Laser Therapy: Erbium Laser Resurfacing

Forehead lines recur after laser resurfacing but pretreatment with Botox results in a longer lasting result

Erbium laser resurfacing

Aging and photodamaged skin develops several characteristics including dryness, wrinkling, discoloration, small visible blood vessels called telangiectasias and loss of elasticity resulting in loose hanging skin. Laser resurfacing techniques burn off the outer layer of the skin. This can remove discolored skin lesions, visible blood vessels and stimulates the underlying tissue to tighten and grow new collagen. With the formation of a new outer layer of skin, fine wrinkles may disappear and deeper wrinkles soften. The goal of resurfacing is to restore a healthy looking outer layer of skin with a smooth texture, even color, and increased resiliency. The risks of laser resurfacing include infection, skin pigment lightening, skin darkening, prolonged redness, and scarring.

The Erbium YAG laser can be used for superficial wrinkles especially around the mouth and eyes. Some skin tightening can be seen but significantly less than with more invasive CO2 laser resurfacing. It is also good for skin lesions caused by photodamage of nonfacial areas as the neck, chest, and back of the hands where use of a CO2 laser is not recommended. The advantages of the Er:YAG device is that it is very precise, ablating a defined layer of skin without deeper heat damage. Replacement of the outermost layer of skin is complete in 5-10 days. Depending on how deep the tissue removal is ordered, post procedure redness resolves in 1-3 weeks.

The disadvantage of the Er:YAG laser is that since it creates less excess heat damage below the defined depth of skin to be removed, it stimulates less underlying collagen shrinkage and regrowth than the CO2 laser. This results in significantly less tissue tightening. Also since it does not close off blood vessels as it burns, there is more bleeding than with the CO2 laser.

However, there are now lasers that combine two separate laser heads to achieve the precise ablation of a defined skin layer and some of the additional thermal damage to stimulate collagen formation. With these devices you can actually dial in the amount of heat damage you want to occur. The more heat added and also the deeper the ablation prescribed, the more new skin is formed with less wrinkling and more tone. However, more aggressive resurfacing also carries more risk and inconvenience. Healing time is longer. There is more pain involved requiring IV sedation or even general anesthesia. There are higher rates of complications including prolonged redness and downtime, abnormal skin lightening or darkening, and scarring.

For those who want to avoid the increased downtime and risk of side effects, there is the microlaser peel. It involves a single pass with an Er:YAG laser that penetrates only partially through the epidermis (the outer most layer of the skin as opposed to into the dermis which is the deeper underlying layer of skin). This requires only topical anesthetic cream. It can be repeated several times every 4 weeks. There is little downtime, so even with deeper peels, patients can return to work in 3-4 days. For the microlaser peel the face is cleaned and degreased. A topical anesthetic is placed and left on for 45-60 minutes. A dose of Valium can be given by mouth for some sedation as well. Eye protection shields are placed. For the Sciton Profile device, (Er:YAG laser), the laser can be set to ablate (vaporize) 20-70 microns deep into the skin. Less depth is used on the chest (15-25 microns) and the hands (10-15 microns). The treatment takes about 20-30 minutes.

Afterwards, the skin is covered with Aquaphor ointment. Valtrex is taken for 5 days. Sun screen of at least SPF 30 is recommended. Pain medications, may be needed post procedure for deeper peels. A follow up evaluation is scheduled.

An extended microlaser peel an be done for signs of aging and photodamaged around the eyes. Because this is a little more aggressive treatment, the lower eyelids are injected with an anesthetic, and an anesthetic cream is placed on the rest of the face. A microlaser peel is done on the face ablating to a depth of 20-60 microns. The area around the eyes are fully resurfaced with ablation to a depth of 60 microns and additional heat energy is dialed in to an additional 50 microns.

A new laser resurfacing goal would include no downtime, no medications, and no anesthesia. It would be quick and with instant satisfaction. An Arctic peel is a superficial laser ablation, using blown cold air for anesthesia. There are no medications and no downtime. Ablation is to a depth of 10 microns with no complications including no herpes, and no discoloration side effects. Patients tolerate the procedure very well. And they can have multiple procedures done with continued improvement until a desired effect is described


PROFILE™ CONTOUR™ 2.94-μM LASER MODULE:
MICROLASERPEEL™ (RESURFACING)
SAFE START PROTOCOL
The following protocol is a safe start guide based upon the clinical observations of
experienced physicians.

Introduction
The successful results from laser resurfacing have been evident for a number of years.
However, the extreme levels of carbon dioxide laser peels created unwanted and extended periods of recovery for many patients. Chemical peels, performed for over 3,000 years, have a broad selection of effect from light ‘daily’ peels to heavy changes.
The MICROLASERPEEL introduces the light quick recovery side to laser resurfacing. MICROLASERPEEL patients are able, in almost all cases, to experience improvement in damaged skin with the aid of a topical anesthetic cream and a recovery period of one to five days without cumbersome dressings, downtime, and general anesthesia. The busy life style of many patients leads them to the decision of a series of light MICROLASERPEELs rather than a single significant but traumatic carbon dioxide peel for the improvement of their damaged skin on both face along with neck, chest, and hands. Nothing else in the current aesthetic armamentarium can offer the benefits of the MICROLASERPEEL for safety, controllability, speed, and convenience with near indifference to skin color.

The PROFILE Contour has a LAPG™ Telecentric computer guided scanning device that allows the user to provide a very uniform treatment at high speeds. The scanner is a significant advance, providing treatment consistency and reproducibility unachievable by hand placed laser treatments. The result is seen as a smooth and even treatment of the skin without unwanted laser footprint or complication.

Epidermal and Dermal Resurfacing
The epidermis is a robust and resilient structure with an average thickness, on the face, of
about 110 microns. It functions as a physical barrier to protect the deeper dermis, and retain the skin’s hydration. It is often the source of fine lines and discolorations in aging skin. The MICROLASERPEEL, 10 to 50 microns in selected depth, will not fully penetrate the epidermal barrier of the skin. Therefore the safety, shortened recovery time, and ease of care with these procedures produce a product preferred by many patients and physicians. For most patients, the average depth of the epidermis is shed every 28 days. It is therefore easy to calculate the recovery time of the epidermis from a MICROLASERPEEL.

1. PRE-TREATMENT CONSIDERATIONS
CAUTION: Selection of patients must include evaluation of Fitzpatrick
Skin Type (I-VI). The MICROLASERPEEL is a purely ablative procedure
without the coagulation mode that may lead to long term or permanent
hypo- or hyper-pigmentation issues. However, darker skin types may
have transient pigmentary loss in the more aggressive MICROLASERPEELs
(40-50 micron). The transitory loss is a natural healing phenomenon with
a potential period of 3 to 30 days. If transitory loss occurs it should not
be treated during the healing process with steroids, hydroquinone, or
other topical/systemic that might affect healing or pigmentary processes.

Classification of Skin Types
Fitzpatrick Scale
The following table offers a broad guidance to identifying skin types based on hair, skin and eye color as well as sun reaction.

Type Hair Color Skin Color Eye Color Sun Reaction
I Red Light Blue-green Burn, never tan
II Blonde Light Blue Burn, may tan
III Brown Medium Brown Burn, then tan
IV Brown-black Moderatebrown Brown-black Tan
V Black Dark brown Dark Tan
VI Black Black (African) Dark Tan

1.1. CLEAN SKIN
Use a mild cleanser to remove any dirt, makeup, or moisture from the treatment
area. Follow with an alcohol wipe. Allow alcohol to evaporate before treatment. Use
special care around the eyes.

1.2. ANESTHESIA
Use a topical preparation, as needed, to alleviate discomfort for sensitive patients or
sensitive areas prior to treatment. Read the manufacturer’s guidelines for the
application and duration of the anesthetic. Remove before treatment with mild soap
and water or an alcohol swab, then plain water. Dry the area thoroughly before
treatment.

1.3. HANDPIECE CLEANING
Prior to each treatment, clean the scanner or handpiece optics with an alcohol swab.
Check the lenses during long procedures and clean as necessary.

1.4. EYE PROTECTION
Always use eye protection for the patient, the operator, and anyone in the laser
treatment room during the treatment.

1.5. TREATING AREAS OTHER THAN THE FACE:
1.5.1. Neck and Chest
The epidermis of the neck and chest is both thinner than that of the face and
has fewer adnexal healing structures. Peels beyond 20 microns are not
recommended as a single event. Retreatment may occur as early as 8 weeks.
This procedure may not be ideal for patients with known healing deficiencies.
1.5.2. Hands and other Body Areas
The epidermis of the hands and general body surfaces is both thinner
than that of the face and has fewer adnexal healing structures. Peels
beyond 20 microns are not recommended as a single event.
Retreatment may occur as early as 8 weeks. This procedure may not be
ideal for patients with known healing deficiencies.

2. SETTING TREATMENT PARAMETERS
2.1. DELIVERY
2.1.1. SCANNER
The LAPG Telecentric scanner is the common choice for MICROLASERPEEL.
The scanner allows for complete and uniform application of the laser energy.
Care should to be taken to apply adjoining scans without gap or excessive
overlap of the previously scanned area. The spot overlap within the scanned
pattern may be adjusted from 10-50% (30% is default). The telecentric
(‘collimated’) scanner will generate a uniform pattern from near contact up to
approximately 6 inches from the skin surface.
Many physicians divide the total ablation evenly between two passes to avoid
the presence of scanner patterns on the skin. (i.e., 40 micron ablation
performed as two 20 micron passes) The scanner should always be held
perpendicular to the skin surface for efficient and uniform ablation. Single
scan rate and the repeat period of consecutive scans may be adjusted to the
comfort of the user. This selection will not alter the ablative settings or
outcomes of the procedure.

2.1.2. HANDPIECE
The Erbium:YAG handpieces may be used for MICROLASERPEEL. The options
are 2 mm, 4 mm, and 5 mm spot sizes. The 4 mm matches the spot size of
the LAPG Telecentric scanner. The stacking of consecutive pulse should be
monitored and avoided in most circumstances.

2.1.3. FLUENCE
The FLUENCE required depends on the amount of tissue to be removed. The
laser may be set by the MICROLASERPEEL defaults: Level One – 10 microns,
Level Two- 20 microns, or Level Three – 30 microns. The laser may also be set
manually from 10 – 50 micron ablation depth.
Microlaser Peel Protocol –051804 v4.5b
Patient response can vary. Generally, the more healthy the skin and the patient
the less the redness from treatment and the faster the healing response.
Fluence should be selected based on expected outcome, patient pain
tolerance, and expected ‘downtime’ for healing after assessing the individual
patient needs. The desired response is erythema and possible edema within a
few minutes of laser application. The redness and healing (often similar in
appearance to varying degrees of sunburn) will increase with the depth of the
Peel and will vary by patient.
Excessive fluence or poor control of the laser may lead to epidermal/dermal
injury.

3. TECHNIQUE
3.1. PATIENT POSITION
It is often easiest to lay the patient horizontally (supine or dorsal recumbent) and
stand directly behind the patient’s head. Elevate the table so the patient’s head is
as high as the top of the laser console. Sitting upright during ablation of the face or
other body area is not contraindicated.
3.2. TEST AREA
To confirm that laser and accessories are performing normally, it is useful for the
operator to test on a nonflammable inanimate object like a wooden tongue
depressor.
Treating a test area at the beginning of a patient’s first treatment can establish their
response threshold and help them understand the audible and sensory
components of the treatment.

3.3. SCANNER/HANDPIECE POSITION
Position the patient so the SCANNER/HANDPIECE can be held perpendicular to
the skin surface. If using a handpiece, assure that the contact probe of the
handpiece stays in contact with tissue.
The distal end of the plume evacuator should be as close as possible to the
ablative site. The tubing is nonflammable. Tubing not within one inch of the
operative site will capture less than 50% of the plume and debris from the laser
site.

4. TREATMENT METHOD
Performing two passes of the treatment area rather than one will reduce the
‘footprint’ appearance on the patient. Divide the ablative depth evenly between two
passes. (i.e., 40 micron ablation by performing two 20 micron passes) Match the
“trailing edge” of the next scan to the “leading edge” of the previous scan. The
computer-guided scanner will give a uniform treatment with selected beam
placement within the scan.
5. TREATMENT GOALS
Patient response can vary. Generally, the more healthy the skin and/or the patient the
less the redness from treatment and the faster the healing response. Fluence should be
selected based on expected outcome, patient pain tolerance, and expected ‘downtime’ for
healing after assessing the individual patient needs. The desired response is erythema
and possible light edema within a few minutes of laser application. The redness and
healing (often similar in appearance to varying degrees of sunburn) will increase with the
depth of the Peel and will vary by patient.
6. POST-TREATMENT CONSIDERATIONS
6.1. OBSERVATIONS
Erythema, edema, and a sunburn sensation should be noticed in the treatment area
for up to twelve hours after treatment. This is a purely ablative procedure. Swelling
should be present only as a short-term response. Patients undergoing 40-50 micron
ablation may choose to sleep sitting upright the first night after the procedure to
avoid swelling of facial tissues. Often tissue will peel or flake as a result of the
ablation. Peeling or flaking usually occurs after 24 -48 hours. The slough may be
expedited with a nonirritating exfoliant.
6.2. INTERVENTION
While not often used, cold compress can provide some comfort after treatment. Post
treatment discomfort may be relieved by oral pain relievers or valium for patient
comfort. It is important for the treated area to remain soft and pliable during healing
through the use of topical occlusive applications (Aquaphor, Vaseline, etc) The site
should not be allowed to dry.
6.3. INTERVAL
Recommended time interval between treatments is a minimum of 8 - 10 weeks.
Retreatment in an earlier period may create additional discomfort or sensation at
time of treatment.
7. CONCURRENT PROCEDURES
COMBINATIONS – Noninvasive light-based treatments like hair removal or collagen
stimulation may occur prior to MICROLASERPEEL. All other procedures should not be
performed concurrently.
8. CONCLUSIONS
Patients choose MICROLASERPEEL over more aggressive laser methods and chemical peel
because of its control and rapid healing times with little down time. Therefore it may be of advantage to perform several light peels over a period of time rather than one or two more aggressive applications. However, this will not replace a phenol peel or aggressive
carbon dioxide resurfacing in the Type III wrinkle patient. Most medical practices see this as the missing link between a series of microdermabrasions and the application of aggressive laser or chemical peels. When performed on Thursday or Friday many female patients can return to work or activities on the following Monday in make-up without visible signs of the procedure having been performed.

Profile™ Contour™ Module
ABLATIVE RESURFACING – LASER SKIN PEEL;
EPIDERMAL LESIONS & ACNE SCARS
The following protocol is a safe start guide based upon the clinical observations of
experienced physicians.
Introduction
The successful results from laser resurfacing have been evident for a number of years.
However, the extreme levels of carbon dioxide laser peels created unwanted and extended periods of recovery for many patients. Chemical peels, performed for over 3,000 years, have a broad selection of effect from light ‘daily’ peels to heavy ‘once in a life time’ changes. Erbium resurfacing introduces the light to moderate recovery side to laser resurfacing. Erbium resurfacing patients are able, in many cases, to experience improvement in damaged skin with the aid of a topical anesthetic cream and a recovery period of one to ten days often without cumbersome dressings, downtime, and general anesthesia. More aggressive resurfacing will require the use of general anesthesia and will promote the use of occlusive dressings for several days.

The busy life style of many patients leads them to the decision of a single or series of Erbium resurfacings rather than a single significant but traumatic carbon dioxide peel for the improvement of damaged skin on their face as well as neck, chest, and hands. Nothing else in the current aesthetic armamentarium can offer the benefits of the Erbium resurfacing for safety, controllability, speed, and convenience with near indifference to skin color.

The Profile Contour has a computer guided scanning device, the LAPG Telecentric Scanner, that allows the user to provide a very uniform treatment at high speeds. The scanner is a significant advance, providing treatment consistency and reproducibility unachievable by hand placed laser treatments. The result is seen as a smooth and even treatment of the skin without unwanted laser footprint or complication.

Epidermal and Dermal Resurfacing
The epidermis is a robust and resilient structure with an average thickness, on the face, of
about 110 microns. It functions as a physical barrier to protect the deeper dermis, and retain the skin’s hydration. It is often the source of fine lines and discolorations in aging skin. The Erbium resurfacing, 10 to 50 microns in selected depth, will not fully penetrate the epidermal barrier of the skin. Therefore the safety, shortened recovery time, and ease of care with these procedures produce a product preferred by many patients and physicians. The average depth of the epidermis is shed, on average, every 28 days. It is therefore easy to calculate the rethickening and recovery time from an Erbium resurfacing. The same calculations seem to apply even when dermal ablation is involved. Due to the active and dynamic nature of the recurring dermis and epidermis multiple treatments are not directly additive. Four 40 microns peels spaced 8 weeks apart will not achieve the same outcome as one 160 micron peel. It is important to avoid ablation of the full thickness of both the epidermis and dermis. Full thickness ablation markedly increases the risk of scarring and long term tissue deformity.

Epidermis (μ) Dermis (μ) E/D (μ) Hypodermis (μ) Total
Mental 149 1375 1524 1020 2554
Forehead 202 969 1171 1210 2381
Upper lip 156 1061 1217 931 2381
Lower lip 113 973 1086 829 1915
Tip of nose 111 9 18 1029 735 1764
Neck 115 138 253 544 697
Cheek 141 909 1050 459 1509
Glabella 144 324 468 223 691
Eyelids 130 215 345 248 593
Average skin thickness

1. PRE-TREATMENT CONSIDERATIONS
CAUTION: Selection of patients must include evaluation of Fitzpatrick
Skin Type (I-VI). The Erbium resurfacing is an ablative procedure selected
with or without the coagulation mode. Note that using coagulation mode
while ablating the epidermis may lead to long term or permanent hypo or
hyper-pigmentation issues in skin types IV-VI. However, darker skin types
may have transient pigmentary loss in the more aggressive pure ablative
Erbium resurfacings (50+ micron). This transitory loss is a natural healing
phenomenon with a potential period of 3 to 30 days. If transitory loss
occurs it should not be treated during the healing process with steroids,
hydroquinone or other topical/systemic that might affect healing or
pigmentary processes.

Classification of Skin Types
The following table offers a broad guidance to identifying skin types based on hair, skin and eye color as well as sun reaction.

Type Hair Color Skin Color Eye Color Sun Reaction
I Red Light Blue-green Burn, never tan
II Blonde Light Blue Burn, may tan
III Brown Medium Brown Burn, then tan
IV Brown-black Moderate brown Brown-black Tan
V Black Dark brown Dark Tan
VI Black Black (African) Dark Tan

Fitzpatrick Skin Chart
1.1. CLEAN SKIN
Use a mild cleanser to remove any dirt, makeup, or moisture from the treatment
area. Follow with an alcohol wipe. Allow alcohol to evaporate before treatment. Use
special care around the eyes.
1.2. ANESTHESIA
With ablations of 40 microns or less a topical preparation, as needed, is used to
alleviate discomfort for sensitive patients or sensitive areas prior to treatment.
Read the manufacturer’s guidelines for the application and duration of the eutetic
anesthetic application. Remove before treatment with mild soap and water or an
alcohol swab, then plain water. Dry the area thoroughly before treatment.
Ablations of more than 50 microns usually required the use of general
anesthesia, conscious sedation, or injection of local anesthesia. Proper and
adequate protocol and safety should be taken for all use of anesthesia.
1.3. HANDPIECE CLEANING
Prior to each treatment, clean the scanner or handpiece optics with an alcohol swab.
Check the lenses during long procedures and clean as necessary.
1.4. EYE PROTECTION
Always use eye protection for the patient, the operator, and anyone in the laser
treatment room during the treatment.

2. TREATING AREAS OTHER THAN THE FACE:
2.1. Neck and Chest
The epidermis of the neck and chest is both thinner than that of the face and has
fewer adnexal healing structures. Peels beyond 20 microns, pure ablation mode, are
not recommended as a single event. Coag should not be added to the energies used
on the neck. Retreatment may occur as early as 8 weeks. This procedure may not
be ideal for patients with known healing deficiencies.
2.2. Hands and other Body Areas
The epidermis of the hands and general body surfaces is both thinner than that of the
face and has fewer adnexal healing structures. Peels beyond 20 microns, pure
ablation mode, are not recommended as a single event. Coag should not be added to
the energies used on the neck. Retreatment may occur as early as 8 weeks. This
procedure may not be ideal for patients with known healing deficiencies.
2.3. Epidermal Lesions
When treating for actinic keratosis (AK) or seborrheic keratosis (SK), the goal is to
remove the epidermis to the appropriate depth of the lesion.
Using either the 4mm spot or 2 mm spot choose the 10 micron setting and a repetition
rate of 1-5 hertz. Ablate the area by making a pass covering the entire lesion. Use a
4 x 4 gauze sponge and wipe any residue from the area to assess the lesion
clearance. Make additional passes until the lesion is gone. Pinpoint bleeding
indicates that the papillary dermis has been reached. Apply a topical medication, such as Aquaphor or Neosporin. and sunscreen to protect the wound. Sunscreen is
essential to prevent hyperpigmentation, especially for darker skin types. On day 4-7
begin treatment with hydroquinone to prevent hyperpigmentation on darker skin.
Sunscreen and hydroquinone will reduce the probability of hyperpigmentation in Asian
and darker Fitzpatrick skin types.

2.4. Acne Scars
These are generally assessed as if histology is mid papillary to upper reticular. It is better to avoid treatment into the reticular dermis.
Using either the 4mm spot or 2 mm spot choose the 10 micron setting and a repetition rate of 1-5 hertz, trace the outer margins of acne scars, deplaning the ridges. The idea is to decrease the highly demarcated ridges to blend into the valleys. After deplaning the ridges in an area, use the scanner and set the laser to the appropriate depth (extending to the papillary dermis) and treat the entire area to promote uniform healing. The patient should expect a 30% improvement or better. Remember that the rebuilding of collagen takes months. The best results will be seen at 6 months post treatment although results may be better at one year. The same precautions and post-operative treatment as resurfacing should be followed. If they are not placed on hydroquinone and do not use sunscreen, Asians and darker Fitzpatrick skin types are more susceptible to hyperpigmentation.

3. SETTING TREATMENT PARAMETERS FOR RESURFACING
3.1. DELIVERY
3.1.1. SCANNER
The Erbium:YAG scanner is the common choice for Erbium resurfacing. The
scanner allows for complete and uniform application of the laser energy. Care
should to be taken to apply adjoining scans without gap or excessive overlap
of the previously scanned area. The spot overlap within the scanned pattern
may be adjusted from 10-50% (50% is default). The telecentric (‘collimated’)
scanner will generate a uniform pattern from near contact up to approximately
six inches from the skin surface. Many physicians divide the total ablation evenly between two to three passes to avoid the presence of scanner patterns on the skin. (i.e., 180 micron ablation performed as three 60 micron passes or two 90 micron passes ) The
scanner should always be held perpendicular to the skin surface for efficient
and uniform ablation. Single scan rate, scan size and shape, and the repeat
period of consecutive scans may be adjusted to the comfort of the user. This
selection will not alter the ablative settings or outcomes of the procedure.

3.1.2. HANDPIECE
The Erbium:YAG handpieces may be used for Erbium resurfacing. The
options are the 2mm, 4mm, and 5 mm. The 4mm matches the spot size of
the Erbium:YAG scanner. The stacking of consecutive pulse should be
monitored and avoided in most circumstances.

3.2. FLUENCE
The FLUENCE required depends on the amount of tissue to be removed. The laser may be set for both ablative depth and coagulative action for deeper collagen stimulation and
potential tissue tightening. Patient response can vary. Generally, the more healthy the skin and the patient, the less the redness from treatment and the faster the healing response. Fluence should be selected based on expected outcome, patient pain tolerance, and expected ‘downtime’ for healing after assessing the individual patient needs. The desired response is erythema and possible edema within a few minutes of laser application. The redness and healing will increase with the depth of the Peel and will vary by patient. The Coag portion of fluence selection is based on the amount of collagen change or possible tissue tightening wanted or basic hemostasis. For patients with Fitzpatrick IV-VI skin tone no Coag is recommended during the ablation of the first 80-100 microns of tissue removal. If the treatment is divided into three passes, many physicians will use low to moderate Coag levels in the second pass and less in the third. Excessive Coag addition in the third pass may lead to unnecessary tissue slough four to ten days into the recovery period due to creation of a light necrotic tissue layer. However, the unwanted slough will not affect the final outcome of the treatment. Excessive fluence or poor control of the laser may lead to epidermal/dermal injury.

3.3. TECHNIQUE
3.4. PATIENT POSITION
It is often easiest to lay the patient horizontally (supine or dorsal recumbent) and
stand directly behind the patient’s head. Elevate the table so the patient’s head is
as high as the top of the laser console. Sitting upright during ablation of the face or
other body area is not contraindicated.
3.5. TEST AREA
To confirm that laser and accessories are performing normally, it is useful for the
operator to test on a nonflammable inanimate object like a wooden tongue
depressor.
Treating a test area at the beginning of a conscious patient’s first treatment can
establish their response threshold and help them understand the audible and
sensory components of the treatment.

3.6. SCANNER/HANDPIECE POSITION
Position the patient so the SCANNER/HANDPIECE can be held perpendicular to
the skin surface. If using a handpiece, assure that the contact probe of the
handpiece stays in contact with tissue.
The distal end of the plume evacuator should be as close as possible to the
ablative site. The tubing is nonflammable. Tubing not within one inch of the
operative site will capture less than 50% of the plume and debris from the laser
site. The plume is considered the aerosol existence of blood borne pathogens.
The control of blood borne pathogens is clear and established.
3.7. ANESTHESIA
Topical anesthesia is often adequate for ablations of 40 microns or less. Ablations
of 50 microns or more often require conscious sedation, general anesthesia or
local anesthesia injection for the patient. Proper and adequate protocol and safety
should be taken for all use of anesthesia.

4. TREATMENT METHOD
Performing two to three passes of the treatment area rather than one will reduce
the ‘footprint’ appearance on the patient. Divide the ablative depth evenly between
two or more passes. (i.e., 40 micron ablation by performing two 20 micron passes,
or 180 micron ablation with two 90 micron or three 60 micron passes) Match the
“trailing edge” of the next scan to the “leading edge” of the previous scan. The
computer-guided scanner will give a uniform treatment with selected beam
placement within the scan.
There is no need to wipe debris from the treatment areas between passes. Wiping
of tissue is not required after the final pass.
Use a slower rep rate, smaller scanned area, or lower repeat rates as needed.
5. TREATMENT GOALS
Patient response can vary. Generally, the more healthy the skin and/or
the patient the less the redness from treatment and the faster the
healing response. Fluence should be selected based on expected
outcome, patient pain tolerance, and expected ‘downtime’ for healing
after assessing the individual patient needs. For ablation of less than
50 microns the desired response is erythema and possible light edema
within a few minutes of laser application. The redness and healing
(often similar in appearance to varying degrees of sunburn) will
increase with the depth of the Peel and will vary by patient. For
ablations of more than 50 microns there is the possibility of an open
wound that must be addressed by an occlusive dressing for one to
three days (Silon, Second Skin, etc).

6. POST-TREATMENT CONSIDERATIONS
6.1. OBSERVATIONS
Erythema, edema, and a sunburn sensation should be noticed in the treatment area
for up to twelve hours after treatment. This is a purely ablative procedure. Swelling
should be present only as a short-term response. Patients undergoing 40-50 micron
ablation may choose to sleep sitting upright the first night after the procedure to
avoid swelling of facial tissues. Often tissue will peel or flake as a result of the
ablation. Peeling or flaking usually occur after 24 -48 hours. The slough may be
expedited with a nonirritating exfoliant.
6.2. INTERVENTION
Cold compress can provide some comfort after treatment. Post treatment discomfort
may be relieved by oral pain relievers or valium for patient comfort. It is important for
the treated area to remain soft and pliable during healing through the use of topical
occlusive applications (Aquaphor, Vaseline, etc) The site should not be allowed to
dry.
6.3. INTERVAL
Recommended time interval between treatments is a minimum of 8 - 10 weeks.
Retreatment in an earlier period may create additional discomfort or sensation at
time of treatment.
6.4. CONCURRENT PROCEDURES
COMBINATIONS – Noninvasive light-based treatments like hair removal or collagen
stimulation may occur prior to Erbium resurfacing. All other procedures should not be
performed concurrently.
7. CONCLUSIONS
Patients choose Erbium resurfacing over more aggressive laser methods and chemical peel because of its control and rapid healing times with little down time. Therefore it may be of advantage to perform several light peels over a period of time rather than one or two more aggressive applications. However, this will not replace a phenol peel or aggressive carbon dioxide resurfacing in the Type III wrinkle patient. Most medical practices see this as the missing link between a series of microdermabrasions and the application of aggressive laser or chemical peels. When performed on Thursday or Friday many female patients experiencing ablations of 40 microns or less may return to work
or activities on the following Monday in make-up without visible signs of the procedure having been performed. More aggressive ablations require longer periods or recovery and
recuperation.