Erbium Laser skin resurfacing

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Considered by some to be milder than CO2 laser, Erbium resurfacing is an excellent alternative which offers the advantages of increased precision and variability in resurfacing depth.

Recovery tends to be quicker and it is more commonly used in darker skin-types.

Erbium resurfacing, like CO2 is performed in order to:


1. Completely renew facial skin

2. Tighten the skin to help reduce the consequences of laxity

3. Remove wrinkles

4. Treat scarring

5. Improve elasticity and skin thickness


This facial laser surgical procedure is performed under a special type of local anaesthetic. Treatment of skin laxity and wrinkles around the eyes can also be

incorporated into the treatment.

Not all Erbium laser is the same. This is a fully ablative Erbium laser procedure that is only performed by a handful of experienced laser surgeons worldwide. It requires a surgical grade laser that uses 2 different types of Erbium which, in combination, provide optimal resurfacing. Dr Convery is one of the few laser surgeons worldwide who has the knowledge and the experience to offer this procedure and has performed numerous cases. He uses the Sciton Joule laser which is the most powerful and advanced Erbium laser available.

As you will see from the photos below Dr Convery is capable of performing what few others worldwide are capable of. The level of skin rejuvenation is simply outstanding.

This degree of improvement requires 7 days of downtime (As the procedure is usually performed on the Friday list this translates to 1 week off work). In order to fully understand the nature of the recovery period Dr Convery has included a comprehensive photo diary of a case he performed.

Depending on the individual patient’s wishes, requirements and agreed treatment plan, Dr Convery can treat specific facial areas to different depths. This may involve a full face or part face treatment – a common example will be periorbital treatment (around the eyes only). Eyelid tightening treatment with fully ablative Erbium laser is a very effective technique. The result is similar to that seen following fully ablative CO2 treatment, though the tightening effect builds gradually over a 3 month period following treatment. For clients who are not keen on surgical blepharoplasty, fully ablative Erbium eyelid treatment will give a considerable improvement for eyelid skin laxity and wrinkles.

The greatest benefit of this procedure is that the results are permanent. Once healing is complete the skin you are left with is your new skin. The procedure doesn’t have to be repeated like other cosmetic treatments such as dermal fillers or BotoxTM. As long as the client takes good care of their skin results will last for many years before the need to consider doing anything further.

Aggressive procedures can be performed on lighter Fitzpatrick 1-3 skin types (Caucasian, Mediterranean, Very light Asian). Treatment for darker skin types (Fitzpatrick 4 – 6) must be delivered less aggressively due to potential for pigmentation side effects.


TREATMENT DETAILS

Once the client has seen Dr Convery for a consultation and treatment has been deemed appropriate, an appointment will be arranged to carry out the procedure. During the consultation a prescription for prophylaxis (preventative) medications will be issued. These medications are to be used as instructed during the recovery period following the procedure. Taking these medications minimises the risk of harmful side effects such as infection following this type of more aggressive skin laser surgery.

It is important that the client has somebody available to drive them home after the procedure is performed. Clients must not expect to drive back home themselves.

Dr Convery will see the client before the procedure in order to prepare and clarify things. A consent form will be signed, giving permission for the procedure to be carried out. Antiviral tablets will be then administered as well as an optional sedative.

Pre-procedure photos will be taken and following this the face will be cleansed and prepared with a special type of topical local anaesthetic gel. Sometimes Dr Convery will use additional anaesthetic techniques such as tumescent anaesthesia or nerve blocks. These involve small injections of local anaesthetic under the skin.

Anaesthetic preparation will last for about 45 minutes. Following this the Client will be moved into the procedure room and prepared for the fully ablative Erbium laser procedure. If treatment around the eye area is to be performed then the client will have had anaesthetic eye-drops applied and metal contact lens style eye-shields will be inserted. If the eyelid region is not being treated then simple adhesive eye-shields (that stick over the eyes) will be applied. In most cases clients who opt for full face treatment usually will want to incorporate the benefits of eyelid treatment as well. It is therefore commonplace for clients to have both treatments performed in the same session.

The procedure will usually take around 45 minutes to complete.

The level of discomfort experienced during the procedure is typically a prickly burning sensation that usually can reach up to a 5 out of 10 subjective severity. Dr Convery has never encountered anyone who has been unable to cope with the procedure from a pain or discomfort point of view. Pain or discomfort from this type of laser surgery is best described as moderate at the most.

Upon completion of the procedure the client’s face will feel very hot. It is best described as a sun-burn sensation and this will last for up to 24-48 hours. Following removal of protective eye-wear a barrier cream is applied to the freshly treated skin. This cream acts as an impermeable barrier to protect the denuded or exposed skin from dehydration and infection.

Detailed aftercare instructions will be discussed and issued in a written format to the client. These instructions must be adhered to strictly. Strict sun avoidance will need to be maintained in the immediate recovery phase and up to a month at least post procedure. Use of a broad spectrum sunblock (SPF50 minimum) is recommended for at least 3 months post procedure.

Clients are at risk of infection during the first few days following the procedure. It is important to keep the face clean and strictly adhere to the aftercare instructions to minimise this risk. Dr Convery usually gives a once a day antibiotic dose to minimise bacterial infection risk. An antiviral tablet must also be taken for 7 days – this will be prescribed as twice or three times daily and this will be discussed at the appointment. There will also be a pack containing medications for use ONLY if instructed to do so by Dr Convery.

Standard practice is to monitor day by day healing through the use of ‘selfie’ photos taken by the client and sent to the contact details issued by Dr Convery. This allows for provision of real-time advice during the recovery period. Any client having this procedure will have a direct line of communication with Dr Convery at all times throughout recovery. Close monitoring of this nature allows any potential complications to be dealt with quickly and risks minimised.

Typically, after 7 days, clients can return to work. Depending on the depth of resurfacing, redness may take a few weeks to settle. A light foundation can be applied to mask this redness. Use of perfume free gentle cleanser and appropriate moisturiser is recommended. A high quality SPF 50 sunblock must be used and steps to avoid sun exposure must be taken for the weeks following treatment. If these steps are ignored, clients may find that they develop brown pigmentation on the treated areas of the face (post inflammatory hyperpigmentation). Although this will spontaneously settle, it is better to avoid it by observing the sun avoidance precautions. If brown pigmentation seems especially stubborn or is slow to settle, a cream may be prescribed to expedite the process.


POTENTIAL COMPLICATIONS

Fully ablative Erbium resurfacing is one of the most aggressive type of skin resurfacing procedure undertaken by Dr Convery.

As Dr Convery is an expert in cutaneous laser surgery the incidence of side effects is low and fully ablative Erbium laser is considered a safe procedure.

However, with any laser resurfacing treatment complications are possible. In fully ablative Erbium laser these include the following:


Post Inflammatory Hyperpigmentation (skin darkening)

Post Inflammatory Hyperpigmentation (PIH) is the most common side effect. It is more common on darker skin types. Thankfully it usually spontaneously improves. Improvement can be expedited by the addition of topical treatment such as hydroquinone 4% cream. Duration of PIH depends on the severity of the inflammation that created it in the first place. Complete resolution can take anything from a few weeks to 6 months depending on severity. Sun exposure is the most common aggravating factor and this is why strict sun avoidance is important in the first few weeks following treatment. If the aftercare instructions are strictly adhered to one is much more likely to avoid this type of complication.


True Hypopigmentation and Pseudo-hypopigmentation (skin lightening)

Hypopigmentation is the medical term for lightening of the skin. After fully ablative Erbium resurfacing it is normal for the skin to be slightly lighter. This is due to the way that the organised collagen in the new skin reflects more light. This gives an impression of a slightly lighter colour. This effect is called pseudo-hypopigmentation.

True hypopigmentation is lack of melanin production due to damage caused to melanin producing cells by thermal injury from the laser. This is rare with fully ablative Erbium resurfacing as the new skin is repopulated with new melanin producing cells from layers deeper than those reached by the laser. If true hypopigmentation occurs, it can take many months to recover and it can, in fact, be permanent.


Demarcation lines

This is usually only an issue if a face is partly treated (eg. Treatment limited to around the mouth for smokers lines). The new skin may be subtly different in shade to the surrounding skin leading to a visible line of demarcation between treated and untreated areas. This is less likely in lighter skin types. Dr Convery usually prefers to avoid part treatment for this reason and will treat the whole face albeit with a variable depth depending on what needs to be achieved. This allows for a more blended result. It is important to note that if lighter freckled skin is part treated there will also be a demarcation between untreated freckled skin and treated freckle free skin.


Infection (bacterial/viral/fungal)

This can happen in any kind of laser resurfacing.

HSV infection (cold sore virus) is the most common kind but is usually prevented by taking an antiviral medication as directed for 7 days during the recovery period. Bacterial infection prophylaxis is also issued by Dr Convery in the form of a once daily antibiotic tablet taken for 7 days after the procedure.

Fungal infection is also a possibility and we will include medications in the aftercare pack to treat this should it occur. It is however only necessary to start these if Dr Convery instructs.

Uncontrolled infection can then go on to result in hypertrophic (raised bumps) scarring. Thankfully if caught and treated early any problems can be prevented. This is why Dr Convery monitors the healing closely with the use of ‘selfie’ photos daily for the first week.


Scarring

This is a possibility but exceptionally rare.

The most likely cause of scarring would be uncontrolled infection. This is highly unlikely due to insistence by Dr Convery on direct photo monitoring in the first week post treatment.

The second reason is due to a thermal injury directly created from the laser (burn). This is extremely unlikely due to Dr Convery’s level of experience and expertise.


Ectropion (Applies only to eyelid treatments)

This is a treatment in which the eyelid skin is over-tightened. It can lead to eversion (out-turning) of the eyelid margins and an inability to completely close the eye. Mild cases may improve with non-surgical management but more severe cases may require corrective oculoplastic surgery.


Prolonged redness (erythema)

This is not really a complication. After fully ablative Erbium laser every client will experience this to some degree, though it is notably less than that experienced following a typical CO2 treatment. It tends to progressively settle over approximately 2-3 months. It is important to understand that whilst redness remains, the likelihood of developing post inflammatory hyperpigmentation (browning/tanning of the skin) still exists. It is therefore important to take sun avoidance precautions and uses SPF 50 sun block until the redness has completely settle.


Post-resurfacing contact dermatitis

This complication of laser surgery is more likely in aggressive forms of laser resurfacing such as fully ablative Erbium and CO2 resurfacing. This is a form of increased sensitivity of the skin that is encountered by a proportion of individuals post laser resurfacing. In some cases it can be quite severe. Mild irritants can trigger a disproportionately large irritation of the skin (burning and itching) that then can result in prolonged redness and darkening of the skin. It is usually treated by topical steroid ointment if it occurs and eventually spontaneously settles. Triggering can be minimised by the use of mild perfume free cleansers and skin products post treatment. Dr Convery can advise on suitable products. Close monitoring allows us to identify and resolve this problem when it does occur.


Erosive pustular dermatosis

This is an extremely rare dermatological condition that can be triggered by any type of skin injury including laser. There are only a few case reports worldwide following laser surgery. It is an exceptionally rare consequence but effectively amounts to the failure of the skin to completely heal after treatment. Management would be undertaken in a specialist dermatology unit if this was to occur but the consequence of this could be permanent scarring.


AFERCARE

This treatment is designed to renew, tighten and improve the texture of the facial skin. It is an aggressive procedure and requires strict adherence to these aftercare instructions.

Some immediate tightening is seen, though this effect is much milder than with CO2 laser. Further tightening occurs over the following 3 months via the ‘wound-healing’ effect.

Immediate and visible benefits can be seen in the form of reduction in laxity (tightening), reduction in wrinkles, removal of sun damage, increase in elasticity and improvement in collagen density and thickness.

It is a procedure that is also used to improve acne scarring by causing contraction of the skin, a degree of direct physical vaporization of the acne scars and remodelling of the collagen within the deeper layer of skin (dermis). Fractional Erbium laser may be used in combination with the fully ablative treatment, providing additional benefit in acne scar remodelling.

What you will experience following the treatment:

 You will experience a burning sensation following treatment and swelling of the face will develop over the next 24 hours. The burning sensation takes 24-48 hours to resolve.

 Over the next three to four days the face will feel tight and swollen. There can be weeping of yellowish serous fluid for up to 4 days after the procedure.

 Crusts may develop over the first few days post procedure and must not be removed. They will come away leaving fresh new skin underneath as healing continues.

 It is not unusual to experience some degree of itching between 4-6 days following the treatment. Dr Convery will advise on how to manage this.

 At the end of 7 days the skin will have largely healed. There should be no further crusted areas. The skin will remain pink and this will settle progressively over the following weeks.

 It will usually be safe to return to a simple skin care regime 7 days post treatment.


NEVER PICK OR REMOVE SKIN FLAKES OR CRUSTS. ALLOW THEM TO SHED NATURALLY. PICKING WILL INCREASE THE LIKELIHOOD OF SCARRING.


Please note the time periods above may vary according to the strength of treatment. For example, the duration of crusting may be longer in more aggressive treatments.


YOU WILL BE ISSUED WITH A SKINCARE PACK CONTAINING DERMOL FACEWASH, AQUAPHOR CREAM AND A PACK OF STERILE GAUZE ON COMPLETION OF THE PROCEDURE.

Skincare day 1 to day 8

It is imperative that you adhere strictly to the following skin care routine after Erbium laser treatment. The skin barrier has been temporarily impaired by the laser. Premature application of your normal skincare products will result in inflammation, irritation, slow healing and may increase the risk of pigmentation problems and/or scarring. You are more susceptible to contact irritant and allergic dermatitis during this first 14 day period.

After the first 7-8 days have elapsed you must use a sunscreen SPF50 for the following 6 weeks. You must minimise your sun exposure at all times

throughout the treatment and for 6 weeks after treatment.

Morning

1. Wash the face in the morning with Dermol face wash and allow to air dry OR pat dry gently with a clean face towel or clean kitchen roll (DO NOT RUB).

2. Apply Aquaphor barrier cream to the face. This will protect the skin and stop it from drying out while the epidermal barrier is healing.

3. Take any antiviral and/or antibiotic tablets according to instructions that Dr Convery may have prescribed. Complete the course of medication.

Throughout the day

 Top up the Aquaphor cream at any point when the skin starts to feel dry and tight. This should be at least twice throughout the day. Allowing the skin to become too dry will slow the healing process.

Evening

 Repeat steps 1 & 2 (and step 3 if you have been prescribed the medication)

Before going to bed

Dr Convery will review you at 2 weeks following treatment but do not hesitate to contact him before this if you need earlier advice/review/information. Remember to send healing ‘selfie’ photos at least every two days so that Dr Convery can monitor your healing. Use the details on the contact card.


Skincare – Day 8 to week 6 post treatment

Your skin will have healed sufficiently by day 8 after treatment. You will now be able to return to work. You will notice that the skin will still be red. This redness will settle over the next 6-12 weeks. During this period your skin will be more sensitive than normal. It is important that very mild cleansers, moisturizers and make-up be used in this period. Some products contain acetyl alcohol, retinoids and alpha hydroxy acids that can potentially irritate the skin and delay healing. These should be avoided or minimised.

Sunscreen is also very important. High factor (SPF50+) is ideal. Sunscreens that contain physical filters rather than chemical filters are preferred as they are less likely to irritate the skin. Physical barrier sunscreens are sometimes less popular because they leave a prominent white residue on the skin.

I have recommended a basic skincare regime that can be used during this period that will minimize any irritation to the skin, speed the healing process and optimize the results of your Erbium laser treatment.

Morning

1. Wash face with Avene Cleanance soapless gel cleanser.

2. Apply Avene Hydrance Optimal Light moisturizer.

3. Optional – Lycogel foundation is a specially formulated foundation that can be colour matched to your skin and safely applied post laser treatment to help mask any redness whilst things continue to settle.

4. Apply Heliocare 360 oil free sunscreen. Occasionally this preparation can result in tightness in which case it can be substituted for the Heliocare SPF 50

UVA & UVB protection.

Evening

1. Wash face with Avene Cleanance face wash

2. Apply Avene Cicalfate cream.

Maintain strict sun avoidance at all times. Use of a wide brimmed hat is advisable when practical.

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Young lady whose main concern was skin and eyelid laxity, as well as generally ‘crepy skin’ around her eyes

 
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This lady had lived abroad and was very active. Fair skinned, she has picked up a lot of sun-damage and pigmentation


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