Ebook: Quản lý các biến chứng của quy trình thẩm mỹ Xử lý các vấn đề phổ biến và các vấn đề không phổ biến khác

1. Complications of Superficial and Medium Chemical Peels 2. Nonpermanent Fillers and Permanent Fillers 3. Complications of Fractional Lasers 4. Complications of Vascular Lasers 5. Complications of Removal Lasers 6. Intense Pulsed Light Complications 7. Complications of Photodynamic Therapy 8. Complication of Biorivitalization 9. Complications of Mesotherapy 10. Complications in Radiofrequency (RF) 11. Complications of Botulinum Toxins 12. Management of Complications of Microdermabrasion and Dermabrasion 13. Complications of Needling

Management of Complications

of Cosmetic Procedures

Antonella Tosti • Kenneth Beer

Maria Pia De Padova

ISBN 978-3-642-28414-4 ISBN 978-3-642-28415-1 (eBook)

DOI 10.1007/978-3-642-28415-1

Springer Heidelberg New York Dordrecht London

Library of Congress Control Number: 2012942342

© Springer-Verlag Berlin Heidelberg 2012

This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illus- trations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or

by similar or dissimilar methodology now known or hereafter developed Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its cur- rent version, and permission for use must always be obtained from Springer Permissions for use may be obtained through RightsLink at the Copyright Clearance Center Violations are liable to prosecution under the respective Copyright Law.

The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibil- ity for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect to the material contained herein.

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Prof Dr Antonella Tosti

Department of Dermatology

and Cutaneous Surgery

Miller School of Medicine

1 Complications of Superficial and Medium Chemical Peels 1

Maria Pia De Padova and Antonella Tosti

2 Nonpermanent Fillers and Permanent Fillers 9

Murad Alam and Nowell Solish

3 Complications of Fractional Lasers

(Ablative and Nonablative) 23

Robert Anolik and Roy G Geronemus

4 Complications of Vascular Lasers 37

Norma Cameli, Giovanni Cannarozzo, Paolo Bonan,

Nicola Bruscino, and Piero Campolmi

5 Complications of Removal Lasers 47

Remington

6 Intense Pulsed Light Complications 57

Hillary Julius

7 Complications of Photodynamic Therapy 65

Martin Zaiac, Adriana Abuchar, and Mercedes Florez

Suveena Bhutani and Neil S Sadick

11 Complications of Botulinum Toxins 97

Kenneth R Beer and Jacob Beer

12 Management of Complications of Microdermabrasion

A Tosti et al (eds.), Management of Complications of Cosmetic Procedures,

DOI 10.1007/978-3-642-28415-1_1, © Springer-Verlag Berlin Heidelberg 2012

1

1.1 Introduction

Super fi cial and medium peelings include

sali-cylic acid 25–30%, glycolic acid 70%, pyruvic

acid 40–60%, trichloroacetic acid 20–35%, and

combination of salicylic acid or Jessner peel with

trichloroacetic acid

Super fi cial and medium peelings are utilized to

induce a damage limited to the epidermis and

pap-illary dermis This results in epidermal

regenera-tion and postin fl ammatory collagen neoformaregenera-tion

Since their potency is mild, repea ted treatment is required to obtain the desired effects Choice of peel depends on skin type and indication

Super fi cial and medium chemical peels ally cause mild and transitory side effects The most common complication is the development

usu-of pigmentary changes, which are especially seen

in patients with dark phototypes Development of this complication may be due to utilization of a peeling which is too strong for the patient’s pho-totype or to inadequate photoprotection in the postpeeling period

1.2 Technology 1.2.1 Glycolic Acid 30–70%/Pyruvic

Acid 40–60% [ 1– 3 ]

Glycolic and pyruvic acid peelings are utilized for the treatment of photoaging, melasma and postin fl ammatory pigmentation, and acne scars Pyruvic acid can also be used for active acnes Advantages

Mild desquamation

• Short postoperative period

• Disadvantages Penetration often not uniform for glycolic

• acid Pyruvic acid causes intense stinging and burn-

• ing sensation during the application and pro-duces pungent and irritating vapors for the upper respiratory mucosa

Complications of Super fi cial and Medium Chemical Peels

Maria Pia De Padova and Antonella Tosti

Department of Dermatology and Cutaneous Surgery ,

Miller School of Medicine, University of Miami ,

even if several months may be needed

Topical steroids and topical and

sys-•

temic antibiotics are useful for treatment

of most complications

Jessner’s solution is utilized for the treatment of

photoaging, melasma and postin fl ammatory

pig-mentation, and active acne

Salicylic acid peeling is utilized for the treatment

of melasma and postin fl ammatory pigmentation,

and comedonic and active acne

during the application

Minimal ef fi cacy in patients with signi fi cant

•

photodamage

1.2.4 Trichloroacetic Acid 15–35%

Trichloroacetic acid is utilized for the treatment of

photoaging and acne scars Low concentrations

can be utilized for the treatment of melasma and postin fl ammatory pigmentation

Advantages Low cost

• Uniformity of application

• Penetration can be easily evaluated by the

• color of frost Disadvantages Stinging and burning sensation during the

• application High concentrations are not recommended in

• skin types V to VI Can cause hypo/hyperpigmentation

•

1.2.5 Combination Peeling: Salicylic

Acid 25% + TCA 15–30% [ 4, 5 ]

Pretreatment with salicylic acid permits to obtain

a medium peeling with low TCA concentrations and therefore avoids pigmentary complications especially in dark phototypes

Combination peeling with salicylic acid + TCA is utilized for the treatment of photoag-ing and acne scars Combination peeling with low concentrations of TCA can be utilized for the treatment of melasma and postin fl ammatory pigmentation

Advantages Can be used in all skin types

• Disadvantages Risk of overpeeling

• Can cause hypo/hyperpigmentation

•

1.2.6 Contraindications to Super fi cial

and Medium Peelings

Contraindications to super fi cial and medium peelings include:

History of hypertrophic scars

• Connective tissue disorders

• Active skin disorders on the treatment sites

• History of treatment with systemic retinoids

•

in the previous 4 months Oral anticoagulant treatment

• Pregnancy

•

1.2.7 Prepeeling Care

This is essential to obtain uniform penetration and

avoid postin fl ammatory hyperpigmentation

Pres-cribe topical products containing 1–2% salicylic

acid, 2–3% pyruvic acid, or 0.05% retinoic acid to

be applied three times a week for 1 month Prescribe

4% topical hydroquinone three times a week for

1 month Application of these topicals should be

interrupted 4 days before the procedure to avoid

excessive penetration of the peeling agent

Treatment with oral antivirals should be started

2 days before the procedure in patients with

his-tory of recurrent herpes simplex infections

A detailed informed consent should be given to

the patient at this time to give her/him the

possi-bility of understanding the procedure and asking

possible questions before treatment We always

also provide written information about the

proce-dure It is very important to explain clearly to the

patient that super fi cial and medium peels require

multiple sessions and can improve but not

com-pletely resolve photoaging, pigmentary disorders,

and acne scars to avoid excessive expectations

It is mandatory to obtain good quality pictures

before starting the procedure This is an essential

documentation for follow-up and for possible

medicolegal issues

1.2.8 Postpeeling Care

It is very important to explain the patient to

abso-lutely avoid sun exposure and prescribe a sun

block to be applied several times a day

For the immediate postpeeling period, the

patient should also apply a moisturizing cream

three to four times a day The patient should also

be instructed to avoid scratching or peeling the

skin A mild skin cleanser can be utilized without

rubbing

When reepithelization is complete, which

usu-ally takes 7–10 days, the patient can resume

application of topical products containing 1–2%

salicylic acid, 2–3% pyruvic acid or 0.05%

retin-oic acid, and 4% topical hydroquinone to prepare

the skin for the next procedure

The patient should regularly wear a total sun block between peeling sessions and up to 6 months after the last session

1.3 Epidemiology

of Complications

Super fi cial and medium peels are widely utilized worldwide in both women and men The relative safety of these peelings in dark phototypes explains their utilization in different races

1.4 Clinical Features 1.4.1 Minor Local Adverse Reactions

Intense swelling

• Eye irritation due to vapors of the peeling

• solution (e.g., pyruvic acid and TCA)

Transitory nose and oral irritation is common

• with pyruvic acid

Irritative contact dermatitis: this may be

• caused by application of inadequate topical products (scrubs, exfoliating agents) before complete reepithelization

Exudative erosions: this is due to premature

• removal of scales and crust and is most com-monly seen after medium-deep peelings It is very important to instruct the patient to not manipulate the skin after peeling

Prolonged erythema: in some patients,

ery-• thema persists after 3 weeks from the proce-dure (Fig 1.1 ) These patients require a close follow-up as they are at risk of developing postin fl ammatory hyperpigmentation If the patient complains of itching, consider contact dermatitis Exclude other skin disorders inclu-ding lupus erythematosus

Dishomogeneous skin color: this is due to

• irregular penetration of the peeling agent (Fig 1.2 ) This occurs more frequently in patients with mixed skin as penetration is higher in greasy as compared with dry skin areas Possible causes include inadequate prepara-tion of the skin to the procedure, incorrect

application of the peeling agent, or inadequate

neutralization

To avoid this side effect, it is important during

•

the procedure to re-treat the skin areas that do

not develop erythema or frosting but being

careful not to overpeel the other areas

Persistent itching/burning sensation: this is

•

due to skin dryness and usually resolves in a

few weeks Consider contact dermatitis from

topical products (Fig 1.3 )

Skin hypersensitivity: patients complain of

•

burning and erythema when applying cosmetic

products This is most commonly seen in

patients with fair complexion submitted to

multiple procedures

Localized skin infections: herpes simplex

reac-•

tivation is common in patients with recurrent

HSV infection (Fig 1.4 ) It is important to start

prophylaxis with systemic antivirals 2 days

before the procedure Impetigo may occur if the patient scratches or removes crusts Acneiform eruptions: these usually develop a

• few days after peeling with TCA and may per-sist for 1 month (Fig 1.5 ) Peelings may tem-porarily worsen papulopustular acne, and some patients develop active papules and pustules in

Fig 1.1 ( a , b ) Persistent erythema after TCA peeling for the treatment of melasma Note resolution of melasma and

erythema after 3 months The patient was treated with mild steroids and 4% hydroquinone

Fig 1.2 Dishomogeneous skin color with whitish areas

and telangiectasias

Fig 1.3 Contact dermatitis due to postpeeling moisturizers

Fig 1.4 Mild herpes simplex of the lip after TCA peeling for lentigo

the immediate postpeeling period These

patients can be treated with systemic

antibiot-ics as in the management of active acne

Milia: these are uncommon after peeling and

•

usually caused by use of occlusive postpeeling

topical product (Fig 1.6 )

Allergic reactions: these may be due to the

•

peeling agent or to the topical products applied

in the prepeeling or postpeeling period

Allergic contact dermatitis to peeling agents is

rare and occurs most frequently with

resorci-nol Patch testing is necessary

1.4.2 Major Local Adverse Reactions

Corneal damage: accidental dropping of the

after deep peeling and produce a porcelain skin

appearance and mild telangiectasia (Fig 1.2 )

Atrophic scars: these may be due to

overpeel-• ing, to secondary infections, or to removal of crusts in compulsive patients

Hypertrophic scars: these are a serious side

• effect! Never treat patients with history of hypertrophic scars or keloids

Diffuse or spotted hypopigmentation: this is a

• consequence of excessive penetration of the peeling agent in some skin areas and usually depends on inadequate evaluation of the patient’s skin type (Fig 1.7 )

Diffuse or spotted hyperpigmentation: this is

• usually due to inadequate evaluation of patient’s phototype Dark phototypes are more suscep-tible to develop hyperpigmentation This is already evident 2–3 weeks after peeling Ochronosis: this is a complication of pro-

• longed utilization of hydroquinone and is more commonly observed in patients with dark phototypes The skin presents a bluish black discoloration

1.4.3 Systemic Adverse Reactions

Cardiac arrhythmia: this may occur with

phe-• nol and resorcinol peelings Death following a serious cardiac adverse reaction has been reported

Laryngeal edema and toxic shock syndrome

• have been reported with phenol

Salicylism: it is characterized by rapid

breath-• ing, tinnitus, abdominal cramps, and neuro-logical symptoms It has been reported after

Fig 1.5 Acneiform eruption after pyruvic acid peeling

Fig 1.6 Milia

Fig 1.7 Hypopigmented spots after 70% glycolic acid peeling in a patient of color

application of 20% salicylic acid on extensive

body areas (50%) or after application of 50%

salicylic acid We never observed this

compli-cation despite our large experience with

sali-cylic acid peels

Hypothyroidism is a very uncommon side

5 days then moisturizing cream to be applied

frequently to improve dryness

Systemic: methylprednisolone 8 mg/day for

tion, rinse immediately with tap water that dilutes

the concentration Refer to ophthalmologist

Topical: eyedrops containing low-potency

ste-•

roids and antibiotic for a few days

Nose and oral irritation

•

Rinse with tap water or physiologic solution

•

Make the patient drink a glass of water

Explain that this is transitory and does not

few days Prescribe bleaching agents

(hydro-quinone 3–4%, kojic acid, arbutin, azelaic

acid) after reepithelization as the risk of

tion Then, prescribe a moisturizer to be

applied every 3 h and a topical preparation

containing an antibiotic in association with a

steroid Explain necessity of complete

avoid-ance of sun exposure

Cosmetics containing antioxidants

• Systemic: methylprednisolone 8 mg/day for

• 2–3 weeks Dishomogeneous skin color

• Topical: 3–4% Hydroquinone and topical

• tretinoin for 2 months Enforce the need of sun block application sev-

• eral times a day

Persistent itching/burning sensation

• Topical: hydrocortisone cream once a day for

• 3–5 days Consider a topical antibiotic for a few days to

• prevent infection

Systemic: cetirizine 10 mg/day for 10 days

• Skin hypersensitivity

• Prescribe preservative and fragrance-free

• moisturizers Avoid overcleaning

Systemic: cetirizine 10 mg/day for 30 days

• Herpes simplex

• Treat with systemic antivirals (acyclovir, pen-

• cyclovir, famcyclovir) for 5 days Impetigo

• Prescribe systemic antibiotics (azithromycin,

• amoxicillin, or tetracyclines if MRSA (methi-cillin-resistant Staphylococcus aureus) is suspected)

Acneiform eruptions

• Prescribe oral tetracyclines as for the treat-

• ment of acne Milia

• Prescribe topical 0.05% tretinoin

• Allergic reactions

• Prescribe systemic and topical steroids for a

• week

1.5.2 Major Local Adverse

Reactions [ 1 ]

Corneal damage

• Eye bandage and ophthalmologic referral

• Textural changes

• Prescribe topical 0.05% tretinoin and camou fl age

• products Skin needling can improve texture Atrophic scars

•

Wait for 2 months after peeling before

treat-•

ing Possible treatments include skin needling,

injections of hyaluronic acid/collagen fi llers,

ately Prescribe silicone gel sheets for

6 months Then, treat with intralesional

injec-tions of triamcinolone acetonide 10–40 mg/

0.05% tretinoin, and 0.01% fl uocinolone

ace-tonide or 5% hydroquinone, 0.1% tretinoin,

and 0.1% dexamethasone

A soft peeling with 25% salicylic acid, 40%

•

pyruvic acid, or 5% retinoic acid can reduce

the pigmentation Absolute sun avoidance

1.6 Summary for the Clinician Box

1.6.1 What to Do if You Feel You

steroid (methylprednisolone 8 mg/day) for a

few days and monitor strictly the patient in the

postpeeling period Prescribe a moisturizer to

be applied 4–5 times a day and explain the

necessity of complete avoidance of sun exposure

Inadequate modality of application resulting

•

in dishomogeneous frosting You can re-treat the skin areas that do not

• develop erythema or frosting Be careful not

to overpeel the other areas

Accidental dropping of the peeling solution

• into the eyes, mouth, or other sensitive regions

Rinse immediately with tap water that dilutes

• the concentration Refer to ophthalmologist in case of eye involvement

References

1 Tosti A, Grimes PE, De Padova MP (2012) Color atlas

of chemical peels, 2nd edn Springer, Berlin

2 Perić S, Bubanj M, Bubanj S, Jančić S (2011) Side effects assessment in glicolyc acid peelings in patients with acne type I Bosn J Basic Med Sci 11(1):52–57

3 Dréno B, Fischer TC, Perosino E, Poli F, Viera MS, Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker

I, Wang B (2011) Expert opinion: ef fi cacy of super fi cial chemical peels in active acne management – what can

we learn from the literature today? Evidence-based recommendations J Eur Acad Dermatol Venereol 25(6):695–704

4 Vanhooteghem O, Henrijean A, Devillers C, Delattre L,

de la Brassinne M (2008) Trichloracetic acid peeling: method and precautions Ann Dermatol Venereol 135(3): 239–244

5 Berson DS, Cohen JL, Rendon MI, Roberts WE, Starker I, Wang B (2009) Clinical role and application

of super fi cial chemical peels in today’s practice

J Drugs Dermatol 8(9):803–811

6 Fabbrocini G, De Padova MP, Tosti A (2009) Chemical peels: what’s new and what isn’t new but still works well Facial Plast Surg 25(5):329–336

A Tosti et al (eds.), Management of Complications of Cosmetic Procedures,

DOI 10.1007/978-3-642-28415-1_2, © Springer-Verlag Berlin Heidelberg 2012

of their undesired effects

Although injectable augmentation materials are extremely well tolerated, their use runs up against the law of rising expectations That is, patients expect these procedures to be so pain-less, quick, uncomplicated, and unnoticeable that they can fi nd even the most minor unanticipated outcomes to be disconcerting and upsetting For this reason, it is desirable to discuss before treatment some of the most common potential sequelae (e.g., bruising and swelling) that have now been well described in the literature [ 2– 4 ] and can be temporarily socially embarrassing Additionally, it behooves the injector to take steps

to minimize these minor outcomes

2.1 Short-Term Undesired Effects 2.1.1 Injection-Associated Discomfort

Short-term effects of injectables include fort upon injection as well as postinjection skin redness, swelling, and bruising With regard to

Nonpermanent Fillers and Permanent Fillers

Murad Alam and Nowell Solish

M Alam , M.D., MSCI (*)

Section of Cutaneous and Aesthetic Surgery,

Department of Dermatology , Northwestern University ,

676 N St Clair St, Ste 1600 , Chicago 60611 IL , USA

Department of Otolaryngology , Northwestern University ,

Division of Dermatology , University of Toronto,

Women’s College Hospital ,

Toronto , ON , Canada

Key Features

Review of common, self-limited

post-•

treatment sequelae, about which patients

can be forewarned and reassured

Methods for identi fi cation and treatment

•

of medium-term complications,

includ-ing reassurance of patients, and

appro-priate strategies to mitigate duration and

impact of these

Strategies for avoidance of long-term

•

and permanent complications,

includ-ing maintaininclud-ing vigilance for early

detection of emerging serious problems,

which can sometimes by aborted by

prompt intervention

injection-associated discomfort, some amount is

experienced with all fi llers One factor associated

with greater discomfort is the viscosity and

conse-quent injection pressure associated with the

injectant Thicker hyaluronic acid preparations

(e.g., Restylane) [ 5 ] and calcium hydroxylapatite

preparations (e.g., Radiesse) are among the more

viscous temporary fi llers Upon injection, these

fi rmly displace surrounding tissue, thus inducing

pain Another relevant factor is the caliber of the

needle Calcium hydroxylapatite requires at least a

27-gauge needle, and poly- l -lactic acid, a 25- to

27-gauge needle; in the latter case, the thicker

nee-dle is not necessary because of a uniformly elevated

viscosity, but rather because of the tendency of the

reconstituted solution to contain focal thick

inclu-sions that tend to clog thinner needles Obviously,

thicker needles tend to injure more tissue upon

injection and thus to elicit greater injection

discom-fort The anatomic site of injection also modi fi es

pain Perioral injections, injections of the lip, and

injections of the periocular skin, especially lower

eyelids, are among the most painful due to the

increased sensory innervation at these sites

To a large extent, injection pain has become

less of an issue since the introduction of

hya-luronic acid fi llers with lidocaine already mixed

in (e.g., JUVÉDERM XC, Restylane-L) While

calcium hydroxylapatite and poly- l -lactic acid

do not come premixed, adding lidocaine to them

is now also routine

Several mechanisms can be used to further

dimin-ish injection pain Immediate preinjection application

of ice or of a vibratory sensation during injection can

decrease discomfort In the case of vibration, a

hand-held vibrating back massager, or similar device, can

be used The ef fi cacy of this procedure is predicated

on the fact that vibratory sensation and sharp pain are

transmitted through common neural pathways, with

transmission of one type of sensation reducing

con-current experience of the other If a vibrating device

is not available, pinching the skin at the same time as

piercing it with a needle can be of bene fi t Topical

anesthetic preparations, both commercially

prepack-aged types (e.g., LMX) and custom preparations

pro-duced by compounding pharmacies, may be of some

use in providing relief If topicals are to be used, they

should be applied prior to injection for at least 30–60

min and usually under occlusion of transparent

dressings (e.g., Tegaderm, Saran Wrap) or repeatedly rubbed into the skin every 10–15 min In general, however, injection pain is experienced beneath the level that can be treated by topical anesthetics Thus, this modality is usually more effective at convincing the patient that the physician is concerned about pain management than at markedly reducing physiologi-cally experienced pain It should also be noted that topical anesthesia should be used sparingly or not at all on mucosal surfaces, such as the wet part of the lip, as systemic absorption can occur Nerve blocks,

on the other hand, can be extremely helpful The most commonly placed blocks are those of the infraorbital nerve, for treatment of the nasolabial folds and upper lips, and the mental nerve, for treat-ment of the lower lip and marionette lines Full blocks can be easily placed intraorally, with a 30-gauge needle attached to a 3-cc syringe containing 0.5–2.0% lidocaine with 1:100,000 or 1:200,000 epi-nephrine Alternatively, articaine 1% with 1:100,000 epinephrine may be injected With a pH of 7 and an onset of action of 1–2 min, it is less painful and faster acting than Xylocaine Usually 0.5–1 cc to each infraorbital foramen and 0.2–0.4 cc to each mental area is suf fi cient Miniblocks, which consist of place-ment of as little as 0.1 cc of anesthetic solution into the sulcus superior to the third incisor bilaterally with

an additional injection into the mucosa above the frenulum in the midline, can also achieve excellent anesthesia of the fi bers of the infraorbital nerve Some physicians may prefer to place blocks transcutane-ously without having patients to open their mouths While patients will still feel some pain after nerve blocks, they may tolerate this residual discomfort better if they are instructed that complete anesthesia with intradermal injection would be counterproduc-tive Speci fi cally, they should understand that full

in fi ltration with injected anesthesia would result in undesired fi lling of the potential spaces and rhytids that are targets for augmentation Consequently, less

fi ller material would be placed, and only an plete and shorter-lasting correction would be possible

Patients have widely varying pain tolerance for injectable augmentation materials Some

fi llers, like various hyaluronic acid preparations (e.g., JUVÉDERM, Restylane), are minimally viscous, come prepackaged with anesthetic, and are well tolerated by virtually all patients Nerve

blocks are often preferred by patients when

injecting hyaluronic acid derivatives, calcium

hydroxylapatite, and poly- l -lactic acid A small

subset of extremely sensitive patients

paradoxi-cally fi nd nerve blocks more distressing than

fi ller injections without anesthesia; these patients

complain of persistent numbness and strange

sensations after nerve blocks and, needless to say,

should not receive these in the future

2.1.2 Redness and Swelling

Redness and swelling (i.e., erythema and edema)

tend to result immediately after injection with

many fi llers (Fig 2.1 ) Both are local effects of

puncture trauma and associated in fl ammation as

well as the hygroscopic properties of the fi ller

being used Speed of injection may play a role in

the amount of swelling Slower injection

tech-nique may reduce the amount of swelling [ 6 ]

Redness will usually persist for a few hours to

overnight, but swelling can last longer, up to

1–2 days When the lip is injected, swelling may

be more noticeable and usually last 1–3 days, and

occasionally longer Likewise, following multiple

injections with poly- l -lactic acid, especially

when used for diffuse facial lipoatrophy, edema

or fat redistribution manifesting as an elevated

contour may persist for several days to a week In

general, the more material is injected, the greater

the duration and extent of swelling

As with mild injection-associated discomfort,

redness and swelling are best managed by apprising

patients in advance of these likely outcomes In addition, careful injection technique can reduce the degree of both redness and associated edema Whether the fi ller is placed via a serial injection technique or by linear tunneling with threading, minimizing the number of skin punctures limits the associated trauma Even when poly- l -lactic acid is injected in multiple small aliquots, the needle may

be partially withdrawn and redirected instead of completely removed and reinserted Dilution with larger volumes of sterile water, up to 8–10 per cc for the face and as much as 15 cc for the dorsal hand, may also reduce the risk of needle clogging and minimize skin trauma with poly- l -lactic acid Postinjection application of ice packs for 5–10 min de fi nitely reduces the risk of swelling Concerned patients may be allowed to use ice packs at home every few hours the day of the injec-tion, but warned to avoid excessive use, which may cause cold injury to their skin If patients are returning to work or social engagements immedi-ately after injection, they should be encouraged to apply concealing makeup until the redness sponta-neously remits Makeup with a greenish tint is most able to camou fl age red coloration It is, how-ever, the swelling that typically limits social acti-vity the day of treatment

2.1.3 Bruising

Bruising (i.e., ecchymosis) is an inadvertent and occasional effect of soft-tissue augmentation (Fig 2.2 ) One cause of bruising is needle-associated

Fig 2.1 Periocular and lip edema after hyaluronic acid

derivative fi llers This is frequent and can persist for up to

1–2 days before complete remission

Fig 2.2 Upper lip ecchymoses following injection with hyaluronic acid derivative fi llers

perforation of vessels, usually dermal veins, during

fi ller injection Additionally, crushing or rupture of

vessels secondary to the pressure of adjacent fi rm

tissue materials can result in localized or widespread

ecchymoses If bruising occurs, it may be evident right

after injection, but often, notably in patients taking

platelet disaggregators, bruising is delayed Resolution

may be gradual, over approximately 5–10 days Even

when it does occur, bruising tends to be localized and

not markedly dis fi guring A group headed by

Geronemus has reported that treatment of

post-proce-dure bruising with pulsed-dye laser can hasten its

resolution Non-purpura-inducing settings are

typi-cally used for this treatment It is important for

patients to understand that bruising does not

inter-fere with the clinical result

Needle perforation of vessels can be avoided by

understanding the super fi cial anatomy of the face

and also studiously refraining from impinging

upon visible dermal medium-caliber vessels Side

lighting and cleansing the skin with alcohol pads

can illuminate bluish dermal vessels Ecchy moses

because of fi rm fi llers compressing nearby vessels

are more dif fi cult to prevent, especially if large

quantities of thicker fi ller materials are used One

technique entails canalization of the super fi cial fat

with a long 1.25-in needle; this allows injection of

viscous materials over a wide area without having

to reperforate the dermis repeatedly, thus

minimiz-ing risk of hematoma or bruisminimiz-ing Injection at the

level of the super fi cial fat is also inherently less

likely to cause bruising due to the decreased

den-sity of this layer and its relative dearth of vessels

per unit volume compared to the dermis

When bruising does occur, immediate fi rm

pressure over gauze should be applied to the

involved area for a few minutes Ice packs may

also be used Pressure—and to a lesser extent,

ice—can limit the extent of the bruise The most

common locations for bruises are the perioral

rhytids, the lower eyelids (with injections of poly

l -lactic acid or hyaluronic acid derivatives under

the eye reliably inducing bruising), the upper third

of the nasolabial fold, the upper lip, and the lateral

edge of the lower lip Patients should be reassured

that the effects are transient and will not impair

the fi nal correction associated with the fi ller At

the same time, they should understand that the

bruise may darken for a day or so before it slowly

resolves over a week to 10 days

An adverse effect similar to bruising is frank bleeding This can result when a vessel of moder-ate caliber is perforated by an injection needle Almost without exception, fi rm pressure for 1–5 min will stop pinpoint bleeding Cautery and ligation are exceedingly rarely, if ever required

A novel method for minimizing bruising sists of substituting ultra fi ne fl exible cannulas for injection needles The process begins with mak-ing a small puncture wound using a standard metal needle A blunt 1.5-in 27-gauge is then threaded through this opening and connected to the injec-tion syringe (DermaSculpt, CosmoFrance, 227 Michigan Ave #404, Miami Beach) Subse quent injections are delivered by withdrawing and repo-sitioning this cannula, and the lack of a sharp tip reduces the risk of repeated perforations of small vessels This technique can be time-consuming and requires practice; it may be most useful when treating patients who are highly susceptible to bruising or delivering large amounts of injectant

con-in an anatomic area at risk for bruiscon-ing

2.1.4 Overcorrection

and Undercorrection

Since the goal of fi llers is to improve aesthetic appearance, precision regarding the site and quantity of injection is imperative to ensure the most attractive result Potential problems include overcorrection, undercorrection, and asymmetry With the exception of the least viscous forms

of collagen (e.g., Cosmoderm, Zyderm), which are no longer available in the USA, signi fi cant overcorrection is not necessary with injectable

fi llers and should be avoided Relatively little of most temporary fi llers will dissipate immediately after injection All facial anatomic sites are, however, subject to some immediate swelling upon injection, and this should be taken into account when determining the degree of appro-priate correction For instance, the lips will swell upon needle trauma even in the absence of any delivered material, and postinjection swelling for 2–3 days is not uncommon Patients should

be reassured that their “Angelina Jolie” lips are a transient phenomenon on the way to desired lip size within a day or two In general, undercorrec-tion is a less serious problem than overcorrection

since patients can always be asked to return in

1–2 weeks for a touch-up procedure to replete

any missed or incompletely treated areas When

injecting patients who are acutely concerned

about looking unnaturally injected or receiving

fi llers for the fi rst time, it may be prudent to

deliberately undercorrect at the fi rst visit

Maintenance of symmetry is important

regard-less of how much material is delivered There are

two measurements that are helpful in maintaining

right-left symmetry: quantity injected and visible

correction On the one hand, when using the

tra-ditional 1-cc syringe of injectable, the injector

should ensure that approximately equal amounts

are delivered into corresponding structures, such

as the lips or nasolabial folds, on each side of the

face At the same time, given that most faces are

slightly asymmetrical to start, visual inspection

should be used to verify that both sides look

com-parably fi lled That is, to give the appearance of

equality, exactly equal quantities need not be

injected into right and left Alternating small

ali-quot injections on either side may collectively

permit achievement of symmetry

2.2 Medium-Term Undesired

Effects

2.2.1 Visible Implants

Implanted material that remains visible near the

surface of the skin is an aesthetically problematic

undesired outcome Typically manifesting as a

blanched or white papule, or as a palpable lump,

visible injectant is invariably a result of injections

that are too super fi cial or excessive in quantity [ 7 ]

If temporary fi llers like hyaluronic acids, poly l

-lactic acid, and calcium hydroxylapatite are injected

into the high (e.g., papillary) dermis or epidermis,

they may be sequestered in a layer where they are

not easily metabolized Visible blanched or bluish

areas can persist for months, even after the

remain-der of the implant effect has disappeared

Care must be taken to avoid this problem

When injections are placed using the serial

punc-ture technique, the injector should ensure that at

least the mid-dermis is reached before the syringe

plunger is depressed and that injection ceases as

the needle is pulled back out During injection,

it is extremely important to watch the skin near the needle tip to ensure the absence of blanching indicative of super fi cial placement; rapid ascer-tainment and needle repositioning can mitigate the problem Once a blanched area has been created, fi rm massage may help to break this up The patient should be asked to open their mouth, and extremely fi rm pressure be applied by the phy-sician between thumb and fore fi nger to fl atten and spread the super fi cial focus of injectant At the same time, the patient should be warned that this maneuver may induce a bruise If hyaluronic acid

fi llers are placed too high in the papillary dermis, a visible blue papule may become evident, some-times immediately, occasionally a few days later; after super fi cial injection of calcium hydroxylapa-tite, a white papule may occur Either can be very easily corrected by puncturing the site with a 25-

or 27-gauge needle and expressing the material Notably, injections of the thinnest form of colla-gen (e.g., Cosmoderm, Zyderm) can be placed high in the dermis without problems Indeed, thin collagens and other fi ne-line products are designed

to fi ll fi ne skin lines, and injection-related colored blanching is a good sign, con fi rmatory of adequately super fi cial placement

While poly- l -lactic acid is usually injected too deeply to cause a visible nodule, subcutaneous nodules can occur and should be avoided After injection of poly- l -lactic acid, the patient should

be instructed to perform fi rm massage for 5 min, 5 times a day, for 5 days; it is important to impress upon the patient the importance of this by demon-strating the technique and by warning that intrac-table, dis fi guring nodules may result if further massage is not performed at home Poly- l -lactic acid can cause visible and dif fi cult-to-treat nod-ules under the eyes and in the lips The lower eye-lid nodules resemble syringomas, can persist for years, and are extremely dif fi cult to treat Therefore, poly- l -lactic acid should not be used

in the eyelids and lips

2.2.2 Nodule Formation

An uncommon, but troublesome, outcome of injectable augmentation is nodule formation Historically, reports of nodules were believed to

be associated with hypersensitivity reactions

For instance, there have been other anecdotal

reports of post-hyaluronic acid hypersensitivity

and granulomatous reactions, including

abscess-like nodules and foreign body reactions on the

nasolabial folds and lips (Figs 2.3 , 2.4 , and

patients treated with Restylane and Hylaform

between 1996 and 2000 found that both

sub-stances were associated with sporadic cases of

injection site skin reactions (4 with Hylaform

and 2 with Restylane), including indurated

nod-ules (3 with Hylaform and 1 with Restylane)

[ 14 ] Nodules either appear to emerge

immedi-ately after treatment, likely as a result of

super fi cial injection or excessive injection to a

given location, or, alternatively, may emerge

several weeks later as a result of local

in fl ammatory or granulomatous foreign body reactions, which have been seen in the histopa-thology of some of these nodules Nodules have also been noted with the use of poly- l -lactic

acid, with rates of nodule formation ranging from 6% to 52% in a series of fi ve open-label clinical studies from Europe and the USA [ 15–

18 ] The majority of nodules, described as pable but non-visible subcutaneous micronodules, occurred within the fi rst year, and most resolved Palpable but not visible small subcutaneous nod-ules occur red in as many as half of the patients, with onset at an average of 218 days (range, 9–748 days) Nodule formation from poly- l -

pal-lactic acid can be reduced by diluting the material

with 5–8 mL rather than the lower volume (4 mL)

used in these studies (Fig 2.6 ) In one study with

calcium hydroxylapatite, 56% of patients had no

nodules; 36% had minimal nodule formation;

8%, moderate; and 0%, severe [ 19 ] Submucosal

nodules following calcium hydroxylapatite

tended to occur at the lips, with all save 8%

remit-ting within 4–6 weeks of treatment

Treatment of nodules is similar regardless of

the causative fi ller material Nodules are treated

by squeezing aggressively, massaging for several

days, injecting corticosteroid, and ultimately

con-sidering puncture and aspiration Dermabrasion

has been used to reduce nodules, but even if

indu-ration is successfully reduced by this technique,

textural abnormalities, pigmentary abnormalities,

and scar may result because the injectant is often

localized in the deep dermis, not the epidermis In some cases, resolution has been attained by treatment with allopurinol [ 20 ] or by surgical excision Either uniformly hard or cystic in com-position, nodules may express the contained fi ller upon aspiration Thus, when a nodule associated with calcium hydroxylapatite injection is incised,

a powdery, pasty white material is often easily extruded in a manner similar to the expression of

fi rm nodules It should be noted that while ules of the inner wet lip are not visible, and hence not dis fi guring to others, they can be equally trou-blesome to the affected patients: patients may inadvertently bite down on the overlying, protrud-ing mucosa, or they may obsessively palpate these annoying nodules with their tongues

Intradermal or intraoral nodules of the lips can

be resistant to simple corrective treatments, such

as steroid injections In general, steroid injections can be useful for diminishing the in fl ammatory response and possibly rupturing a nodule so as to express its contents and lead to resolution; at the same time, injudicious placement or inadvertent overtreatment with injectable corticosteroids can

Fig 2.5 ( a–b ) Lip abscess from overinjection of fi ller material ( a ), and in a different patient, bumps on the vermilion from super fi cial injection of hyaluronic acid derivative fi llers ( b )

Fig 2.6 Infraorbital nodule associated with injection of

poly- l -lactic acid for cheek augmentation Poly- l- lactic

acid must be massaged aggressively and frequently for up

to 5 days to avoid this outcome Injections in the lower

eyelid area are best avoided

easily result in an indented, atrophic scar that may

be dif fi cult to correct Most nodules will

eventu-ally remit with time The most conservative

man-agement entails gentle at-home massage and

reassurance of the patient, and close follow-up If

nodules do not spontaneously involute over some

predetermined time interval, usually the lifetime

of the fi ller involved, more aggressive corrective

action may be needed Incision and drainage using

a sharp blade, such as a #11, may be

contem-plated One innovative way to remove persistent

lip nodules, especially those associated with

per-manent fi llers, entails using a naked laser fi ber to

perforate the lip with tiny holes [ 21 ] Once the

laser energy lique fi es the residual fi ller, this can

then be extruded from the holes In this manner,

the trauma and potential scarring associated with

a macroscopic lip incision may be avoided

When nodules are comprised of hyaluronic

acid fi llers, they can be dissipated by injection of

hyaluronidase [ 22, 23 ] , which is commercially

available as a solution in injection-ready vials

Since the surrounding skin has a low

concentra-tion of hyaluronate, the enzyme dissolves the

unwanted aliquot of injectable material without

harming the skin substrate This technique is

par-ticularly helpful when hyaluronic acid derivative

injections into so-called “tear trough”

depres-sions result in excessive, asymmetric under-eye

swelling that would otherwise last months For

infraorbital augmentation, implants with hyaluronic

acids that are in slurry form, or premixed with

water (e.g., Restylane, Medicis), may be

prefer-able to use of those that are not (e.g., JUVÉDERM,

Allergan) The latter may be more likely to absorb

water and enlarge in size over several months,

thus resulting in a bulging, translucent

appear-ance that may require correction (Fig 2.7 )

The conservative approach to managing

nod-ules presupposes that there is no associated

hypersensitivity response necessitating further

evalua tion and management This assumption is

now believed to be usually correct for

nonperma-nent fi llers, but not necessarily for permanent

fi llers That is, for most temporary fi llers, nodule

formation is typically a manifestation of super fi cial

or excessive injection, and as such, an error in

technique rather than an immune response

2.2.3 Hypersensitivity Responses

Nonetheless, there is some evidence that sitivity responses can occasionally be elicited by nonpermanent fi llers [ 24 ] Most signi fi cantly, injectable bovine collagen can cause cutaneous allergy, and patients must be skin-tested twice, a month apart, to reduce the likelihood of this out-come However, a study in which 428 patients received injection of human-derived collagen (e.g., Cosmoderm) into the forearm and were followed for 2 months found no instances of cutaneous hypersensitivity; this has led to relaxation of the skin-testing recommendation when human colla-gen is used [ 25 ] While skin testing prior to use of human collagen is not deemed necessary by the FDA, the package inserts for human collagen (CosmoDerm and CosmoPlast) continue to note that use in people with a known allergy to bovine collagen has not been studied Of course, in view of the current withdrawal from the US market of all collagen fi llers, this is of mostly historical interest

Fig 2.7 Infraorbital overinjection of hyaluronic acid derivative fi ller resulting in accentuation rather than reduc- tion of tear trough

The non-collagen fi llers are much less likely

to induce immune responses This derives from

the fact that these materials are believed to be

highly biocompatible Speci fi cally, calcium

hydro-xylapatite granules are biodegraded in a manner

analogous to the turnover of bone mineral,

hyaluronic acid is a complex sugar that naturally

occurs in human skin, and poly- l -lactic acid is a

resorbable polymer similar in composition to the

commonly used polyglactin 910 (Vicryl) suture

A few cases of local hypersensitivity after

injec-tions of hyaluronic acid derivatives have been

reported; these may be due to residual proteins,

given that hyaluronic acid is derived either from

cocks’ combs of domestic fowl or fermentation

using streptococci bacteria Data presented at

the eleventh Conference on Retroviruses and

Opportunistic Infections (February 2003)

indi-cated that in a cohort of 94 patients treated with

injectable poly- l -lactic acid, 1% had an

anaphy-lactic reaction

Overall, cutaneous hypersensitivity reactions

associated with nonpermanent fi ller materials are

relatively uncommon Moreover, it is dif fi cult to

ascertain whether such reactions are due to a true

allergic diathesis or local irritation associated with

the quantity and location of a bolus of injectant

Whatever the etiology, there are a signi fi cant

number of reports of red indurated bumps over

areas treated with hyaluronic acid fi llers that

app-ear up to 3 months after treatment Lasting several

months, they clear up spontaneously, but topical

application of tacrolimus ointment (Protopic)

speeds healing as it does with delayed

hypersensi-tivity after collagen injection Local reactions may

also respond to topical or intralesional steroids, or

to incision and drainage

2.3 Rare, Serious, and Possibly

Unrelated Undesired Effects

Prepackaged injectable fi llers are extremely safe

and widely used As a consequence, it is dif fi cult

to know whether the few rare effects reported are

truly related to the fi llers or incidental, unrelated

fi ndings in patients who happen to have received

augmentation Additionally, each fi ller material

has speci fi c recommendations for injection nique that can minimize problems with use; for example, poly- l -lactic acid is a thick, heteroge-nous solution that clogs needles and syringes, which consequently need to be frequently changed to avoid inadvertent placement of exces-sively large aliquots into the skin

tech-Relatively commonly reported undesired effects that are dif fi cult to ascribe to fi llers them-selves include headache, sinusitis, and other respiratory symptoms These may be a sign of concurrent unrelated mild illness or respiratory infections In some cases, headache may result from the injection process itself: it has been shown by others that needling of the forehead in the absence of injection of any material can occa-sionally induce headache

2.3.1 Infection

Itch, acne, and herpes simplex virus reactivation (e.g., “cold sores”) have been reported in a few instances and may be associated with inadvertent skin irritation during the injection process However, these effects may also be unrelated and reported by patients only because they incorrectly believe them to be related Cutaneous bacterial infection and resulting scar may rarely be associ-ated with extrusion of super fi cially placed implants Management of implant-related infec-tion entails use of topical and oral antibiotics; scar is best managed by prevention

Signi fi cantly, reuse of fi ller material beyond the date of package opening does not appear to be associated with short-term or long-term risk of infection As it may be cost-effective for a patient

to use leftover material later, this has practical implications Two separate research groups have empirically assessed the risk of contamination in reused packages and have not detected any loss

of sterility [ 26, 27 ] An allied concern is that called bio fi lms in human skin may contain infec-tious agents that can interfere with fi ller placement and render fi llers more likely to induce subclini-cal infections [ 28 ] This remains an active area of debate and research Nonetheless, as a precau-tion, the makers of calcium hydroxylapatite

so-(BioForm/Merz) no longer advocate placement

of fi ller injections through the oral mucosa

2.3.2 Systemic Illness

Rare, serious effects that have been seen in

patients treated with fi llers include collagen

vas-cular disease and facial nerve palsy The

infre-quency of reports of these makes it impossible to

speculate regarding their etiology or causal

con-nection to fi ller materials

2.3.3 Injection-Site Necrosis

One rare but serious undesired effect that may be

causally related to injection of fi ller materials is

injection-site necrosis (Fig 2.8 ) [ 29 ] Observed

rarely after glabellar or perinasal injections, this

has been traced to the proximity of

medium-cali-ber local vasculature, which can be tamponaded

or occluded Speci fi cally, inadvertent injection of

the angular artery (nasolabial fold area) or

supra-trochlear artery (glabellar area) with viscous

fi llers induces an ischemic response with

viola-ceous bluish-gray discoloration, pain, erosion,

and ulceration [ 30 ] While the clinical

presenta-tion can vary from a diffuse pink blush to a

retic-ulated red-brown erythema, the startling

appearance does not usually presage serious

problems Most cases are localized and transient,

with a few cases of residual hyperpigmentation

that remits Current fi ller injections have not been

implicated in embolic phenomenon resulting in

retinal artery thrombosis, one case of which was

reported in the distant past following use of Zyplast

collagen

That being said, uncommon but more severe

cases of injection-site necrosis can result in

full-thickness skin slough, scar, and permanent dis fi

g-urement There does not appear to be any speci fi c

way to avoid these more serious complications,

which usually manifest with signi fi cant

discom-fort and are believed to be associated with arterial

occlusion Recommendations to “pull back” on

the injection syringe prior to injection are not

practical, given the very fi ne caliber of the

nee-dles typically used and the limited amount of

back pressure that can be created in a pre fi lled syringe Probably the most useful recommenda-tions are to inject relatively super fi cially in the subcutis and, when injecting in an anatomic region of concern (i.e., nasolabial, glabellar, etc.),

to inject slowly at a rate of approximately 0.3 cc/min Slow injections are less likely to reverse the intravascular pressure and permit retrograde movement of fi ller into the vessel

Should occlusion of a vessel occur, the fi rst step is to recognize the problem Flushing the affected area with saline may diminish vascular tamponade associated with adjacent but not intravascular fi ller injection If a linear thread consistent with vascular occlusion is seen, man-ual pres sure can be exerted to push the fi ller back out of the vessel In the case of hyaluronic acid injections, hyaluronidase should be injected into the affected site While some advocate the use of vasodilators, such as nitroglycerin ointment, there

is limited evidence of their ef fi cacy Hyperbaric oxygen may potentially be of therapeutic utility and has been used by some practitioners Past the acute phase, treatment is conservative Hyaluro-nidase may again be injected upon follow-up, but

in general, this is a period for reassurance and

“hand-holding.” Patients may be eager for ventions, but they should be reassured that much

inter-of the persistent redness, swelling, or crusting inter-of their face will spontaneously heal and that aggres-sive measures may worsen the fi nal outcome

Fig 2.8 Early necrosis associated with hyaluronic acid

fi ller occlusion of lip vasculature This may subsequently ulcerate and heal with scarring

Mild topical steroids may be of use both to reduce

in fl ammation and to provide anxious patients with

a relatively harmless therapeutic intervention

2.3.4 Compatibility with Laser

and Energy Devices

Another potential adverse event is alteration or

degradation of injectable fi llers due to treatment

of the overlying skin with lasers, lights, and

energy devices Speci fi cally, it has been

sug-gested that nonsurgical tightening by deeply

pen-etrating radiofrequency modalities may result in

heat delivery that may cause liquefaction,

migra-tion, or destruction of injectable implants At

least one human study has found this not to be the

case, with biopsies of recent hyaluronic acid

injections showing that these are unaffected by

monopolar radiofrequency treatment; the

cos-metic effect of calcium hydroxylapatite injections

may actually be augmented by the same

treat-ments [ 31 ] Another trial has extended these

fi ndings, trying virtually every type of available

cutaneous energy device to disrupt hyaluronic

acid injections immediately after placement but

not fi nding evidence of any such disruption [ 32 ]

2.3.5 Problems with Permanent

Fillers

Long-lasting or potentially permanent fi llers are

not commonly used in the USA but may be used

more often in Canada, Europe, South America,

and Asia At present, the only two permanent

fi llers in use in the USA are liquid injectable

sili-cone and poly(methyl methacrylate) (PMMA)

microspheres suspended in 3.5% bovine collagen

solution; part of the reluctance to use

longer-last-ing and permanent fi llers stems from the concern

that complications, if they arise, may be similarly

persistent

Silicone may be injected as oil (Silikon 1000)

that is approved for intraocular tamponade after

retinal detachment and used off-label as a

cutane-ous fi ller Local reactions such as pain, swelling,

and ecchymosis are common in the immediate

aftermath of injection Rarely, indurated areas of

the skin and in fl ammatory nodules and granulomas may also appear after silicone injection These prob lems may occur years after the initial injection [ 33 ] and are dif fi cult to treat Modest improve-ment has been reported with topical application of imiquimod, intralesional injection of corticoster-oids, and oral minocycline [ 34, 35 ] In the USA, to minimize the risk of such complications, many conservative practitioners use liquid silicone mostly for treatment of acne scarring, which requires small aliquot injections, and for patients with HIV-associated lipoatrophy In selected cases, it may be appropriate to apprise patients of the potential long-term risks prior to treatment

PMMA microspheres suspended in 3.5% bovine collagen solution (Arte fi ll) have been available in Europe and Canada in the current or antecedent versions since the mid-1990s Since the early days, the material has been improved, with the spheres produced now being of much more uniform size After this fi ller material is injected into the skin, the bovine collagen phase

of the implant is degraded and resorbed, and the PMMA component is left behind The PMMA microspheres persist and induce a granulomatous foreign body reaction, which elicits formation of

a fi brous capsule shell around them This nation of spheres and fi brous tissue collectively results in fi lling of the targeted soft-tissue defect Adverse reactions, which include telangiectasia, hypertrophic scarring, allergic reactions, and hypertrophic scarring, can appear months to years after injections Super fi cial placement or use of excess product can induce visible small nodules

combi-or ridges Treatment of such textural tions is dif fi cult, and while intralesional steroid injections have been reported to be successful, one of the authors (N.S.) fi nds that even multiple treatments usually result in only partial resolu-tion In resistant cases, surgical extraction or excision may be necessary [ 36 ]

Conclusion

Overall, prepackaged injectable soft-tissue augmentation materials are extremely safe and well-tolerated materials that provide many options for facial rejuvenation Undesired effects tend to be minor and prone to sponta-neous resolution resolve within a few days to

a week Rare is the patient who encounters

more than mild discomfort, with possible

tran-sient redness, swelling, and bruising Lumps

and nodules occur infrequently, are usually

easily treated, and are only rarely associated

with immune responses or cutaneous

hyper-sensitivity Discussion of bene fi ts and risks

with patients before injection, coupled with a

thorough understanding of the speci fi c

tech-niques required for the use of particular fi llers,

should enable surgeons to use these materials

with few problems

References

1 Alam M, Gladstone H, Kramer EM, Murphy JP Jr,

Nouri K, Neuhaus IM, Spencer JM, Spenceri E, Van

Dyke S, Ceilley RI, Lee KK, Menaker G, Monheit

GD, Orentreich DS, Raab B, Smith KC, Solish NJ,

American Society for Dermatologic Surgery (2008)

ASDS guidelines of care: injectable fi llers Dermatol

Surg 34 Suppl 1:S115–S148

2 Andre P, Lowe NJ, Parc A, Clerici TH, Zimmermann

U (2005) Adverse reactions to dermal fi llers: a review

of European experiences J Cosmet Laser Ther 7:

171–176

3 Lowe NJ, Maxwell CA, Patnaik R (2005) Adverse

reactions to dermal fi llers: review Dermatol Surg

31:1616–1625

4 Duffy DM (2005) Complications of fi llers: overview

Dermatol Surg 31:1626–1633

5 Dover JS, Carruthers A, Carruthers J, Alam M (2005)

Clinical use of restylane Skin Therapy Lett 10:5–7

6 Glogau RG, Kane MA (2008) Effect of injection

tech-niques on the rate of local adverse events in patients

implanted with nonanimal hyaluronic acid gel dermal

fi llers Dermatol Surg 34(Suppl 1):S105–S109

7 Hirsch RJ, Narurkar V, Carruthers J (2006)

Management of injected hyaluronic acid induced

Tyndall effects Lasers Surg Med 38:202–204

8 Lupton JR, Alster TS (2000) Cutaneous

hypersensi-tivity reaction to injectable hyaluronic acid gel

Dermatol Surg 26:135–137

9 Sha fi r R, Amir A, Gur E (2000) Long-term

complica-tions of facial injeccomplica-tions with Restylane (injectable

hyaluronic acid) Plast Reconstr Surg 106:1215–1216

10 Fernandez-Acenero MJ, Zamora E, Borbujo J (2003)

Granulomatous foreign body reaction against

hyaluronic acid: report of a case after lip

augmenta-tion Dermatol Surg 29(12):1225–1226

11 Raulin C, Greve B, Hartschuh W, Soegding K (2000)

Exudative granulomatous reaction to hyaluronic acid

(Hylaform) Contact Dermatitis 43:178–179

12 Sidwell RU, Dhillon AP, Butler PE, Rustin MH (2004) Localized granulomatous reaction to a semi-perma- nent hyaluronic acid and acrylic hydrogel cosmetic

fi ller Clin Exp Dermatol 29:630–632

13 Matarasso SL, Herwick R (2006) Hypersensitivity reaction to nonanimal stabilized hyaluronic acid

J Am Acad Dermatol 55:128–131

14 Lowe N, Maxwell CA, Lowe P, Duick MG, Shar K (2001) Hyaluronic acid skin fi llers Adverse reactions and skin testing J Am Acad Dermatol 45:930–933

15 Lerner H (2004) Sculptra-P030050 (presentation to General and Plastic Surgery Devices Advisory Panel) Division of general, restorative and neurological devices, plastic and reconstructive surgical devices, food and drug administration

16 Forbes-McKean K, Handler JA (2004) Sculptra (injectable poly-L-lactic acid) PMA P030050 (pre- sentation to General and Plastic Surgery Devices Advisory Panel) Dermik Laboratories

17 Collins S, Levin J, Lerner H (2004) FDA panel ommends approval of New-Fill HIV Treat Bull 5 5(5); p 21

18 Valantin M-A, Aubron-Olivier C, Ghosn J, Laglenne

E, Pauchard M, Schoen H et al (2003) Polylactic acid implants: results of the open-label study VEGA AIDS 17:2471–2477

19 Meszaros L (July 2003) Collagen alternatives for facial soft-tissue augmentation offers good results Cosmetic Surgery Times

20 Reisberger E-M, Landthaler M, Wiest L, Schroder J, Stolz W (2003) Foreign body granulomas caused by polymethylmethacrylate microspheres Arch Dermatol 139:17–20

21 Cassuto D, Marangoni O, De Santis G, Christensen L (2009) Advanced laser techniques for fi ller-induced complications Dermatol Surg 35(Suppl 2):1689–1695

22 Soparkar CN, Patrinely JR, Tschen J (2004) Erasing restylane Ophthal Plast Reconstr Surg 20:317–318

23 Lambros V (2004) The use of hyaluronidase to reverse the effects of hyaluronic acid fi ller Plast Reconstr Surg 114:277

24 Parada MB, Michalany NS, Hassun KM, Bagatin E, Talarico S (2005) A histologic study of adverse effects

of different cosmetic skin fi llers Skinmed 4:345–349

25 (2003) CosmoDerm/CosmoPlast collagen replacement therapy (condensed package insert) In: CosmoDerm and CosmoPlast: replacing natural collagen (patient brochure) Inamed Aesthetics, Inamed Corporation

26 Bhatia AC, Arndt KA, Dover JS, Kaminer M, Rohrer

TE (2005) Bacterial sterility of stored nonanimal bilized hyaluronic acid-based cutaneous fi ller Arch Dermatol 141:1317–1318

27 Bellew SG, Carroll KC, Weiss MA, Weiss RA (2005) Sterility of stored nonanimal, stabilized hyaluronic acid gel syringes after patient injection J Am Acad Dermatol 52:988–990

28 Rohrich RJ, Monheit G, Nguyen AT, Brown SA, Fagien

S (2010) Soft-tissue fi ller complications: the important role of bio fi lms Plast Reconstr Surg 125:1250–1256

29 Glaich AS, Cohen JL, Goldberg LH (2006) Injection

necrosis of the glabella: protocol for prevention and

treatment after use of dermal fi llers Dermatol Surg

32:276–281

30 Cohen JL, Brown MR (2009) Anatomic

consider-ations for soft tissue augmentation of the face J Drugs

Dermatol 8:13–16

31 Alam M, Levy R, Pavjani U, Ramierez JA, Guitart J,

Veen H, Gladstone HB (2006) Safety of radiofrequency

treatment over human skin previously injected with

medium-term injectable soft-tissue augmentation

materi-als: a controlled pilot trial Lasers Surg Med 38:205–210

32 Goldman MP, Alster TS, Weiss R (2007) A

random-ized trial to determine the in fl uence of laser therapy,

monopolar radiofrequency treatment, and intense

pulsed light therapy administered immediately after hyaluronic acid gel implantation Dermatol Surg 33:535–542

33 Travis WD, Balogh K, Abraham JL (1985) Silicone granulomas: report of three cases and review of the literature Hum Pathol 16:19–27

34 Bauman LS, Halem ML (2003) Lip silicone lomatous foreign body reaction treated with Aldara (imiquimod5%) Dermatol Surg 29:429–432

35 Owens JM (2005) Soft tissue implants and fi llers Otolaryngol Clin North Am 38:361–369

36 Lemperle G, Romano JJ (2003) Soft tissue tation with Artecoll: 10-year history, indications, techniques, and complications Dermatol Surg 29: 573–587

A Tosti et al (eds.), Management of Complications of Cosmetic Procedures,

DOI 10.1007/978-3-642-28415-1_3, © Springer-Verlag Berlin Heidelberg 2012

3

3.1 Introduction

Laser resurfacing is a proven method for ing unwanted changes in skin tone and texture The fi rst widely available devices were fully abla-tive, but these carried substantial risks, particu-larly for scarring and hypopigmentation Fully nonablative alternatives, which were safer, offered

counter-a welcome counter-alterncounter-ative but were less effective In

2004, the seminal concept of fractional thermolysis was introduced, delivering meaning-ful clinical results while maintaining an improved safety pro fi le [ 28 ]

In this chapter, we aim to review tions and management strategies of fractional laser systems Although complication rates will

complica-be cited and may serve as a reference, it should

be noted that rates in any clinician’s practice depends on training, experience, choice of device, settings, and prophylactic regimens, among other variables The discussion that follows derives from an extensive literature search of the MEDLINE database Representative studies of common complications will be discussed along with the few reports of unusual complications

3.2 Technology

Fractional photothermolysis delivers laser in a pixilated pattern instead of continuous sheets The pixilated treatment columns heal rapidly because of nearby fi broblasts and stem cells located within unaffected surrounding skin and

Complications of Fractional Lasers (Ablative and Nonablative)

Robert Anolik and Roy G Geronemus

Key Features

Laser resurfacing counters unwanted

•

changes in skin tone and texture

Fractional lasers deliver pixilated

include treatment-related side effects as

well as uncommon complications

A clinician’s training and conscientious

available, evidence-based literature are

best for management of adverse effects

if they arise

R Anolik , M.D (  )

Clinical Assistant Professor of Dermatology ,

Weill Cornell Medical College, New York

NY Associate, Laser & Skin Surgery Center

of New York , New York

e-mail: ranolik@laserskinsurgery.com;

www.laserskinsurgery.com

R G Geronemus , M.D

Clinical Professor of Dermatology ,

New York University Medical Center, New York

NY Director, Laser & Skin Surgery Center of New York

of New York , New York

e-mail: rgeronemus@laserskinsurgery.com;

www.laserskinsurgery.com

skin appendages Fractional systems may include

nonablative or ablative lasers, resulting in

nonab-lative fractional resurfacing (NAFR) devices or

ablative fractional resurfacing (AFR) devices

Indications for fractional resurfacing continue

to expand The list includes photoaging, scarring

(whether from acne, trauma, or surgery),

pigmen-tary changes, striae, burns, residual hemangiomas,

deposition disorders, poikiloderma of Civatte,

and premalignant disorders [ 39 ]

Contraindications are best determined by

patient history and exam History of keloids and

koebnerizing dermatitides, such as lichen planus,

psoriasis, or vitiligo, may serve as

contraindica-tions Recent isotretinoin use is a relative

con-traindication because of atypical scarring reported

with its use, although this has not been con fi rmed

in any formal study [ 35 ] Recent extensive

sur-gery in the treatment area serves as a relative

con-traindication as a result of the altered blood

supply [ 21 ]

We advise clinicians adopting these

technolo-gies to start conservatively Develop a sense of

treatment reaction and results Avoid too elevated

energies, densities, pass counts, and bulk heating

These preventative strategies have proven to

diminish complication rates [ 26 ]

Expectations should be discussed with the

patient in advance Our NAFR patients are told to

expect redness, swelling, tenderness, itching, dry

skin, and black peppery-like specks which may

produce a bronzed appearance in the days after

treatment The specks, or bronzing, are the

clini-cal result of accumulations of melanin and

so-called microepidermal necrotic debris (MEND)

under intact stratum corneum and over

laser-induced dermal wounds [ 28 ] In contrast, patients

undergoing AFR are told to expect more dramatic

effects, including redness and swelling for a week

and residual redness up to a month or slightly

longer Various degrees of oozing, bleeding,

bruising, crusting, and delayed peeling are also

expected along with mild discomfort

Pre- and posttreatment care differs among

cli-nicians In our of fi ce, we adhere to the following

protocol to ensure patient safety and comfort

when treating the entire face Pain management

includes topical lidocaine 7%/tetracaine 7% 1 h

before treatment, along with ketorolac 60 mg intramuscularly if aggressive NAFR settings or AFR is planned AFR patients also receive acet-aminophen/oxycodone 5/325, diazepam 5 mg, and ondansetron 4 mg 1 h before treatment with facial nerve blocks 15 min before treatment Rarely, intravenous sedation is required for those with marked pain intolerance or anxiety

To limit risk of infection, NAFR patients are given valacyclovir 500 mg orally twice daily for

3 days starting the day of treatment, while AFR patients are given valacyclovir 500 mg along with dicloxacillin 500 mg orally twice daily for 7 days starting the day before treatment AFR patients

go home wearing a sterile mask and are instructed

to cover the treated area with viscous emollients except when cleansing with distilled water every

4 h until reepithelialization occurs, usually by day 3 Noncomedogenic emollients are to be used

to limit acneiform outbreaks thereafter

Just after treatment, NAFR and AFR patients receive a pulsed light-emitting diode (LED) photo treatment to counter posttreatment erythema For edema, patients apply ice and receive prednisone

60 mg orally for 3 days starting the day of treatment

Sunscreen, hats, and other sun-protective sures are emphasized to limit possible ultraviolet-induced postin fl ammatory dyspigmentation

We ensure AFR patients have escorts home, particularly because of possible disorientation caused by opiate and anxiolytic medications

3.3 Epidemiology of Complications

Complication rates vary depending on the adverse event, and these rates are cited below throughout the discussion of clinical features

Age, sex, and geographic region are not reported to affect complication rates, although darker skin type does Graber et al presented 961 NAFR treatments in patients with skin types I to

V [ 20 ] In this analysis, patients with one or more

of nine possible complications were compared to the patients without complications The compli-cation group had a statistically signi fi cant darker skin type, speci fi cally skin type 2.16 versus 2.02,

p = 0.0071 Unsurprisingly, this was most evident

in the incidence of postin fl ammatory

hyperpig-mentation Otherwise, the analysis revealed no

difference with respect to sex, treatment

indica-tion (i.e., photo damage, scar, etc.), or laser

parameters

3.4 Clinical Features

Because side effects are direct consequences of

fractional laser treatment itself, we do not

con-sider them complications Still, this chapter

would be incomplete without their mention In

contrast, complications may or may not be

idio-pathic, serious, and with long-term repercussions

Recognition of the various side effects and

com-plications (Table 3.1 ) is critical for initiating

management and limiting severity and duration

of their sequelae A discussion of management

follows later in this chapter

3.4.1 Side Effects

Side effects from treatment-related trauma include

transient bronzing, edema, erythema, fl aking,

increased sensitivity, pain, pruritus, super fi cial

scrat-ches, and xerosis (Fig 3.1 ) Compared to NAFR

methods, AFR results in greater intensity of these

effects along with additional effects of epidermal

ablation, such as crusting, pinpoint bleeding,

Table 3.1 Side effects and complications reported in fractional laser resurfacing

Side effects Associated symptoms, if any

Bronzing Crusting/pinpoint bleeding/erosions/

blisters/petechiae a Edema, transient Erythema, transient Flaking

Increased sensitivity Pain

Pruritus Super fi cial scratches Xerosis

Unusual side effects and complications

Associated symptoms, if any

Acne/milia Drainage Anesthesia toxicity Perioral tingling, tinnitus,

confusion, seizure, palpitation Cicatricial ectropion Foreign body sensation,

tearing, dry eye Dermatitis Pruritus Dyspigmentation

Edema, prolonged Eruptive keratoacanthomas

Pain, pruritus, bleed Erythema, prolonged

Infection Pain, drainage Papules

Recall phenomenon Scarring, including hypertrophic

Pain, pruritus

a Crusting/pinpoint bleeding/erosions/blisters/petechiae are only common complications of AFR, not NAFR

Fig 3.1 A NAFR patient displaying erythema 1 day after treatment ( a ) and bronzing 3 days after treatment ( b )

erosions, blisters, and petechiae (Figs 3.2 and

3.3 ) Although common, these side effects are

generally well tolerated and brief

An early review of common side effects

fol-lowing NAFR was presented by Fisher and

Geronemus [ 13 ] All patients developed

postpro-cedure erythema, generally resolving by 3 days

Xerosis was reported in 86.6%, presenting 2 days

after treatment and resolving by day 5 or 6 Local

edema was reported in 82% Overall, edema was

nearly immediate and resolution occurred by

day 3 Sixty percent reported fl aking starting on

day 2 or 3 and ending by day 5 Although 46.6%

reported super fi cial scratches, this trended

down-ward dramatically with physician experience and

improved technology Pruritus was noted in 37%

arising 3 days after treatment Bronzing was

reported by 26.6%, yet described as an

uncon-cerning suntan by many patients Increased

sensi-tivity was reported in 10%, which resolved within

Fig 3.2 Erythema, edema, and mild crusting in a patient after AFR treatment The patient is shown before treatment

( a ) and 3 days after treatment ( b )

Fig 3.3 Marked crusting in a patient 3 days after AFR treatment

2 weeks One hundred percent reported pain

dur-ing the procedure, but this pain was easily

toler-ated when pretreating with 30% lidocaine in

ointment None of the patients experienced

scar-ring, infection (including herpetic activation),

dyspigmentation, or prolon ged erythema

Numerous other reports have since been

pub-lished that endorse the above fi ndings and rates

of NAFR side effects, particularly erythema and

edema [ 3, 22, 37, 42 ]

Ablative fractional lasers produce many of the

side effects seen with nonablative fractional

devices Though still transient, the manifestations

are usually longer lasting

Thirty-two AFR patients were treated by

Gotkin et al using single or multiple passes with

or without stacking of pulses [ 19 ] These

treat-ments were applied to a number of sites, including

the face, neck, trunk, and extremities All patients

experienced edema and erythema for a week after

the procedure By 2 and 4 weeks, 21 and 15

patients continued to show edema, respectively

Similarly, 27 and 3 patients showed erythema at

these time points, respectively At 3 and 6 months,

no patients showed edema or erythema Bronzing

or oozing was another common feature in these

patients, with all patients showing elements of

these, but only 2 by 2 weeks and none thereafter

Edema and erythema also follow relatively

localized treatments Weiss et al treated 19

atro-phic scars three times using an AFR laser at

1–4 month intervals [ 43 ] More than 70%,

experi-enced edema within the fi rst hour after each

treat-ment, but this fell to 20–25% on assessment at

1 week By 4–6 weeks after the fi rst treatment,

edema persisted in 1 of 19 scars None showed

edema at 4–6 weeks after the second or third

treat-ments Similarly, nearly all patients, more than

90%, experienced erythema in the fi rst hour after

each treatment By 1 week, more than 93% still

showed erythema, and at 4–6 weeks, more than

72% showed erythema After this point, however,

erythema was uncommon and, when present, was

only in trace amounts At 3 and 6 months after

fi nal treatment, 13% and 11% of assessed scars

showed trace erythema, respectively

Crusting, pinpoint bleeding, erosions, blisters,

and petechiae are uncommonly seen following

NAFR because of maintenance of epidermal integrity Stotland et al documented bullae after just one of the study’s 84 NAFR treatments of striae distensae [ 37 ] In contrast, these features

of epidermal disruption are common to AFR treatments

Following a series of AFR treatments to the face, Chapas et al found crusting and oozing in 80% of 13 subjects after the fi rst two treatments [ 7 ] These features resolved within a week After the third treatment, two patients experienced ooz-ing and crusting for the period of 1–3 weeks after the procedure No patients experienced these changes at 3 months posttreatment Petechiae developed in 53%, which resolved within 7 days after the fi rst two treatments and 3 days of the third

Similarly, in Weiss et al.’s study of 19 scars treated with an AFR laser, about half of patients developed transient crusting or pinpoint bleeding

in the fi rst 72 h after treatment [ 43 ] None onstrated these fi ndings on follow-up exam 4–6 weeks after any treatment session Fewer than one-third developed petechiae in the hours

dem-to days following each treatment [ 43 ]

An unusual variant, namely, delayed pinpoint purpura, was described in a patient following treat-ment of facial rhytides using an AFR laser [ 10 ]

On day 4 after treatment, purpuric macules were observed on the forehead and nose However, his-tory revealed postprocedure pruritus and pain leading the patient to rub her skin and take ibupro-fen on days 3 and 4 These purpura resolved within

a week upon discontinuation of the ibuprofen and starting triamcinolone ointment for pruritus Numerous additional studies of AFR offer an abundance of evidence that these side effects, particularly edema and erythema, should be expected and transient [ 33, 41 ]

3.4.2 Uncommon Side Effects

and Complications

3.4.2.1 Acne/Milia

Fractional technology substantially curtailed acneiform eruptions, seen in up to 83% of fully ablative laser resurfacing patients [ 5 ] In general,

acneiform eruptions develop in less than 10% of

NAFR treatments [ 3, 13, 20, 42 ] Among 961

NAFR treatments in one study, authors noted just

1.87% of cases with these eruptions [ 20 ]

A unusual case report details pustular,

acnei-form eruptions following treatment with a NAFR

laser with a cracked laser tip [ 25 ] The authors

speculate that the cracks may have caused random

scatter, possibly overheating some areas and

driv-ing the reaction

AFR laser studies similarly show low levels of

acneiform responses (Fig 3.4 ) [ 19 ] A study of 32

AFR patients treated in a variety of body sites

showed 1, 6, and 2 acneiform responses at 2 weeks,

1 month, and 3 months, respectively, after a single

treatment [ 19 ] No acneiform responses were

observed at 6 months

3.4.2.2 Anesthesia Complications

Whenever anesthetics are used, risk of toxicity

exists Although quantities used in fractional

pho-tothermolysis are generally well below toxicity

ranges, the complication was reported in the

litera-ture by Marra et al [ 29 ] One patient out of nearly

1,000 treated in their of fi ce developed symptoms

of lidocaine toxicity It followed application of

lidocaine 30% to the face and neck, which remained

on the patient for the hour before and during

treat-ment Lab studies con fi rmed toxic levels of

lido-caine in the blood The lidolido-caine toxicity may have

stemmed from a combination of its duration of

application, concentration, and potentially enhanced

absorption during treatment because of the laser’s

disruption of the epidermal barrier

3.4.2.3 Cicatricial Ectropion

Cicatricial ectropion is a particularly uncommon manifestation of fractional laser treatments Although it may be considered a subset of scarring, its functional and symptomatic effects distinguish

it from other types of scars

Fife et al describe a case of cicatricial pion after full-face AFR [ 11 ] At 2 days, swelling and serosanguinous oozing limited the right lower eyelid and cheek At 1 week, the patient reported right lower eyelid thickening and droop-ing At 1 month, the exam revealed a 1 cm scar on the right central lower eyelid with ectropion Injection of 0.1 ml of 5 mg/ml triamcinolone acetonide nearly eliminated the scar at 2 months and the ectropion resolved

3.4.2.4 Dermatitis

Dermatitis following fractional laser resurfacing

is rarely reported One study of NAFR reports a prevalence of less than 1% [ 20 ] Though uncom-monly reported, one should consider this fi nding considering the irritant potential from the treat-ment and the allergic potential of pre- and postre-surfacing topical agents

3.4.2.5 Dyspigmentation

Pigmentary change is unacceptably common lowing full ablative resurfacing In most cases it presents as delayed-onset hypopigmentation and has been reported in up to 57% of patients [ 9,

fol-32 ] Fractional resurfacing has nearly eliminated the risk

Among NAFR studies, rates of tion are particularly low In the Fisher et al study

dyspigmenta-of 60 follow-up visits after NAFR with skin types I

to IV, no patients developed dyspigmentation [ 13 ]

In the Graber et al review of 961 NAFR treatments with skin types I to V, postin fl ammatory hyperpig-mentation developed in 0.73% [ 20 ] Skin type I was never affected, and those with pigmentation achieved resolution after an average of 50.57 days

No other forms of dyspigmentation developed Other large studies endorse these fi ndings Just 1 of 202 and 1 of 84 patients developed tran-sient postin fl ammatory hyperpigmentation after NAFR treatments in the studies by Cohen et al and Stotland et al., respectively [ 8, 37 ]

Fig 3.4 Acneiform eruption in a patient 3 days after

AFR treatment

Darker skin types have a higher susceptibility

for change [ 34 ] In two studies of Asian skin, one

comprising 37 patients and another with 45,

postin fl ammatory hyperpigmentation was

appre-ciated in 11.1% and 17.1% [ 6, 22 ]

AFR devices show more postprocedure

dys-pigmentation, though still transient and not in

the majority In several studies, each comprised

of more than 30 subjects and involving skin

types I to V, 20–40% of patients have been

reported to have some degree of postin fl ammatory

hyperpigmentation at 1 month follow-up [ 19,

3 months

Importantly, no cases of permanent

dyspig-mentation, particularly delayed-type

hypopig-mentation, have been reported following AFR

This is supported by Hunzeker et al in which

2,000 patients showed no long-term

complica-tion [ 23 ]

3.4.2.6 Edema, Prolonged

Prolonged edema should be viewed as very

unusual When present beyond 2–3 days after

NAFR and beyond 4–6 weeks after AFR, edema

may be viewed as prolonged

Few reports mention edema persisting beyond

this period In one study, less than 1% of cases of

edema persisted beyond 2 days after NAFR [ 20 ]

Similarly, less than 5% of AFR-related

edema-tous responses have been reported to persist

beyond 4–6 weeks [ 43 ]

3.4.2.7 Eruptive Keratoacanthomas

A particularly unusual fractional laser

complica-tion is the erupcomplica-tion of keratoacanthomas These

low-grade carcinomas were reported after fully

ablative resurfacing but were fi rst reported to

fol-low NAFR by Mamelak et al [ 18, 27 ] Such an

eruption has yet been reported with AFR

Although the patients were reported as

hav-ing actinic damage in the affected areas before

treatment, the reader should not view such

dam-age as a contraindication for fractional

resurfac-ing In fact, the authors of this chapter have

presented data regarding the effectiveness of

1,927 nm thulium NAFR for the treatment of

actinic keratoses [ 17 ]

3.4.2.8 Erythema, Prolonged

Like edema, erythema uncommonly persists When present beyond 3–4 days after NAFR and beyond 4–6 weeks after AFR, erythema should

be viewed as prolonged

Prolonged erythema reportedly occurs in fewer than 1% of NAFR treatments [ 20 ] Long-term evaluation of sites treated with an AFR laser show trace erythema in 13% and 11% at 3 and

6 months, respectively [ 43 ]

3.4.2.9 Infection

Herpetic eruptions are relatively common and ous infectious complications after fractional laser treatments Before fractional treatments developed, nonfractional resurfacing triggered herpetic erup-tions in about 7% [ 30 ] In contrast, NAFR treat-ments reportedly trigger herpes simplex outbreaks

seri-in less than 2% [ 20 ] Others have reported rates as low as 0.1% [ 36 ] On the whole, these studies involve patients receiving antiviral prophylaxis Bacterial infections are less common than viral following NAFR, in ranges of 0.1–0.2% [ 20, 36 ] Fungal infections are even rarer [ 11 ] Most recently, herpes zoster and atypical myco-bacteria have been reported The few reports high-light their infrequency but also their potential Three cases of herpes zoster eruptions have been shown coursing along trigeminal branches after NAFR [ 12 ] Additionally, a case of mycobacterium chelonae has been reported following AFR [ 31 ]

3.4.2.10 Papules

A non-speci fi c papular eruption following tional laser rarely reported Stotland et al indi-cated papules arose in four of the study’s 84 NAFR treatments of striae distensae [ 37 ] These papules resolved within 2–3 weeks

3.4.2.11 Recall Phenomenon

Rare reports of a “recall” of treatment zone thema exist in the literature [ 15, 16 ] The events follow NAFR with an Nd:YAG laser emitting 1,320- and 1,440-nm wavelengths After resolu-tion of initial treatment-related erythema, the patients reportedly developed episodes of ery-thema in the treatment areas after exposure to hot water or direct sunlight

3.4.2.12 Scarring, Including

Hypertrophic

Both NAFR and AFR show little evidence of

scarring Its infrequency is re fl ected in the

litera-ture In the Graber et al review of 961 NAFR

treatments and the Hunzeker et al review of more

than 2,000 AFR treatments, no patients

devel-oped scarring [ 20, 23 ]

Still, few reports of scarring exist Four cases

were described after AFR by Fife et al [ 11 ] One

of these cases led to ectropion and is described

earlier in this chapter The other three patients

developed linear scarring on the neck These

were preceded by erythematous, indurated,

exu-dative plaques associated with super fi cial

infec-tion A culture in one case grew methicillin-resistant

Staphylococcus aureus

Avram et al describe another fi ve patients

referred to their clinic after developing

hypertro-phic scarring of the neck following AFR [ 4 ]

Two cases were described extensively In one,

horizontal lines of delayed wound healing became tender, scaly, and indurated in linear arrays Biopsy con fi rmed presence of hypertro-phic scar In the other case, the patient noted neck tightness at 2 weeks followed by vertical and horizontal linear bands at 3 weeks Notably, both patients described were also treated on the face without reported undesirable sequelae

In our own experience, after treating sands of patients with nonablative and ablative fractional lasers, no patients developed scarring Like the Avram et al team, however, patients who developed fractional laser-induced scarring have been sent to our of fi ces for subsequent man-agement One patient in particular developed marked scarring after a full face AFR session by

thou-an outside physicithou-an (Fig 3.5 ) Fortunately, we have been able to dramatically improve her appearance with repeated sessions of NAFR, pulsed-dye laser, intralesional triamcinolone, and intralesional 5- fl uoruracil (Fig 3.5 )

Fig 3.5 A patient referred to the authors’ of fi ces for

management of scars she developed following AFR

treat-ment The patient is shown on presentation to our of fi ces

( a ) and after subsequent treatments with repeated NAFR,

pulsed-dye laser, intralesional triamcinolone, and

intrale-sional 5- fl uoruracil ( b )

3.5 Management

For many complications, prevention is the most

important management step As discussed earlier,

history, physical, and both pre- and

postproce-dure care contribute to prevention More cautious

laser densities and energies have been

statisti-cally shown to reduce complications such as

ery-thema, edema, and pain [ 26 ] Combining lower

MTZ density with additional treatment passes

has also limited adverse effects, notably

dyspig-mentation [ 7 ]

For the majority of side effects and

compli-cations, little to no evidenced-based literature

exists speci fi c to their management following

fractional laser resurfacing Much of the

man-agement in settings of fractional lasers is

anec-dotal, unpublished, and simply draws upon

standard dermatologic care of in fl amed skin

For example, when faced with bronzing, fl aking,

increased sensitivity, pruritus, and xerosis, we

recommend gentle skin care with mild soaps

and noncomedogenic emollients For severe

pruritus, we would consider once or twice daily

application of a topical corticosteroid When

noting super fi cial scratches or crusting/pinpoint

bleeding/erosions/blisters, we recommend a

viscous emollient, such as Aquaphor Healing

Ointment®, for better wound healing until skin

has reepithelialized

Particularly uncommon complications, such as

eruptive keratoacanthomas, transient nonspeci fi c

papules, and recall phenomenon, have no

man-agement studies in fractional laser settings simply

because of their infrequency If faced with

kera-toacanthomas, we would advise excision if few in

number or alternative approaches, such as

sys-temic isotretinoin, if greater in number based on

management of the same concerns when

unre-lated to fractional resurfacing [ 40 ] If a papular

eruption or recall phenomenon occurred, we

rec-ommend mild skin care and observation for

reso-lution, as occurred in cases cited in the literature

(as discussed earlier)

What follows here are additional itemized

management steps that draw from our experience

as well as evidence-based strategies found directly

in the fractional resurfacing literature

3.5.1 Acne/Milia

When acneiform responses occur, our treatment depends on degree of reaction If minimal and the post-treatment viscous emollient is no longer being used or able to be discontinued, the erup-tion may resolve on its own with transition to noncomedogenic skin care agents If a more sub-stantial reaction arises, we institute acne care, often topical or, if needed, systemic antibiotics

If a patient has a marked history of acne, one could consider a prophylactic oral acne treat-ment regimen

Select evidence-based management:

• Doxycycline concomitant with laser treat-–

ment (Category 5) [ 3 ] Alster et al reported that roughly 5% of 50 patients undergoing NAFR of atrophic scars experienced acneiform eruption [ 3 ] When oral doxycycline was administered to the affected patients with subsequent treatments, they report

no further acneiform response

3.5.2 Anesthesia Toxicity

No studies speci fi cally evaluate management strategies of anesthesia toxicity in the setting of fractional laser resurfacing In the event we faced this concern, management would likely include monitoring and symptomatic management Select evidence-based management:

• Lorazepam, intravenous fl uids, observation –

(Category 5) [ 29 ] Marra et al describe a case in which a patient developed symptoms of lidocaine toxicity [ 29 ] After administration of lorazepam and intrave-nous lactated Ringer solution, the patient improved while under close observation

Select evidenced-based management

•

Intralesional triamcinolone acetonide

–

(Category 5) [ 11 ]

Fife et al presented a case of cicatricial

ectro-pion following AFR [ 11 ] At 1 month following

resurfacing, 0.1 ml of 5 mg/ml triamcinolone

acetonide was injected into the palpable scar

Near total elimination of the scar and complete

resolution of the ectropion was appreciated the

following month

3.5.4 Contact Dermatitis

Although no studies speci fi cally evaluate

man-agement of contact dermatitis in the setting of

fractional laser resurfacing, we recommend

stan-dard dermatologic care including gentle skin care

(mild soaps, gentle emollients) and would

con-sider topical corticosteroids as needed

3.5.5 Dyspigmentation

Management of dyspigmentation particularly

starts with prevention We ensure our patients

understand the need for sun protection during the

postprocedure healing phase For

hyperpigmen-tation that appears to be slowly resolving, we

would consider a gentle NAFR treatment or

pos-sibly a mild Q-switched ND:YAG treatment at

C, and sunscreen (Category 5) [ 8 ]

Smaller spot diameter with nonadjacent

–

delivery of MTZ during treatment and

postprocedure sun protection,

hydroqui-none, and tretinoin (Category 4) [ 38 ]

In a study of 59 patients undergoing NAFR

treatments, one developed postin fl ammatory

hyperpigmentation The patient was managed

with topical tretinoin, hydroquinone, vitamin C,

and sunscreen, ultimately reaching resolution of

hyperpigmentation at 6 months [ 8 ]

Tan et al used a speci fi c AFR device and

protocol to assess its effects on seven patients

with skin types IV or V [ 38 ] By employing a

relatively small spot diameter of 1.30 mm, the authors argue less bulk heating occurs Addition-ally, the MTZs were laid down in a nonsequential order to allow further thermal relaxation before

an adjacent MTZ was generated No patients experienced postin fl ammatory hyperpigmenta-tion However, in addition to the laser modi fi -cations, patients were to remain indoors for 7 days, apply hydroquinone and tretinoin on days 3–14 after treatment, among other measures to limit pigmentary abnormalities

3.5.6 Edema, Transient or Prolonged

Little literature speci fi cally evaluates the agement of edema in the setting of fractional laser resurfacing In our practice, for aggressive nonablative or ablative fractional resurfacing, we offer oral corticosteroids, often prednisone 60 mg daily for 3 days, starting on the day of treatment

man-In addition, cool compresses and elevation are encouraged

3.5.7 Erythema, Transient

or Prolonged

Erythema should be expected, at least transiently

We employ pulsed light-emitting diode photo modulation treatments in our practice Otherwise,

we recommend gentle skin care to soothe the

in fl ammatory response is recommended to speed resolution

Select evidence-based management:

• Light-emitting diode (LED) photo modula-–

tion (Category 2) [ 1 ] Topical ascorbic acid (Category 3) [

Lower densities and/or energies –

(Cate-gory 2) [ 26 ] Twenty patients, following full-face NAFR, were treated with a 590 nm LED array to either half of the face [ 1 ] LED-treated facial halves demonstrated diminished and more rapidly dis-sipating erythematous responses

Ascorbic acid (vitamin C), compounded in either a cream or serum, was applied to facial halves of 21 patients following fully ablative CO

resurfacing [ 2 ] When compounded in serum, but

not in cream, erythema was statistically less

evi-dent than the untreated control half

As has been described previously, lower

den-sities and/or energies have been shown to limit

adverse reactions, including erythema [ 26 ]

3.5.8 Infection

Once again, prevention is the most important

The published literature regarding infection

fol-lowing fractional laser treatments focuses on

pro-phylaxis and depends on the practitioner

Our prophylactic regimen is detailed earlier in

this chapter If a suspected infection does arise,

we recommend cultures (consider viral, routine

bacterial, anaerobic bacterial, acid fast, and

fun-gal) be performed and empiric antibiotic agents

be administered Modi fi cations to treatment

regi-mens should then be employed based on culture

results If infection spread, one should closely

monitor vitals to look for sepsis

3.5.9 Pain

Topical, injectable, oral, intramuscular, and

seda-tive pain management strategies are employed or

considered in our patients, as described earlier In

addition, we use a handheld forced cold air device

Fisher et al treated 20 patients with and

with-out a handheld forced cold air device during

NAFR [ 14 ] Nineteen of twenty noted decreased

pain with the handheld cooling

3.5.10 Petechiae and Delayed Purpura

In the event of petechiae or purpura immediately

or days after treatment, a combination of time

and avoidance of anticoagulants should lead to

resolution If purpura were marked enough, we

would consider pulsed-dye laser treatment [ 24 ]

Select evidenced-based management

• Avoidance of unnecessary NSAIDs, aspi-–

rin, vitamin E, ginkgo biloba, and other blood-thinning agents (Category 5) [ 10 ]

In the one reported case of delayed purpura, a patient’s self administration of NSAIDs preceded the delayed purpura and its elimination from her regimen led to resolution

3.5.11 Scarring, Including

Hypertrophic

We would consider intralesional corticosteroids with 5- fl uorouracil, pulsed dye laser, and possi-bly gentle NAFR Given its infrequency, little is available in the literature speci fi c to this setting Select evidenced-based management

• Topical steroids (Category 5) [

Avram et al report success in resolution of hypertrophic scarring of the neck with topical clobetasol 0.05% cream twice daily Residual mild hypopigmentation persisted

3.6 Summary for the Clinician Box

Fractional laser resurfacing diminishes unwanted changes in skin tone and texture Fractionating the laser allows far greater chance of success with less risk compared to past nonfractionated alternatives Adverse effects of fractional lasers consist of treat-ment-related side effects and unusual complica-tions Although management of complications begins with prevention, the clinician should be prepared to identify and respond to side effects and complications as they arise Like the spectrum

of adverse effects, management options are diverse Where available, the authors’ experiences and evidence-based literature are cited to guide other clinicians in management of the adverse effects

References

1 Alster TS, Wanitphakdeedecha R (2009) Improvement

of postfractional laser erythema with light-emitting diode photomodulation Dermatol Surg 35:813–815

2 Alster TS, West TB (1998) Effect of topical vitamin C

on postoperative carbon dioxide laser resurfacing

ery-thema Dermatol Surg 24:331–334

3 Alster TS, Tanzi EL, Lazarus M (2007) The use of

fractional laser photothermolysis for the treatment of

atrophic scars Dermatol Surg 33:295–299

4 Avram MM, Tope WD, Yu T et al (2009) Hypertrophic

scarring of the neck following ablative fractional

car-bon dioxide laser resurfacing Lasers Surg Med

41:185–188

5 Bernstein LJ, Kauvar AN, Grossman MC et al (1997)

The short- and long-term side effects of carbon

diox-ide laser resurfacing Dermatol Surg 23:519–525

6 Chan HH, Manstein D, Yu CS et al (2007) The

preva-lence and risk factors of post-in fl ammatory

hyperpig-mentation after fractional resurfacing in Asians

Lasers Surg Med 39:381–385

7 Chapas AM, Brightman L, Sukal S et al (2008)

Successful treatment of acneiform scarring with CO 2

ablative fractional resurfacing Lasers Surg Med

40:381–386

8 Cohen SR, Henssler C, Horton K et al (2008) Clinical

experience with the fraxel sr laser: 202 treatments in

59 consecutive patients Plast Reconstr Surg 121:

297e–304e

9 Dijkema SJ, van der Lei B (2005) Long-term results

of upper lips treated for rhytides with carbon dioxide

laser Plast Reconstr Surg 115:1731–1735

10 Fife DJ, Zachary CB (2009) Delayed pinpoint

pur-pura after fractionated carbon dioxide treatment in a

patient taking ibuprofen in the postoperative period

Dermatol Surg 35:553

11 Fife DJ, Fitzpatrick RE, Zachary CB (2009)

Complications of fractional CO 2 laser resurfacing:

four cases Lasers Surg Med 41:179–184

12 Firoz BF, Katz TM, Goldberg LH, Geronemus RG,

Polder KD, Friedman PM (2011) Herpes zoster in the

distribution of the trigeminal nerve following

non-ablative fractional photothermolysis of the face: report

of 3 cases Dermatol Surg 37(2):249–252

13 Fisher GH, Geronemus RG (2005) Short-term side

effects of fractional photothermolysis Dermatol Surg

31:1245–1249

14 Fisher GH, Kim KH, Bernstein LJ et al (2005)

Concurrent use of a handheld forced cold air device

minimizes patient discomfort during fractional

photo-thermolysis Dermatol Surg 31:1242–1243

15 Foster KW, Fincher EF, Moy RL (2008) Heat-induced

“recall” of treatment zone erythema following

frac-tional resurfacing with a combination laser

(1320 nm/1440 nm) Arch Dermatol 144:1398–1399

16 Foster KW, Kouba DJ, Fincher EE et al (2008) Early

improvement in rhytides and skin laxity following

treatment with a combination fractional laser emitting

two wavelengths sequentially J Drugs Dermatol

7:108–111

17 Geronemus RG, Weiss E, Chapas AM, Desai S,

Brightman L, Hale EK, Karen JK, Bernstein LJ (2010)

Finally! A well-tolerated and effective treatment for

actinic keratoses on the face Paper presented at the

American society for laser medicine and surgery 30th annual conference, Phoenix, 2010

18 Gewirtzman A, Meirson DH, Rabinovitz H (1999) Eruptive keratoacanthomas following carbon dioxide laser resurfacing Dermatol Surg 25:666–668

19 Gotkin RH, Sarnoff DS, Cannarozzo G et al (2009) Ablative skin resurfacing with a novel microablative

CO 2 laser J Drugs Dermatol 8:138–144

20 Graber EM, Tanzi EL, Alster TS (2008) Side effects and complications of fractional laser photothermoly- sis: experience with 961 treatments Dermatol Surg 34:301–305

21 Hayes DK, Berkland ME, Stambaugh KI (1990) Dermal healing after local skin fl aps and chemical peel Arch Otolaryngol Head Neck Surg 116: 794–797

22 Hu S, Chen MC, Lee MC et al (2009) Fractional resurfacing for the treatment of atrophic facial acne scars in Asian skin Dermatol Surg 35:826–832

23 Hunzeker CM, Weiss ET, Geronemus RG (2009) Fractionated CO 2 laser resurfacing: our experience with more than 2000 treatments Aesthet Surg J 29:317–322

24 Karen JK, Hale EK, Geronemus RG (2010) A simple solution to the common problem of ecchymosis Arch Dermatol 146:94–95

25 Kim DH, Lee SJ, Kang JM et al (2007) Cracks on the tip: an unusual complication using the fractional pho- tothermolysis system J Eur Acad Dermatol Venereol 21:1280–1281

26 Kono T, Chan HH, Groff WF et al (2007) Prospective direct comparison study of fractional resurfacing using different fl uences and densities for skin rejuve- nation in asians Lasers Surg Med 39:311–314

27 Mamelak AJ, Goldberg LH, Marquez D et al (2009) Eruptive keratoacanthomas on the legs after fractional photothermolysis: report of two cases Dermatol Surg 35:513–518

28 Manstein D, Herron GS, Sink RK et al (2004) Fractional photothermolysis: a new concept for cuta- neous remodeling using microscopic patterns of ther- mal injury Lasers Surg Med 34:426–438

29 Marra DE, Yip D, Fincher EF et al (2006) Systemic toxicity from topically applied lidocaine in conjunc- tion with fractional photothermolysis Arch Dermatol 142:1024–1026

30 Nanni CA, Alster TS (1998) Complications of carbon dioxide laser resurfacing An evaluation of 500 patients Dermatol Surg 24:315–320

31 Palm MD, Butterwick KJ, Goldman MP (2010) Mycobacterium chelonae infection after fractionated carbon dioxide facial resurfacing (presenting as an atypical acneiform eruption): case report and litera- ture review Dermatol Surg 36(9):1473–1481

32 Prado A, Andrades P, Danilla S et al (2008) Full-face carbon dioxide laser resurfacing: a 10-year follow-up descriptive study Plast Reconstr Surg 121:983–993

33 Rahman Z, MacFalls H, Jiang K et al (2009) Fractional deep dermal ablation induces tissue tightening Lasers Surg Med 41:78–86

34 Rokhsar CK, Fitzpatrick RE (2005) The treatment of

melasma with fractional photothermolysis: a pilot

study Dermatol Surg 31:1645–1650

35 Rubenstein R, Roenigk HH Jr, Stegman SJ et al (1986)

Atypical keloids after dermabrasion of patients taking

isotretinoin J Am Acad Dermatol 15:280–285

36 Setyadi HG, Jacobs AA, Markus RF (2008) Infectious

complications after nonablative fractional resurfacing

treatment Dermatol Surg 34:1595–1598

37 Stotland M, Chapas AM, Brightman L et al (2008)

The safety and ef fi cacy of fractional photothermolysis

for the correction of striae distensae J Drugs Dermatol

7:857–861

38 Tan KL, Kurniawati C, Gold MH (2008) Low risk of

postin fl ammatory hyperpigmentation in skin types 4

and 5 after treatment with fractional CO 2 laser device

J Drugs Dermatol 7:774–777

39 Tierney EP, Kouba DJ, Hanke CW (2009) Review of

fractional photothermolysis: treatment indications

and ef fi cacy Dermatol Surg 35:1445–1461

40 Vandergriff T, Nakamura K, High WA (2008) Generalized eruptive keratoacanthomas of grzybowski treated with isotretinoin J Drugs Dermatol 7:1069–1071

41 Walgrave SE, Ortiz AE, MacFalls HT et al (2009) Evaluation of a novel fractional resurfacing device for treatment of acne scarring Lasers Surg Med 41:122–127

42 Wanner M, Tanzi EL, Alster TS (2007) Fractional photothermolysis: treatment of facial and nonfacial cutaneous photodamage with a 1,550-nm erbium- doped fi ber laser Dermatol Surg 33:23–28

43 Weiss ET, Chapas A, Brightman L et al (2010) Successful treatment of atrophic postoperative and traumatic scarring with carbon dioxide ablative frac- tional resurfacing: quantitative volumetric scar improvement Arch Dermatol 146:133–140