Cosmetic

Side Effects and Complications of VariablePulsed Erbium:Yttrium-Aluminum-Garnet

Laser Skin Resurfacing: Extended Experience
with 50 Patients
Elizabeth L. Tanzi, M.D., and Tina S. Alster, M.D.
Washington, D. C.

Recent advances in technology have provided laser surgeons with new options for cutaneous laser resurfacing.
Despite its popularity, there is limited information on the
short-term and long-term side effects and complications
of variable-pulsed erbium:yttrium-aluminum-garnet
(erbium:YAG) laser skin resurfacing. The purpose of this
study was' to prospectively evaluate postoperative wound
healing, side effects, and complications of multiple-pass,
variable-pulsed erbium:YAG laser skin resurfacing for facial photodamage, rhytides, and atrophic scarring. Fifty
consecutive patients with facial photodamage, rhytides, or
atrophic scarring were treated with a variable-pulsed erbium:YAG laser. Side effects and complications relating to
postoperative healing, erythema, and pigmentary changes
were tabulated. Patients were evaluated at postoperative
days 3 through 7 and at 1, 3, 6, and 12 months after laser
skin resurfacing. The average time for reepithelialization
was 5.1 days. Prolonged erythema (>1 month) was observed in three patients (6 percent). Transient hyperpigmentation occurred in 20 patients (40 percent), with an
average duration of 10.4 weeks. No cases of hypopigmentation or scarring were seen. In summary, a variablepulsed erbium:YAG laser can safely be used for the treatment of facial photodamage,
rhytides, and atrophic
scarring. Although more postoperative erythema is seen
after variable-pulsed erbium:YAG laser treatment than is
usually produced with a short-pulsed erbium:YAG system, the side-effect profile and recovery period after
variable-pulsed erbium:YAG laser skin resurfacing still
are more favorable than after multiple-pass carbon dioxide laser skin resurfacing.
(Plast. Reconstr. Surg. Ill:
1524, 2003.)

sue, resulting in controlled vaporization.' Associated residual thermal injury in the dermis
initiates collagen shrinkage and remodeling.v "
Although other methods of cutaneous resurfacing such as dermabrasion and chemical
peels are still in use, the clinical results they
typically produce do not equal those of controlled laser vaporization.?:"!
Laser systems currently available for cutaneous resurfacing include high-energy pulsed
and scanned carbon dioxide, short-pulsed erbium:YAG, and "modulated" (variable-pulsed
erbium:YAG or combined
erbium:YAG/
carbon dioxide) systems. Although carbon
dioxide laser skin resurfacing
has been
shown to effect excellent clinical improvement of facial photodamage,
rhytides, and
atrophic scars,6-8,l2-16it is associated with an
extended reepithelialization
period and, in
some cases, prolonged erythema that may
persist for several months.Fr'" More important, the potential for delayed-onset, permanent hypopigmentation
may be seen in as
many as 20 percent of patients following multiple-pass carbon dioxide laser treatment."
In response to these disadvantages, other laser systems were developed in an attempt to
limit the prolonged recovery period and potentially high morbidity of these procedures.
The short-pulsed erbium:YAG laser was approved for cutaneous laser resurfacing by the
Food and Drug Administration in 1996. The
2940-nm wavelength emitted by the erbium:

Cutaneous laser resurfacing has revolutionized the treatment of facial photodamage, rhytides, and atrophic scarring. Based on the principles of selective photothermolysis, cutaneous
resurfacing lasers target water-containing tis-

From the Washington Institute of Dermatologic Laser Surgery. Received for publication February 5, 2002.
DOl: 10.1097/01.PRS.0000049647.65948.50
1524

Vol. 111, No. 4 /

ERBIUM:YAG

LASER RESURFACING

YAG laser corresponds to the peak absorption

coefficient of water and is absorbed 12 to 18
times more effectively by superficial, watercontaining cutaneous tissue than the 10,600-nm
wavelength of the carbon dioxide laser.s! Shortpulsed (250 /-Lsec)erbium:YAGlasers reliably ablate 5 to 15 /-Lmof tissue per pass at a fluence of
5 J/cm2, producing a residual zone of thermal
damage not exceeding 15 /-Lm.22,23These findings
are in contrast to the changes observed after
carbon dioxide cutaneous laser resurfacing,
which produces 20 to 60 /-Lmof tissue ablation
and up to 150 ius: of residual thermal damage
per pass. As a result of precise tissue ablation and
a limited zone of thermal damage, short-pulsed
erbium:YAG laser treatment results in faster
reepithelialization and an improved side-effect
profile compared with carbon dioxide cutaneous
laser skin resurfacing.24-27 Because of these advantages, it was initially postulated that the
short-pulsed erbium:YAG laser system would
completely replace the carbon dioxide laser as
a resurfacing tool; however, this initial enthusiasm was tempered by poor intraoperative hemostasis and the system's limited ability to
effect significant collagen shrinkage. 8,22
To address these limitations, modulated erbium:YAG laser systems were developed to improve hemostasis and increase the amount of
collagen shrinkage. With extended pulse durations up to 500 /-Lsec,variable-pulsed erbium:
YAGlaser systems combine tissue ablation with
induction of dermal collagenization by means
of controlled thermal injury." Despite the increasing popularity of variable-pulsed erbium:
YAG laser skin resurfacing treatments, there is
limited information documenting the shortterm and long-term side effects and complications of this procedure. The objective of this
study was to prospectively evaluate postoperative wound healing, side effects, and complications of multiple-pass, variable-pulsed erbium:
YAG laser skin resurfacing for the treatment of
facial photodamage, rhytides, and atrophic
scarnng.
MATERIALS

AND METHODS

Fifty consecutive patients (47 female and

three male, aged 21 to 71 years, skin phototypes I through V) with moderate-to-severe facial photodamage, rhytides, or atrophic scars
were included in the study. Five patients (10
percent) reported dermabrasion to the involved areas more than 3 years before study
initiation. Eleven patients (22 percent) had

1525
received collagen injections in the remote past.
Three patients (6 percent) had undergone a
full face lift more than 5 years before the study.
Two patients (4 percent) had undergone fullface carbon dioxide laser skin resurfacing 6
years previously, and one patient (2 percent)
had received a phenol peel more than 5 years
before the study.
Each patient received laser treatment in an
outpatient surgical facility by a single surgeon
(T.S.A.) with a dual-mode sequential ablation/
coagulation pulsed erbium:YAG laser (Contour; Sciton, Palo Alto, Calif.). Cutaneous anesthesia was obtained with regional nerve
blocks using 1% lidocaine with 1:200,000 epinephrine. For full-face procedures, intravenous anesthesia was administered by a certified
nurse anesthetist using a combination
of
propofol, midazolam, fentanyl, and ketamine.
The laser was calibrated to 90-/-Lmablation
(22.5 J/cm2) and 50-/-Lmcoagulation using a
square scanning handpiece with 50 percent
overlap to vaporize the epidermis in a single
pass over the entire face. An additional one to
two regional passes were delivered using identical laser settings to treat residual rhytides or
scars. Laser scans were placed adjacent to one
another without overlapping, thereby preventing char formation. Partially desiccated skin
was thoroughly removed with saline-soaked
gauze between each laser pass, producing skin
with a clean, pale-pink hue with minimal to no
bleeding. The partially desiccated tissue remaining from the final laser pass was left intact
to serve as a biological wound dressing.
Immediately after treatment, Aquaphor ointment (Beirsdorf, Inc., Wilton, Conn.) was applied to the irradiated skin. Each patient was
instructed to perform gentle facial rinses with
dilute acetic acid soaks several times daily, followed by application of Aquaphor and a cooling mask (SkinVestment, Inc., Washington,
D.C.). A 10-day course of prophylactic antiviral
treatment (valacyclovir 500 mg two times per
day) was prescribed beginning on the day of
surgery. Patients were observed closely during
the first postoperative week, during which time
any residual coagulated debris was gently loosened and/or removed with cool compresses.
All patients were able to apply camouflage
makeup within 7 to 10 days postoperatively.
The patients were evaluated daily during
postoperative days 3 through 7, and at 1, 3, 6,
and 12 months after laser skin resurfacing. The
presence and duration of side effects and com-

PLASTIC AND RECO STRUCTIVE SURGERY, Aprill,

1526
plications were recorded at each postoperative
patient visit (Fig. 1). If prolonged erythema or
hyperpigmentation was noted, the patient was
evaluated every 2 weeks until its complete resolution. Daily use of topical 5% glycolic acid
(M.D. Forte; Herald Pharmacal, Inc., Colonial
Heights, Va.), and/or 0.1 % Nfurfuryladenine
(Kinerase; ICN Pharmaceuticals,
Aurora,
Ohio), and/or
kojic acid/lactic
acid mix
(KojiLac-C; Young Pharmaceuticals, Wethersfield, Conn.) was prescribed for patients with
hyperpigmentation,
as were biweekly to
monthly 30% glycolic acid peels that were performed in-office until the dyspigmentation was
corrected (Fig. 2).
RESULTS

The average time to reepithelialization (defined by the absence of serous discharge and
the presence of new skin) was 5.1 days. Post-

2003

treatment erythema was seen in all patients

studied; however, it persisted longer than 1
month in three patients (6 percent). Postinflammatory hyperpigmentation was observed at the
J-month follow-up visit in 20 patients (40 percent), predominantly in those patients with
darker skin tones. Total resolution of dyspigmentation was noted within an average of 10.4 weeks.
Mild acne occurred in eight patients (16 percent) during the first postoperative week, presumably because of the use of occlusive ointment. All cases of acne were easily controlled
with oral minocycline (75 mg two times per day
for 1 week). Five patients experienced milia (10
percent) and dermatitis was noted in three patients (6 percent), the latter condition resolving
with the use of a mild topical corticosteroid
cream. No cases of herpetic or fungal infections
were encountered; however, nine patients (18
percent) experienced limited superficial bacte-

FIG. 1. (Above, left) Photodamaged skin before laser skin resurfacing. (Above, right) Three days after variable-pulsed erbium:
YAG laser treatment, superficial bacterial infection was suspected and confirmed with cultures. (Below, left) Mild erythema without
evidence of residual infection was seen after 1 week on oral antibiotics. (Below, right) Prolonged clinical improvement was noted
12 months postoperatively.

Vol. 111, No. 4 /

ERBIUM:YAG

1527

LASER RESURFACING

FIG. 2. (Above, left) Moderate atrophic scarring on the cheeks of a man with skin phototype N. (Above, right) Complete
reepithelialization and mild erythema wa~noted 1 week after variable-pulsed erbium:YAGlaser treatment. (Below, left) Hyperpigmentation evident at 1 month postoperatively resolved with the use of topical bleaching creams and light glycolic acid peels
by the third postoperative month (below, right).

rial infections that responded fully to oral ciprofloxacin (500 mg two times per day for 5 days).
No hypopigmentation or hypertrophic scarring
was observed in any study patient throughout the
12-month study period (Table I).
DISCUSSION

Laser skin resurfacing has become one of

the most popular techniques for the treatment

of cutaneous photodamage, rhytides, and atrophic scars." Although previous reports have
documented the efficacy of modulated erbium:
YAG laser skin resurfacing for these indications,30-37limited data exist concerning the frequency, severity, and duration of side effects
and complications associated with its use.
The immediate postoperative recovery period and incidence of prolonged erythema are

TABLE I
Side Effects of Variable-Pulsed Er:YAGLaser Treatment"

Skin Type

I
II
III
IV
V

Total

Prolonged
Erythema

Hyperpigmcntation

Infection

Acne

Milia

Dermatitis

20
16
7
5
2
50

2
1
0
0
0
3 (6%)

2
4
7
5
2
20 (40%)

4
3
1
1
0
9 (18%)

3
4
1
0
0
8 (16%)

2
2
1
0
0
5 (10%)

1
1
1
0
0
3 (6%)

* Er:YAG, erbium-yttrium-argon-garnet.

Hypopigmentation

0
0
0
0
0
0

Scarring

0
0
0
0
0
0

1528
more favorable with variable-pulsed erbium:
YAG laser treatment than with cutaneous carbon dioxide laser resurfacing. Prolonged erythema occurs in a significantly large number of
patients following multiple-pass carbon dioxide laser skin resurfacing.6,17-20 In the present
study of 50 patients treated with a variablepulsed erbium:YAG laser, reepithelialization
was complete in an average of 5 days, and only
three (6 percent) cases of prolonged erythema
were seen. In a split-face comparison of 16
patients following pulsed carbon dioxide and
variable-pulsed erbium:YAG laser skin resurfacing, Rostan et aP6 reported decreased erythema, less edema, and faster healing on the
side treated with the erbium:YAG laser.
Postinflammatory hyperpigmentation
is not
uncommon following cutaneous laser resurfacing.8,17-20 Jeong and Kye34 documented hyperpigmentation in eight of 35 patients (23 percent, skin photo types III through V) treated
with a variable-pulsed erbium:YAG laser for pitted acne scars. Similarly, 40 percent of our
patient -predominantly
those with darker
skin tones-developed
hyperpigmentation. All
cases of hyperpigmentation
responded completely to a combination oflight chemical peels
and topical bleaching creams. Although hyperpigmentation
following variable-pulsed erbium:YAG laser skin resurfacing can last longer
than that seen after treatment with a shortpulsed erbium:YAG laser, it is not as persistent
as that observed after multiple-pass carbon dioxide laser resurfacing
(average: variablepulsed erbium:YAG laser, 10.4 weeks; carbon
dioxide laser, 16 weeks) .17,22,37
Delayed-onset, permanent
hypopigmentation is a serious complication of any type of
laser skin resurfacing procedure and often
takes several months to develop. To date, there
have been only three published cases of hypopigmentation
as a consequence of variablepulsed erbium:YAG laser treatment.Y'" Although hypopigmentation was not observed in
our study population at the I-year follow-up
evaluation, additional confirming studies are
warranted to assess its true incidence.
In conclusion, variable-pulsed erbium:YAG
laser skin resurfacing is relatively safe for facial
photodamage, rhytides, and atrophic scarring.
The variable-pulsed erbium:YAG laser offers
several advantages over short-pulsed erbium:
YAG laser systems, including improved intraoperative hemostasis and visibility and enhanced
clinical outcomes. Although the reepithelial-

PLASTIC AND RECONSTRUCTIVE

SURGERY,

April 1, 2003

ization process and the persistence of postoperative erythema after variable-pulsed erbium:
YAG laser resurfacing are more prolonged
than those seen following short-pulsed erbium:
YAG treatment, the overall side-effect profile
and recovery period' are more favorable than
after multiple-pass carbon dioxide laser resurfacing. In addition, and of particular importance in the treatment of patients with darker
skin tones, the postinflammatory
hyperpigmentation seen with variable-pulsed erbium:
YAG laser skin resurfacing is less persistent
than that observed after treatment with the
carbon dioxide laser.
Tina S. Alster, M.D.
Washington Institute of Dermatologic Laser Surgery
2311 M Street, N. W, Suite 200
Washington, D. C. 20037
talster@skinlaser.com
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