Facial Surgery Procedures
The American Academy of Cosmetic Surgeons reports that 72 percent of people who consult cosmetic surgeons do so because they''re interested in facial work. The reason is simple - the face is the most visible part of the body. Whether we like it or not, we''re judged by first impressions, and our faces tell the stories of our lives. In 1996, over half a million individuals had some kind of facial cosmetic surgery, some involving a hospital stay and many using general anesthesia.
Facial laser peeling, by contrast, can be done in one afternoon in a doctor''s office. Local anesthesia can be used if the doctor is an expert in the use of tumescent anesthesia (see chapter 15 for more information on tumescent anesthesia). The results are generally excellent, and the recovery is quite manageable.
Patients desire facial laser peels for a variety of reasons: most often for wrinkles, acne scarring, discoloration, and other skin imperfections. Most of our patients choose to treat the entire face, but some have work done only around the eyes or the mouth. Either way, if done skillfully, laser peeling can produce remarkable improvements.
In the "old days" before laser peels came into common use, two techniques were used instead; "dermabrasion" and "chemical" or "acid" peeling. Although these procedures are still used today, they produce more frequent complications, including scarring and/or permanent changes in skin color. These things can happen with a laser peel, but it''s rare.
Dermabrasion involves using a tiny electric sander which revolves at a very high speed, and literally "sands" the surface of the skin. A good surgeon can "rub out" wrinkles or acne scars to an even plane, but it requires a lot more skill than the laser, and scarring or uneven results are more common. Dermabrasion also produces a lot of bleeding. It''s been said in some medical texts that 50 percent of dermabrasion patients wish they''d never had the procedure.
Acid peeling is the chemical version of the same idea. Rather than sanding the skin surface, one of two acids - phenol or trichloracetic (TCA) - is applied to produce a deep, hopefully even, injury to the old skin. Phenol produces a lot of wrinkle shrinkage, but also produces permanent color loss in virtually every case. Patients often end up with a white cast to their faces, which will need to be covered up with make-up. Generally this is acceptable only in elderly patients.When enough TCA (40 to 50 percent strength) is applied to produce significant wrinkle shrinkage and deep penetration, there is at least a three to five percent chance of scarring. When it penetrates too deep, scarring occurs. No one can accurately predict how this more powerful TCA will penetrate the skin. In my opinion, this makes deep TCA peeling unacceptable.
Superficial TCA peeling, however, is an excellent technique. Low concentrations of TCA are placed on the face, producing skin changes that are obvious during the application process but are different from the deep TCA peel. This is also good for texture improvement. Recovery time for this lighter peel may only be four to five days, but deep wrinkles are not affected. Fruit acid, such as 40 to 70 percent Glycolic acid, is also being used in a similar fashion as the light (20 to 25 percent) TCA peeling.
By 1994, laser technology had entered the mainstream as a treatment to replace dermabrasion and chemical peels. Not every doctor has adopted the new technology. Laser equipment is very expensive - more than $100,000 for a state-of-the-art setup - and special training is required. But the medical community''s feeling overall is that laser peeling is more predictable and complication-free than the other techniques.
How to Prepare for Facial Laser Surgery
Prior to facial laser surgery, some patients are asked to treat their faces with Retin A® and/or skin bleaches or creams for two to four weeks. Because dark skinned people can sometimes darken further after the procedure, they are frequently advised to treat their skin before surgery to prevent this. We also require our patients to take an anti-viral medication such as Valtrex® or Acyclovir® to prevent cold sores, which can be stimulated by the treatment. Cold sores can spread all over the face and cause scarring if they occur after treatment when the skin is raw. You also don''t want to undergo a surgical procedure if you are ill or if you have unstable medical problems. Your doctor will counsel you about any limitations.
I believe that preparing for your recovery is the most important element to consider when it comes to facial laser peeling. Patients should be given an accurate picture of what to expect during this period, because frankly, a newly peeled face is not a pretty sight. Most patients choose to stay in the house for a week or two after the procedure, as their faces are either bandaged, or if exposed, raw and swollen. So plan to take adequate time off from work, and don''t book any important social engagements until at least two weeks after your laser peel. Let your family and friends know what to expect.
How It''s Done
When you arrive at your doctor''s office, you''ll get your picture taken (before and after photos are very important). Then you''ll be given a sedative, and while you''re relaxing, the doctor may draw on your face to mark the areas to be treated. Your face will then be washed with an antiseptic solution and the tumescent solution will be injected with a tiny needle to numb the face. If the doctor is not using tumescent, he may alternatively have an anesthesiologist put you to sleep.
By the time the doctor begins working with the laser tool, you shouldn''t feel anything at all. The laser "zaps" small areas on the face as the doctor moves carefully from one area to the next, treating each in turn, making sure to blend everything evenly. In the past, lasers could only work on very small spots, about an eighth of an inch at a time. But now, the technology has improved to the point where we can "laser" spots about 1.5 centimeters (about two-thirds of an inch) in diameter, using a laser pattern generator. This is an important advance, because working with larger spots produces a much more even effect.
The laser doesn''t actually burn the skin, because there''s very little heat transfer involved. Instead, it vaporizes the skin surface by making the water boil inside the skin. During the process, the treated skin changes in a way that allows the doctor to wipe off the top layers with a wet gauze pad. With each zap of the laser, the doctor can see new, fresh skin appear. Almost no bleeding occurs. Each laser zap lasts a fraction of a second, and if you''re awake (but sleepy) during the procedure, you''ll hear it working - zip, zip, zip - and you may hear the doctor and staff talking and working around you. The whole process lasts about an hour when the pattern generator lasers are used.
When the procedure is finished, you may be feeling drugged, and you''ll need someone to drive you home. When you get there, you may want to sleep for a few hours until the drugs work their way out of your system. The next morning you''ll generally feel normal.
You''ll often leave the doctor''s office with a dressing on your face or sometimes a layer of Vaseline® on your skin. There are many different schools of thought about dressings, and doctors are continually learning more about which are most effective. I believe that dressings are important for recovery from a peel deep enough to remove wrinkles effectively. The depth of the treatment is proportional to the risk, the recovery and the results. For very deep peels, it''s helpful to leave dressings in place for about five days (some doctors do deep peels without dressings, but I don''t feel this is as safe). A clear benefit is that patients have virtually no pain when modern full-face dressings are used for a full five days. They describe their dressings as annoying but not painful. For lighter peels used to treat more minor facial problems, a dressing may be removed sooner or may not be needed at all.
Our deep-peel patients leave the office with their faces wrapped like a mummy or "the invisible man." The eyes and lips are exposed, and may swell, and they look very strange at first. One patient''s four-year-old son became very frightened when his mom returned home with her face bandaged. He wouldn''t let her near him until her face normalized. He even had nightmares. Depending on the depth of your laser peel, you might want to make arrangements to have very young children stay at Grandma''s for a few days, or prepare them well for the event.
Pain just isn''t a big issue with most laser peel recoveries when the full face dressing is used. Some people have a slight burning sensation (if you are having much pain, get in to see the doctor right away - you may be having a cold sore outbreak which can cause scarring). Others have itching, and special creams may be used to relieve this. The most irritating thing is the night-and-day facial wrap and the strange feeling of your swollen face. For the first day or two, it will help to ice your face several times a day for ten to twenty minutes with a damp washcloth (or the dressing) between the skin and the ice.
You may also find that the swelling (and sometimes the dressing) makes it difficult to move your mouth comfortably for the first couple of days. Some people lose a little weight because they don''t eat much. When the dressing is removed, your face will be red and still swollen. Your skin will feel dry and tight, and you should keep it lubricated with whatever cream your doctor recommends.
The best path to a speedy recovery is by way of the hyperbaric chamber. It''s an expensive and high-tech piece of equipment sometimes found in hospitals for use with seriously ill patients, such as burn victims. Today, there are only a few places in the United States where facilities other than hospitals have hyperbaric chambers, but this will likely change soon. The chamber may have the potential to cut healing time almost in half, and is remarkably effective on laser peels.
Depending on the depth of your laser peel, you can expect to look presentable with makeup in one to two weeks. During the second and third weeks, the swelling decreases, but redness remains. Don''t expect to lose all the redness for several months. You may also experience some temporary darkening, which can be treated with bleaching creams and should disappear in time.
Just as in your recovery, your results are related to the depth of the peel. It''s not recommended for a doctor to go too deep in one session, so for some very wrinkled faces or deep acne scars, patients may require a second procedure to get the best results. People who smoke tend to have deeper lines around their lips and may require a deeper laser peel. Sometimes there are fine details which aren''t noticeable until after healing is complete, and these patients may return for an additional laser treatment. It''s simple to "touch up" a small area. The vast majority of the patients in our office are delighted with their results.
Your skin should look softer, younger and smoother. Wrinkle removal can be very dramatic. With deeper peels, the new skin will "shrink to fit" your face. Healing of human injuries is accomplished by shrinkage of the tissue, and what the laser does is provide a careful "injury" to the skin. Brown spots generally disappear. Patients are usually asked to use light moisturizers for at least a month. Occasionally, acne breakouts can occur as a result of this at one to three months, but it can be treated by decreasing the lubricants and possibly prescribing antibiotics.
It is highly recommend you read "How to Evaluate Cosmetic Surgery Photos" for disclaimers about facial procedures and to help you detect trick photography. Click on any thumbnail to view patient photos: