Comprehensive Facial Rejuvenation: CHAPTER NINE: CUTANEOUS REJUVENATION
CHAPTER NINE: CUTANEOUS REJUVENATION
Although the principal focus of this book is surgical, incision-based, intervention for the aging face, a thorough understanding of cutaneous resurfacing modalities must also be sought to offer the patient the most complete rejuvenative regimen. Patients who only exhibit actinic damage, such as superficial dyschromias and textural skin changes, without actual ptosis of tissues would be more suitable candidates for resurfacing than traditional lifting procedures. In addition, resurfacing may be effectively combined with lifting procedures for patients who exhibit both tissue ptosis and photodamage if flap integrity may be ensured – e.g., with subperiosteal elevation of the brow the skin may be safely resurfaced concurrently – or deferred for several weeks until flap vascularity is restored.
The facial aesthetic surgeon must not only master the technical aspects of some of the myriad resurfacing modalities that abound but know when to select a particular technique and further when to combine techniques to achieve maximal benefit for the patient. The authors stress the importance of careful selection of a few, reliable techniques that have proven efficacy rather than the quixotic quest to implement all of the techniques that are available today.
As important as technical mastery is the commensurate understanding of the complicated and often confusing postoperative management of the resurfaced patient, which involves an intensive, almost daily encounter to guide the patient successfully through the process. To date, no text has lucidly revealed this aspect of patient care in a pragmatic, detailed, and systematic fashion. During the postoperative period, complications such as dermatitis and rarely scarring may arise and must be swiftly identified and treated to minimize adverse outcomes.
This chapter will conclude with a primer on basic skin care and rejuvenative topical agents, such as tretinoin-based products, for those patients who are not yet ready for any surgical therapy or those who would like to maintain the longevity of their surgical result. Physicians often relegate this type of care to the aesthetician and disavow the necessity to learn more about skin care. However, the physician should be at minimum partly responsible for this knowledge, as he or she must decide when it is safe for the resurfaced patient to use camouflaging products and effectively answer simple queries regarding which products may be appropriate for the newly resurfaced skin.
Preoperative Considerations: Patient Selection & Relevant Anatomy
Before considering what technique would be appropriate for a particular patient, the surgeon must have a well-structured understanding of the types of resurfacing modalities available. Basically, cutaneous resurfacing may be divided into two principal categories: non-ablative and ablative therapy. The former represents a recent advance in resurfacing which promotes dermal remodeling via collagen synthesis without any epidermal effacement. Accordingly, as the epidermis is entirely untouched during non-ablative therapy, no benefit is obtained for the photodamaged outer skin. Instead, limited fine to moderate rhytidosis may be addressed with multiple treatment sessions over a period of several months to permit sufficient time for collagen-dermal remodeling to occur. Similarly, as the epidermal layer is maintained entirely intact, the patient experiences no downtime and is subjected only to a brief, painless treatment session that leaves no residual edema, ecchymosis, or erythema. Again, it should be emphasized that this new technique must be selectively employed in the suitable patient with the individual fully cognizant of the inherent limitations for facial rejuvenation.
The authors have investigated the potential benefit of this newer technique in a blinded, prospective, histological analysis using a porcine model. The results of this study were quite revelatory: the histological specimens harvested from the non-ablative, pulsed-dye laser-treated skin demonstrated statistically significant collagen remodeling in both a quantitative (collagen band width, nuclei per high powered field) and qualitative (overall dermal thickness) fashion as compared with untreated skin. The dermal depth could not be quantitatively measured because the thickness exceeded the punch-biopsy instrument in all the laser-treated (both ablative and non-ablative) skin. Further, the degree of collagen remodeling favorably compared with that of ablative, carbon-dioxide laser-treated areas. However, this preliminary data must be cautiously assessed, as these results were obtained in an animal model; and human clinical trials are warranted to establish the precise role that non-ablative therapy should play in facial rejuvenation.
The early clinical trials have been somewhat equivocal. Fitzpatrick’s study showed a statistically significant aesthetic improvement in patients’ hemifaces that were treated with a non-ablative, pulsed-dye laser as compared with a placebo-controlled (cryogen spray alone) side. All photographic analyses were conducted in a blinded, prospective method. These findings were further corroborated with histologic samples taken from each side that revealed significant collagen synthesis on the treated side compared with the controlled, untreated side. Despite histological improvement, one study showed limited clinical patient satisfaction. However other studies have corroborated the benefit of non-ablative techniques for mild to moderate skin pathologies. , , , ,
The authors have found that the best results obtained with this technology may be obtained in patients with mild to moderate fine rhytidosis, particularly in the periocular region, e.g., crow’s feet at the lateral canthus and crepe-like wrinkles that traverse below the eye. The ideal candidate for this treatment strategy is the younger individual (in his/her 30s) who exhibits minimal photodamage (dyschromias and other epidermal damage) with fine, periocular rhytidosis. These patients are also very well suited to botulinum-toxin injections, which may be used in combination or independently of non-ablative laser therapy. Patients who exhibit more marked rhytidosis, actinic damage, or ptotic tissues will not significantly benefit from this technique and should be dissuaded from undertaking non-ablative therapy.
Cutaneous, ablative resurfacing represents the more traditional method of facial-skin rejuvenation in which the entire outer layer of the epidermis is removed along with a partial thickness of the underlying dermis to effect a favorable aesthetic result. Ablative resurfacing may be undertaken via three principle methods: mechanical abrasion, chemical exfoliation, and laser therapy. Each modality has its own unique characteristic benefits and drawbacks, and at times combination of these techniques may offer the patient the most favorable means of obtaining the desired objective. Mechanical abrasion may range from the least invasive microdermabrasion (which effectively acts as a non-ablative method of facial rejuvenation) to the more aggressive technique of dermasanding to fully ablative dermabrasion. The latter offers precise control of uneven cutaneous contour and texture and is particularly well suited in the acne-scarred skin. Although acne scarring does not strictly fall within the confines of the topic of the aging face, a discussion of this clinical scenario will be conducted, as treatment of this pathology clearly illustrates the role of effective combined resurfacing. Similar to the varied mechanical methods of resurfacing, chemical peeling agents differ in their potency from the light glycolic and Jessner’s solutions to the more invasive higher-strength trichloroacetic acid (TCA) and phenol mixtures. 35% TCA and phenol prove their incontestable benefit to reverse significant photoaged skin with moderate rhytidosis. Laser therapy for facial rejuvenation may be entirely non-ablative (as discussed above) via laser and light therapies intended for this purpose, such as the intense pulsed-light devices or the pulsed-dye laser adjusted to lower fluences. Alternatively, traditional ablative lasers such as the carbon-dioxide (CO2) laser efface the epidermis to effect the desired rejuvenation and may be more appropriate for severely photodamaged skin. The other ablative laser that has been widely advocated, the Erbium:YAG (Er:YAG) laser, has theoretical advantages over the CO2 laser, including less thermal injury and more specific collagen photothermolysis, but has fallen short in practical usage due to poor hemostasis and limited effect. Therefore, the authors do not advocate use of this particular type of laser whether as an adjunct to the CO2 laser or alone, as there is no real perceived advantage that the Er:YAG offers over comparable chemical peeling.
Any ablative resurfacing modality, however, carries with it considerable morbidity, which includes risk of hyper- and hypopigmentation, dermatitis, perioperative edema, protracted erythema, milia and acne outbreaks, physical discomfort, an involved cleaning and occlusive regimen, need for solar protection, and the most dreaded outcome, potential scarring. Despite these limitations, ablative resurfacing achieves remarkable success in rejuvenating severely photodamaged skin and is still a mainstay of therapy for those patients who require intensive rejuvenation and who are willing to accept the expected recovery period. All patients are thoroughly counseled that the postoperative period will be quite involved and should fully comprehend that their appearance will be analogous to that of a burn victim. Patients are informed of their expected postoperative appearance at the outset so that they may be psychologically well equipped to handle their temporary disfigurement. Proper preoperative counseling is an essential element to successful postoperative care.
The various resurfacing techniques that are available today offer the aesthetic facial surgeon an unprecedented ability to achieve a desired cosmetic outcome. However, every resurfacing technique should not be viewed as flawless or universal in its clinical benefit. The reader is advised to avoid a “compartmentalized” perspective in which every cutaneous problem is solved by a single technique. As will be addressed shortly, each modality has inherent drawbacks but also distinct advantages, which if appropriately combined with other resurfacing techniques will offer the patient the optimal result.
As alluded to earlier, an important consideration is that resurfacing cannot address all cutaneous problems, namely, skin redundancy or volume excess. If the patient presents with dermatochalasis, or excessive upper-eyelid skin, the surgeon should remove the redundant skin to restore a youthful countenance. Similarly, brow ptosis or cheek jowling should be corrected with a brow lift or rhytidectomy, respectively. Steatoblepharon, or pseudoherniation of fat, of the eyelids is amenable to fat removal or repositioning. Deep or fine rhytids, which are the product of continuous facial motion, may be better served with a paralytic agent, such as botulinum toxin. However, the authors admit that ablative (and even non-ablative) resurfacing has been observed to yield a more tightened facial appearance by virtue of the collagen stimulation.
When deciding which resurfacing technique to employ, one should reflect on three key guidelines: (1) the subunits of the face (2) the depth of the facial pathology and (3) the Fitzpatrick skin grade of the patient. The face may be divided into so-called subunits (perioral, periocular, nasal, brow and cheek), which tolerate different resurfacing modalities to varying degrees. For example, the lower eyelid tends to withstand the pigmentary ablation of the CO2 laser better than the jawline. It has been noted that the line of demarcation between hypopigmented face and pigmented neck may become more pronounced over the years as the facial skin continues to undergo some progressive depigmentation. Therefore, full-face laser resurfacing should be undertaken with caution, especially considering the protracted erythema that the patient must bear. The depth of the facial lesion (scar, rhytid, etc.) should be considered when deciding what resurfacing modality may be best suited. For example, deep acne scarring may be more effectively addressed with dermabrasion than TCA peel. Finally, the patient’s Fitzpatrick score has significant impact on the short- and long-term tendency toward hyper- and hypopigmentation. Accordingly, laser resurfacing should be used with greater restraint in darker-skinned individuals, especially when considering the greater disparity in color (lighter face and darker neck) that may arise along the jawline.
Generally speaking, any kind of resurfacing should not be carried out concurrently with a surgical procedure in which the resurfaced area is also undermined. However, the authors have achieved favorable results with minimal morbidity in select patients (non-smokers, non diabetics) in which a shorter, cutaneous flap is dissected and a lighter endpoint of the chemical peel (less frosting) is achieved or only a single CO2 pass is undertaken. In addition, the peel and laser are feathered gently toward the distal aspect of the flap to limit risk of flap compromise. However, caution must always be exercised if combined surgery and resurfacing are performed and may not be advisable, especially to the neophyte surgeon. As a rule, patients who have undergone a surgical undermining procedure should wait at least a period of 9 months before being resurfaced. Similarly, a patient who recently underwent aggressive resurfacing procedure should expect to wait 9 months before a surgical undermining procedure.
Besides an assiduous assessment of the patient’s aesthetic deficits, the surgeon must review a pertinent clinical history that may adversely contribute to the patient’s outcome. Clearly, conditions that would inhibit proper wound healing should be assessed, which include prior history of keloid or hypertrophic scarring, tobacco use (of any kind), diabetes mellitus, and active and ongoing acne. Of note, the authors have not witnessed any adverse scarring even in patients who have a history of hypertrophic or keloid scarring if resurfacing is confined to the face, as the unique healing properties of the face limit the potential for these exuberant forms of scarring. Also, if the patient will continue to engage in daily and protracted sun exposure, this activity, especially in the postoperative period, should be highly discouraged for risk of poor healing, scarring, dermatitis, and marked hyperpigmentation. Patients who have considerable bodily actinic damage should be advised that their rejuvenated face might not appropriately match the advanced nature of the sun-damaged skin of their body; and this disparity might prove troublesome to them if proper preoperative advice is not delivered. As is well known, the most significant medicine that is an absolute contraindication to ablative resurfacing is use of isotretinoin (Accutane) for any duration over the prior year. The reduction of the pilosebaceous glands that this medication engenders predisposes the patient to the very real risk of uncontrolled scar formation. Also, patients who have undergone prior undermining of their skin, e.g., a rhytidectomy or brow lift, are at a slightly increased risk of scarring due to injury to the regenerative pilosebaceous glands. The very rare cases of scarring that the authors have witnessed have all occurred in patients who have undergone a prior facial surgical procedure in which cutaneous undermining was undertaken. Nevertheless, the physician should not unduly frighten the patient regarding this limited risk but should remain vigilant in the postoperative period for this potential outcome.
As part of the preoperative regimen, an oral antiviral medication is commenced two days prior to the actual procedure if resurfacing is planned in the perioral region. If the patient manifests a herpetic outbreak despite prophylaxis (which is rare), he or she will remain on the antiviral medication at twice the dosage for an additional week from the onset of the outbreak. Usually, herpetic lesions may be distinguished from acne or milia in the timing of onset (typically 6 to 7 days postoperative) characteristic clustering and vesicular nature of the lesions, and intense burning sensation in the affected areas. If the patient should manifest these symptoms, the authors instruct the patient to contact the office immediately so that proper intervention may be initiated. Perioperative antibiotics that target the skin flora, such as cephalexin, are also routinely implemented in patients for a one-week duration postoperatively although their proven efficacy may be debated. In the past, hydroquinone and retinoic acid were dispensed to the patient a few weeks prior to the planned procedure for daily topical application, but this regimen has since been abandoned. Alster’s study of 100 prospectively evaluated and controlled patients showed no benefit of either agent in the reduction of post-inflammatory hyperpigmentation – which corroborates the authors’ empirical observations. Her rationale for this lack of efficacy was attributed to the removal by the peel or laser of all superficial melanocytes that were treated by the above topical agents.
Ideal Candidates for Resurfacing
Younger Patient (30’s)
Fine Periocular Rhytidosis
Limited Tissue Ptosis
(Also Consider Adjuvant Botox)
Chemical Peel (Jessner’s/35% TCA)
Any Age with Epidermal Photodamage
Mild to moderate rhytidosis
Limited perioral rhytidosis
Limited Tissue Ptosis
Generally older patient with deeper rhytidosis
not amenable to chemical peel (e.g., perioral or glabellar rhytidosis)
Consider limiting laser resurfacing to discrete subunits (best-tolerated areas
are the periocular, perioral, and glabellar regions) due to risk of hypopigmentation, especially demarcated at the jawline, and morbidity of laser resurfacing
Combined resurfacing for acne and rhinophyma (see text)
Patients understand the longer recovery time (several months of erythema)
Depressed surface irregularities (e.g., acne scarring)
In conjunction with scar revision (6 weeks after)
Deeper wrinkles (perioral) in lieu of laser resurfacing
Intraoperative Considerations: Technique & Salient Technical Points
Instrumentation/Equipment for Chemical Peel
(Resorcinol 14 g, Salicylic acid 14 g, Lactic acid 14 cc, QS ethanol 100 cc)
35% TCA Solution*
*A local pharmacist can make the above solutions and may need to know what are the ingredients of Jessner’s solution, as listed above, when formulating the mixture)
100% Acetone (may be purchased at a local hardware store)
4 X 4 Gauzes
Balanced Saline Solution (for eye flush if chemical peel inadvertently enters the eye)
Intravenous Versed Sedation (optional but recommended)
A. Non-Ablative Laser Therapy (Pulsed-Dye Laser)
As mentioned above, various devices that emit broadband light or, alternatively, true lasers, have been used as a non-ablative instrument. The authors have had extensive experience with the pulsed-dye laser and have found that this type of laser has an unparalleled safety profile and is well tolerated by the patient. In addition, the pulsed-dye laser may also be used to eradicate superficial vascular ectasias, such as cherry angiomas or spider veins. As the epidermis should be protected during treatment, a cooling spray should be employed (20 ms duration, 20 ms prior to laser emission), which is equipped with most Candela pulsed-dye laser models. In the above-cited animal study, the authors have noted that the only variable that did not affect collagen remodeling was use of a cryogen spray, which in turn further served to limit the risk of hyperpigmentation. However, increasing fluence, spot size, and pulse duration statistically affected the amount of collagen remodeling. Nevertheless, practically speaking, a safe parameter for non-ablative laser resurfacing that will virtually ensure limited to no ecchymosis, edema, or discomfort but still achieve a favorable clinical improvement is a 10-mm spot size, set at 4 J/cm2 with use of the cryogen spray.
Proper laser precautions should be observed (e.g., posted laser signs, eye protection, and trained staff). Both physician and staff should don appropriate laser goggles tailored to the 585 to 595 nm wavelength. As the laser will need to pass in close proximity to the patients’ eyes to address the periocular rhytids, it is advisable to have the physician hold the patients’ eyes firmly shut with the non-dominant hand rather than use protective eyewear for the patient. The patient should be forewarned that the laser light is quite bright, especially when passed near the eye, even when the eye is completely closed. In addition, the patient may be gently startled by the cooling spray that immediately precedes laser delivery and should be informed of the initial laser pulse. Of note, 1 to 2 passes of the laser are sufficient for each treatment session. Full-face laser treatment may also be performed if the patient exhibits fine rhytidosis elsewhere that would be amenable to non-ablative therapy. Generally, 3 to 4 treatment sessions administered at 1-month intervals are advocated to achieve maximal benefit for the patient. As emphasized, proper patient selection and education are prerequisites to patient satisfaction.
B. Chemical Exfoliation (Jessner’s/35% TCA)
For patients with epidermal actinic damage, even those who are still quite young, i.e., in their 30s, who have mild to moderate rhytidosis, chemical exfoliation with combined Jessner’s/35% TCA proves to be a reliable and effective treatment modality. This section will discuss the technical aspects involved in achieving a uniform, safe, reproducible result.
Unquestionably, vigorous and thorough cleansing of the skin with 100% acetone is a critical first step to ensure that an even peel will be attained. The acetone solution should be applied with a 4 x 4 gauze, which more effectively abrades the skin than cotton ball or a cotton-tip applicator would be capable. The purpose of the acetone is twofold: remove the outer layer of oil and function as a keratolytic of the stratum corneum, both of which may serve as physical barriers to attain a deep and uniform peel. The patient should be informed that the application of acetone might be somewhat unpleasant due to the noxious odors and the vigorous application.
The Jessner’s solution, which is comprised principally of alpha hydroxy acids (see above text box), acts to complete the keratolytic process. Jessner’s solution may be applied with relative impunity as the liberal application usually only penetrates into the outer epidermal layer. Oftentimes, a light frost may be evident but only indicates a reversible salt deposition rather than the irreversible blanching that ensues due to protein coagulation when the actual TCA peel is applied. Unlike the TCA peel, no visual change of the skin color is targeted, as the superficial nature of the Jessner’s solution usually does not impart any color change. The patient does not require any sedation for this part of the procedure, as the Jessner’s solution usually only engenders a mild tingling sensation and only rarely frank discomfort.
Like application of TCA, the subunit principle is followed with application of Jessner’s solution. First, attention is paid to the lower eyelid/periocular region in the same fashion as will be described for the TCA peel. The patient is placed in an upright position, inclined approximately 60 degrees from the horizontal. This semi-inclined orientation minimizes inadvertent entry of solution into the eyes during application over the lower eyelid region while maintaining patient comfort. The assistant gently holds cotton-tip applicators at both the lateral and medial canthi in order to prevent tears from unevenly diluting the peeled area and, more importantly, to minimize peel solution from entering the eye via capillary conduction. A bottle of balanced-saline solution (BSS) should always be on the tableside should the patient report any ocular irritation or burning. (If the patient does complain of ocular discomfort, the surgeon should recline the patient to a supine position and gently flush the eyes with BSS with the stream targeted at the medial canthus. This method minimizes reflex closure of the eye that would impair proper ocular irrigation.) The Jessner’s solution is applied with a cotton-tip applicator in the lower eyelid region and with a cotton ball for the remainder of the face. It is important that the cotton ball be squeezed semi-dry before applying the solution to avoid unintentional trickle of solution onto the neck. Furthermore, the used cotton-tip swabs and cotton balls should be promptly discarded into the waste bin so that confusion does not arise as to which cotton ball was used for which peel solution.
After each lower eyelid/periocular region has been treated, the surgeon should advance in a systematic fashion by subunit from forehead/temple region, right cheek region, left cheek region, the upper lip/lower lip/chin region, and then nasal region. The order is not important, but it is recommended that the surgeon proceed in the same order every time to ensure that no area is repeeled or missed. The nasal and upper-lid areas are relatively recalcitrant to significant rejuvenation with a peeling agent but are treated nonetheless to achieve a complete and uniform peel. However, the upper-lid area is treated very superficially given the attenuated skin in this area and the attendant risk of scarring. Also, the cheek and chin subunits should be gently feathered for about a centimeter onto the neck to curtail an abrupt transition. If a lifting procedure is entertained concurrently or independently, the transposition of ptotic tissues upwards may result in the unpeeled area of the neck also moving upward into the facial region.
After the Jessner’s has been completed, the TCA may be immediately applied. First, the patient is marked out along subunits with a surgical marking pen, as the application of TCA must rigorously conform to the subunit principle to avoid over-, under-, or retreatment of areas. If the patient is marked out before the Jessner’s solution, the marked areas will be lost or markedly diminished by the Jessner’s peel. Before the patient is sedated, the lower-eyelid area is again treated first with the same technique and patient positioning described above for the Jessner’s application. Although the patient will experience noteworthy burning discomfort, the lower eyelid application must be undertaken with the patient fully awake or only minimally sedated so that he or she may report any ocular burning due to entry of peeling solution into the eyes. In order to offset the burning sensation, a cooling fan is held by the second assistant at the level of the patient’s waist and aimed tangentially upwards toward the face, as a more direct gust may cause undesirable tearing and reflexive blinking.
Unlike with Jessner’s application, the blanched appearance of the skin is a critical factor in determining when the desired endpoint is achieved. The skin first assumes a mild erythema as the papillary dermis is entered, then a light frost, to finally a more complete, opaque white. After a few minutes, the skin may begin to regress back to a light erythema, fooling the physician into thinking that the area is under treated. The return to erythema is a major reason that the subunit principle should be adhered to in order to avoid retreatment of areas known to be already treated. Generally, the endpoint should be a completely uniform frost but not excessively opaque, which may risk scarring. Experience will dictate proper depth of the peel, and review of the enclosed DVD will further enhance education. As mentioned, the upper eyelids should be only lightly treated (light frost), as this particular area exhibits much thinner skin. The nose and forehead tend to withstand a deeper peel, but a deeper peel is not generally effective for the former area in any case. If the peeled area appears to have been over treated, immediate application of gauze impregnated with water should be undertaken to dilute the peel solution and retard the action of the peel.
The authors advocate application of the TCA peel to discrete areas of deep rhytidosis first, if such areas are present, before evenly applying the solution to the entire subunit because the edema and frost that follow a coat of TCA effectively camouflage the linear areas of rhytidosis. Immediately after the subunit is treated, the area is covered with a gauze soaked in iced water in order to minimize patient discomfort and to terminate the chemical process. Iced pads may be reapplied as necessary to maintain patient comfort.
The neck and d colletage area may be treated with a lighter TCA peel, e.g., 15 to 25%. However, the reader is cautioned that aggressive and repeated application of a lighter-strength TCA will eventually equal that of a higher concentration. The desired color change should be a light and semi-translucent white and not assume a completely opaque appearance.
After the peeling is complete, Aquaphor ointment (Beiersdorf, Wilton, CT) is generously applied over all peeled areas of the face with a tongue depressor. As the epidermis remains intact for several days, no occlusive dressing is required.
C. CO2 Laser Resurfacing
As discussed in the preoperative section of this chapter, CO2 laser resurfacing should be reserved for deeper rhytidosis, particularly the perioral rhagades, and for patients who are willing to contend with the longer recovery period. Deeper rhytids of the glabella and perioral areas are only minimally addressed with a Jessner’s/TCA peel, and patients should recognize that limitation. An alternative to the laser is the phenol peel, but the authors have more limited experience with this peeling technique, which is not discussed herein. The reader is advised to be facile with various resurfacing techniques that have different advantages but not to feel obligated to master all the Byzantine number of techniques available today.
As of the last few years, the authors have been reluctant to subject patients to a full-face laser except in the more rare instances when deeper, panfacial rhytidosis mandates use of this modality. The facial areas that tend to be best suited for laser resurfacing are the glabellar, lower eyelid, and perioral regions. If the laser is applied only to discrete areas of the face, then a chemical peel should be considered in the adjacent areas to blend in the areas of resurfacing. Obviously, all areas should be peeled first before laser is applied to adjacent areas to avoid uncontrolled depth of the peel in areas that have been laser resurfaced. Like the TCA peel, the laser is generally applied by subunit so that adjacent TCA peeled areas may blend effectively with the laser-treated areas. The laser is set at the recommended start-safe parameters that correspond with a power density for tissue ablation (10 J/cm2). The laser is held perpendicularly to the skin but aimed tangentially at the perimeter of the resurfaced area to camouflage the transition with the peeled areas. The second pass of the CO2laser is undertaken to effect greater collagen remodeling and dermal ablation and is applied almost exclusively in a tangential fashion to minimize excessive thermal injury and depth of resurfacing. Beyond these enumerated technical considerations, laser resurfacing is technically much less demanding than chemical exfoliation and does not require further elaboration in this section. Unlike the TCA peel, the resurfaced areas are fully denuded of epidermis and require both Aquaphor ointment and an occlusive dressing (N-Interface, Richardson, TX) to facilitate re-epithelialization and principally to lessen discomfort.
The most established resurfacing technique is mechanical dermabrasion. The authors favor a wire-brush over the diamond fraise for its speed and more effective abrasion. Diamond fraises tend to be more forgiving for the novice operator and hold less risk of injury and scarring. The authors have observed no scarring in the patients after dermabrasion or after the use of combined resurfacing techniques. Dermabrasion is the most technically demanding resurfacing tool and should be used with proper training and with a gentle touch. It is more time consuming to achieve a uniform abrasion and appropriate feathering than other modalities. It is obviously restricted from use near the eye in the surrounding periocular region. Another disadvantage is the relative aerosolization and splatter of blood-borne particles that may transmit viruses and other infectious agents to the operator and personnel. (The surgeon and all assistants in the immediate proximity of the dermabrader should be adequately covered with surgical gowns and facemasks outfitted with clear visor shields to avoid contamination with aerosolized splatter of blood and skin particles.) Hypopigmentation may also develop after dermabrasion, especially in the higher Fitzpatrick patients; and the authors caution against deep dermabrasion in darker skin-toned individuals in favor of sequential lighter dermabrasion. However, the authors feel that laser still promotes greater hypopigmentation than dermabrasion for the same depth-of-wound injury because of the thermal effects of the laser.
Dermabrasion offers the undisputed advantage for addressing deeper scars, such as cystic acne scarring, and deeper rhytids, as found periorally. However, in patients with very deep “ice-pick” acne scarring, direct excision of the pitted area with a No.11 blade followed by wound closure should be undertaken as an initial step before subsequent dermabrasion is carried out 6 weeks later. Unlike CO2 laser intervention, dermabrasion avoids thermal injury, allowing for faster healing time and less protracted erythema than with the laser. However, the laser may be better than dermabrasion for the perioral region as one study suggests , but this matter is controversial. Further, dermabrasion has been successfully used to treat deep, perioral rhagades. Many have touted the beneficial collagen remodeling seen with the CO2 laser, but one study that compared the histological changes in dermabrasion and CO2 laser found no difference in a porcine model . Dermabrasion proves to be a superior instrument when treating the recalcitrant and deeply embedded scars of severe acne. Although dermabrasion may be viewed as a “low-tech” modality, its unique advantages should recommend this treatment option in many different clinical scenarios. Therefore, the facial plastic surgeon should keep this invaluable tool in his or her armamentarium.
Mechanical dermabrasion may be best carried out under general anesthesia when a significant area must be resurfaced for several reasons. First, use of local anesthesia may be limited to minimize tissue distortion that may interfere with correct identification of tissue depth. Second, patient movement is reduced, which is critical to safe and successful dermabrasion. Third, a curious phenomenon of unconscious, reflexive patient quivering, which is witnessed when dermabrasion is carried out under sedation, is avoided. However, limited dermabrasion should be conducted under the minimum anesthesia that would aid in patient comfort and secure patient compliance.
When dermabrasion is carried out near the lip, the surgeon should ensure that the rotation of the dermabrader head should be toward the lip edge to lessen the chance that the lip should be caught in the dermabrader. Similarly, 4 x 4 gauzes used to wipe the blood from the resurfaced area should maintain a distance from the dermabrader head to minimize ensnarement. Dermabrasion should be carried out with a firm hand and a gentle touch. The full weight of the instrument should not rest on the skin surface but only the lightest contact established. The surgeon should observe the microlaceration of the skin and the bleeding that ensues as the papillary dermis is violated. After the initial pass of the dermabrader has been completed, the surgeon should then rotate the direction of the dermabrader head perpendicular to the first pass to achieve uniform resurfacing and laceration of the dermis. The depth of dermabrasion is dependent on the depth of the pathology but should generally not greatly exceed the level of initial bleeding observed at the level of the papillary dermis. At the end of the procedure, all dermabraded areas are dressed with Aquaphor ointment and an occlusive dressing similar to laser-treated areas.
E. Combined Resurfacing Techniques
The following clinical scenarios should help the reader better appreciate how these disparate resurfacing modalities may be effectively combined to achieve a desired effect.
1. Acne Scarring
Acne scarring offers a prime example of how various resurfacing modalities may be combined to achieve an improved cosmetic result. First and foremost, the patient must fully appreciate the limitations of aesthetic improvement possible. The deep scars which descend into and interdigitate with the underlying subcutaneous tissue are refractory to complete elimination but may be realistically improved 30 to 50%, as patients are counseled. The literature however quotes best improvements of 70 to 80% . Further, the patient must have all active acne lesions resolved for at least 9 months prior to considering any treatment. The collagenases that predominate during active eruptions can lead to significant scar formation if resurfaced. Additionally, as previously mentioned, the patient must have terminated any isotretinoin (Accutane) use for a minimum of 6 months but, more favorably, 1 year.
Acne scarring tends to be worse in the malar region but also may affect the chin, temple and forehead areas. Oftentimes, a TCA peel may be employed to address concomitant photodamage in less scarred areas as well as to feather the deeper resurfaced skin with the surrounding areas. In higher Fitzpatrick patients (III or IV), TCA peels are applied more widely with spot-focused dermabrasion in only the deeper scars to minimize inflammatory hyperpigmentation. Further, as previously stated, the authors only dermabrade to the superficial papillary dermis in these darker-skinned patients with the intention of further dermabrasion sessions to minimize possible hypopigmentation that may otherwise occur with deeper dermabrasion. If a chemical peel is performed, it should be done first for two reasons: (1) the eyelid region (if resurfaced) should be done first when the patient is more awake to avoid inadvertent entry of peel solution into the eye (2) the peel should be performed on intact epidermis & dermis prior to any dermabrasion or CO2 laser to avoid an uncontrolled full-thickness injury in denuded areas.
Dermabrasion is then carried out on areas of deep, acne scarring in the previously described transverse fashion (the skin is abraded in one direction and then redirected perpendicularly to the original path). Patients should also be cautioned that pore size may increase (and rarely decrease in size) with dermabrasion, especially over the central areas of the face. It is imperative to observe the change in pore size during dermabrasion and to abort any further passes of the dermabrader if the pore size appears to be enlarging.
The laser is then passed over the dermabraded areas once or twice in order to tighten the collagen further and to provide some limited hemostasis. The CO2 laser is selectively delivered to only the areas of severe acne scarring and feathered into the surrounding areas. At the conclusion of the procedure, the exposed, treated areas are coated with Aquaphor ointment, and the laser-treated areas have an additional N-terface (Winfield Laboratories, Inc., Richardson, TX) dressing applied to minimize air exposure and resulting discomfort.
Rhinophyma serves as another excellent model for combined facial resurfacing. The disfiguring, bulbous quality of the rhinophymatous nasal tip has such excessive volume that laser resurfacing alone or cautery may take an unnecessarily long time to debulk the tissue. The thermal damage of either of these modalities alone has also led to unfavorable scar contracture and at times nasal valvular collapse and obstruction. Cold-knife excision alone is imprecise and tends to cause significant hemorrhagic loss. What the authors have found to work well is a combination of hot and cold techniques that allow rapid debulking, fine-tuning, and hemostasis. Review of the disease process and details of the surgical technique may be found in Chapter 7, “Rejuvenation of the Aging Nose,”
3. Facial Rhytidosis
For thicker, discrete lesions such as actinic keratoses and seborrheic keratoses, the lesion should be first removed by a No.10 (or No.15) blade in a shave resection followed by CO2 laser to vaporize the remaining tissue and to restore a more even contour. Conversely, dyschromias and fine to moderate rhytids respond more favorably to a TCA peel. As noted before, the TCA peel offers a faster recovery period and diminished risk of hypo- or depigmentation than the CO2 laser. As mentioned earlier, deeper rhytids, such as perioral rhagades, may be better treated with the CO2 laser, if patients accept the sequela of protracted erythema and risk of hypopigmentation. An acceptable alternative to the CO2 laser for thick keratoses and deep rhytids is dermabrasion. Dermasanding with silicon-carbide sandpaper may be used for relatively small lesions of actinic keratosis.
Salient Technical Points
Chemical Exfoliation (Jessner’s/35% TCA)
1. Vigorous application of acetone with a 4 x 4 gauze is required to ensure adequate oil removal and a consequently uniform peel.
2. Jessner’s may be liberally applied, and no skin-color endpoint is targeted.
3. The patient should be then marked out with a surgical marking pen to define the subunits, which the surgeon should rigorously follow.
4. Always begin application of the TCA to the periocular region first, as the patient should by minimally sedated to report any discomfort and in an upright position so that the chemical solution has less of a chance to enter the eye.
5. Always have balance saline solution on standby to irrigate the eye if any reported irritation should arise.
6. Apply TCA first to discrete rhytids before applying a more even coat over the particular subunit, as edema will erase any evidence of rhytidosis after one pass of the TCA.
7. Always squeeze out the TCA-impregnated cotton ball before application to minimize accidental excess trailing down the neck.
8. Discard every used cotton ball into the waste bin to minimize potential confusion over what solution remains on the cotton ball.
9. Use discretion when peeling the upper lid region which benefits little from peeling and has a risk of scarring due to the thinness of the skin.
10. Abort any peel reaction that appears to have passed too deeply with moistened gauze, as water dilutes the peel concentration.
CO2 Laser Resurfacing
1. Ensure that the patient understands the more protracted recovery period.
2. Treat only discrete areas of deep rhytidosis (lower eyelid, glabellar, and perioral regions) rather than the entire face if possible due to the longer recovery time and the risk of progressive jawline depigmentation.
3. Ensure that all laser-treated areas are symmetrical, as patients may express undue concern over any areas that are not perceived to be perfectly symmetrical.
4. The second pass of the laser should be only aimed tangentially over a broader area to effect collagen tightening.
5. If a concurrent chemical peel is planned in adjacent areas to achieve a more even resurfacing, the peel should always be completed first.
1. Dermabrasion proves to be excellent modality for acne scarring, second-stage scar revision, and for rhinophyma refinement.
2. It is the technically most challenging resurfacing modality.
3. The diamond fraise may be more forgiving (but less efficient) than the wire brush and may be particularly well suited for the novice surgeon.
4. The surgeon and proximal operating staff should be gowned and protected with visored face masks because of the aerosolization of blood and skin particles.
5. The weight of the dermabrader should never fully rest on the skin surface but gently controlled to permit superficial abrasion.
6. After the first dermabrasion pass, the second should be directed perpendicular to the first in order to effect even cutaneous abrasion and maximal microlaceration of the dermis.
7. The periocular region should not be resurfaced with a dermabrader for risk of lacerating the delicate eyelid skin.
8. When working near the lips, the dermabrader should be directed toward the lip to avoid accidental and disastrous ensnarement of the lip. Similarly, 4 x 4 sponges should remain a distance from the rotating dermabrader head.
9. The depth of dermabrasion should not greatly exceed the initial bleeding encountered at the level of the papillary dermis to avoid potential scarring.
Postoperative Considerations: Care, Follow-up, & Complications
A. Postoperative Care & Follow-up
Postoperative care may be overwhelming for many patients, and a strict, daily postoperative-visit schedule (at least for the first five consecutive days) is followed to reassure patients about the expected sequelae and also to instruct them on the daily care regimen. Prior to establishing a daily follow-up routine, the office staff received numerous phone calls into the evening hours from fearful and concerned patients. Now, practically no telephone communication transpires except for the routine policy of contacting patients the night of surgery to answer questions and to promote a positive physician-patient rapport. Also, the intensive teaching that trained staff members disseminate to patients in the postoperative period is most suited to be undertaken at that time and not in the preoperative phase for fear that the worried patient would unduly elect not to undergo the procedure. Further, postoperative instructions given before the procedure most likely will be forgotten if relayed verbally or confuse the patient if presented in a detailed written format.
The First Five Days
As mentioned, the initial few days post-resurfacing must involve good physician (or staff)-patient communication to mitigate patient fears and to provide the requisite instruction as to the proper cleaning regimen to which the patient should adhere. An important principle to which the authors subscribe is the early application of iced, cold packs to the treated areas. A marked reduction in postoperative edema has been witnessed with the liberal use of cold packs in patients who have undergone any type of resurfacing as well for those patients who have undergone surgical procedures, such as rhytidoplasty, browlift, or blepharoplasty. Ice packs should be initiated immediately after the resurfacing procedure is complete. (In fact, as mentioned, iced gauze is applied immediately to each subunit after that area has undergone chemical peeling.) Patients are asked to apply cold packs routinely, as tolerated, for the next 24 hours. They are also advised preoperatively to acquire a pack of frozen peas that they can use as an effective cold pack when they arrive home. Clearly, vigilant icing should never be a substitute for a gentle surgical hand and good operative technique.
The patient who has undergone a chemical peel? has a markedly different experience than that of his or her post-laser counterpart. Accordingly, treatment protocols differ somewhat to reflect this divergence in experience (Table 1). Post-laser patients have an exposed dermis, which causes significant discomfort especially when the dermal layer lies in direct contact with the ambient air (Figure 1). Therefore, laser-treated skin is covered with a thick coating of Aquaphor and an occlusive dressing (N-terface), followed by additional Aquaphor ointment, and then trimmed 4 x 4 gauze. This multi-layer protection serves to reduce patient discomfort from a perceived 6 to 8 (of 10) on a pain scale to 1 to 2 (as gleaned from the authors’ survey of their patients). A recent study has confirmed the reduction of pain in individuals with closed dressing versus open wounds in laser-resurfaced patients, as well as the absence of any increase in bacterial infections or contact dermatitis. If the occlusive dressing should become displaced, patients are asked to apply additional Aquaphor ointment over the exposed area rather than trying to readjust the dressing, for patients typically adjust only the overlying gauze and not the N-terface dressing which exacerbates rather than alleviates any dryness.
The following day after resurfacing, the patient is examined to ensure that a sufficient coating of Aquaphor is in place (usually 1 to 2 mm in thickness) and that the multi-layered dressing is correctly situated. The occlusive dressing is maintained for a period of two days after which the patient follows the same regimen as the chemically exfoliated patient. If the dressing has fallen away, then a fresh N-terface/gauze dressing is applied and trimmed accordingly to reduce bulkiness and to fit the contours of the face. Additionally, the N-terfrace/gauze dressing is removed from the perioral region and reapplied postoperative day 1 in order to clean this area that is typically prone to exudative build-up.
Unlike the laser-treated patient, the chemically resurfaced patient still maintains an epidermal layer after the procedure for several days. The discomfort that the chemically resurfaced individual experiences post-resurfacing usually lasts about 4 hours after the procedure and then dissipates to some extent. No occlusive dressing is applied, but a thick coating of Aquaphor ointment is evenly distributed over the treated areas. The patient should be instructed to begin cleaning the affected areas on the first postoperative day. The patient should however be advised to remove all the Aquaphor ointment with a cotton ball moistened with distilled water before attempting to clean the resurfaced areas. The cleaning regimen involves a 1/2 tablespoon of white vinegar mixed with one cup of distilled water. This mixture is gently applied with a cotton ball to the affected areas twice a day for the first postoperative day and then four times daily thereafter. The vinegar and water should be rinsed off with distilled water. The resurfaced area may then be dried by rolling a cotton-tip applicator over the cleaned areas. The authors have found that conventional faucet water has caused more irritation than distilled water but recognize that water purity is a regionally dependent variable. Further, cleaning the skin more frequently or less so has led to either discomfort and protracted healing or build-up of exudate, respectively. Although the epithelial layer is maintained for several days, the patient may still report some discomfort whenever the skin is cleaned.
During the first few postoperative days, the photodamaged skin of the chemically resurfaced patient will begin to turn ashen and fall away in a piecemeal fashion. The patient may be alarmed at the abrupt darkening of the skin and the subsequent erythematous base that arises underneath the old epithelial remnants but should be appropriately assuaged that all of this is expected. Both the laser and chemically treated patients should continue the above described cleaning regimen during the initial five days. In addition, after the first 3 days, patients should be able to tolerate showering with tepidly warm water cascading down their forehead, which will not only effectively soothe the treated areas but also soak the skin encouraging sloughing of dead epithelial cells. Prior to this period, premature showering will cause undue discomfort and should be avoided. The laser-treated patient usually will need to wait 4 to 5 days before warm water may be tolerated against the face. Shampooing may be permitted if the shampoo is mild and kept away from the affected areas during the period of re-epithelialization.
Many topical ointments have been tried on the resurfacing patient with varying success. Plain petroleum products tend to evaporate much more quickly than Aquaphor and thereby prove to be less desirable. More sophisticated products, such as copper-peptide solutions (Neova, Procyte Corp., Redmond, WA), have resulted in undesirably high incidence of dermatitis in the authors’ experience. After trying many high-end specialty skin-care lines, the authors have returned to simple, less expensive products, which tend to have fewer ingredients and which the authors contend contribute to the lower incidence of adverse skin reactions that have been witnessed. The single most important factor that contributes to the onset of dermatitis – which can lead in turn to pruritus, erythema, delayed healing, and even scarring – is application of products too early (prior to completed epithelialization) and that are chemically irritating to the skin.
Of note, patients are instructed to sleep in a semi-inclined posture so as to alleviate some of the expected edema. Further, maintaining a supine position will also prevent unintended removal of ointment, which can both soil the sheets and expose the healing skin to excessive dryness. However, patients who have failed to follow this prescribed policy have healed equally well and are not compelled to subscribe to this regimen if they cannot tolerate it.
From Five to Ten Days
Treatment protocols do not differ significantly between the first and the following five days. Attention to moisture with a thick coating of Aquaphor is still the most important aspect to successful and rapid healing. As is well documented in the literature, uneven and delayed healing may be attributed to desiccation and exudative covering of a wound. Gentle, yet vigilant, cleaning and soaking will remove the unwanted exudate that can transform into an encrusted scab if left without moisture (Figure 4). Likewise, a wet, fibrinous exudate will retard effective epithelialization and should be appropriately removed. Furthermore, a moistened exudate may foster the colonization and possible infection in the treated areas leading to slower epithelialization and irritative dermatitis. However, the patients are strongly cautioned about refraining from picking at their scabs or crusts so as to avoid potential scarring.
Epithelialization rate is quite variable (Figure 2A, 3) but is usually complete by ten days. Aquaphor ointment must be continued until full epithelialization is realized. Epithelial breaks may be observed under crusting or, conversely, in areas aggressively cleaned. The cleaning regimen should be carefully followed so as to avoid unnecessary delay in epithelial growth. Even if the occlusive ointment results in milia or acne formation, it must be continued until all the epithelialization is complete. To simplify matters, all patients are kept on Aquaphor ointment for at least ten days (or longer if epithelialization has not been concluded) unless full epithelialization is completed earlier and considerable milia have plagued the patient.
Unlike the cleaning regimen outlined during the first five days in which vinegar and water are preferred, Cetaphil (Galderma, Alliance, TX) cleanser has proven to be a safe and reliable agent that works more vigorously than vinegar and water solution and may be tolerated by the patient after five days of healing have transpired. As with all treatment protocols, careful attention must be paid to tailor a plan on an individual basis. If the patient finds that Cetaphil proves to be too harsh an agent at that stage, then a vinegar and water preparation should be maintained instead.
After Ten Days
The most critical period of time in healing involves the first 8 to 10 days during which time the denuded skin undergoes re-epithelialization. As mentioned, if re-epithelialization has not fully occurred by ten days, then Aquaphor ointment should be continued until that time occurs (Figure 3). Once epithelialization is completed, a gentle moisturizer may be used, such as Ceptaphil lotion (Galderma). The patient should be cautioned to avoid Cetaphil lotion that has any sunscreen contents as this chemical element may contribute to an irritative (immediate) or contact (delayed) dermatitis. After epithelialization is concluded, Cetaphil lotion is better tolerated than Aquaphor because the thickness of the coating is less, which minimizes the chance of milia formation and is more cosmetically acceptable. However, if the patient begins to experience significant dryness then he or she should alternate Aquaphor ointment at night followed by Cetaphil lotion during the day until the dryness subsides.
After epithelialization is completed, the patient may begin to don cosmetic camouflage as desired. However, if the patient does not desire entry into the public eye, usage of cosmetic products is discouraged for as long as possible to expedite healing and minimize dermatitis. Consultation with a trained aesthetician may be required to determine the best products that hold minimal potential for dermatitis. Liquid-based products tend to have more preservatives and should be avoided for the first thirty days. Conversely, mineral-based, all natural, powder foundations may be better tolerated by the newly resurfaced skin. After trying many product lines, the authors have experienced almost no dermatitis with the Jane Iredale (Iredale Mineral Cosmetics, Ltd., Denver, CO) concealing make-up that contains a titanium-dioxide sunblock. Also, chemical sunscreens that contain octyl methoxycinnamate tend to be more irritative than physical blocking agents such as titanium dioxide or zinc oxide and should be avoided for at least thirty days.
After the initial 3 to 4 weeks, the patient should be enrolled on a regimen of topical retinoic acid to maintain the benefits of the chemical peel or laser-treated skin. The regimen should be started on an every other or every third-day basis to ensure that no sensitivity develops and should be advanced to a daily dosage if the patient’s new skin tolerates it. In order to minimize sensitivity, the skin should be cleansed and completely dry (approximately 10 to 30 minutes after cleaning) before any retinoic acid is applied. In addition, only a pea-sized amount should ever be used, and the immediate lower-lid area (between the lid margin and the orbital rim) should be carefully avoided so that no inadvertent entry of solution into the eye occurs. If the patient still has erythema, then retinoic acid should be deferred until all erythema subsides. As a reminder, erythema typically resolves by 2 to 3 weeks after a TCA peel and often only after 2 to 3 months for CO2 laser-treated areas.
Table 1: Postoperative Care for the Chemically Resurfaced Patient*
Postoperative Days Ointment Regimen Cleaning Regimen Makeup Regimen
1-5 Days Aquaphor Vinegar & Water**
BID for the first postoperative day, then QID thereafter None
5-10 Days Aquaphor (until epithelialization is complete) Cetaphil Cleanser (without sunscreen) None
10-30 days Ceptaphil Lotion Cetaphil Cleanser
(without sunscreen) Natural, powder-based make-up with titanium dioxide or zinc oxide sunblock
(when epithelialization is complete)
*The laser-treated patient follows the same regimen except he or she has an occlusive dressing for the first 2 postoperative days. Accordingly, the patient cannot clean the skin during this period when the occlusive dressing is applied.
**1/2 tablespoon of vinegar mixed with 1 cup of distilled water, then rinsed off with distilled water, and dried with a cotton-tip applicator. Patients may begin showering on postoperative day 3 as tolerated.
B. Complications, Sequelae & Management
Milia and Acne Outbreaks
Usually milia develop after the first 8 to 10 days and are unusual before this period of time. If some lesions occur early on, they most likely represent acne uncovered by the recent resurfacing (Figure 2B). However, all these lesions should be carefully delineated from herpetic outbreaks, which exhibit clustering of lesions, vesicular appearance, and intense burning. Milia formation may be exacerbated by prolonged use of an occlusive petroleum-based ointment, such as Aquaphor. Most milia should be left undisturbed, as the majority spontaneously resolve. However, if they persist for several weeks or prove to be troublesome to the patient, they may be unroofed with an 18-gauge needle (or No.11 Bard-Parker blade), and the contents expressed with two opposing cotton-tip applicators applied with pressure to the milial site. Numerous milia that present or persist after 3 to 4 weeks may be effectively treated with topical retinoic acid applied daily until resolution. Acne, on the other hand, which at times may be indistinguishable from milia may be treated with a course of tetracycline. Antibiotic administration may be required even several weeks to months after resurfacing as the body adapts to the newly formed skin.
As previously mentioned, a preoperative course of hydroquinone fails to address the deeper melanocytes that persist after a resurfacing procedure. Instead, hyperpigmentation commonly develops after 3 to 5 weeks post-procedure and should be treated with hydroquinone, or an alternative, lightening agent. Prophylactic usage of hydroquinone prior to 3 weeks should be discouraged, as this agent tends to be quite irritative to the new skin. Prophylacic 4% hydroquinone has been used at 3 weeks postoperatively, starting every other day at bedtime for 1 to 2 weeks followed by daily application in those patients exhibiting a Fitzpatrick III or higher skin-grade. Glyquin (ICN Photonics, Ltd., Orangeburg, NY), which contains 4% hydroquinone, has been found to be less irritative than other hydroquinone formulations. This product also contains a sun protection factor (SPF) 15 among its ingredients. Fortunately, hyperpigmentation is quite readily treatable.
*Patient Results May Vary
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