CC
A 41-year-old female presents to you complaining of generalized sun damage from years of “tanning.”
HPI
She would like to have her skin “lasered” to erase the years of excessive sun exposure. She states that despite her blue eyes, she could tan with sun exposure in her youth. She grew up in California and used to “live at the beach.” She thinks she will eventually need a facelift but wants to avoid it for now.
PMHX/PDHX/medications/allergies/SH/FH
Noncontributory. She takes lisinopril for mild hypertension and quit smoking 25 years ago. She denies any recent use of Accutane but does use some Retin A when she “remembers to.” She denies any history of abnormal scarring and herpetic outbreaks. She had an upper eyelid blepharoplasty 10 years ago.
There are contraindications to CO 2 laser resurfacing:
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Fitzpatrick skin types IV to VI (there is an increased risk of dyspigmentation in patients with darker skin; Fig. 83.1 )
• Fig. 83.1 Fitzpatrick skin types I to VI. - •
History of keloids
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Recent oral isotretinoin therapy (a 12-month waiting before resurfacing is traditionally recommended)
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Morphea
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Scleroderma
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Prior radiation therapy (which limits the skin’s ability to heal in a timely fashion)
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Cutaneous disorders (vitiligo, lichen planus, and psoriasis are relative contraindications)
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Active herpes outbreaks or other ongoing infections in the targeted area (laser treatment should be postponed until the condition has resolved)
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Ongoing ultraviolet exposure
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Recent medium or deep chemical
Examination. The patient appears older than her stated age but is in good spirits and interactive. She has several scattered brown dyschromias throughout her face with fine static and dynamic rhytids under her eyes and around her mouth particularly. She has some age-related atrophic changes to the midface and temporal regions as well as platysmal banding, laxity to the anterior neck, and early jowling. Her skin is otherwise clear without scarring or active comedones. She has Fitzpatrick skin type II (see Fig. 83.1 ).
Imaging. Standardized preoperative and serial postoperative photography is mandatory for cosmetic procedures. Frontal animated and repose as well as oblique and profile images are recommended.
Labs. Routine preoperative laboratory testing is not required for resurfacing procedures unless dictated by the patient’s medical history.
Assessment
Middle-aged female with Fitzpatrick skin type II and signs of photoaging. As a general rule, lighter skin types are more favorable to resurfacing, particularly laser resurfacing. Given her slightly tanned skin, she is at risk for hyperpigmentation postoperatively.
Treatment
Skin preparation
It is recommended that patients undergoing resurfacing procedures prepare the skin with hydroquinone and topical tretinoin 4 to 6 weeks earlier to minimize risk of postoperative complications and speed healing after resurfacing. Use of hydroquinone preoperatively is strongly recommended for this patient.
Anesthesia
If the patient is not under general anesthesia, thoughtful anesthetic technique is a must. A combination of intravenous (IV) sedation with complete blockade of facial sensory as described by Zide and Swift will allow the patient to tolerate laser application. Topical anesthetic alone is unlikely to provide sufficient comfort to tolerate ablative resurfacing.
Resurfacing
In general, two forms of fractional CO 2 resurfacing are used, high fluence with low density versus low fluence and higher density. The higher fluence treatments are more uncomfortable and require more postoperative healing but tend to result in more improvements versus the lower energy treatments. Treatment of the neck and chest have higher risk of scarring given the significant reduction on pilosebaceous unit density (30–40× less) in these areas, thereby reducing the healing capacity of the epidermis. Before resurfacing, the face is cleaned and prepped with an alcohol swab and allowed to fully dry before laser application. Lower eyelids often require treatment, and care must be taken to protect the cornea with either corneal shields or obstructing carefully with a tongue depressor when treating near the eye itself. Avoid the vermillion border because it is possible to efface this well-defined anatomic margin with resurfacing. One pass of higher energy treatment is generally sufficient, but deeper or denser rhytids may require a second pass, particularly around the lower eyelids and cheeks and periorally. Caution: More aggressive treatment requires a more ideal patient and skin type and significantly more experience. Debridement between passes is not required, and when the treatment is completed, a generous coat of petroleum jelly or Aquaphor is applied.
Postresurfacing care
Although more cumbersome dressing are available, they do not seem to provide a significant improvement versus more simplified techniques in the author’s opinion. Cold compresses may benefit in postoperative discomfort but come with an increased risk of scratching, irritating, or even frostbiting the lasered skin. In general, postlaser discomfort is brief and mild. Starting on postoperative day 1, the patient should gently wash the lasered areas with a mild hypoallergenic soap, pat dry, and reapply Aquaphor three to five times daily. On postoperative day 3 or 4, vinegar soaks may be added to the regimen three times daily. Note that some patients may develop a contact allergy and irritation to vinegar with frequent use. After the treated areas have fully reepithelialized around day 6 to 9, Aquaphor may be switched to a gentle topical moisturizer, and makeup may be applied if desired. Postlaser resurfacing care is perhaps the most tedious of any of the facial cosmetic surgery procedures and mirrors burn care in many ways. A fastidious patient and an observant provider are a must.
Complications
Erythema
Some degree of erythema after treatment is expected, but if the erythema persists, it may become problematic. More aggressive treatments in lighter skinned individuals usually result in prolonged redness but can also occur in patients with a history of facial flushing, eczema, and rosacea. Short courses of topical steroids may be effective, but if not quickly responsive, be sure to rule out contact dermatitis or infectious causes. Fortunately, although common, persistent erythema is rarely permanent.
Acne
It is important that acne be under good control before resurfacing, given that severe acne can lead to atrophic scarring, which may the reason some patients seek resurfacing. Minor flares in acne may occur during the posttreatment phase because of use of heavy emollients in the first days and weeks. These flares should resolve when these emollients are discontinued. If persistent, topical or oral antibiotics may be required. After skin sensitivity has diminished, other topical agents such as glycolic acids and tretinoin may be used.
Infection
The primary role of the skin is to prevent infection; however, during the postlaser period, this function is temporarily compromised. Perioperative use of oral antibiotics and antivirals is the standard of care for most CO 2 laser treatments. Oral antiviral prophylaxis should start 24 to 48 hours before resurfacing and be continued through the first 5 to 7 days postoperatively. Standard prophylactic doses of famciclovir or valacyclovir are usually sufficient, but if a breakthrough infection occurs, the dose should be increased or a second agent considered. Rarely, IV antivirals may be required in nonresponsive cases.
Scarring
The most effective ways to prevent scarring are to use proper intraoperative technique, meticulous postoperative care, and infection prevention. For instance, overlapping or stacking of laser scans may lead to scarring. More worrisome, scarring in the lower eyelid or cheek region has the potential to disrupt the lower eyelid adaptation to the globe of the eye and result in ectropion. Fortunately, scarring is fairly rare when the aforementioned guidance is adhered to, but some patient factors may also contribute to cicatricial formation, including prior resurfacing, recent use of isotretinoin, history of keloids or hypertrophic scarring, and poor compliance with care. If scars occur, initial therapy should include topical or intralesional corticosteroids, silicone sheeting, or pulsed-dye laser therapy. Multimodal and multiple treatments may be required in the most difficult cases.
Pigment disorder
It is common for post-laser patients to experience postinflammatory hyperpigmentation after resurfacing. Although pretreatment of the skin with topical tretinoin and hydroquinone may reduce the risk, it still occurs, particularly in those with darker skin types. Fortunately, this almost always resolves with time. Good postoperative skin care and avoidance of irritation as well as judicious use of topical steroids creams can reduce the frequency somewhat, but the most effective treatment is preparing the patient for transient hyperpigmentation and close follow-up when it occurs. Hypopigmentation, a more uncommon and unfortunate complication, is the loss of functional melanocytes after deeper resurfacing treatment; it may become permanent. This is more common in deep phenol peels and aggressive dermabrasion, but it can occur with laser treatments when the excess energy reaches the melanocytes or melanosomes. Pseudo hypopigmentation can also occur and is simply the improvement in laser-treated skin versus untreated and is more likely to occur when the treatment lines in moderately and severely damaged skin are not carefully blended during the procedure.
Discussion
CO 2 laser resurfacing is the gold standard for skin rejuvenation in patients with photoaging; however, it should not be viewed as a panacea for total facial rejuvenation, which involves age-related changes that are unaffected by laser treatment, particularly ptosis and volume changes. It is best viewed and used as an adjunctive or finishing treatment in a cache of other surgical and nonsurgical rejuvenation procedures. Resurfacing alone can lead to disappointment in a patient who expects to look 10 or 20 years younger with one isolated procedure. Thus, preoperative guidance with softened expectations is as vital as counseling the patient for common risks and benefits. Successful postlaser resurfacing management requires the acceptance that some complications (hopefully, minor) will occur rather than hoping they can be entirely avoided. But when applied in the correct setting and with a well-prepared patient and an even better prepared surgeon, it can yield beautiful and predictable results ( Fig. 83.2 ).
