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Skin Resurfacing
Skin Resurfacing

Skin resurfacing means removal of the upper layer or layers of skin that, with age and time, have become more aged looking. This may be commonly a formation of wrinkles but also directly involves the changes that occur with exposure sunlight, particularly ultraviolet A rays over one’s lifetime. By removing these upper layers of the skin by whatever technique Dr. Perkins recommends (and for the particular area of the face, neck or chest), and with appropriate postoperative care, new surface skin heals from the deeper layers of your own skin.

The result is a more youthful, less wrinkled and certainly less sun damaged appearance. Methods of skin resurfacing range from the use of chemical peels to lasers that remove the upper layers of skin and also create some heat for collagen tightening, and dermabrasion or the sanding of the skin to smooth it out.

Chemical Peels

Chemical peels achieve smoother, less wrinkled skin and alleviate imperfections, such as splotchy coloration and sun spots. Chemical peels are ideal for removing sun damage due to long-term sun exposure in combination with what is called photo aging or aging due to the sun’s ultraviolet A and B rays. It also achieves smoother skin with removal of fine wrinkles, to even medium-depth wrinkles. Peels can be performed on their own or in combination with other facial plastic surgery procedures. Dr. Perkins often performs chemical peels during facelift and blepharoplasty (eyelid) procedures to enhance the patient’s overall surgical results, as the skin will look as youthful as the newly rejuvenated eyes, neck and jawline. State-of-the-art chemical peeling involves choosing the proper chemical peel agent for the needs of each individual patient in the area of the face, neck or chest that most needs to be treated. It is safe and effective when directed by an experienced facial plastic surgeon.

Many surface or superficial peels can be done by skin care specialists, or estheticians. At Dr. Perkin’s office, we have a medical spa (Spa 170 West) with trained licensed estheticians performing light chemical peels and other treatments to the skin’s surface to improve the texture and discolorations. The estheticians use light settings for laser that, with multiple treatments, can improve some fine line wrinkling. In addition, red colors and brown spots can be treated with the same machine at a different setting called Intense Pulsed Light.

These procedures can be done under either topical numbing anesthesia or without the need for anesthetic and help mild degrees of aging skin and discolorations. However, when one is not achieving their desired results from these more superficial treatments, Dr. Perkins would recommend a medium-depth chemical peel, sometimes combining this with laser resurfacing or dermabrasion to get the best desired effect in each and every area of the face, neck and chest.

Whenever Dr. Perkins performs one of these medium-depth procedures or a deeper treatment, they require at least monitored sedation, but most commonly anesthesia administered by an anesthesiologist for a short period of time while the procedure is being performed.

What’s Involved In a Chemical Peel

The chemical peel involves the application of a special mixture of chemicals or a chemical to the skin. This is done after specially preparing the skin to remove any soaps or oils. Light, moderate and deeper peels are available and vary in the strength of their chemical mixture. The lighter and superficial-depth peels are performed by our licensed estheticians at Spa 170 West.

Light peels that our estheticians perform often involve the application of glycolic acid or other lighter chemical peeling agents, such as a combination of fruit acids. Our estheticians also perform lighter percentage treatments of a TCA (trichloracetic acid) peel. Dr. Perkins uses a stronger, medium-strength, TCA chemical peel to achieve a more one-time treatment, effect but it does require anesthesia and at least sedation in order to tolerate this. In the past, phenol mixtures were used frequently but, with lasers, they are used less frequently today. Dr. Perkins, however, does still use phenol as the chemical peel agent for certain areas, such as the crow’s feet and wrinkles under the eyes, as an excellent medium level chemical peel.

Phenol and TCA peels are very good for removal of dyschromias or irregular splotchy pigmentation and light to mild wrinkles of the face. Once the upper layer is peeled off, new skin (the epidermis) will heal fairly rapidly. The epidermis is the surface layer of skin. However, underlying the epidermis, is the collagen layer which becomes damaged and wrinkled with time, creating visible surface wrinkles. Even though much of this improvement is seen quite quickly, further collagen tightening and smoothing occurs over a three-to-four-month period of time.

Chemical Peel Down Time

Patient downtime varies by the depth of the peel. Lighter peels will leave the skin pink for a few hours, or even peel lightly and heal within four to five days. However, while deeper peels can have a healing time of several days (a week to a week and-a-half), the results can be significantly more dramatic. Lighter and medium peels can be thought of as a deep sunburn where the top layer of skin peels, “blisters off” in three to five days, leaving a pink, weepy surface. Within the next two to four days after that, fresh new skin is healed over. The deeper peels take between one and two weeks to heal because re-epidermal resurfacing occurs from sweat and oil glands deep within the dermis of the skin, the thickest and deepest layer of the skin.

Chemical peeling is a true skin rejuvenation procedure, removing precancerous skin cells (which is very important) as well as visible wrinkling and sun damage of the face that is already apparent. The results from a chemical peel can be quite dramatic and are long-lasting. Lighter or medium depth peels may be repeated in the future.

Laser Resurfacing

One of the more common techniques Dr. Perkins uses for resurfacing the skin to treat wrinkling and long-term sun damage is one of two types of lasers to remove the upper layer of skin and tighten the deeper dermis.

Laser skin resurfacing is a procedure confined to the facial area, which is endowed heavily with multiple oil glands and hair follicles for safe and rapid healing. Areas of the neck and particularly the chest that are often quite sun damaged, show precancerous skin cells or thinner skin with less numbers of deeper dermal structures, such as oil glands and hair follicles to resurface the skin. Therefore, laser resurfacing, except on very light settings, is not usually used for the neck or the chest. TCA chemical peel done by Dr. Perkins under a sedation anesthesia is frequently used to improve the texture and appearance of the neck and chest. It is important to use chemical peeling of the neck and chest, particularly the neck, fading up across the jawline of the face to blend the treatment areas from the deeper laser treatment to the more medium depth treatment of the chemical peel on the neck. This assures that the skin tones are as even as possible between the face, neck and chest after removing the sun damaged look to the skin.

The most common type of laser used for skin resurfacing is the carbon dioxide laser which has been around at least twenty-five to thirty years. It has been refined quite a bit over that period of time with improvement in technology. CO2 lasers typically ablate (remove the epidermis and first layer of dermis) using a wavelength of laser light that is absorbed by water within the skin cells. This makes them “vaporize” away immediately, rather than form a layer that peels off as a chemical peel. This creates a second-degree level burn, just like a chemical peel does but, immediately upon the finish of the procedure, the wound is very weepy and oozy. It then will quickly become ready for new epidermis to heal over the surface in the first week.

New technologies with laser resurfacing have added a fractionated component. This means that micro wounds are being made in a very controlled rapid fashion, deeper into the dermis, creating tightening of the collagen deeper into the skin and requiring less ablation of the surface. This allows for slightly more rapid healing than the original CO2 laser but still with dramatically improved results.

Dr. Perkins uses both carbon dioxide laser resurfacing and erbium laser resurfacing. There is a fine tune difference between these lasers, and Dr. Perkins would recommend which would be most appropriate for a patient’s skin type, skin tone and condition of the skin. The erbium laser is a different wavelength and can also be fractionated as well as be used in the ablative fashion. Both techniques are used and still require a week to two weeks of healing for the initial stage. Any resurfacing technique, whether chemical peel or laser resurfacing, has a pink or reddish look to the brand-new skin which lasts several weeks before it fades.

Despite using local anesthesia nerve blocks and infiltration of the local anesthesia to minimize discomfort, laser resurfacing requires general anesthesia or anesthesia administered by an anesthesiologist in order to tolerate the procedure at the depth required to get rid of the significant photo damage and skin wrinkling. These procedures are performed at the Meridian Plastic Surgery Center, an ambulatory surgery center.

Laser Resurfacing Healing

Typical healing from laser resurfacing can be new epithelium within seven days, and in some areas up to ten days. It is important to understand that any resurfacing technique is intended to remove as much wrinkling and sun damaged skin as possible but with total safety. It is not uncommon to have a few residual wrinkles here and there, or a sun spot that may recur, knowing that a secondary procedure could touch this up and make it better. Dr. Perkins always relies on the level of safety in performing these resurfacing techniques.

Scar Revision

One procedure Dr. Perkins uses laser resurfacing for is scar revision. The formation of scars on the face can be emotionally disturbing to the person who has them, especially if they are wide, elevated, depressed discolored or appear long. Severe scars can also diminish or distort normal facial features. Once a scar forms, it is basically permanent, however, scar revision is the surgical procedure that can improve the appearance of unsightly or disfiguring scars. Sometimes scars are required to be made when repairing the wounds after having a skin cancer removed (which Dr. Perkins and his associates perform on a routine basis). Even though those scars are very good scars, they can be improved with laser surface abrasion or dermabrasion.

The goal of surgically treating scars is to make a new scar that will be less noticeable than the previous or present scar: an exchange of a bad or unsightly scar for a better or minimally noticeable scar. Scar revision can encompass surgically removing the scar entirely or a dermabrasion/laser resurfacing procedure to lessen the scar’s prominence and noticeability. These procedures frequently require the patient to undergo some type of anesthesia. This could be a small area only requiring a local anesthetic. or larger areas requiring sedation and local anesthesia, to full-face resurfacing after scar revision, such as for acne scarring, requiring general anesthesia.

Some people present with having had acne as a teenager and young adult and have more permanent scarring from acne. While all of these scars cannot be completely removed, scar revision technique, in this case, often involves laser resurfacing in combination with dermabrasion to make the surface of the skin appear as smooth as possible, even though the scars are not entirely removed.

Patients should always seek out a board certified facial plastic surgeon who performs scar revision and resurfacing on a regular basis and has natural-looking outcomes and happy patients. This type of procedure requires a surgeon with a high skill level and expertise.


Effacing or blending facial scars, whether they be traumatic, acne or surgical scars, can be done with laser resurfacing or a technique Dr. Perkins likes and commonly uses, called dermabrasion. Women will complain to Dr. Perkins that their lipstick “bleeds” into the vertical lines around their mouth. Dermabrasion is a preferential treatment, along with fractionated CO2 laser, for treatment of upper and lower lip vermilion wrinkles to minimize their visibility and lipstick bleeding.

Techniques, such as chemical peel or laser resurfacing are used to resurface and smooth most of the wrinkles of the upper lip, but dermabrasion may be required to get the deepest wrinkles. Dermabrasion is used on top of or in conjunction with laser resurfacing where a deeper layer of treatment is indicated. Dr. Perkins commonly performs CO2/erbium laser resurfacing for fine and medium wrinkles of the upper and lower lips. Dermabrasion is usually required for deeper, etched in lines of the upper and lower lip vermilion and perioral region.

Some people have skin with rough texture and some pitting as a result of acne scarring or scarring from previous soft tissue trauma. These textural problems and visible scarring can be satisfactorily improved with a technique called dermabrasion. Deep wrinkles are also very nicely treated with this deeper resurfacing technique, as the wrinkles come from the deepest collagen layers of the skin. These wrinkles are improved, often dramatically, with dermabrasion.

Dermabrasion is similar to smoothing the surface of a piece of fine furniture or wood; however, a scratch in the wood can be sanded all the way to the deeper level of the wood and the scratches removed, but this is not true of the skin. Acne scarring, for example, comes from the deepest layer of the dermis and sanding all the way through this layer would create scarring itself. Dermabrasion basically refinishes the top layers of skin through controlled scraping or mechanical abrasion to allow the collagen to reorient into a tighter smoother appearance; then it is covered with new epidermis. New skin is healed over this and the scars, although still present, are much less visible and certainly less noticeable, with light shadows. This procedure can be performed alone of in conjunction with other facial plastic surgery.

Dermabrasion is a surgical resurfacing technique in which abrasion is performed to reveal the dermal layer of the skin – which sits between the epidermis (top layer) and deeper subcutaneous tissues. It can also be ideal for removing wrinkles of the lips around the mouth. In fact, dermabrasion for wrinkles around the lips and on the borders of the lips can best be affected in one single treatment by dermabrasion. Dr. Perkins performs “perioral” (area round the mouth) dermabrasion at the same time as facelift to correct these wrinkles. He sometimes performs laser resurfacing of the area and then dermabrasion to treat the deeper wrinkles.