Clinical Procedures in Laser Skin Rejuvenation - part 2 pot

INDICATIONS The most common uses for laser skin resurfacing are to treat wrinkles and acne scars of the face.. Box 3.1 Indications for laser skin resurfacing• Photodamage • Rhytids • Acn

Among the absolute hallmarks of an aging face are the

changes associated with the skin The most common

changes associated with facial skin aging are those due

to photoaging (skin damage related to chronic sun

exposure) This results in dyspigmented, wrinkled,

inelastic skin, with associated redness and dryness

Furthermore, mild to moderate facial wrinkling and

laxity with benign and malignant lesions round out the

skin changes that should be addressed through many of

the techniques presented in this book See Tables 2.2

and 2.3, which show the Fitzpatrick and Glogau

classi-fications of skin types and wrinkles respectively

VOLUME LOSS

It is easy to overlook this particular component of facial

aging Since surgical procedures reposition and lift, it is

only natural, but incorrectly, assumed that the cause ofthat descent is skin laxity and gravity However, on fur-ther examination, evaluation, and analysis, it is clear thatdescent and laxity can result from volume loss As illus-trated in Figure 2.3(a), a fully inflated balloon appearsrobust and lacks contour abnormalities However, asseen in Figure 2.3(b), a deflated balloon has the poten-tial to not only descend, but also become deformed.Thedifference between Figure 2.3(a) and 2.3(b) is nota gen-eral laxity of the balloon’s tarp, but rather the volumeinside the balloon Reinflating the balloon, as opposed

to repositioning the tarp, is responsible for eliminatingall of those identifiable features

Likewise, many of the features that we will discussbelow are in part due to a loss of volume, and oneshould train one’s eyes to appreciate that volume loss inthe following areas: the temporal fossa, the lateralbrow, and the malar eminence Furthermore, volumeloss may be seen in the lips and perioral region Finally,

it should be appreciated that overall loss of volume in

Table 2.2 Fitzpatrick skin types

I Caucasian; blond or red hair, freckles, Very sensitive Always burns easily, never

II Caucasian; blond or red hair, freckles, fair Very sensitive Usually burns easily, tans with

III Darker Caucasian, light Asian Sensitive Burns moderately, tans gradually;

fair to medium skin tone

IV Mediterranean,Asian, Hispanic Moderately sensitive Rarely burns, always tans well;

medium skin tone

V Middle Eastern, Latin, light-skinned Minimally sensitive Very rarely burns, tans very easily;

very dark skin tone

Table 2.3 Glogau wrinkle scale

1 no wrinkles Early 20s or 30s Early photoaging: early pigmentary changes, no keratoses, fine wrinkles

2 wrinkles in motion 30s to 40s Early to moderate photoaging: early senile lentigines, no visible keratoses,

the subcutaneous tissue can make certain bony features

much more prominent along the infraorbital rim,

as well as the submandibular triangle, wherein the

submaxillary gland appears quite prominent

CHIN POSITION

The next step in the facial analysis process is to assess

the location of the chin in relationship to the patient’s

lower lip as well as the surrounding tissue One should

look for the appearance of jowling, chin ptosis, chin

retrusion, submental fat accumulation and severe

neck skin laxity Following the path of the mandible

posteriorly, the next assessment is the general berance and width of the angle of the mandible.Atrophy and medial displacement of the angle of themandible or atrophy of the masseter muscle can in factcontribute to a narrow and withdrawn facial contour.The nasolabial lines are now assessed for their pres-ence and degree, as well as for the contribution made

protu-to these lines by pprotu-totic skin and subcutaneous tissuesuperior to them In my experience, the presence of anasolabial fold is less due to ptosis of the malar fat padthan to atrophy of the malar fat pad with resulting pto-sis (see the balloon concept illustrated in Figure 2.3)

of the resulting subcutaneous tissue Elevation of themalar tissue superiorly and slightly posteriorly assesses

Fig 2.3 Two identical balloons.The one in (a) is inflated and is rigid and wrinkle-free.The one in (b) is partially deflated, itssurface contains ripples, like wrinkles, and it is lax and subject to deformation from wind or gravity Human skin is like the tarp

on these balloons Fully inflated skin appears youthful and robust Deflated skin sags and reveals wrinkles and furrows

the degree of laxity, as well as the overall effect of

repositioning this tissue to efface the nasolabial line

and to reinflate the malar mound

PERIORAL REGION

The lips are now evaluated for the prominence of the

white roll, the philtral ridge, and robust red lips The

maxillary teeth should be visible and the mandibular

teeth hidden.White lip wrinkles are also assessed

PERIORBITAL REGION

Finally, attention is then directed towards the

peri-orbital region Signs of upper lid ptosis are identified

and documented Lower lid laxity and position are

identified and documented Brow position is similarly

considered Unlike the current trend of repositioning

the brow cephalically, I find that a lower placed brow

in both women and men, in combination with a more

robust lateral brow fullness, provides a sophisticated

and ageless appearance An overly elevated brow does

not convey youth It conveys surprise.The absence and

presence of forehead, glabellar, and periorbital rhytids

are evaluated and documented Lower lid

pseudo-herniation of fat is noted, as is the presence of an

infra-orbital hollow The degree of nasojugal depression is

documented, and photographs taken at an earlier age

are reviewed to ascertain which of the facial features

were present in youth and which were subsequently

acquired with aging

SUMMARY

Technical expertise, however important to obtainingexcellent and consistent results, is only part of theequation The wrong technique performed flawlesslywill typically reveal a result that is below par, whilethe correctly chosen procedure performed just satis-factorily typically results in acceptable if not extra-ordinary results We can only recommend the mostsuitable procedure if we perform a thorough and accu-rate analysis, and that analysis includes not only anassessment of the patient’s facial features, but alsotheir desires, expectations and their notions on whichprocedures they feel most comfortable with to getthere.Therefore, proper and thorough analysis is para-mount for it will lead us to selecting the most appro-priate treatment plan and consequent results for anyindividual patient and thus predictable and consistentoutcomes

Nevertheless, analysis cannot be learned in a uum Analysis inevitably requires that we compare itwith an idealized version, and even then it requires us

vac-to understand the pathophysiology by which we got vac-tothat point, and then we must correlate those findingswith a suitable treatment

PLAN

Knowledge in all of these domains and re-exploring all

of these disciplines are essential parts of our growth asphysicians

Although skin resurfacing has been performed for

centuries in the forms of chemical peels, sanding, and

dermabrasion, it was not until the 1990s that lasers

were safely and effectively used as a resurfacing tool

Initially, carbon dioxide (CO2) lasers with a

wave-length of 10 600 nm (1006µm) were used as a

destructive tool Technology advanced quickly in the

1990s from continuous-wave CO2lasers to pulsed

CO2 lasers to help minimize the thermal damage

produced by the older CO2 lasers Ultrashort pulse

technology emerged, as did computerized pattern

generator (CPG) scanning devices that allowed for a

more standardized delivery of the laser pulses

Because of the prolonged healing required and the

risks associated with CO2lasers, the erbium : yttrium

aluminum garnet lasers (Er:YAG) lasers with

stronger water absorption (2940 nm) and less

ther-mal damage were developed Er:YAG lasers proved

to be excellent ablative tools, with shorter healing

times, but did not provide the same tightening that

was achievable with CO2 resurfacing The next

advance came in the form of erbium lasers with

longer pulse widths that could provide more heating

and thermal damage in the skin The short-pulsed

erbium lasers were combined with CO2 lasers and

long-pulsed Er:YAG lasers to try to blend the

bene-fits of shorter healing times with more substantial

skin tightening

Attempts to improve the laser resurfacing

tech-nique continue to be studied, with a concentrated

effort now looking at nonablative options to induce

dermal remodeling and fractionated skin resurfacing

to minimize the risks from skin ablation and to shortenthe healing times for patients This chapter will focus

on ablative resurfacing, with an understanding that theprinciples behind good patient selection and care willremain paramount despite continued changes in thelasers that might be developed

INDICATIONS

The most common uses for laser skin resurfacing are

to treat wrinkles and acne scars of the face Any dermal process should improve with laser resurfacing,including lentigines, photoaging, actinic keratosis,and seborrheic keratosis (Box 3.1) Some dermallesions, such a syringomas, trichoepitheliomas, andangiofibromas, will improve with laser resurfacing,but results will vary with the histologic depth of theprocess In our experience, there is a high recurrencerate with dermal lesions Actinically induced disease,including actinic keratosis (AK) and actinic cheilitis,can respond very well to laser resurfacing Superficialand nodular basal cell carcinomas have been success-fully treated with the UltraPulse CO2laser The curerates achieved by Fitzpatrick’s group was 97% inprimary lesions (mean follow-up 41.7 months).1Inaddition, the use of laser resurfacing may be used pro-phylactically to reduce the risk for the development offuture AK and AK-related squamous cell carcinoma.2

epi-Prevention of some basal cell carcinomas may beachieved, although this has not been definitivelydemonstrated.3

3 Carbon Dioxide Laser Resurfacing, Fractionated

Resurfacing and YSGG Resurfacing

Dee Anna Glaser, Natalie L Semchyshyn and Paul J Carniol

Box 3.1 Indications for laser skin resurfacing

• Photodamage

• Rhytids

• Acne scars

• Benign adenexal tumors

• Benign epidermal growths

Despite the multiple uses, by far the prime use in

our office is for the improvement of facial photoaging,

rhytids, and acne scars.To date, ablative laser

resurfac-ing is the most efficacious technique we have to treat

perioral rhytids (Fig 3.1)

PATIENT SELECTION

The key to successful laser resurfacing is properpatient selection (Table 3.1) Potential candidatesneed to have a realistic expectation of the outcome,risks, and significant amount of time required to heal,

as well as the time to see the final results The ‘ideal’patient has fair skin with light eyes, has no history ofpoor wound healing, and is comfortable with wearingmake-up during the postoperative healing period.Thehistory should specifically address issues that relate towound healing, such as immunodeficiency, collagenvascular diseases, anemia, diet, scarring history,keloid formation, recent isotretinoin usage, and pastradiation therapy to the area The history shouldinclude the patient’s general health, current or pastmedications, and mental health issues Diseasesknown to koebnerize are also a relative contraindica-tion – these include psoriasis, vitiligo, and lichenplanus Diseases that reduce the number of adenexalglands or alter their function are relative contraindi-cations and need to be reviewed – these include colla-gen vascular diseases such as systemic lupuserythematosus and scleroderma A history of herpes,frequent bacterial infections, or frequent vaginalcandidiasis is not a contraindication, but should benoted to better plan how to treat the patient duringthe perioperative period

Equally important is to ascertain the pigmentresponse of the patient (in terms of hyperpigmenta-tion or hypopigmentation) to sun exposure or injuries

In our experience, patients with Fitzpatrick skin type

IV are some of the most challenging to treat due totheir risks of postoperative dyschromias Patients willneed to avoid sun exposure for several months afterthe surgery, and the physician needs to document thepatient’s ability to do so along with their ability to usebroad-spectrum sunscreens daily In the Midwest ofthe USA, with four distinct seasons, it is preferable

to perform deep resurfacing procedures during thewinter months to minimize sun exposure However, athorough review of a patient’s travel plans during the3- to 4-month healing period then becomes impor-tant Although most patients recognize the risks of atrip to a warm sunny destination, many may under-estimate the risks with higher altitudes such as withsnow skiing

Fig 3.1 Significant reduction in perioral rhytids

at 4 months

a

b

Preoperative care

The preoperative care should begin at the time that the

patient decides to undergo laser skin resurfacing

Photoprotection and prevention of tanned skin should

be maximized before surgery Melanocyte stimulation

before the laser resurfacing may increase the risk of

postinflammatory hyperpigmentation after the

proce-dure.A sunscreen with a sun protection factor (SPF) of

30 or higher should be used daily, along with an

ultra-violet A (UVA) blocker such as zinc oxide, titanium

dioxide, or avobenzone We advise patients to

supple-ment sunscreen use with physical measures such as

large sunglasses and hats

The use of topical therapy before surgery is

com-mon – this might include topical tretinoin,

hydro-quinone and antioxidants It is clear that the use of a

topical retinoid is quite valuable before skin

resurfac-ing with chemical peels through its action on the

stratum corneum and epidermis The use of topical

tretinoin can increase the penetration of the peel,

pro-vide a more even peel and enhance healing.4,5Due to

the high affinity for water with the CO2and Er:YAG

lasers, these lasers are very capable of evaporating the

epidermis without the use of tretinoin There may be

other effects that could theoretically improve the laser

resurfacing process and healing Retinoids regulate

gene transcription and affect activities such as cellular

differentiation and proliferation They can induce

vascular changes of the skin and a reduction and

redistribution of epidermal melanin.6 Retinoids (at

least theoretically) can speed healing and perhaps

reduce pigmentary changes Thus, it is our practice tobegin a topical retinoid at least 2 weeks prior to theprocedure – even earlier if possible

Because of the relatively common development ofpostinflammatory hyperpigmentation after laser resur-facing, especially in the darker skin tones, many physi-cians will pretreat with a bleaching agent such ashydroquinone (HQ) HQ works by inhibiting theenzyme tyrosinase, which is necessary for melaninproduction within the epidermis It can also inhibit theformation of melanosomes There is a clear role for

HQ products after laser resurfacing to treat mentations; this will be discussed later in the chapter

hyperpig-HQ may not have any clinical effect when used prior

to laser surgery, since the melanocytes that it is ing on are all removed during the laser procedure It iscertainly not unreasonable to initiate HQ in a 3–5%cream for those patients at high risk for developinghyperpigmentation after their procedure Like thetopical retinoids, it can be irritating and should be dis-continued if it is causing an irritant dermatitis A rareside-effect of HQ is exogenous ochronosis, but thisusually occurs only with prolonged use of higher con-centrations and should not develop even in predis-posed individuals within just a couple of weeks.7

work-There is no proven role for the use of topical oxidants, alpha-hydroxy acids, or beta-hydroxy acids,but they are often in the skin care regimen of patientsand we do not discontinue their use prior to laserresurfacing

anti-Tobacco smoking can delay wound healing, andpatients are strongly encouraged to stop tobaccouse.As an alternative, if the patient is unable or unwill-ing to stop smoking at least 2 weeks prior to the

Table 3.1 Patient selection

Unable/unwilling to perform wound care Tendency to poor wound healing/scar

Isotretinoin therapy within prior 6–12 months History of radiation therapy in area

History of collagen vascular disease History of vitiligo

Diseases that koebnerize (e.g., psoriasis) Pregnancy/breastfeeding

Unable/unwilling to avoid sun exposure postoperatively

procedure, he or she is encouraged to switch to a

tobaccoless product such as a patch or gum

The use of oral antiviral therapy is standard practice,

even if the patient does not have a history of herpes

simplex virus (HSV) infections Typically, famciclovir

or valacyclovir is used in prophylactic doses such as

famciclovir 250 mg twice daily or valacyclovir 500 mg

twice daily Doses need to be adjusted for renal

dys-function.The patient begins therapy the day before the

procedure and continues until re-epithelialization

is complete It can be helpful to keep antiviral therapy

in the office to administer to the patient if he or she

forgot to initiate therapy before the procedure

The use of prophylactic systemic antibiotics is of

questionable value prior to surgery and remains

con-troversial.8A first-generation cephalosporin is typically

used by one of us (NLS), while no antibiotics are

rou-tinely used by the other (DAG) Interestingly, recent

animal studies have shown that CO2laser resurfacing

reduces microbial counts of most microorganisms on

lasered skin compared with skin treated using

mechan-ical abrasion.9On the other hand, nasal mupricin is

routinely prescribed (by DAG) for healthcare workers

due to the current high rates of methicillin-resistant

Staphylcoccus aureus(MRSA) in hospitals and nursing

homes Unfortunately, the incidence of MRSA in the

community is also increasing, and MRSA may be

encountered in non-healthcare workers.10,11Surgeons

should monitor their local communities for

recom-mendations regarding community-acquired MRSA

There have been no published studies on the use of

antifungal therapy prior to laser resurfacing, although

Candidainfections can develop during the

postopera-tive period, especially when occlusive dressings are

used It has been our practice, and that of others, to

treat women with a known history or frequent or

recurrent vaginal candidiasis with oral fluconazole

after the procedure, even when using open healing

techniques.9

Botulinum toxin is routinely administered to our

patients prior to laser resurfacing of the face

Placebo-controlled studies have demonstrated improved results

when compared with laser resurfacing alone.12,13

Pre-operative use of botulinum toxin type A can diminish

rhytids as well as textural, pigmentational and other

features of skin aging when used in conjunction with

laser resurfacing.13Our preference is to treat at least 2weeks prior to laser surgery and repeat at approxi-mately 3 months postoperatively

Patients are given instruction sheets listing skincareitems they will need after the procedure along withtheir prescriptions for postcare medications Thesewill be discussed later in the chapter

Laser resurfacing

Before coming into the office for their procedures,patients are instructed to wash their face well Afterdrying, they apply a topical anesthetic cream such asEMLA (a eutectic mixture of lidocaine 2.5% andprilocaine 2.5%) under occlusion with a plastic wrap.This is left intact for 2–2.5 hours One of us (NLS)will reapply the topical anesthetic 45 minutes prior tothe procedure The EMLA not only helps to providecutaneous anesthesia, but also hydrates the skin, whichdecreases the procedure’s side-effect profile.14Furtheranesthesia or analgesia can be obtained with nerveblocks, local infiltration of lidocaine, tumescent anes-thesia or diazepam, and, in our office, intramuscularmeperidine and midazolam, or ketorolac, is used Thetopical agents are removed prior to beginning the laserprocedure

When using the UltraPulse CO2 laser (Lumenis,Santa Clara, CA), the face is treated at 90 mJ/45 W,and the first pass is usually performed at a density of 7for central facial areas (periorbital, glabellar, nose, andperioral): the upper and lower eyelids are treated at adensity of 6 with the energy setting at 80 mJ.The den-sity should be decreased to 6 and then 5 when feather-ing to the hairline and jawline The first pass isintended to remove the epidermis, which is wiped freewith a wet gauze in the central facial areas only, and asecond pass is performed to central facial areas at adensity of 4–5 (90 mJ), depending on the tighteningneeded If required, the second pass on the eyelids isperformed at a density of 4 Energies are decreasedtowards the periphery of the face A third pass may beneeded in areas of acne scarring or in the perioralarea with deeper wrinkles As with any laser proce-dure, careful monitoring of tissue response duringtreatment is performed to determine the necessity ofany additional passes and energy level used

A similar approach is taken when using one of the

combined Er:YAG lasers such as the Sciton laser (Palo

Alto, CA).The first pass is used to remove the

epider-mis and frequently 25 J/cm2(100µm ablation, zero

coagulation) with 50% overlap is used A second or

third pass is used to heat and hopefully to induce skin

tightening Ablative and coagulative settings are used

with a typical second, pass and a commonly used

set-ting would have 50% overlap with 10µm ablation and

80µm coagulation

Where there are very deep rhytids or scars, the

erbium laser in just the ablative setting can be used in a

single spot to help sculpt the edges It is important to

remember that when used in the ablative mode, there

is very little (if any) hemostasis, and pinpoint bleeding

can help identify the depth of resurfacing

Laser resurfacing is best done to the entire face

to avoid lines of demarcation between treated and

untreated skin The procedure should be carried into

the hairline and at the jaw and chin; a feathering

tech-nique should be used This includes a zone of

decreased energy, decreased density, or pulse

over-lap When treating a patient with moderate to severe

photodamage, it is important to blend into the neck

as much as possible One approach is to lightly

resur-face the neck with a chemical peel; in our office, a

Jessners and/or glycolic acid peel is used Another

option is to laser the neck, which will be reviewed

later in the chapter

Postoperative care

Wound care is critical, and regimens vary among

physicians Occlusive and nonocclusive dressings are

available Occlusive dressings cover the skin and are

usually removed in 1–3 days These can decrease

patient discomfort, but may promote infection by

har-boring bacteria or yeast When opaque, the dressings

can mask visualization of the wound, thus delaying the

detection of an infection Clear dressings (e.g., Second

Skin) allow the patient and medical team to look at the

lasered skin When used in our office, they are most

commonly removed on the second day postoperatively

and the patient is switched to open healing

Open dressings or nonocclusive dressings are

usu-ally petroleum-based ointments Frequent soaking and

cleaning are necessary (at least 4 times daily), followed

by frequent application of petroleum jelly, Aquaphorointment or one of the many wound care ointmentsthat are available Additives, fragrances, or dyes willincrease the chance of contact allergic or irritant der-matitis developing and should be limited as much aspossible In very sensitive individuals, pure vegetableshortening can be used Dilute vinegar can be used tosoak and debride the wound, promote healing, andinhibit bacterial growth

Wound care needs to be performed until epithelialization is complete Depending on the type oflaser used and how aggressive the surgeon was with his

re-or her settings, re-epithelialization should be completewithin 5–10 days Prolonged healing times canindicate an infection, contact dermatitis, or otherproblem, and increases the risks of complications

COMPLICATIONS AND THEIR MANAGEMENT

Complications following laser surgery are relativelyinfrequent, but when they do occur, they need to betreated quickly and efficiently to minimize patientanxiety and long-term morbidity.15Obviously, goodpatient selection, surgical management, and postoper-ative care are necessary to help prevent complications,but, even in the best of cases, complications do occur(Box 3.2)

Box 3.2 Complications of ablative laser resurfacing

• Activation of herpes simplex virus (HSV)

The most common complications seen immediately

postoperatively are swelling and exudative weeping

related to the degree of wounding If facial swelling

is severe, oral or intramuscular steroids, and non

steroidal anti-inflammatory agents (NSAIDs) can be

administered Milia formation is common, with the

development of small white papules, usually < 1mm

in size, which need to be distinguished from pustules

Papules are an occlusive phenomenon, and will

resolve without treatment

Infections can occur, and may be bacterial, viral, or

fungal in nature (Table 3.2).16 Signs and symptoms

include pain, redness, pruritus, drainage (usually not

clear), yellow crusting, and sometimes erosions,

vesi-cles or pustules may develop (Fig 3.2) Pruritus,

espe-cially, should alert the physician to a possible infection

Appropriate evaluation may include tzanck smear,

potassium hydroxide (KOH) prep, gram stain, and

cultures to accurately diagnose the causative agent

Treatment should begin early, pending culture results

Fitzpatrick’s group found that half of their patients

who developed a post-laser infection had more than

one microorganism Thus, broad coverage should be

initiated, and should generally include an agent that

will cover Pseudomonas aeruginosa

Acne is another complications that can be seen

rela-tively early in the course Oral antibiotic therapy and

discontinuation of petroleum-based ointments usually

suffice Topical acne therapies are not generally well

tolerated, due to skin sensitivity, and need to be usedjudiciously

Contact dermatitis can occur, and may be due to anallergic reaction or an irritant reaction It may occurwithin the first few weeks or months after laser resur-facing Redness, pruritus, and delayed healing may benoted, but vesiculation is rare Topical antibiotics are

a common cause of allergic contact dermatitis, andshould be avoided Patients may be using them withoutthe knowledge of their physician Topically appliedagents should be reviewed and discontinued Dyes andfragrances that are added to laundry detergents, fabricsofteners, and skincare items are also potential causes.Discontinuation of the offending agent(s) and topicalcorticosteroids should be initiated early.17

Table 3.2 Causative agents encountered in CO2laser

Fig 3.2 A postoperative infection at day 3, with redness,edema, yellow drainage and crusting, and pustules.Thepatient noted increasing discomfort and pruritus

a

b

PIGMENTARY ABNORMALITIES

Hypopigmentation

Lightening of the skin is desirable for most patients

undergoing facial rejuvenation Patients who undergo

resurfacing of cosmetic units such as the perioral area or

periocular area may exhibit a noticeable difference

between the ‘new’ treated skin and the untreated skin

that exhibits the various dyschromias associated with

photoaging This should be avoided as indicated

previ-ously, but when faced with such a patient, treating the

remaining skin will lighten the hyperpigmentation and

help to blend in the differences.Although topical agents

such as retinoids and hydroquinones can be used, visible

results take months and are not practical for most

patients Resurfacing is the fastest way to improve

patients’ appearance in these cases Depending on the

severity, a chemical peel such as a Jessner’s/35%

trichloroacetic acid (TCA) peel may be sufficient, or

laser resurfacing can be performed Superficial

resurfac-ing is all that is required for most, and the Er:YAG laser

is an excellent device.The goal is to remove the

epider-mis, and one or two passes maybe all that is required

This heals rapidly and with minimum risks

In the very sun-damaged patient, it may be difficult

to find a good stopping point In these instances,

treat-ing the full face may only accentuate the discoloration

of the neck Light rejuvenation of the neck can be

done, but may accentuate the damage to the chest

Light resurfacing can be performed down the neck and

chest area, extending onto the breast – but this may

then accentuate the damage to the arms and forearms,

etc In these patients, a combination of modalities can

be used: topical agents as described above for the

entire area; laser resurfacing of the face; lighter

resur-facing of the neck and chest (we generally use

chemi-cal agents such as 20–30% TCA or 70% glycolic acid,

but Er:YAG laser resurfacing is used successfully by

many physicians); and chemical resurfacing of the

arms, forearms, and hands with 20–30% TCA or 70%

glycolic acid

Another option is the use of nonablative laser

tech-nology such as the ‘Photofacial’ technique Several

intense pulsed light (IPL) systems are now available,

which use a broad-spectrum intense pulsed light

source with changeable crystals attached to the

hand-piece to filter out undesirable wavelengths Thismodality has been applied to the face, neck, chest, andupper extremities Numerous treatment sessions arerequired, but are generally well tolerated, with little

to no ‘healing-time’ for the patient.The fluence varieswith skin type and area, but the neck is generallytreated more conservatively and using lower fluences

It is important that the operator carefully place the ters to avoid overlapping and also to prevent skippedareas or ‘footprinting’

fil-Depigmentation

True depigmentation of the skin following laser facing is more difficult to treat than the pseudohypo-pigmentation described above The skin acquires awhitish coloration and does not flush or change colorwith normal sun exposure (Fig 3.3) A slight texturalchange can even be noted at times such that make-updoes not ‘stick’ to the skin well or does not last as long

resur-as make-up applied to other areresur-as The latter sents superficial scarring or fibrosis It can occur afterany form of resurfacing, but it is more commonlyencountered with CO2laser resurfacing and is muchless common with Er : YAG resurfacing Like pseudo-hypopigmentation, depigmentation seems to be more

repre-Fig 3.3 Persistent depigmentation 2½ yearsfollowing CO2laser resurfacing that was performed in theperioral area only

evident when cosmetic units are treated individually

or when a cosmetic unit such as the upper lip is treated

more aggressively than the surrounding skin

Depigmentation has been considered a permanent

complication of CO2laser resurfacing.When evaluated

histologically, there is a varying quantity of epidermal

melanin present Residual epidermal melanocytes are

present, indicating that repigmentation should be

pos-sible Mild perivascular inflammation has been noted

in 50% of biopsies, and superficial dermal fibrosis was

present in all biopsies.18This suggests that the

patho-genesis of the laser-induced hypopigmentation may be

related to a suppression of melanogenesis and not

complete destruction of the melanocytes

Grimes et al18have reported successful treatment of

hypopigmentation following CO2 laser resurfacing

using topical photochemotherapy twice weekly.18Seven

patients were treated with topical 8-methoxpsoralen

(0.001%) in conjunction with UVA therapy Moderate

to excellent repigmentation was demonstrated in 71%

of the patients Using the same reasoning, narrowband

UVB and an eximer laser may both be effective

Narrowband UVB, which emits at 311–312 nm, has

been reported to be efficacious for vitiligo, while

excimer lasers emit at 308 nm and can be targeted

to a given site.19Alexiades-Armenakas et al20 have

reported two patients who were treated for

laser-induced leukoderma using an excimer laser They

speculate that repigmentation is related to the

stimu-lation of melanocyte proliferation and migration,

along with the release of cytokines and inflammatory

mediators in the skin

Potential disadvantages of any of these therapies,

however, include the time necessary to see

repigmenta-tion, cost, erythema and pruritus during therapy, and

hyperpigmentation of skin immediately surrounding

the treated skin, which can take months to return to

normal Unfortunately, the results are mixed, and

return to baseline can occur after therapy is

discontin-ued Repigmentation has been an unrealistic goal, and

until more data are available on investigative tools such

as phototherapy, an honest discussion must take place

with the patient Additional resurfacing of the

unaf-fected skin may be helpful to reduce any hyper

pigmen-tation or dyschromia if present, but will only help to

reduce the differences with adjacent areas Once again,

care should be taken not to re-treat too aggressively

Scarring

The development of scarring following laser surgery isperhaps the most feared and distressing complicationencountered Deeper wounds are more likely to result

in scarring, which is not usually encountered unlessthe wound extends into the reticular dermis.However, since this is the level that is generally tar-geted with the CO2laser to eradicate wrinkles, acnescars, and varicella scars, cosmetic surgeons will befaced with scarring if they perform enough proce-dures Hypertrophic scars can develop anywhere, butare most likely to occur around the mouth, chin,mandibular margin, and less often over other bonyprominences such as the malar and forehead regions.Nonfacial skin is also more likely to develop scarringdue to the relative paucity of pilosebaceous units andadenexal structures It has been the experience of one

of us (DAG) that patients with a history of acne ring, regardless of prior isotretinoin use, are morelikely to develop delayed wound healing and hyper-trophic scarring when compared with the averagepatient

scar-The surgeon should be alerted to possible scarringwhen there is delayed wound healing for any reason.Infections need to be treated early and aggressively.Candidal, bacterial, and herpetic infections can delayhealing, prolong the inflammatory stage, and increasethe chance that the wound will heal with scar develop-ment Likewise, contact dermatitis that is not con-trolled early and poor wound care are potentialprecursors for postoperative scarring

Early on, the treated skin may appear redder thanthe surrounding skin As the process continues, tex-tural changes can be discerned with palpation of thearea (Fig 3.4), and, as time progresses, a mature scarwill develop In the early stages, topical steroids mayhave a role.A medium to potent steroid should be usedtwice daily, but should be applied only to the area ofconcern and not to the entire lasered area If pro-longed erythema alone is noted without any dis-cernible textural changes, a class II or III steroid maysuffice but if thickening or induration is present, a class

I steroid should be considered.The patient needs to bemonitored closely so that steroid-induced atrophy,stria, or telangectasia do not develop and so thatprogression of the scarring can be followed

Intralesional glucocorticosteroids are probably

more effective than topical steroids if textural changes

and induration have developed.We typically use

triam-cinolone acetonide diluted to a concentration of 2.5–5

mg/cm3for facial scars, but will use 7.5–10 mg/cm3

for very thick or indurated scars A 30-gauge needle is

used to minimize further trauma to the area, and the

injection is given into the superficial dermis of the

scar Injections can be repeated every 2–4 weeks,

depending on the response or progression of the scar

Treatment should be continued until the skin returns

to the same texture and consistency as the surrounding

tissue Overtreatment can result in atrophy, and

telangectasia can develop

Some surgeons use occlusion therapy in the early

stages of scarring A very large number of silicone gel

dressings have become available over the past few

years If utilized, they should be applied to the scar

daily and worn for 12–24 hours per day as tolerated

A mild dishwashing detergent can be used to clean the

dressing An onion skin extract, Menderma gel (MerzPharmaceuticals, Greensboro, NC), is also marketed

to improve and prevent scarring Its efficacy in notknown, and patients using any such product need to

be monitored for irritant and allergic contactdermatitis

Another treatment used after laser surgery to treatscars is 5-fluorouracil (5-FU).21This antimetabolite is

a pyrimidine analog and works by inhibiting fibroblastproliferation A concentration of 50 mg/cm3 isinjected into the scar and a total dose of 2–100 mg isused each injection session Although effective, theinjections are quite painful The addition of Kenalogshould be considered and is mixed such that 0.1 cm3 ofKenalog 10 mg/cm3is added to 0.9 cm3of the 5-FU(45 mg 5-FU) Less pain and potentially greaterefficacy are associated with the latter solution.Approximately 0.05cm3is injected per site, separated

by approximately 1 cm Injections should be formed two or three times weekly initially, and onlythe indurated portions of the scar should be injected.Side-effects include pain with injection, purpura, andrarely superficial tissue slough

per-Flashlamp-pumped dye laser (FLPDL) therapy iseffective, and was first described by Alster.22Thesettings typically used with the 585 nm FLPDL are5–7.5 J/cm2with a 7 mm spot size or 4–5 J/cm2with

a 10 mm spot size Newer vascular lasers and intensepulsed light sources are also being used to treat surgi-cal scars The V Beam (Candela Corp., Wayland, MA)has a wavelength of 595 nm and a cryogen spray tohelp cool the epidermis is our preferred laser forscars Broad-spectrum, intense pulsed light such as theVascuLight (Lumenis, Santa Clara, CA) has been effec-tive with a 570 nm filter Treatments are administered

at 3- to 4-week intervals, and generally will require aminimum of 2–4 treatment sessions

Patients may develop anxiety about having ‘morelaser surgery’ if they have already developed a scarfrom previous laser surgery, but these techniques aregenerally well tolerated and with minimal risks.Because of the low fluences used, purpura generallydoes not develop Although well accepted as an effec-tive treatment, not all studies have demonstrated goodresults using the pulsed dye laser for scars In a study

by Wittenber et al,23the flashlamp pulsed dye laser andsilicone gel sheeting showed improvement in scar

Fig 3.4 (a) Persistent erythema with textural changes at

6 months post CO2laser resurfacing (b) Scar development

present at the lip 6 months post CO2laser resurfacing

b a