfacing. METHODS: Ten patients were treated with four passes at 1.7 J with a 4 mm diameter spot and the CO2 at 5 W with a 50-msec pulse at a frequency of 10 Hz. Photoaging scores as well as thermal damage and new collagen formation were compared immediately before and after treatment as well as at 2 weeks and 3 months postoperatively. RESULTS: The average pretreatment periorbital score was 6.2 The average posttreatment periorbital scores were 4.2 (P =.0239) at 2 weeks postoperatively (32% improvement) and 3.8 (P =.0028) at 3 months postoperatively (38% improvement). The average pretreatment perioral score was 5.9. The average posttreatment perioral scores were 3.0 (P =.0001) at 2 weeks postoperatively (49% improvement) and 3.3 (P =.0009) at 3 months postoperatively (44% improvement). The average pretreatment cheek score was 4.7. The average posttreatment cheek scores were 2.7 (P =.0066) at 2 weeks postoperatively (43% improvement) and 3.8 (P =. 0152) at 3 months postoperatively (36% improvement). The average pretreatment forehead score was 4.7. The average posttreatment forehead scores were 3.8 (P =.0340) at 2 weeks postoperatively (33% improvement) and 3.6 (P =.0147) at 3 months postoperatively (37% improvement). The average depth of collagen measured in the dermis pretreatment was 29 microm. The average depth of collagen 3 months posttreatment was 54 microm. This is an average increase of 25 microm or an 86% increase in collagen (P =.006). The average thermal damage immediately after treatment was 20 microm. CONCLUSION: The CO2/Er:YAG laser utilized with four passes at the above-mentioned parameters results in a similar degree of improvement as other forms of laser resurfacing with high-energy, short-pulsed CO2 lasers.     

Resurfacing of Pitted Facial Acne Scars with a Long-Pulsed Er:YAG Laser

BACKGROUND: Conventional short-pulsed Er:YAG lasers show less effective hemostasis and weak photothermal damage on papillary dermis. Recently, newer long-pulsed Er:YAG laser systems has been developed. OBJECTIVE: To evaluate the clinical and histologic effects of long-pulsed Er:YAG laser resurfacing for pitted facial acne scars. METHODS: Thirty-five patients with pitted facial acne scars were treated with a long-pulsed Er:YAG laser. All patients had Fitzpatrick skin phototypes III-V. A pulsed Er:YAG laser with a 5 mm handpiece at a setting of 7.0-7.5 J/cm2 with a 10-msec pulse duration was used. The laser was fired at 5 Hz, with four to five passes. In 28 patients, the results of laser treatment were evaluated for the degree of clinical improvement, duration of erythema, pigmentary change, and any adverse events at 2 weeks, 1 month, and 3 months. In seven patients, skin biopsy specimens were obtained at the following intervals: immediately, 1 week, 2 weeks, 4 weeks, and 8 weeks postoperatively for histologic examination. RESULTS: The results of long-pulsed Er:YAG laser resurfacing for pitted facial acne scars were excellent in 10 patients (36%), good in 16 patients (57%), and fair in 2 patients (7%). Erythema occurred in all patients after laser treatment and lasted longer than 3 months in 15 patients (54%). Postinflammatory hyperpigmentation occurred in 8 patients (29%). But the pigmentation faded or disappeared within 3 months. One patient (4%) experienced mild hypopigmentation. Pruritic symptoms that required medical intervention occurred in 16 patients (57%). Mild to moderate postoperative acne flare-up occurred in 8 patients (29%). No other adverse effects such as scarring, bacterial infection, or contact dermatitis were observed. CONCLUSION: In conclusion, resurfacing with a long-pulsed Er:YAG laser is a safe and very effective treatment modality for pitted facial acne scars.     

Single-Pass Carbon Dioxide Versus Multiple-Pass Er:YAG Laser Skin Resurfacing: A Comparison of Postoperative Wound Healing and Side-Effect Rates

BACKGROUND: Ablative laser skin resurfacing with carbon dioxide (CO2) and erbium:yttrium-aluminum-garnet (Er:YAG) lasers has been popularized in recent years and their side effects individually reported. No prior study, however, has directly compared the relative healing times and complications rates between the two different systems. OBJECTIVE: To evaluate and compare postoperative wound healing and short- and long-term side effects of single-pass CO2 and multiple-pass, long-pulsed Er:YAG laser skin resurfacing for the treatment of facial photodamage and atrophic scars. METHODS: A retrospective chart review and analysis of sequential clinical photographs were performed in 100 consecutive patients who underwent laser skin resurfacing with single-pass CO2 (Ultrapulse 5000; Coherent, Palo Alto, CA, N=50) or multiple-pass, long-pulsed Er:YAG laser resurfacing (Contour; Sciton, Palo Alto, CA, N=50). All laser procedures were performed by a single operator for the amelioration of facial rhytides or atrophic scars. The rate of re-epithelialization, duration of erythema, and presence of complications were tabulated. RESULTS: The average time to re-epithelialization was 5.5 days with single-pass CO2 and 5.1 days with long-pulsed Er:YAG laser resurfacing. Postoperative erythema was observed in all patients, lasting an average of 4.5 weeks after single-pass CO2 laser treatment and 3.6 weeks after long-pulsed Er:YAG laser treatment. Hyperpigmentation was seen in 46% of the patients treated with single-pass CO2 and 42% of the patients treated with the long-pulsed Er:YAG laser (average duration of 12.7 and 11.4 weeks, respectively). No incidences of hypopigmentation or scarring were observed. CONCLUSION: Skin resurfacing with single-pass CO2 or multiple-pass long-pulsed Er:YAG laser techniques yielded comparable postoperative healing times and complication profiles.     

Resurfacing of Pitted Facial Acne Scars Using Er:YAG Laser with Ablation and Coagulation Mode

Although the conventional, short-pulsed erbium: yttrium-aluminum-garnet (Er:YAG) laser provides substantial clinical improvement for pitted, facial acne scars, it shows less effective hemostasis and limited residual thermal effect in the dermis. Recently, dual-mode Er:YAG laser systems with both ablation and coagulation modes have been developed. The purpose of this study was to evaluate the clinical and histologic effects of resurfacing pitted, facial acne scars with a dual-mode Er:YAG laser. Twenty patients with pitted facial acne scars underwent laser resurfacing using a computerized-scanning, dual-mode Er:YAG laser. All patients had Fitzpatrick skin types ranging III–V. Initially, the epidermis was removed in two passes using the ablative settings. This step was followed by two passes in a mixed ablation and coagulation mode, to produce further ablation and controlled, residual thermal damage. A final pass in a ablation mode was used to remove necrotic tissue. Laser overlapping was approximately 30%. The results of laser treatment were evaluated for the degree of clinical improvement, duration of erythema, pigmentary change, and any adverse events at two weeks, one month, and three months. In two patients, skin biopsies were obtained at the following intervals: immediately and two weeks postoperatively for histologic examination. There was a 75% average clinical improvement observed in pitted, facial acne scars after laser treatment. Complete wound healing occurred between six and eight days. On histologic examination, complete re-epithelialization was observed at two weeks. Erythema occurred in all patients after laser treatment and lasted longer than three months in 10 patients (50%). Post-inflammatory hyperpigmentation occurred in 12 patients (60%) two to four weeks after laser treatment and lasted longer than three months in one patient (5%). One patient (5%) experienced mild hypopigmention. Mild to moderate, postoperative acne flare-up occurred in seven patients (35%). No other adverse effects were observed. In conclusion, resurfacing with a dual-mode Er:YAG laser is a safe and effective treatment modality for pitted, facial acne scars.     

Erbium:YAG Laser Resurfacing for Refractory Melasma

BACKGROUND: Melasma is a facial dyspigmentation which is a common complaint in patients with darker skin tones. Many current therapies used for this condition are ineffective and can cause significant adverse effects. OBJECTIVE: The purpose of this study was to evaluate the role of erbium:YAG laser resurfacing in the management of refractory melasma. METHODS: Ten female patients with melasma unresponsive to previous therapy of bleaching creams and chemical peels were included in this study. Full face skin resurfacing using an erbium: YAG laser (2.94 microm) was performed using 5.1-7.6 J/cm2 energy. Clinical evaluations using the Melasma Area and Severity Index (MASI) and melanin reflectance spectrometry measurements were taken preoperatively and at 0.5, 1, 1.5, 3, and 6 weeks and 3, 5, and 6 months postoperatively. Adverse effects after laser resurfacing such as prolonged erythema, infection, and hyperpigmentation were recorded. RESULTS: There was marked improvement of the melasma immediately after laser surgery using the parameters outlined; however, between 3 and 6 weeks postoperatively, all patients exhibited post-inflammatory hyperpigmentation. Decreased MASI and melanin reflectance spectrometry measurement scores were noted after biweekly glycolic acid peels and at the end of 6 months, significant clinical improvement in the melasma was seen compared to the preoperative evaluation. CONCLUSION: Erbium:YAG laser resurfacing effectively improves melasma; however, the almost universal appearance of transient post-inflammatory hyperpigmentation necessitates prompt and persistent intervention. The use of this laser therapy is recommended only for refractory melasma.     

Laser Resurfacing of the Neck with the Combined CO2/Er:YAG Laser

BACKGROUND: Several clinical studies on laser resurfacing on the neck have yielded variable results with adverse sequelae of hypopigmentation and scarring using the CO2 laser. The Er:YAG laser on the neck resulted in an improved appearance with no adverse sequelae. The combined CO2/Er:YAG laser is a laser that combines a low fluence CO2 laser with the Er:YAG laser in a near simultaneous beam. OBJECTIVE: To study the effects of the CO2/Er:YAG laser on the neck. The decreased nonspecific thermal damage of the CO2/Er:YAG laser should result in decreased postoperative erythema and improved wound healing. METHODS: Eleven patients were treated with the CO2/Er:YAG laser on the neck as well as the face at identical settings. The face was treated with four passes while the neck was treated with two passes. The patients were evaluated for the first 2 weeks then 3-6 months postoperatively. Patients were asked about treatment satisfaction and improvement in skin texture and color using a 25% scale. Skin texture and color, as well as improvement in wrinkling and adverse results were judged by a dermatologist using a 0-4 scale. RESULTS: Moderate improvement was seen in skin color while a higher degree of improvement was seen in skin texture and wrinkling in all 11 patients. No adverse sequelae, including hypopigmentation or scarring, were observed. The majority of patients had a 75-100% improvement in skin texture and color in addition to a 75-100% overall satisfaction rating. CONCLUSIONS: There is a higher degree of overall patient satisfaction, as well as improvement in skin texture and skin color, compared to patients treated with the Er:YAG laser alone. The CO2/Er:YAG laser is a highly effective laser for neck resurfacing with no adverse sequelae to date.     

Laser Resurfacing of the Neck with the Erbium:YAG Laser

Background.  Laser resurfacing of the face is widely used to correct the effects of photoaging. The neck also develops a similar degree of photoaging, but is not usually treated because a higher incidence of adverse effects can occur with laser treatment.
Objective.  To present a new method for treating photoaged skin of the neck with an erbium:yttrium aluminum garnet (Er:YAG) laser.
Methods.  Twenty patients underwent Er:YAG laser resurfacing of the neck with one of two methods. Method 1 consisted of using the Er:YAG with a 5-mm diameter collimated beam at a fluence of 8.7 J/cm² followed by a second pass using a 0.2 mm diameter non-collimated spot at 1.7 J in a defocused mode with spot sizes ranging from about 5 to 10 mm in diameter (fluences from 2–9 J/cm²). Method 2 consisted of treating the entire neck with a single pass of the Er:YAG laser with a 4 mm diameter non-collimated spot at 1.7 J (fluence of 13.5 J/cm²). A second pass at identical settings was made on the upper half of the neck with a more defocused pass using a 6–10 mm diameter spot (fluence of 2–6 J/cm²) on the lower half of the neck. Patients were evaluated by two nontreating physicians as to overall satisfaction and improvement in skin texture and color.
Results.  Overall, 51% of patients were satisfied with their results. Skin texture improved an average of 39%. Method 1 produced a 28% improvement, Method 2 a 48% improvement. Skin color improved an average of 37%. Method 1 produced a 28% improvement, Method 2 a 45% improvement.
Conclusion.  Photoaged skin of the neck can be effectively treated with the Er:Yag laser with minimal adverse effects.     

The Effects of Variable Pulse Width of Er:YAG Laser on Facial Skin

BACKGROUND: The use of CO2 and Er:YAG lasers for resurfacing has increased significantly in the past few years. Er:YAG laser causes pinpoint bleeding during and after treatment with a typical pulse width of 250 microsec. A longer pulse of Er:YAG laser can potentially coagulate dermal blood vessels and increase the residual thermal damage (RTD). OBJECTIVE: To evaluate the effects of various pulse durations of Er:YAG laser on the depth of RTD and bleeding. METHODS: The preauricular skin of a volunteer was exposed to Er:YAG laser at 250-, 350-, and 700-microsec pulse durations, with a fluence of 5 J/cm2. The number of passes varied between 6 and 16. The treated skin was excised and a histologic evaluation was done. RESULTS: The maximum depth of RTD was 50 microm and there was decreased bleeding with a 700-microsec pulse duration. CONCLUSION: The increased pulse duration of Er:YAG laser of 700 micros does not increase the maximum reported RTD and therefore would not change the recovery time and may have a beneficial effect on hemostasis.     

Skin Resurfacing with Laser in Asians

The carbon dioxide laser has been a popular dermatological tool, but for the cosmetic surgeon. The laser's usefulness has been limited due to the risk associated with hyperpigmentation and scarring, when attempting superficial aesthetic surgery. The new Tru-Pulse CO₂ Laser (Tissue Technology, Inc.) overcomes this limitation by providing a unique pulse duration of 60 μsec designed to reduce thermal damage and designed to promote rapid healing. Laser resurfacing with the Tru-Pulse Laser provides many potential benefits.     

Combination Surgical Lifting with Ablative Laser Skin Resurfacing of Facial Skin: A Retrospective Analysis

BACKGROUND: Cutaneous aging is manifested by rhytides, dyschromias, and skin laxity. Ablative laser skin resurfacing can effectively improve many signs of skin aging; however, the photoaged patient with facial laxity often requires a surgical lifting procedure in order to obtain optimal results. Concerns with delayed or impaired wound healing has led to reluctance to perform both procedures simultaneously. OBJECTIVE: To report the clinical results and side effect profiles after concomitant surgical facial lifting procedures and ablative carbon dioxide or erbium:YAG laser resurfacing in a series of patients. METHODS: A retrospective analysis and chart review was performed in 34 consecutive patients who underwent combination CO(2) or erbium:YAG laser skin resurfacing and surgical lifting procedures, including S-lift rhytidectomy, blepharoplasty, and brow lift. Side effects and complication rates were tabulated. RESULTS: The side effect profile of the combined surgical-laser procedures was similar to that reported after a laser-only procedure. The most common side effect was transient hyperpigmentation which occurred in 20.6% of treated patients. None of the patients experienced delayed reepithelialization, skin necrosis, or prolonged healing times. CONCLUSIONS: Concurrent laser skin resurfacing and surgical lifting of facial skin maximizes aesthetic results without increased incidence of adverse effects. Patients benefit from the consolidation of anesthesia and convalescent times as well as enhanced global clinical outcomes.     

Minimally Ablative Erbium:YAG Laser Resurfacing of Facial Atrophic Acne Scars in Asian Skin: A Pilot Study

BACKGROUND Atrophic scars are dermal depressions caused by collagen damage most commonly occurring after inflammatory acne vulgaris. There are little published data regarding the effectiveness and safety of minimally invasive lasers in the treatment of atrophic acne scars in darker skin types.
OBJECTIVE The purpose was to evaluate the efficacy and safety of a low-fluence 2,940-nm erbium:YAG laser in the treatment of atrophic acne scars in Asian patients.
MATERIALS AND METHODS Nine patients aged 19 to 45 years with mild to moderate atrophic facial scars and Skin Types IV and V were treated with topical anesthesia and one to two passes with an erbium:YAG laser two times at 1-month intervals. Treatment parameters were 6-mm spot size, fluence of 400 mJ, pulse duration of 300 μs, and repetition rate of 2 Hz.
RESULTS At 2 months after the last treatment, mild to moderate clinical improvement was noted in all patients compared to baseline. Treatment was well tolerated. Side effects consisted of posttreatment erythema, peeling, and crusting, which resolved within 1 to 2 weeks. There was no postinflammatory hyper- or hypopigmentation, blistering, or hypertrophic scarring.
CONCLUSION Low-fluence erbium:YAG facial resurfacing was effective and safe in patients with mild to moderately severe atrophic acne scarring.     

The Effect of a Mucopolysaccharide-Cartilage Complex Healing Ointment on Er:YAG Laser Resurfaced Facial Skin

BACKGROUND: There are several types of dressings which may be utilized after facial laser resurfacing. Laser surgeons favoring the open type of dressing have used the Aquaphor original formula to reduce the loss of moisture from laser resurfaced skin. The objective of this study was to compare the effectiveness of a mucopolysaccharide-cartilage complex (MCC) containing healing ointment with the standard therapy of Aquaphor ointment in treating erythema, edema, and skin erosion caused by Er:YAG laser resurfacing of facial skin. OBJECTIVE: To compare healing time after Er:YAG laser resurfacing treated side-by-side with MCC as compared with Aquaphor. METHODS: Nineteen patients completing Er:YAG laser resurfacing were randomly assigned to receive MCC healing ointment on one side of their face and standard therapy with Aquaphor on the other for eight consecutive treatment days. Immediately after surgery and again on days 1, 2, 3, 4, 7, and 8, the severity of erythema, edema, and erosion was scored on a 0-3 scale (0 = no observable effect, 1 = mild, 2 = moderate, 3 = severe). Photographs were taken at each follow-up visit. Following scoring on study day 0, the day of resurfacing, treatment was applied according to the left or right assignment code of the randomization schedule. RESULTS: Mean severity ratings for all variables (erythema, edema, and erosion) were consistently lower for MCC healing ointment as compared to Aquaphor ointment. Based on the calculated overall efficacy index, MCC ointment was statistically superior to Aquaphor for all three variables: erythema, P <.001; edema, P =.017; erosion, P <.001. CONCLUSION: The results of our study demonstrate that MCC healing ointment may provide an advantage over the standard therapy of Aquaphor ointment in the treatment of edema, erosion, and erythema caused by laser resurfacing of facial skin. Mean daily severity scores were consistently lower and improvement tended to occur earlier with MCC healing ointment.     

Er:YAG Laser Treatment of Verrucous Epidermal Nevi

BACKGROUND: The term verrucous epidermal nevi refers to benign hyperplasia of the epidermis. Numerous treatment modalities have been tried, but no ideal treatment is yet available. We would like to present our experience with Er:YAG laser ablation in the treatment of verrucous epidermal nevi. OBJECTIVE: The purpose of this study is to assess the long-term results of Er:YAG laser treatment of verrucous epidermal nevi. METHODS: Twenty patients with verrucous epidermal nevi were treated with Er:YAG laser. Twelve patients were treated with the variable-pulsed Er:YAG laser, a 5-mm handpiece at the setting of 7.0 to 7.5 J/cm2, at a 500-micros pulse duration. The dual-mode Er:YAG laser, with a 2-mm handpiece at the setting of 6.3 J/cm2, at a 350-micros pulse duration (25 microns ablation), was used in eight patients. The laser was fired at 5 Hz until all epidermal nevi were removed. The results of treatment were evaluated for the changes of skin lesions, texture, and color by physicians over a 24-month period. RESULTS: After a single laser treatment, successful elimination of the verrucous epidermal nevi was observed in 15 patients. Five patients (25%) showed a relapse within 1 year after the treatment. Postoperative healing time was 7 to 10 days. Erythema occurred in all patients after the laser treatment and subsided in 2 months. Postinflammatory hyperpigmentation occurred in two patients (10%). One patient (5%) experienced transient hypopigmentation. Mild to moderate postoperative acne flare-up occurred in one patient (5%) with facial lesions. No other adverse effects, including scarring, were observed. CONCLUSION: The Er:YAG laser ablation is an effective, safe, and nonscarring method for the treatment of verrucous epidermal nevi.     

Carbon Dioxide Laser Resurfacing of Rhytides and Photodamaged Skin

Carbon dioxide (CO₂) laser resurfacing has been used as a method to treat rhytides and photodamaged skin. This laser offers several advantages over previously utilised modalities but its use has several inherent risks. This article will review important aspects of CO₂ laser resurfacing including laser-skin interactions, patient selection, effective pre- and post-operative regimens and potential complications. Received for publication 3 January 1998; accepted 24 February 1998     

Nonablative Laser Skin Resurfacing using a 1540 nm Erbium Glass Laser: A Clinical and Histologic Analysis

BACKGROUND: A variety of laser systems have recently become available that allow for selective dermal remodeling without disruption of the epidermal surface. Modest clinical improvement in mild to moderate photoinduced facial rhytides with minimal morbidity is typical of these nonablative lasers, providing a significant advantage over traditional ablative laser systems. OBJECTIVE: To determine the clinical and histologic effects of a novel 1540 nm erbium glass laser on facial rhytides. METHODS: Patients with mild to moderate periorbital and perioral rhytides received a series of three monthly treatments with a 1540-nm erbium-doped phosphate glass laser by a single operator. Photographic and clinical evaluations were independently conducted by the patient and a masked medical observer at each treatment visit and at 1, 3, and 6 months following the final treatment session. Skin biopsies were obtained for histologic analysis by a board-certified dermatopathologist at baseline, immediately following laser irradiation, and at one and six months post-treatment. RESULTS: Slow, progressive clinical improvement of rhytides was noted in all patients after each treatment and continued throughout the extended follow-up period. Side effects of treatment were limited to transient erythema and edema immediately following laser irradiation. No serious adverse effects were noted. Histologic skin changes were not apparent until several months following treatment, when an increase in dermal collagen was noted. CONCLUSIONS: The nonablative 1540 nm erbium glass laser system with contact cooling produces gradual clinical and histologic improvement in mild to moderate facial rhytides with minimal risk of serious adverse sequelae.