Video
Operative Technique
Laser Resurfacing: Safety and Technique
Kaitlin S. Boehm, MD, MEd*; Yash J. Avashia, MD†; Ira L. Savetsky, MD†; Rod J. Rohrich, MD†
INTRODUCTION
The use of laser resurfacing in facial rejuvenation is
expanding. Ablative lasers, including erbium:yttrium-alu-
minum-garnet (Erbium:YAG) and carbon dioxide (CO2)
devices, smooth skin by inducing dermal remodeling
(Scheuer et al1). Erbium:YAG lasers (wavelength 2940)
Downloaded from http://journals.lww.com/prsgo by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 05/01/2022
can impart less dermal injury and have less potential for
hypopigmentation than CO2 laser devices when used in
the ablation mode, in the authors' experience, which
additionally favors faster healing.2,3 In an attempt to miti-
gate thermal injury, fractional CO2 lasers have been devel-
oped. These deliver microcolumns of energy, leaving an
unaffected tissue scaffold with intact dermal vasculature.1
By default, however, fractional CO2 lasers leave areas of
untreated, aged skin. Erbium lasers allow for complete
ablative resurfacing with limited unintended dermal
injury.
PREOPERATIVE PREPARATION
Erbium laser resurfacing is best suited for patients
with Fitzpatrick I and II skin types. Patients apply topi-
cal tretinoin 2–3 times per week for 4–6 weeks and stop 7
days before laser treatment. A 1-week course of acyclovir
500 mg 4 times daily is started 1 day before the procedure.
(See Video 1 [online], which displays preoperative facial
analysis.)
SAFETY CONSIDERATIONS
Safety against thermal injury, and potentially fire, is
paramount. Eye protection for the patient and all operat-
ing room personnel is required. The patient’s eye protec-
tion should be made of metal to prevent corneal injury.4
General anesthetic should be induced with a laser-safe
endotracheal tube, and, if this is not accessible, the endo-
tracheal tube should be wrapped with moist gauze or alu-
minum foil.4 Supplemental oxygen (fraction of inspired
From the *Division of Plastic Surgery, Dalhousie University,
Halifax, Nova Scotia, Canada; and †Dallas Plastic Surgery
Institute, Dallas, Tex.
Received for publication January 12, 2020; accepted March 2,
2020.
Copyright © 2020 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This is
an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
Plast Reconstr Surg Glob Open 2020;8:e2796; doi: 10.1097/
GOX.0000000000002796; Published online 29 April 2020.)
www.PRSGlobalOpen.com 1
oxygen >21%) should be avoided during laser use, and, if
it is required, oxygen should be stopped 1 minute before
treatment. Moist towels should be placed at the periphery
of the treatment area to reduce the risk of drape ignition.
(See Video 2 [online], which displays safety measures and
laser settings.)
TECHNIQUE
The face is prepared using betadine. Profile dual-mode
Erbium:YAG laser (Sciton, Inc., Palo Alto, Calif.) is set to
an ablative depth of 100 microns. The treatment is per-
formed using a systematic approach with 2 passes and 50%
overlap in each facial zone.1 (See Video 1 [online], which
displays preoperative facial analysis.) “Paprika” bleeding
represents injury to the papillary dermis and indicates
treatment endpoint. Blending along the mandibular bor-
der is achieved by passing the laser at an oblique angle.1
Areas with deeper rhytides, namely perioral and forehead,
may warrant a third pass. (See Video 3 [online], which dis-
plays the Erbium:YAG laser technique.)
POSTOPERATIVE CARE
Immediately following laser treatment, Stratamed
(Stratpharma AG, Basel, Switzerland), a silicone-based
ointment, is applied and continued for 24 hours. This is AQ1
followed by Alastin (ALASTIN Skincare, Carlsbad, Calif.)
application, which facilitates wound healing and is reap-
plied daily for 7 days. Patients are discharged home but AQ1
have frequent follow-up monitoring for potential, albeit
rare, complications including hyper/hypopigmentation,
skin necrosis, skin sloughing, prolonged erythema, and
infection.1 Methylprednisolone taper and cephalexin AQ1
500 mg 4 times daily for 4 doses are started on postopera-
tive day 1. (See Video 4 [online], which details postopera-
tive care).
Rod J. Rohrich, MD AQ1
Dallas Plastic Surgery Institute
9101 N. Central Expressway
Suite 600
Dallas, TX 75231
E-mail: rod.rohrich@dpsi.org
Disclosure: Dr. Rohrich receives instrument royalties from
Eriem Surgical, Inc., and book royalties from Thieme Medical
Publishing. The other authors have no financial interest to
declare in relation to the content of this article.
Related Digital Media are available in the full-text ver-
sion of the article on www.PRSGlobalOpen.com.

REFERENCES
1. Scheuer JF III, Costa CR, Dauwe PB, et al. Laser resurfacing at
the time of rhytidectomy. Plast Reconstr Surg. 2015;136:27–38.
2. Farkas JP, Richardson JA, Burrus CF, et al. In vivo histopathologic
comparison of the acute injury following treatment with five frac-
tional ablative laser devices. Aesthet Surg J. 2010;30:457–464.
PRS Global Open • 2020
3. Khatri KA, Ross V, Grevelink JM, et al. Comparison of erbium:YAG
and carbon dioxide lasers in resurfacing of facial rhytides. Arch
Dermatol. 1999;135:391–397.
4. Rohrich RJ, Gyimesi IM, Clark P, et al. CO2 laser safety con-
siderations in facial skin resurfacing. Plast Reconstr Surg.
1997;100:1285–1290.