Fully Ablative Laser Resurfacing
(CO2 & Erbium YAG) - London and Surrey
Co2 laser resurfacing is by far the most powerful skin rejuvenation technique available for facial skin.
It is performed in order to:
- Completely renew facial skin
- Tighten the skin to help reduce the consequences of laxity
- Remove wrinkles
- Improve elasticity and skin thickness
This is a facial laser surgical procedure 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 CO2 and Erbium YAG laser are the same. This is a fully ablative CO2 laser or fully ablative Erbium YAG procedure that is only performed by a handful of experienced laser surgeons worldwide. It needs to be performed using a surgical-grade CO2 and Erbium YAG laser (not an aesthetic grade CO2/Erbium YAG laser which lacks the power and the ultra-short pulse width required to perform this procedure safely). Dr Hussein is one of the few laser surgeons worldwide who have the knowledge and the experience to offer this procedure and has performed numerous cases. He uses the Lumenis Ultrapulse CO2 and Sciton Joule X Erbium YAG laser. These are the world’s most powerful and state-of-the-art skin resurfacing lasers
As you will see from the photos below Dr Hussein is capable of performing what few others worldwide are capable of. The level of skin rejuvenation is simply outstanding.
This degree of improvement will, however, require minimum 14 days at home. At this point you are safe to resume normal chores and activities and medically fit for work. However there will be ongoing redness, inflammation, grainy (orange peel) skin texture and possible hyperpigmentation. It takes 3 months for this to settle completely. So even though you are technically fit for work at 2 weeks it will take 3 months for everything to settle completely and full healing and benefits to be seen.
Dr Hussein can perform a full-face treatment including eyes OR periorbital treatment (around the eyes only). Eyelid tightening treatment with fully ablative CO2 technique is the second most effective technique to reduce eyelid laxity after a surgical blepharoplasty. For clients who are not keen on surgical blepharoplasty, fully ablative CO2 eyelid treatment will give a considerable improvement for eyelid skin laxity and wrinkles. It actually improves lower lid wrinkles and skin surface texture over and above surgical blepharoplasty.
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. As long as the client takes good care of their skin results will last for many years before they need to consider doing anything further.
New type 3 collagen continues to be synthesized for up to 6 months post-procedure meaning that there is further improvement after the immediate healing phase. Dr Hussein is capable of performing laser resurfacing with fully ablative CO2 and Erbium YAG laser on all skin types. In general, darker skin types may encounter a higher chance of hyperpigmentation but this will eventually settle.
DR HUSSEIN’S CASE GALLERY – BEFORE & AFTER
Once the patient has seen Dr Hussein for a consultation and treatment has been deemed appropriate the client will be listed for the procedure. During the consultation, a prescription for prophylaxis will be discussed, once the procedure is scheduled a online prescription for the laser pack including the medications will be organised and purchased prior to procedure.These medications are to be used as instructed by Dr Hussein during the immediate few days 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 patient has somebody available to drive them home after the procedure is performed. Clients must not expect to drive back home themselves.
Dr Hussein will see the patient before the procedure in order to prepare and clarify things. A consent form will be signed giving Dr Hussein permission to carry out the procedure. Antiviral tablets will be then administered as well as an optional sedative. Pre-procedure photos will be taken at the initial consultation, if pre procedure photos have not been taken they will be at this point, the face will be cleansed and prepared with a special type of topical local anaesthetic gel. Dr Hussein will also use additional anaesthetic techniques such as tumescent anaesthesia or nerve blocks. These involve injections of a special type of local anaesthetic under the skin.
Anaesthetic preparation will last for about 45 minutes. Following this, the patient will be moved into the procedure room and prepared for the fully ablative CO2 or Erbium YAG laser procedure. If treatment around the eye area is to be performed then the patient will have had anaesthetic eyedrops applied and metal contact lens style eye-shields will be inserted. If the facial treatment only is performed then 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 patients to have both treatments performed in the same session.
Once Dr Hussein has commenced the procedure it 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 Hussein 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.
Following the completion of the procedure, the patients face will feel very hot. It is best described as a sunburn sensation. This burning sensation will last for up to 24 hours before settling. Following removal of protective eye-wear, a barrier cream called CU3 cream or Eucerin Aquaphor cream is applied to the freshly treated skin. This cream acts as an impermeable barrier to protect the denuded skin from dehydration and infection.
Detailed aftercare instructions will be discussed and issued to the patient. 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. Sunscreen can only be used from at least a month after procedure (see details below in aftercare instructions)
Patients 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 Hussein usually gives a once a day antibiotic dose to minimise bacterial infection risk. There will also be a twice a day antiviral tablet as well. These tablets are to be continued for 14 days after the procedure. There will also be a pack containing medications for use ONLY if instructed to do so by Dr Hussein.
Dr Hussein will typically monitor day by day healing via the VIRTUAL WARD ROUND. This is through the use of ‘selfie’ photos taken by the client and sent to the contact details issued by Dr Hussein. Dr Hussein can then provide real-time advice during the first 14 days of the recovery period. Any patient having this procedure will have a direct line of communication with Dr Hussein at all times throughout recovery. Close monitoring of this nature allows any potential complications to be dealt with quickly and risks minimised.
After 14 days patients can return to work. There will still be some ongoing redness that will take a 12 weeks to settle.
Aftercare instructions must not be ignored by patients otherwise they may develop permanent scarring and textural change of the skin. A brown pigmentation on the treated areas of the face (post-inflammatory hyperpigmentation) can occur but this will spontaneously resolve. Hyperpigmentation can be minimised through sun avoidance.
Fully ablative CO2 resurfacing is the most aggressive type of skin resurfacing procedure undertaken by Dr Hussein. As Dr Hussein is an expert in cutaneous laser surgery the incidence of side effects is low. In Dr Hussein’s hands fully ablative CO2 laser is a safe procedure.
However with any laser resurfacing treatment complications are possible. In fully ablative CO2 laser these include the following:
Post Inflammatory Hyperpigmentation (skin darkening)
This is the most common side effect. It is more common on darker skin types. Thankfully it usually spontaneously improves. Improvement can be speeded up by the addition of topical treatment. Duration usually 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 CO2 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 CO2 resurfacing as the new skin is repopulated with new melanin producing cells from the deeper adnexal structures which are a reasonable distance away from the treated surface of the skin. If true hypopigmentation occurs, it can take many months to recover and can indeed be permanent.
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 Hussein usually prefers to avoid part treatment for this reason and will treat the whole face albeit with a variable strength 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 acyclovir tablet three times daily for 7 days during the recovery period. Bacterial infection prophylaxis is also issued by Dr Hussein in the form of a once daily antibiotic tablet taken for 7 days after the procedure. Fungal infection is also a possibility and as a result Dr Hussein will include medications in the aftercare pack to treat this should it occur. It is however only necessary to start these if Dr Hussein 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 Hussein monitors the healing closely with the use of ‘selfie’ photos daily for the first week.
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 Hussein on direct photo monitoring in the first two weeks post treatment. The second reason is due to a thermal injury directly created from the laser (burn). This is extremely unlikely due to Dr Hussein’s level of experience and expertise as well as the state of the art equipment that he uses. Some procedures carry a naturally greater risk of scarring. These are procedures where the CO2 and Erbium YAG laser are used in combination for really deep resurfacing. These procedures are mentioned below:
Peri-oral combined deep resurfacing
Resurfacing for deep wrinkles around the mouth. To efface these wrinkles required deep combined laser resurfacing that naturally carries a higher risk of hypertrophic scarring.
Combined deep resurfacing for acne scars
Where there are deeper acne scars in the skin, resurfacing depth needs to be pushed. This is commonly on the cheeks. Here there is a naturally greater risk of delayed healing, atrophic or hypertrophic scaring and hypopigmentation.
Cribiform / cicatricial scarring
This is a textured raised scarring that forms a web like pattern on the skin. It occurs very rarely in cases of delayed healing and prolonged inflammation post laser resurfacing. It is slightly more common on the forehead. It has been noted during COVID that mask wearing increases the incidence of this type of scarring. This is why DrH strictly forbids the use of any masks for 3 months after laser resurfacing.
Ectropion (Applies only to eyelid treatments)
This is a treatment in which the eyelid skin is over-tightened. It can lead to eversion 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 CO2 laser every client will experience this to some degree. It tends to progressively settle and generally tends to takes up to 3-4 months to completely settle. 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 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 Hussein can advise on suitable products.
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 sugery. 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.
Capsules as a treatment for severe acne
Severe acne treatments capsules are often cited as a potential danger with regards to laser procedures. The risk of hypertrophic scarring increases when it comes to laser resurfacing when on this medication. The difficult question is how long after cessation of the medication, is laser resurfacing safe to proceed with. Historically there has been a consensus that 6 months is the safe margin. However a growing body of evidence shows that this is far greater than necessary. In his clinical experience Dr H deems it safe to perform full ablation following a 3 month period after cessation. It is also to be noted that if the medication needs to be commenced post resurfacing it should be done no earlier than 3 months post resurfacing and in a low dose longterm course.
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. Immediate and very 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 CO2 laser may also be used for acne scar remodelling but it is a considerably less powerful technique.
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 5 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 Hussein will advise on how to manage this.
- At the end of 10 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.
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 and Aquaphor cream. These are the only two things that should be used to maintain the healing skin over the next 4 weeks. There are also medications in the pack and you will be instructed on how to use these.
Full Ablation – Stage 1 face care (Day 1 to Day 28 post surgery)
Products – Dermol and Aquapor/Vaseline
Face wash after full ablation – General
After fully ablative laser the face should be washed twice a day. The first wash should be on the morning after surgery. From then the face should be washed in the morning on waking and before going to bed at night.
Twice daily face wash should be performed (morning and evening). The purpose of washing the face twice a day is to remove the residue that builds on the face as it slowly oozes serous fluid. This serous fluid tends to drip from the chin and crystallizes into a yellow crust/residue. Facewash removes this residue and the antiseptic agent in the facewash (benzylkonium chloride) reduces any microbial build up on the face. Face washing is important to minimise the risk of infection after fully ablative laser.
Face washing must not be performed more than twice a day. It is tempting to do this when the residue builds up throughout the day. However washing more than twice a day results in unnecessary trauma and irritation of the skin. This then increases inflammation and slows the healing process. By reducing the speed of healing we increase the probability of infection.
It is imperative that you wash your face twice a day. No more and no less.
How do I wash my face?
Facewash should be performed in the shower under running lukewarm water. The water must not be hot. Test it on the back of your hand as you would test temperature for a baby. Washing your face in the sink is not adequate as it is difficult to remove residue by throwing water up at your face. Check that the shower water pressure is reasonable and that the temperature is lukewarm. Rinse the face using copious amounts of shower water. Then apply about a tablespoon of dermol facewash and massage all over the face. Leave on the face for a minute to a minute and a half. It will sting and this is normal. After this period rinse off the dermol wash with plenty of warm shower water. Pressure of face massage should be enough to remove the crystalline residue.
Drying the face
It is possible to dry the face with a disposable paper towel or disposable kitchen roll. You must not use a regular towel as this is not clean enough. If you wish you can allow the face to air dry.
Many patients naturally feel that washing hair should be avoided. Failure to wash hair allows build up of potentially infective debris along the hairline. This will increase the risk of infection after the procedure. Hair can be washed while standing in the shower. With your back to the shower tilt your head backwards and rinse the hair with copious amounts of lukewarm shower water. Then apply shampoo taking care to minimise shampoo foam application to the face but to also ensure that the hairline adjacent to the face is cleaned appropriately. Rinse shampoo backwards. This can be done by tilting the head backwards as if you were having your hair washed at a hairdresser.
Application of Aquaphor or Plain Vaseline (Petroleum Jelly)
The only substance that should be applied to your skin after full ablation for the first month after surgery is Aquaphor OR Vaseline. These two products are safe and the risk of irritation, inflammation and delayed healing is minimal with these products. They create an occlusive barrier over the face that stops it from drying out. This moist occlusive environment favours regeneration and healing of the skin. Aquaphor is less greasy than Vaseline and this will be contained in your laser pack. In around one percent of cases patients may suffer with contact allergy to Aquaphor. The patient usually notices this when there is persistent stinging, burning and discomfort after application. Normally Aquaphor should soothe the skin. In this case Dr Hussein will recommend switching to Vaseline. Remember Aquaphor and Vaseline are to be used for a whole month following surgery. Application of any other moisturisers or healing balms is strictly forbidden. Enough Vaseline or Aquaphor should be applied to the face to ensure good coverage of all lasered areas including the eyelids. It is unnecessary to apply overly thick layers. As it is normal for your face to ooze and be greasy as a result of Vaseline or Aquaphor you should use a clean towel over your pillow when you sleep. Change this towel daily for the first 10 days post surgery.
Sun cream / SPF
Laser procedures and application of sun cream following the procedure usually go hand in hand. Fully ablative laser is an exception to this. This is because the outer barrier layer (epidermis) has been entirely removed. Sun cream is only designed to be applied to healthy intact skin with an epidermal layer. As are most over the counter creams. Having lost this natural barrier temporarily after full ablation your skin will react adversely if suncream is applied too early. It will cause contact irritant dermatitis (a harmful inflammatory reaction to the skin). If this occurs your healing will be delayed. In darker skin patients early application of sun cream is more likely to cause inflammation and hyperpigmentation. It should therefore be avoided for at least one month post full ablation. Once sufficient settling has occurred Dr Hussein will advise sun cream to be started. This will never be earlier than one month. Excessive sun should be avoided. If you are going to develop hyperpigmentation after laser it will occur irrespective of sun cream application. You cannot prevent this from happening. However sticking rigidly to your aftercare instructions will ensure a quicker recovery. Remember sun avoidance NOT sun cream.
Patients often ask about special healing creams such as Cicalfate, Bio oil, Sudocrem, Bepanthen, Biafine, Flammazine or Silicone based gels. These are all strictly to be avoided for a total of three months after surgery. Full ablation is a very specific type of laser surgical procedure. Use of these products before three month will increase the chances of developing permanent scarring. It is imperative that you adhere closely to instructions without experimentation. Silicone based dressings such as kelocote or Stratacel will cause scarring if applied in the first three months.
Mask Wear (Covid masks)
Masks for protection against Covid transmission are strictly NOT to be worn for 3 months after the procedure. It may seem like a good idea as it hides the embarrassing redness after surgery. Use of masks in this 3 month period will lead to a inflammation, folliculitis and a fine web like scarring on the face (cicatricial scarring). This type of scarring is permanent if untreated. DO NOT WEAR A MASK FOR THREE MONTHS. DrHConsult will provide you with a mask exemption letter if necessary. Please note it is now not a legal requirement to wear a mask in the United Kingdom.
Shaving with a razor should be strictly avoided within the first month post full ablation. Electric shavers that rub against the skin with rotary or oscillating heads should also be avoided. From day 14 post surgery a beard trimmer may be used lightly every few days if necessary. Razor shaving may be tentatively commenced 6 weeks after your procedure.
Full Ablation – Stage 2 face care (week 5 to week 12 post surgery)
Face can now be washed normally in sink or shower with a facewash such as Avene Cleanance or Cetaphil Gentle Cleanser. Warm water (not hot) should be used otherwise you will increase redness after washing.
If you are disciplined enough use of Aquaphor or Vaseline should continue for as long as possible throughout this period. It is common however to begin to become tired of the excessive greasy appearance caused by these barrier ointments. You may therefore attempt to switch to CeraVe Facial Moisturiser Cream in the morning after facewash. It is important to hydrate the skin even though you may not have used a moisturiser prior to the procedure. Failure to do this will increase inflammation and redness. Skin sensitivity is still high during this period and it is entirely possible to develop sensitivity/allergy/contact irritant dermatitis to moisturisers and sun cream. You will be able to tell if this is the case as your skin will become red, itchy, bumpy and a burning or stinging sensation will be felt. Despite the offending moisturiser or sun cream you will feel dry and tight rapidly. If this issue develops be prepared to switch back to Vaseline.
In the evening before bed and after washing it is still advisable to use Aquaphor, Vaseline or Neova CU3 copper peptide healing cream.
Products: Aquaphor, Vaseline Petroleum Jelly, Neova CU3 copper peptide cream
You may tentatively start to use sun cream at week 5. Be prepared to stop using it if you develop irritation or allergy. There is no gain from protecting against the sun by invoking an allergic reaction. If you are a darker skin type hyperpigmentation is in fact more likely in this case. If sun cream irritates the face stop applying it. Continue with a default basic routine of Aquaphor or Vaseline only. If you manage to tolerate sun cream well then it is fine to apply it morning time after moisturiser.
Sun creams – La roche posay antihelios 50
Foundation/Tinted moisturiser/Anti-redness creams
It is usual at this stage to become fatigued by redness or in darker skin types, to feel self-conscious because of post inflammatory hyperpigmentation. It is normal for patients to wish to camouflage this. The risk and benefit of any product must be assessed. If that product irritates the skin redness and post inflammatory hyperpigmentation will be prolonged by its use. So the short term gain that is won through camouflage is lost by prolonging the pigmentation or redness issue. You will still be under close supervision and only a message away from the DrHConsult team at this stage. So make sure to alert the team if you believe you are experiencing a problem when commencing these types of products.
Foundation – Lycogel Camouflage Foundation (requires colour matching) Contains SPF 50
Tinted SPF – Skinceuticals UV protection 50 tinted / Heliocare tinted SPF
Anti-redness – Lycogel green tint foundation for redness / Eucerin anti-redness green tint
Full Ablation – Stage 3 face care (Week 12 onwards post surgery)
In over 95% of cases patients will be able to re-instate their normal face care routine at this point. Actives can be cautiously re-introduced. Glycolic or salicylic acid exfoliators can be re-introduced. Niacinamide and anti-oxidants such as Vitamin C can also be re-introduced. Dr Hussein will conduct a 3 month in clinic (where possible) review. After photos will usually be recorded at this stage as now is the time where healing should be complete enough to make accurate before and after assessment. Dr Hussein will happily discuss you skin care routine at this point and can make appropriate recommendations.
Wash face with Avene Cleanance soapless gel cleanser. Apply Avene Hydrance Optimal Light moisturizer. 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. 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.
Wash face with Avene Cleanance face wash Apply Avene Cicalfate cream.