Both of these methods are indicated for the treatment of static wrinkles. The depth of the wrinkle, skin type, and recovery time after the procedure may influence the choice of either method. Usually, patients with a fair complexion benefit from laser resurfacing. Patients with a dark complexion may present hyper- and/or hypopigmenta-tion. Due to skin quality, it is more common that patients with fair and sun-damaged skin may present full-face wrinkling and should be treated first with a skin resurfacing method to decrease the number of rhytides. After 3-6 months, biodegradable fillers may be injected into deeper wrinkles and folds. The degree of collagen remodeling that occurs following laser treatment varies according to laser aggressiveness and levels of enzymes, such as collagenases, which must have stabilized before any biodegradable product is injected. The appropriate time for commencement of collagen treatment is when the erythema subsides.
Some patients who cannot schedule the required recovery time may find fillers a nice method for improving the appearance of wrinkles and scars until the time is appropriate for laser resurfacing.
Patients with darker skin are not suitable for aggressive laser resurfacing and should undergo lighter methods with lasers. For these patients, the combination of a mild exfoliative methods and fillers are quite appropriate. Skin resurfacing should improve skin quality, and fillers should be used to treat deeper defects. Since mild exfo-
liative methods do not promote natural collagen remodeling, both procedures can be done in the same session.
Fillers must be seen as the primary therapy when the deep dermis is compromised. In contrast, laser resurfacing is the first method to be used for superficial rhytides and sun damage. For complex scars, both methods should be used, even though the results are not long lasting. If any resurfacing method reaches the deep dermis, scar tissue may result. Fillers injected too superficially into rhytides may result in nodule formation and cause irregularities in the skin. When full-face resurfacing is performed, laser resurfacing of the nasolabial fold may decrease its depth if it was a superficial crease, because it tightens the skin from both the cheek and upper lip. Aggressive therapy may result in scar tissue formation. Patients with deep nasolabial folds may benefit from combination therapy with fillers and laser. As a rule, the injection of fillers into the dermis should not be carried out until laser-induced collagen remodeling has ceased. If injection of nonbiodegradable fillers or fat transfer are to be carried out in the subdermal layers (fat or muscle), it may be possible to combine them in the same session. Fillers should be injected immediately before laser resurfacing is begun. Vertical lines of the upper and lower lip benefit from laser resurfacing. Results can be quite impressive. If partial improvement is obtained, fillers can be used after the laser resurfacing to achieve better results (Fig. 7.1).
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