Clinical Procedures in Laser Skin Rejuvenation - part 3 pps

By means of digital online energy regulation, the energy of each pulse is actively controlled to match the required value while the laser is in operation.This enables the practitioner to

Variable-pulse Er:YAG systems

Introduced in 2002, the Fontona laser systems feature a

proprietary VSP (Variable Square Pulse) technology

This allows the practitioner to accommodate the laser

pulse duration and its fluence according to the needs of

the specific application (Fig 4.8) By means of digital

online energy regulation, the energy of each pulse is

actively controlled to match the required value while

the laser is in operation.This enables the practitioner to

treat selected tissues without heating the surrounding

tissue unnecessarily.With a short pulse width, the

VSP-shaped Er:YAG laser induces minimal thermal effects to

underlying tissue while rejuvenating the superficial skin

layers through ablation of the epidermis.This allows the

practitioner to offer effective skin rejuvenation

treat-ments with higher comfort levels and shorter recovery

By increasing the pulse duration, more heat is diffused

in the skin and a resulting collateral thermal effect is

achieved Long-pulsed lasers characteristically have

pulse durations of the order of milliseconds, in contrast

to short-pulse durations of the order of microseconds

These thermal effects produce pronounced collagen

contraction and new collagen stimulation in the dermis

Clinical trials have proven a light ablative effect on the

epidermis, relatively noninvasive stimulation of new

collagen formation, and no post-treatment downtime

Fotona’s stacked pulse technology provides a purely

nonablative Er:YAG laser SMOOTH mode for skin

rejuvenation treatments.The thermal SMOOTH mode

allows dermal remodeling and rejuvenation without

affecting the epidermis

The Cynosure CO3 laser has a similar variable-pulse

technology, featuring pulse durations of 0.5, 4, 7, and

10 ms

The FDA has recently given approval for use in theUSA of the BURANE XL Er:YAG laser, which also fea-tures variable triple-pulse technology.The BURANE XLfeatures a specially designed and patented pulse sequencefor each application (coagulation, scars, and wrinkles)that heats the deeper skin layers to a specific temperaturewhile protecting the epidermis by allowing it to cooldown during the pauses of the pulse sequences All thesedosimetry models are based on longer pulse duration andsubablative laser energies for subablative dermal heating

CLINICAL DERMATOLOGICAL APPLICATIONS OF ERBIUM LASERS

Due to its superficial action and tendency to not mote dermal scarring, the Er:YAG laser is well adapted

pro-to ablating and etching superficial cutaneous neoplasmsand cutaneous blemishes (Fig 4.9) The high ablative

38 Clinical procedures in laser skin rejuvenation

Table 4.2 Dermatological conditions treatable with the Er:YAG laser

potential results in microexplosive destruction of the

skin lesions without the associated scarring that would

result from epidermal or dermal excisions Numerous

clinical applications are listed in Table 2

CLINICAL AESTHETIC APPLICATIONS

OF ERBIUM LASERS

LASR with a short-pulsed Er:YAG laser is most

com-monly used for the improvement of fine rhytides In

patients with moderate photodamage and rhytides,

modulated Er:YAG laser skin resurfacing results in

greater collagen contraction and improved clinical

results compared with short-pulsed Er:YAG systems.The clinical improvement of severe rhytides treatedwith a modulated Er:YAG laser can be impressive (Fig.4.10).There are conflicting reports as to whether or notthe endpoints of CO2LASR can be reached even whenablating to similar depths Newman and colleaguescompared a variable-pulse Er:YAG laser with traditionalpulsed or scanned CO2laser resurfacing for the treat-ment of perioral rhytides.9Although a reduced duration

of re-epithelialization was noted with the modulatedEr:YAG laser (3.4 days vs 7.7 days with a CO2laser),the clinical results observed were less impressive thanthose following CO2laser resurfacing Er:YAG laser sys-tems may greatly improve atrophic scars caused by acne,

Erbium laser aesthetic skin rejuvenation 39

Fig 4.9 This patient presented for removal of an irritated seborrheic keratosis, as shown in the preoperative photograph(a).The lesion is excised by sharp intradermal excision (b).The underlying dermal components are ablated and the edges are

‘feathered’ (c).The final result is shown in (d)

b

a

40 Clinical procedures in laser skin rejuvenation

Fig 4.10 This treatment took place over two sessions (a) Preoperative photograph (b) Following excision/ablation of

seborrheic keratosis with basal cell carcinoma.The patient then elected to have aesthetic full-face LASR 1 year postoperatively and

is shown 4 days (c) and 12 days (d) post LASR, with multiple excision ablations

c

d

trauma, or surgery In a series of 78 patients,Weinstein

reported 70–90% improvement of acne scarring in the

majority of patients treated with a modulated Er:YAG

laser10 Pitted acne scars may require ancillary

proce-dures, such as subcision or punch excision, for optimal

results.These procedures can be performed either prior

to or concomitant with Er:YAG laser resurfacing

ERBIUM LASER TECHNIQUES

Cutaneous ablative surgery

In treating superficial epidermal lesions such as

irri-tated seborrheic keratoses, the primary lesion can be

ablated or an epidermal shaving of the lesion followed

by ablative pulses can be performed On most

treat-ments with the short-pulsed laser system, the fluence

is set to 5, which corresponds to about 20 µm of

abla-tion The lesion ablation is continued until the entire

lesion is vaporized The adjacent dermis is ‘feathered’

to taper the cutaneous margins of the lesion

‘Dry erbium’

This is a fairly new term, with the ‘dry erbium’

rep-resenting an epidermal ablation that does not extend

into the papillary dermis, where bleeding is

encoun-tered Often, this treatment is done with subablative

levels of laser energy and is associated with rapid

recovery and a result that is intermediate to

micro-dermabrasion or photorejuvenation but not as

signif-icant as superficial laser resurfacing

Superficial LASR

The technique used for superficial LASR is to set the

fluence to 5 and use three passes.This equates to about

40–60 µm of ablation After the inititial ablation, the

same settings are maintained until punctuate bleeding

is encountered

Medium-depth LASR

The techniques utilized for medium-depth LASR will

be influenced by the Er:YAG laser technology available

and by other techniques that the laser surgeon can callupon With longer-pulsed or dual-mode systems andprogression beyond 60–80 µm, there may be bleedingfrom the dermal plexus, which will slow the proce-dure down It is our preference to change our tech-nique if we wish to accomplish a deep LASR formoderate to deep rhytides.When employing a combi-nation technique for the full face, we generallyperform the CO2laser resurfacing in the first pass,followed by Er:YAG laser ablation of the char Whenusing ablative bipolar RF (BPRF) (Visage, ArthrocareCorp.), we ablate the epidermis and then heat thedermis (Fig 4.11) with several passes of ablativeBPRF.This technique serves to contract dermal colla-gen without excessive thermal damage to the deeperdermal layers.When treating acne scarring, we some-times convert to dermal sanding in the deeper dermallayers

Deep LASREssentially the same techniques are utilized as inmedium-depth treatment, but the deeper dermaltreatment is performed with more passes This is fre-quently necessary for deeply creased upper lip rhytids

It is important to always use a graduated approachfor deeper techniques and to treat the facial skinwith an appreciation of the skin thickness in each facialarea as well as the depth or degree of the rhytids Weoccasionally utilize a fractionated CO2laser pass aftercompleting the medium-depth LASR This involvesspatially separated pulses of the CO2laser over thetreatment area The smallest possible spot size isutilized, with no overlapping of pulses

PATIENT SELECTION AND PERIOPERATIVE MANAGEMENT

As with most aesthetic facial procedures, appropriatepatient selection and reasonable patient expectationsare the cornerstones of any successful intervention Acomplete medical and surgical history should beobtained prior to any recommendations

The contraindications to laser resurfacing are alistic patient expectations, a tendency toward keloid

unre-or hypertrophic scar funre-ormation, isotretinoin useErbium laser aesthetic skin rejuvenation 41

within 6 months prior to surgery, and a lack of patient

compliance with postoperative instructions Other

medical considerations include identifying patients

with reduced numbers of adnexal skin structures, such

as those with scleroderma, burn scars, or a history of

prior ionizing radiation to the skin These patients

should be approached with caution Long-term use of

skin pharmaceuticals such as glycolic acid products or

retinoids may thin the dermis and alter the depth of

penetration of the LASR A history of previous skin

rejuvenation procedures is noteworthy, because these

procedures could potentially slow the wound healing

process due to the presence of fibrosis Patients who

have undergone prior transcutaneous lower lid

ble-pharoplasty or have limited infraorbital elasticity may

be at increased risk for postoperative ectropion.When

applicable, patients who smoke should be discouraged

from doing so before and after surgery to reduce the

risk of delayed or impaired wound healing

Physical examination of the treatment area includes

careful attention to Fitzpatrick skin type and specific

areas of scarring, dyschromia, and rhytid formation

For patients desiring periorbital laser treatment, the

eyes must be examined for scleral show, lid lag, and

ectropion Other epidermal pathology should also be

noted, including seborrheic keratoses, solar

lentig-ines, actinic keratoses, and cutaneous carcinomas.The

author prefers to address this during the LASR, but

some lesions may need to be addressed prior to the

LASR

LASR can lead to reactivation of latent herpessimplex virus (HSV) infection or predispose thepatient to a primary infection during the re-epithe-lialization phase of healing Prophylactic antiviralmedication should be prescribed during the postop-erative period, regardless of a patient’s HSV history.11

Currently used regimens include famciclovir 250 mgtwice daily, acyclovir 400 mg three times daily, orvalacyclovir 500 mg twice daily The medication may

be administered the day before or on the morning oflaser resurfacing, and should be continued for 7–10days or until re-epithelialization is complete.Antibiotics for bacterial prophylaxis may be pre-scribed; however, little data exist to support theiruse, because of the relatively low incidence of post-operative bacterial infections reported The routineuse of antibiotic prophylaxis may increase the inci-dence of antibiotic resistance and predispose patients

to organisms of increased pathogenicity When used,cephalosporin (cephalexin), semisynthetic penicillin(dicloxacillin), macrolide (azithromycin), orquinolone (ciprofloxacin) is administered 1 daybefore or on the morning of surgery, and is continueduntil re-epithelialization is complete.The use of topi-cal antibiotics on the laser-induced wound may berecommended, but neomycin-based products should

be avoided due to a 10% incidence of sensitivity tothis compound

Postoperative wound care can follow an open orclosed method.With the closed method, a semiocclusive

42 Clinical procedures in laser skin rejuvenation

Fig 4.11 Combination resurfacing techniquesutilize other modalities to achieve the sameendpoint that multiplexing pulse duration achieves.Ablative bipolar radiofrequency or fractional CO2laser treatment to the upper dermis enhanceshemostasis and collagen contraction

dressing (Flexan) is placed on the denuded skin These

wound dressings have been shown to accelerate the rate

of re-epithelialization by maintaining a moist

environ-ment In addition, decreased postoperative pain has

been reported with their use The closed method may

create a low-oxygen environment that may promote the

growth of anaerobic bacteria and subsequent infection

As such, many proponents of the closed technique

cur-rently endorse removal of the dressing with wound

inspection 24–48 hours after the procedure, followed

by topical emollients.The open wound technique

con-sists of frequent soaks with cool saline or Domeboro

solution.These soaks are followed by the application of

ointment to promote re-epithelialization while allowing

adequate visualization of the resurfaced wound

Er:YAG laser resurfacing ablates superficial

cuta-neous tissue and causes a thermal injury to denuded

skin.Therefore, some adverse effects are to be expected

and should be considered complications These

‘side-effects’ of cutaneous laser resurfacing include transient

erythema, edema, burning sensation, and pruritus

Short-pulsed Er:YAG laser resurfacing procedures are

associated with a significantly shortened period of

re-epithelialization and erythema when compared with

the CO2laser However, when equivalent depths of

ablation and coagulation are achieved with the

afore-mentioned modulated systems, postoperative healing

times are comparable

LASER RADIATION SAFETY AND

ERBIUM LASERS

All laser devices distributed for both human and

ani-mal treatment in the USA are subject to Mandatory

Performance Standards They must meet the Federal

laser product performance standard, and an ‘initial

report’ must be submitted to the Center for Devices

and Radiological Health (CDRH) Office of

Compliance prior to the product being distributed

This performance standard specifies the safety features

and labeling that all laser products must have in order

to provide adequate safety to users and patients A

laser product manufacturer must certify that each

model complies with the standard before introducing

the laser into US commerce.This includes distribution

for use during clinical investigations prior to deviceapproval Certification of a laser product means thateach unit has passed a quality assurance test and that itcomplies with the performance standard.The firm thatcertifies a laser product assumes responsibility forproduct reporting, for record-keeping, and for notifi-cation of defects, non-compliance, and accidental radi-ation occurrences A certifier of a laser product isrequired to report the product via a Laser ProductReport submitted to the CDRH Er:YAG lasers belong

to safety class IV; i.e., these lasers are high-powerlasers (500 mW for continuous-wave and 10 J/cm2orthe diffuse reflection limit for pulsed), which are haz-ardous to view under any condition (directly or dif-fusely scattered), and are a potential fire hazard and askin hazard Significant controls are required of class

CO2laser systems and so the complication profile may

be similar, but appears to be intermediate in terms

of the most frequent complications of prolongederythema, hyper- or hypopigmentation, and dermalfibrosis or scarring In addition to the complicationsmentioned above, mild complications of Er:YAG laserresurfacing include milia, acne exacerbation, contactdermatitis, and perioral dermatitis Moderate compli-cations include localized viral, bacterial, and candidalinfection The most severe complications include dis-seminated infection and the development of ectropion.Diligent evaluation of the patient is necessary duringthe re-epithelialization phase of healing This is impor-tant, because a delay in recognition and treatment ofcomplications can have severe deleterious conse-quences, such as permanent dyspigmentation and scar-ring.As always, patient selection and avoidance of theseErbium laser aesthetic skin rejuvenation 43

procedures in any patient predisposed to delayed or

abnormal cutaneous wound healing will reduce the

fre-quency of severe postoperative sequellae

Although short-pulsed Er:YAG laser resurfacing has

a significantly better adverse-effect profile and

compli-cation rate when compared with pulsed or scanned

CO2laser resurfacing, long-term data for the

modu-lated Er:YAG laser systems are not yet available

Because the modulated Er:YAG laser systems may be

used to create zones of collateral thermal damage

similar to those created by the CO2laser, further studies

are necessary to determine the incidence of delayed

hypopigmentation

REFERENCES

1 Goldman MP, Fitzpatrick RE Cutaneous Laser Surgery:

The Art and Science of Selective Photothermolysis, 2nd edn St Louis, MO: Mosby-Year Book, 1999:339–436.

2 Kotler R Chemical Rejuvenation of the Face St Louis,

MO: Mosby-Year Book, 1992:1–35.

3 Hebra F, Kaposi M On Diseases of the Skin, Including Exanthemata London: New Sydenham Society, 1874: Vol 3:22–23.

4 MacKee GM, Karp FL The treatment of post acne scars with phenol Br J Dermatol 1952;64:456–9.

5 Kurtin A Corrective surgical planing of skin Arch Dermatol Syph 1953;68:389.

6 Goldberg DJ Lasers for facial rejuvenation Am J Clin Dermatol 2003;4:225–34.

7 Ronel DN Skin resurfacing, laser: erbium YAG eMedicine http://www.emedicine.com/plastic/topic 108.htm (accessed November 2006).

8 Kaufmann R, Hibst R Pulsed 2.94-microns erbium–YAG laser skin ablation – experimental results and first clinical application Clin Exp Dermatol 1990;15:389–93.

9 Newman JB, Lord JL, Ask K, McDaniel DH Variable pulse erbium: YAG laser skin resurfacing of perioral rhytides and side-by-side comparison with carbon dioxide laser Lasers Surg Med 2000;26:208–14.

10 Weinstein C Modulated dual mode erbium CO2lasers for the treatment of acne scars J Cutan Laser Ther 1999; 1:204–8.

11 Tanzi EL: Cutaneous laser resurfacing: erbium:YAG eMedicine http://www.emedicine.com/derm/topic 554.htm (accessed November 2006).

44 Clinical procedures in laser skin rejuvenation

The name laser is an acronym for Light Amplification by

Stimulated Emission of Radiation In 1917, Albert

Einstein was the first to theorize about the mechanism

that makes lasers possible, called ‘stimulated emission’

In 1958, Charles Townes and Aurthur Schawlow

theo-rized about a visible laser system that would use infrared

or visible electromagnetic energy Although some

con-troversy exists regarding the individual who invented

the first laser, Gordon Gould, who first used the term

‘laser’, has been credited with inventing the first light

laser In 1965, the carbon dioxide (CO2) laser was

invented by Kumar Patel Since that time, there has been

a tremendous increase in theoretical and practical laser

knowledge, resulting in an explosion of laser technology

used in thousands of everyday applications

One of the first individuals to report on the effects

of lasers on the skin was Leon Goldman, whom many

consider to be the father of laser medicine Goldman’s

pioneering work using pulsed (ruby) and

continuous-wave argon lasers serves as the foundation for our

present understanding of laser medicine and surgery

The first lasers used to treat skin conditions were

continuous-wave CO2 dioxide, argon, and

argon-pumped tunable dye lasers.The major disadvantage of

continuous-wave lasers is that the side-effects are

related to how long the beam is in contact with the

target (dwell time), and are thus operator-dependent

This resulted in high rates of complications, primarily

in the form of scarring

In the late 1980s, the first pulsed lasers became

avail-able with the introduction of the flashlamp-pumped

pulse dye laser by the Candala Corporation Pulsed

lasers were a major advance in laser medicine, since

energy delivery was now selectable and dwell time ontissue became an independent factor in treatment Theintroduction of pulsed lasers greatly reduced the inci-dence of scarring secondary to laser treatment.The sub-sequent addition of cutaneous cooling during laserdelivery was another significant advance in cutaneouslaser surgery Epidermal protection and increasedpatient comfort secondary to cooling served to advancethe art and science of laser medicine

In the early 1980s, there were few major companiesproviding lasers for cutaneous application.Today, thereare dozens worldwide, and hundreds of laser devices areavailable for use in the treatment of numerous congenitaland acquired skin conditions Along with the explosion

of interest in cosmetic laser surgery came a tremendousnumber of ‘new’ users of this technology.As a result, wehave seen a significant increase in side-effects andcomplications associated with the use of lasers

Since most laser and light sources ultimately aredesigned to heat targets, complications secondary totreatment using lasers and light sources is most oftenrelated to excessive thermal energy delivered duringthe procedure It is this excess thermal energy thatmost often contributes to unfavorable clinical results

In this chapter, we will not address side-effects oflasers that are common or anticipated and oftenunique to the laser or light source used, but will ratherconfine our discussion to complications that are eventsnot generally expected as a result of treatment.Complications secondary to lasers and light sourcesmay be minor or serious, but all need prompt andaccurate diagnosis and treatment to prevent furtherpatient morbidity As shown in Box 5.1, there arenumerous potential complications seen as a result ofthe use of lasers and light sources Box 5.2 lists some

5 Complications secondary to lasers

and light sources

Robert M Adrian

of most common causes of complications resulting

from the use of lasers and light sources (Figs 5.1–5.3)

Box 5.1 Complications of lasers and light sources

Box 5.2 Causes of complications from lasers and light sources

• Lack of basic knowledge and training on a specific

treatment modality

• Incorrect choice of laser or light source to treat a

clinical condition

• Failure to adequately recognize the clinical condition

confronting the operator

• Failure to anticipate, recognize, and treat common or

uncommon postoperative complications

• Failure to refer patients with evolving or

non-responding complications to more experienced colleagues − ‘When you’re in a hole, stop digging.’

• Failure to adequately screen and counsel patients

prior to the procedure, thus avoiding postoperative disappointment and frustration for both patient and treating individual

LACK OF OPERATOR KNOWLEDGE

AND EXPERIENCE

The single most important cause of postoperative

com-plications is lack of proper training and experience of

the treating individual The explosion of interest in

cosmetic laser treatments has served as a magnet for

those who wish to provide such services primarily for

the purpose of financial gain Unfortunately, most of

these individuals are not willing to spend the time or

monetary investment learning the basic science of lasersurgery, treatment protocols, and techniques necessary

to provide safe and effective laser and light source-basedprocedures So-called ‘weekend warriors’ abound.This

is a term used to describe ‘laser experts’ who are stantly unleashed on an unsuspecting public after a fewhours at an evening or weekend training session.The use of a given laser or light source by any indi-vidual should be complemented by a complete under-standing of cutaneous structure and function, basicdermatology, laser safety and physics, infectious diseases

con-of the skin, cutaneous wound care, and management con-ofcommon side-effects and complications It is inconceiv-able how any individual without prior knowledge ortraining in dermatology could reasonably fulfill all of the

46 Clinical procedures in laser skin rejuvenation

Fig 5.1 Severe herpes simplex infection post carbondioxide laser resurfacing (by permission of Jean Rosenbloom)

above prerequisites during a single evening or weekend

‘laser seminar’ My views are not meant to suggest that

only dermatologists or plastic surgeons are suitable to

perform laser- or light-based procedures, but rather

that non-dermatologist physician specialists or allied

health professionals should spend the necessary time

and effort to become properly trained prior to turning

themselves loose on their patients or clients

INCORRECT CHOICE OF LASER OR

LIGHT SOURCE FOR A GIVEN

CONDITION

Despite the fact that there are hundreds of lasers and

light sources available to treat cutaneous conditions,

there are relatively few tissue targets or phones available within the skin (Box 5.3) Although

chromo-it may seem intuchromo-itive, many individuals will oftenuse a given laser or light source to treat a conditionthat is not within the technological scope of thedevice (Figs 5.4–5.6) Although one might concludethat this was related to lack of knowledge and experi-ence, I have found that it is more often related tomonetary consideration on the part of the operator.Common sense would suggest that one would choose

a laser or light source that would reasonably addressthe target chromosphere – however, many examples

of laser clinical condition mismatches are seen inclinical practice

Box 5.3 Cutaneous chromophones

Complications secondary to lasers and light sources 47

Fig 5.2 Severe hypertrophic scarring secondary to CO2

laser burn

Fig 5.3 Hypertrophic scarring after long-pulse YAG lasertreatment of a tattoo

FAILURE TO RECOGNIZE THE

PRESENTING CLINICAL CONDITION

Most physicians and allied health professionals with

training in cutaneous medicine can properly recognize

the clinical condition confronting them Unfortunately,

inexperienced or untrained individuals often fail to

rec-ognize the presenting condition, resulting in worsening

of the condition or complications from treatment

What excuse could one offer for treating a nodular

melanoma as a hemangioma or a linear verrucous

nevus, or tuberous sclerosis as warts, other than lack of

knowledge on the part of the physician? In addition,

many serious medical conditions, such as collagen

vascular disease, congenital neurocutaneous dromes, and vascular anomalies, present for cosmetictreatment while actually needing proper diagnosis andtreatment rather than simply ‘cosmetic’ improvement

syn-FAILURE TO ANTICIPATE, RECOGNIZE AND TREAT COMMON POSTOPERATIVE COMPLICATIONS

Most laser and light source treatments are accompanied

by various postoperative side-effects, which are defined

as conditions that are expected and directly related to

48 Clinical procedures in laser skin rejuvenation

Fig 5.5 Perioral scarring secondary to CO2laserresurfacing

Fig 5.4 Scarring and pigmentation from improper use of

an IPL Device Fig 5.6 Scarring of the chest after CO2laser resurfacing

a

b

the procedure itself Examples include purpura

sec-ondary to pulsed dye laser treatment, pinpoint bleeding

and crusting from Q-switch laser treatment, and

swelling and weeping of the skin after CO2or Er:YAG

laser resurfacing Complications, on the other hand, are

conditions that may or may not be expected, but are

caused by the procedure and are of significant nature to

require proper diagnosis and treatment Such

complica-tions can be relatively minor, such as mild hypo- or

hyperpigmentation, edema, or minor crusting Serious

complications include bacterial, fungal, or viral

infec-tions; severe pigment disturbances; and hypertropic and

keloidal scarring Sepsis and systemic allergic reactions,

although less common, may be life-threatening, and need

prompt proper diagnosis and treatment by skilled,

well-trained individuals Failure to recognize and skillfully

address these complications is a major cause of

COLLEAGUES IN A TIMELY MANNER

All practitioners of laser- and light-based

tech-niques, regardless of experience, have encountered

postoperative complications Morbidity secondary topostoperative complications can often be greatlyreduced in most cases by arriving at the correct diag-nosis and providing prompt treatment Physicians whofail to refer in a timely manner most often do sobecause they actually fail to accurately diagnose thepresenting condition itself Most often, I have encoun-tered failure to recognize and treat postoperative viral(herpes) and fungal (Candida) infection Many patientsare treated for weeks with the wrong diagnosis, only

to rapidly heal when proper diagnosis and treatment isintiated Unfortunately, lack of training and lack ofexperience lead to a failure of proper diagnosis andtreatment, causing significant morbidity for patients.Again, proper training and experience are the primarycauses of late referral of complications

FAILURE TO ADEQUATELY SCREEN AND INFORM PATIENTS PRIOR TO THE PROCEDURE

The cornerstone of a successful cosmetic and laserpractice is informed consent Why? Because an ade-quately informed patient will understand the risks,benefits, and possible outcomes prior to the proce-dure Preoperative counseling with blunt and honestanswers prior to the procedure all but eliminate thelikelihood of postoperative patient dissatisfactionand complaints I have found that patients are muchmore relaxed post-treatment when they had under-gone a detailed discussion covering risks, benefits, andrealistic outcomes prior to the procedure In my opin-ion, informed consent is the single most importantfactor leading to a smooth postoperative experience

Fig 5.7 Scarring from smooth laser treatment of a tatoo