Carbon Dioxide Laser Skin Resurfacing Treatment Protocol for Wrinkles & Acne Scarring

Laser Skin Resurfacing Treatment Protocol: for Wrinkles & Acne Scarring

Robert J Troell, MD, FACS Beauty by Design, Las Vegas NV. Trained at Stanford University Medical Center,
Facial Plastic & Cosmetic Surgeon, Diplomate of six medical specialty boards

Dr Troell’s clinical laser study included 250 patients examined the goal of most aesthetic treatments:

1. cosmetic results
2. severity & length of the recovery period
3. side effects & possible complications.

The laser skin resurfacing treatment protocol is prepared to optimize patient comfort, aesthetic outcome and minimize side effects. This is my current validated clinical treatment protocol that practicing aesthetic physicians may find useful in their own practice.

Pre-Treatment:

Timing of laser best between September 15^th and April 15^th to avoid Summer sun.

4 to 6 weeks prior to treatment- If Fitzpatrick skin classification IV or V (VI is not treated by CO₂ laser)- test patches are performed at four different energy settings (two behind each ear)

One-week prior- Cleansing facial with extractions and either or a combination of chemical peels (usually mandelic and salicyclic), dermal planning, and/or microdermabrasion (in that order if multiple aesthetician treatments)

Two days before treatment- Acyclovir 800 mg twice daily.

 

Day of Treatment:

Patient does not wear makeup.

Gentle facial cleansing in office.

Confirmed laser treatment anatomical areas (face, neck, décolletage).

Review home skin treatment regimen (written instructions included).

Look at laser test patch areas (if performed) to assess the absence or presence of hyperpigmentation to guide laser treatment settings.

Application of topical anesthetic cream for 2 hours (7% tetracaine/7% lidocaine).

(Use of Pliaglis (Galderma) topical anesthetic cream appeared to achieve better anesthesia and is easier to remove since it hardens to a thin film)

Blood draw for platelet rich plasma (PRP) centrifugation.

Administration of oral sedation & analgesic medications (hydrocodone 5-10 mg and lorazepam 1-2 mg) 30 minutes prior to treatment.

Topical anesthesia is removed.

Trigeminal sensory nerve blocks are performed. 1-2 cc of local anesthesia is injected into each nerve (supra-trochlear, supra-orbital, zygomatico-facial, zygomatico-temporal, infra-orbital, anterior superior alveolar, and mental nerves bilaterally). Local anesthetic (10 cc) is composed of 4 cc 1% lidocaine with epinephrine, 5 cc 0.25% bupivacaine with epinephrine and 1 cc of 8.4% sodium bicarbonate.

CO₂ laser settings decided.

(This is the most important aspect to optimize treatment outcome) Per physician experience with the specific type of CO₂ laser, the maximum energy settings are chosen given the underlying skin pathology (wrinkle severity/acne scarring) and Fitzpatrick skin classification. Laser energy levels are lower in Darker skin patients to minimize risk of hyperpigmentation. Laser energy levels are higher in severe wrinkle or acne scarring patients to optimize outcome.

 

Immediate Post-Treatment:

Iced moist cold towels (towels soaked in water and placed in freezer for about ten minutes) topical application for about 5 minutes. (previous used all known treatment methods, including a circulating iced facial mask, however, the iced cold towels seemed to be the best option)

PRP (6-7 cc) is mixed with 2 cc of calcium gluconate for activation (not required if injecting).

Topical PRP is placed on the treated area and massaged into the skin.

Moisturizer is placed topically.

Patient is discharged home.

 

Post-Treatment Skin Care Regimen:

Acyclovir 800 mg twice daily for 8 days post-treatment

Sun avoidance (as much as possible)

DAY 1-3

Gentle skin cleanser use twice daily.

Alastin Skin Nectar

Alastin Occlusive Moisturizer (Vaseline or Aquafor alternatives)

DAY 4-14

Gentle skin cleanser use twice daily.

Alastin Skin Nectar

Alastin Moisturizer (non-occlusive moisturizer alternatives)

Alastin Broad Spectrum Sunscreen (SPF 30+ sunscreen alternative)

Day 14 to 6 weeks

Human Stem Cell cytokine cream (Stemulation or Regenica, Suneva Medical)- if chosen by patient in the treatment regimen. Cost sometimes limits addition.

Alastin Moisturizer (non-occlusive moisturizer alternatives)

Alastin Broad Spectrum Sunscreen (SPF 30+ sunscreen alternative)

Week 3-8

If observed hyperpigmentation occurs (most common time to observe start of hyperpigmentation) or at risk patients (Fitzpatrick type III, IV or V), add IS Clinical White Lightening cream at night to resolve or prevent hyperpigmentation.