Comparison With Other Surface Modalities

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With the proliferation of a- and b-hydoxy acids, various retinoids, numerous antioxidants, microdermabrasion, and numerous peels, it would be the height of arrogance to describe my particular regimen. Every practitioner in the field will find his or her favorites. I would, however, propose a simple "Resurfacing Ladder" which may help place these methods in a useful context for both practitioners and patients.

At the base of the "Resurfacing Ladder" are methods described as Level I. This level refers to modalities that affect only the epidermis. Included here, in my opinion, would be glycolic acid home treatments as well as micropeels, retinoids and other topicals, microdermabrasion, and superficial erbium-YAG resurfacing.

Level II methods may include trichloroacetic acid (TCA) and certain other peels, as well as deep erbium-YAG resurfacing. These methods penetrate into the superficial papillary dermis, have limited recovery downtime and post-inflammatory erythema, and are generally felt to be most useful in treating dyspigmentation.

Level III methods include CO2 resurfacing, phenol peels, and dermabrasion. Because of deeper penetration to or beyond the papillary-reticular junction, these manifest longer recovery and post-inflammatory erythema, as well as increased risk of scarring or pigmentary changes. They also produce the most significant improvement with regard to superficial rhytids, acne scars, and solar elastosis. I believe that CO2 resurfacing has effectively replaced the other two modalities in this level, but whether or not you agree, this algorithm may be useful in your consultation room. This simple approach permits every practitioner the ability to adapt it to his or her own preferences and needs.

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