Perioral Rejuvenation With Ablative Erbium Resurfacing
November 2015 | Volume 14 | Issue 11 | Case Reports | 1363 | Copyright © November 2015
Joel L. Cohen MD
AboutSkin Dermatology and DermSurgery, Englewood, CO
Department of Dermatology, University of California Irvine, Irvine, CA
BACKGROUND AND OBJECTIVE: Since the introduction of the scanning full-field erbium laser, misconceptions regarding ablative erbium resurfacing have resulted in its being largely overshadowed by ablative fractional resurfacing. This case report illustrates the appropriateness
of full-field erbium ablation for perioral resurfacing.
METHODS: A patient with profoundly severe perioral photodamage etched-in lines underwent full-field ablative perioral resurfacing with an erbium laser (Contour TRL, Sciton Inc., Palo Alto, CA) that allows separate control of ablation and coagulation. The pre-procedure consultations included evaluation of the severity of etched-in lines, and discussion of patient goals, expectations, and appropriate treatment
options, as well as a review of patient photos and post-treatment care required. The author generally avoids full-field erbium ablation
in patients with Fitzpatrick type IV and above. For each of 2 treatment sessions (separated by approximately 4 months), the patient received (12 cc plain 2% lidodaine) sulcus blocks before undergoing 4 passes with the erbium laser at 150 μ ablation, no coagulation, and then some very focal 30 μ ablation to areas of residual lines still visualized through the pinpoint bleeding. Similarly, full-field ablative
resurfacing can be very reliable for significant wrinkles and creping in the lower eyelid skin – where often a single treatment of 80 μ ablation, 50 μ coagulation can lead to a nice improvement.
RESULTS: Standardized digital imaging revealed significant improvement in deeply etched rhytides without significant adverse events.
CONCLUSION: For appropriately selected patients requiring perioral (or periorbital) rejuvenation, full-field ablative erbium resurfacing is safe, efficacious and merits consideration. J Drugs Dermatol
Ablative fractional resurfacing methods commonly used in the perioral area provide nowhere near the efficacy of full-field ablation.1 The unique absorption characteristics
of skin for the 2940 nm erbium wavelength make it more effective than full-field CO2 ablation while at the same time decreasing
associated recovery times, and avoiding the hypopigmentation,
and unnatural textural changes commonly seen after
full-field CO2 ablation.2,3
During the 1990s, ablative CO2 laser skin resurfacing largely supplanted chemical peels and dermabrasion because it gave physicians greater control over the depth of injury, and hence results.4 While full-field CO2 resurfacing can produce dramatic results, patients had to accept typically at least 2 weeks of healing
downtime, during which they experienced erythema (which could last for months), inflammation, and edema. Long-term sequelae often included permanent hypopigmentation, which has been reported to occur in up to 40% of patients at 6 months post-treatment with CO2.5
To avoid these problems, fractional photothermolysis was developed
to specifically ablate only a portion of the skin’s surface, creating microscopic channels of ablation separated by zones of undamaged tissue.6 However, the enhanced safety and healing of fractional CO2 photothermolysis comes at the price of lower
efficacy than many patients desire; therefore, often a series of a few or more laser treatment sessions are performed to try to see more significant results with fractional ablative technology.
This report details the advantages of full-field erbium ablation, a modality developed to try to help avoid the pitfalls of fully ablative
CO2 resurfacing while not sacrificing results, specifically in the perioral and periorbital areas.
For pre-procedure anesthesia, the author typically uses an infraorbital
block for the peri-ocular area, and a lip sulcus ring block for the perioral area (with 2% lidocaine without epinephrine
to help visualize the endpoint of pinpoint bleeding).
To treat significant photodamage etched-in lines on the upper lip, the author performs 3 to 4 passes with a dual-mode erbium: yttrium-aluminum-garnet (Er:YAG) tunable resurfacing laser (Contour TRL, Sciton, Inc.) that allows separate tuning of tissue ablation and thermal coagulation (which mediates long-term collagen
remodeling). Using a computer scanned 4 mm spot, the laser is tuned to provide 150 μ of ablation, 0 μ coagulation per pass. Pinpoint bleeding that occurs at this juncture after 3-4 passes
should be gently wiped off. If etched lines remain, patients may require an additional pass at 150 μ ablation, 0 μ coagulation