Dr. Bitner is an expert in all different types of skin resurfacing in Salt Lake City, Utah. This includes laser skin resurfacing with a Sciton Erbium:YAG laser, chemical peels or dermabrasion. If your primary complaint is sags or bulges, surgery is usually necessary. If, however, it is wrinkles and creases, then some type of skin resurfacing will be needed. Oftentimes, both surgery and skin resurfacing can be combined to optimize overall results.
As we get older, changes occur in the skin. These changes include loss of elasticity, thinning and increased laxity. Additionally, changes in pigmentation including lighting of some areas and darkening of others occurs. These change are both genetically predetermined and the result of lifetime cumulative sun exposure. Whenever one addresses concerns of facial aging the tool must match the concern. Surgery is used to correct sags and bulges, whereas skin resurfacing is designed to tighten wrinkles and creases, remove age spots and blend the skin tones. Choosing the right type of skin resurfacing for the problem to be addressed requires vision, experience, the right equipment and the skill to address those concerns.
A recent trend in medicine is the appearance of laser centers with non-surgeons simply buying a laser or some other device and opening up a “cosmetic” practice. They typically have a laser sales representative serving as the primary educator on how the equipment should be used. These doctors will often attend a weekend seminar on use of skin resurfacing devices and consider themselves fully trained. This dangerous trend has lead to many cases of ineffective treatment with disappointing results or true disasters. Lasers and other devices are very useful when used properly and for the right problem. Those improperly trained in use of skin resurfacing devices can, at best, waste the patients time and money providing little to no benefit, and, at worst, produce permanent and disfiguring scarring.
Dr. Bitner is extensively trained in the use of the Sciton Erbium:YAG laser. He has either personally performed or participated in performing literally hundreds of procedures. He is also thoroughly trained in the use of deep (Baker’s Phenol Peel), medium (Jessners-Monheit or Jessners-TCA peel) and light (TCA) peels. Dr. Bitner has learned by first-hand experience how to safely use these tools to effectively give the results patients expect.
Laser Skin Resurfacing
Erbium:YAG (Er:YAG) is a laser with a wavelength of 2940 nm. When discussing lasers, the wavelength is very important as it determines the energy delivered and will target specific substances that will absorb the energy. The Er:YAG laser targets water, a component of skin. The energy can be delivered in a very precise pattern and depth.
The Sciton Er:YAG laser is versatile and can be tuned to differing treatment depths. Typical treatment depths range from 20 micrometers to multiple passes at 80 micrometers or more. An additional and unique setting of the Sciton laser is the ability to use not only different depths but different settings. The ABLATE setting is designed to precisely deliver the laser energy just to the outer layer of skin and remove this layer at a specified depth without out causing thermal injury to the surrounding skin. Conversely, the COAGULATE setting, by changing the pulse width and thermal relaxation time, is designed to release more of the laser energy into the surrounding skin/collagen layer. The thermal injury to the collagen layer stimulates collagen production with tightening and firming of the skin. These two different settings can be used individually or combined to produce optimal results. Further, the settings can be altered and the number of passes can be changed to provide for literally thousands of different treatment results.
Laser skin resurfacing, when done for deeper wrinkles, is very painful and generally needs to be done under some type of anesthesia. Dr. Bitner performs this procedure in his office-based surgical suite with the assistance of a nurse to administer IV medications. The face is completely numbed with local injection. The patient is not put completely to sleep, but sedated enough to be comfortable. The treatment takes about an hour. Laser ointment is applied. Recovery requires 7-10 days where the patient is asked to wash their face and apply the ointment many times a day. Once healed the skin is new and may remain red or pink for an extended period of time (many weeks to even months).
Deep Chemical Peel (Baker’s Peel)
A deep chemical peel is done with agents designed to both remove the outer layer of skin and injure the underlying collagen layer. The result is to smooth and remove deep creases and wrinkles. The agents used are very toxic and are, in fact, designed to burn the skin. As such, this must be done in a very controlled and precise fashion. The Baker’s Phenol Peel is a mixture of Phenol, soap, Croton oil and water. This combination of substances enable not only a very controlled injury of the outer layer of the skin, but also deep penetration into the dermis producing maximum collagen production and subsequent tightening.
This procedure is done under anesthesia with IV sedation. The face must be injected and anesthetized in order for the patient to tolerate this procedure even with sedation. The face is first thoroughly cleaned with water. The oils are then removed from the surface of the skin by cleaning with acetone. The peeling agent is then carefully applied. The face is divided into segments and only one segment at a time is peeled, due to the toxic nature of the Phenol. This procedure also takes about an hour to complete.
After the procedure, laser ointment is also applied and the patient is awakened from anesthesia. The care routine after the peel is similar to that for laser skin resurfacing.
Jessner’s-Monheit (Jessner’s-TCA) Peel
This peel is classified as a medium depth chemical peel. The concentration of the Tri-cholor-acetic acid (TCA) can be varied in strength from 10-35%. Both of these agents have been used independently for many years as light peels. When used in combination, the overall effect is to produce moderate skin tightening and blending of pigment irregularities. The benefit of a medium depth peel is to provide excellent tightening with a shorter recovery period than the deep peel. Additionally, risk of causing permanent lightening of the skin or hypopigmentation is reduced with this medium depth chemical peel.
Most patients require some form of sedation for the Jessner’s-TCA peel. The skin if first cleaned with sterile water and alcohol. The Jessner’s solution is then applied and a light frosting of the skin is observed. Once the frost has cleared, the TCA solution is applied. A more intense frosting of the skin results. Laser ointment is then applied and the care instructions are given, similar to the laser peel. The recovery period generally lasts between 5 and 7 days, depending on the concentration of TCA used.
The Jessner’s-TCA peel is an excellent peel to be used on the neck and chest. The characteristics of the skin on the neck and chest differs from that of the face. As such, lasers and deep peels can not be used. Jessner’s-TCA peel using 15% TCA is ideally designed for use on the chest. This peel helps to even skin tones on the chest, correct pre-existing sun damage and gently tightens wrinkles. The risk of scarring or permanent skin color irregularities is almost non-existant when using the 15% TCA peel.
The principles upon which dermabrasion functions are the same as those for all types of skin resurfacing. The outer layer of the skin is removed. The underlying collagen layer is injured thereby stimulating the healing process. During the healing process, the injured collagen layer strengthens, reorganizes and tightens.
Dermabrasion is literally sanding of the skin. During the procedure, the irregular edges of a scar or wrinkle are abraded down until the entire surface is evened. The depth of abrasion is carefully controlled to produce maximal injury with minimal risk of scarring.
This procedure can be performed with the patient awake, especially when only small segments will be dermabraded. The skin is injected to numb and constrict blood vessels. Special care is taken when dermabrading around the nose and ears. Dermabrasion can not be performed on the eyelids.
Dermabrasion is best used for facial scarring from acne or accidents. It is also the technique of choice for a condition called rhinophyma. Rhinophyma generally occurs in older men where the sebaceous glands of the nose grow excessively. This causes a large, porous appearing nose. Correction of rhinophyma can be done in the office with or without sedation.
The healing process from dermabrasion usually involves frequent application of laser ointment and heals within 7-10 days. The care routine for dermabrasion is similar to that of other types of skin resurfacing.