Nonsurgical facial rejuvenation techniques such as laser resurfacing, soft-tissue dermal fillers, neurotoxin injection, chemical peels, and microdermabrasion are used to treat involutional and actinic facial skin changes. These superficial procedures may precede or be combined with surgical procedures that reposition deeper structures. It is important to remember that the upper eyelid appearance is inextricably linked to the position of the eyebrow. Similarly, the lower eyelid appearance is linked to the position of the midface, as well as the lower face and neck. Subunits of the facial cosmetic superstructure should not be viewed or manipulated individually but must be addressed in the context of the entire face and neck.
Laser Skin Resurfacing
Laser skin resurfacing, a technology popularized in the early 1990s, is designed to reduce wrinkles and enhance the texture and appearance of the facial and periorbital skin. A variety of lasers have been developed to perform laser resurfacing; superpulsed or ultrapulsed carbon dioxide (CO2) and erbium:yttrium-aluminum-garnet (Er:YAG) lasers are the most widely used. The development of superpulsed CO2 lasers has allowed ablative skin resurfacing without excessive thermal damage. Superpulsed and ultrapulsed CO2 lasers deliver small pulses of high-energy light to the skin; pauses between these pulses allow cooling of the tissues in the treated area, minimizing the risk of thermal damage. The Er:YAG laser has a nearly pure ablative effect on collagen and water-containing tissues, with a much smaller zone of thermal injury and much less heat transfer into the tissues than the CO2 lasers.
Laser resurfacing is a useful adjunct to lower blepharoplasty. The skin-shrinking, collagen-tightening effect of laser skin resurfacing often allows the surgeon to avoid making an external incision and removing skin.
Patient selection is vital for successful laser skin resurfacing. Patients with a fair complexion and generally healthy, well-hydrated skin are ideal candidates. Patients with greater degrees of skin pigmentation can be safely treated, but care and caution are needed. The darker the skin pigmentation is, the greater the risk of postoperative inflammatory hyperpigmentation. Contraindications include inappropriate, unrealistic expectations, the presence of collagen vascular disease such as active systemic lupus erythematosus, and significant uncorrected lower eyelid laxity.
Herpes simplex virus infection after laser resurfacing may lead to scarring; therefore, most surgeons prophylactically treat patients with suppressing doses of antiviral agents against outbreaks of herpes simplex virus. Other complications associated with laser skin resurfacing include a variety of ophthalmic problems such as lagophthalmos, exposure keratitis, corneal injury, ectropion, and lower eyelid retraction.
A desire to improve superficial skin characteristics and facial wrinkling without the prolonged period of healing and erythema seen with ablative laser skin resurfacing has led to the development of devices that use fractionated lasers, intense pulsed light, ultrasound, or radiofrequency to deliver energy to the skin. These modalities can potentially even skin tone, remove cutaneous dyschromias or fine wrinkles, and even lift and smooth facial tissues. Each of these devices has its own risks and limitations but offers some improvement in aspects of facial aging, with fewer risks and shorter recovery times than with ablative laser skin resurfacing.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.