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In our study of Fraxel treatments, topical anesthetic (compounded betacaine, lidocaine, or tetracaine) was carefully applied approximately 1 hour before treatment, ensuring that the topical anesthetic did not get into the eyes After removal of the anesthetic, an optical tracer dye was applied and the patients were treated with the SR 750 device at uences ranging from 8 to 20 mJ Either 125 or 250 MTZ/cm2 and a total of 1000 to 2000 MTZs were administered in each area in alternating passes that varied by 90 degrees in orientation until all passes were completed In general, the higher the energy provided, the lower the density and the total number of MTZs There was no observable association between
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5: Periorbital Rejuvenation
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and two to three passes are typically made, ensuring adequate time for skin cooling between passes Pulse stacking must be avoided Metal corneoscleral protective lenses should be placed behind the eyelids during this procedure As with any fractional resurfacing procedure, four to ve treatments are required to achieve best outcomes Treatments are usually spaced 2 to 3 weeks apart but this interval may be varied to accommodate scheduling needs
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After the operation, patients used cold compresses and kept their eyelids moist with a bland ointment such as petrolatum jelly until the wounds healed and makeup could be reapplied Aggressive use of sunblock is encouraged on all treated areas Products such as retinoic acid and its derivatives, glycolic and other fruit acids, and other agents commonly associated with irritation and dermatitis are usually avoided until the eyelids return to normal
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Figure 56 (A) Before fractional skin resurfacing of the eyelids using the Fraxel SR 750 (B) 1 month after four Fraxel SR 750 treatments (Note smoothing of ne wrinkles, improvement of skin texture, and even modest skin tightening)
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PLASMA SKIN RESURFACING OF THE EYELIDS Background
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For patients with moderate to severe degeneration or photoaging of the eyelids whose goal is to achieve skin tightening, smoothing of eyelid and periorbital rhytides, and improvement of dyspigmentation, a more aggressive treatment approach is required While ablative techniques may be appropriate for some of these patients, many would accept a more modest improvement in return for a greater safety pro le than traditional CO2 In an effort to achieve this objective, a recently completed study evaluated plasma skin resurfacing of the eyelids Plasma skin resurfacing involves creation of highenergy gas via the delivery of a pulse of ultra high frequency RF, which excites a tuned resonator, imparting energy to a ow of inert nitrogen gas When the plasma is delivered to the skin, rapid molecular energy transfer occurs with transmission to dermal layers The depth of effect is determined by the amount of energy delivered per pulse Differences between plasma skin resurfacing and laser skin resurfacing techniques include lack of chromophore dependency and maintenance of the structural integrity of treated tissue after delivery of plasma
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total energy delivered and amount of postoperative edema and erythema Superimposing passes and skip areas were carefully avoided Metal corneoscleral protective lenses were used (Oculo-Plastik, Montreal, Canada) for all treatments, and the entire upper eyelid, lower eyelid, and lateral canthal region was treated Systemic sedation or analgesics were not required (Figure 56) Another fractional resurfacing device known as the Af rm (Cynosure Inc, Chelmsford, MA) has also been used successfully on the eyelids This device delivers a 1440-nm beam that is separated via a diffraction grating into individual microspots The depth of injury produced by this device is approximately 300 microns, corresponding to the observed depth of solar elastosis observed histologically, following treatment Topical anesthesia is not required with this device and epidermal protection is provided via forced cold air When used to treat the eyelids, energy settings of 3 to 5 J/cm2 are typically employed Two to three passes are usually applied, keeping the thin lid skin on stretch so as to ensure even distribution of energy Spots are overlapped by 20% to 30%
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