Biomedical Engineering Reference
In-Depth Information
Rhinophyma and Benign Growths
Rhinophyma (128,129) and various small benign growths
such as syringoma (130), trichoepithelioma (131), dermatosis
papulosa nigra, xanthelasma (132), adenoma sebaceum (133),
sebaceous hyperplasia, and epidermal nevi (134,135) have tra-
ditionally been treated with the conventional CO
2
laser and
respond in an even more excellent manner to the resurfacing
CO
2
lasers.
unit, almost never treat an isolated wrinkle or scar, and never
treat two isolated anatomic units simultaneously without
treating the intervening skin. In our offi ce, 90-95% of patients
receive full-face treatment.
Timing of Treatment
Whether to treat early or later is an issue that frequently arises.
The potential advantages of treating early, rather fi ne, subtle
wrinkle lines are that the procedure can be done more superfi -
cially and with less risk of prolonged erythema, pigment
changes, or scarring. Also, greater potential exists for removing
all the photodamaged tissue, achieving a more long-lasting
result, and providing a preventive benefi t regarding future
wrinkling. However, these early changes are usually relatively
subtle clinically and, even when fully removed, result in only
modest cosmetic benefi ts. The primary benefi t may be in halt-
ing the progression of photodamage. The pros and cons of
performing a relatively aggressive procedure for a relatively
minor cosmetic problem need to be discussed in detail and a
decision made with realistic expectations (Table 6.4).
co
2
laser resurfacing: surgical
considerations
Regional vs. Full-Face Resurfacing
The two areas of photodamage and wrinkling that have been
shown to respond dramatically well to laser resurfacing are the
perioral and periorbital regions (101). These areas are not
improved by face-lifting procedures, and although blepharo-
plasty may improve the skin laxity, it does not smooth out the
wrinkle lines and textural changes of the periorbital region.
Chemical peels and dermabrasion have given disappointing
results in both these regions after treatment by the average
practitioner. Treatment success in these regions has given laser
resurfacing its popularity. Either of these areas may be success-
fully treated as an isolated region, but if both areas are to be
treated, it is far better to treat the entire face.
In general, full-face resurfacing will give a better clinical
result in all patients, because treatment of the full cheeks
results in better tightening of the nasolabial lines, lateral
“crow's feet,” and midcheek creases. The same is true of treat-
ing the entire forehead and its effects on glabellar lines, lateral
temporal lines, and upper aspects of crow's feet. In addition,
the even pigmentation and smoothing of the skin result in a
much more pleasant cosmetic appearance than blending new,
smooth skin to photodamaged skin and creating a patchwork
pattern. From a practical standpoint, it is also much easier for
the patient to deal with postoperative erythema that is uni-
form over the full face rather than patchy erythema with mul-
tiple borders to blend. We rarely treat only a single anatomic
Degree of Photodamage and Pigmentation
When dealing with more advanced photodamage, full-face
resurfacing is almost always necessary. Complete removal of deep
lines in a single procedure may not be possible, as previously dis-
cussed. The anticipated improvement is 50-70% (Fig 6.28)
(3,4,97,101,104,136). If further improvement is desired, a second
treatment may be done after 6-12 months to allow new collagen
formation and collagen remodeling. Patients with more advanced
photodamage are usually very pleased with their clinical improve-
ment although it may not be complete eradication of wrinkle
lines. Complete elimination of wrinkle lines is usually not the
patient's goal, and overaggressive treatments may result in pro-
longed healing or hypopigmentation from deep levels of tissue
ablation and deep resurfacing. The physician must effectively
communicate to the patient that some degree of decreased pig-
mentation is a consequence of treatment.
Table 6.4
Early vs. Later CO
2
Laser Treatment of Wrinkles
a
Pros
Cons
Treatment of early wrinkling
More superfi cial resurfacing necessary
Use of relatively aggressive treatment for relatively minor cosmetic
problem
Less risks of scarring, prolonged erythema, and pigment loss
Must weigh risk-benefi t ratio
Complete elimination of wrinkles typically achieved
Patients often very demanding and critical of less-than-perfect
results
Long-lasting results achieved with good maintenance program
Deeper resurfacing procedure and more aggressive therapy necessary
Dramatic improvement often achieved
Greater risks of scarring, prolonged erythema, and pigment loss
Improvement might be subtle
Treatment of late wrinkling
Medical benefi t (e.g., removal of actinic keratoses, squamous cell
carcinoma in situ) common
More than one procedure necessary for complete elimination of
wrinkles
Signifi cant psychologic benefi t
Persistence of benefi ts variable, depending on the depth of
preexisting damage as well as maintenance program
Patient satisfi ed with improvement, with no expectation of complete
eradication of wrinkles
a
Both are successful. Both patient and physician must have realistic expectations. In general, earlier treatment is preferable to later treatment because of decreased
risks and enhanced ability to achieve excellent results.
