Laser facial resurfacing

Preoperative preparation for laser facial resurfacing

Patients undergoing laser skin resurfacing require extensive preoperative preparation and postoperative care. There is still controversy about the need for skin preparation. Some surgeons recommend pre-treatment with hydroquinone, isotretinoin, or glycolic acid. Others do not use any formal preparation for the procedure. Most agree that sun protection is important before resurfacing. Sun exposure can activate melanocytes and cause hyperpigmentation.

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Laser face resurfacing: surgical technique

Before treatment, the cosmetic units of the face must be marked. It is important to mark the patient in a sitting position, since the skin shifts when lying on the back. Marking in this position may result in incorrect marking of the edge of the lower jaw. To prevent the appearance of permanent tattoos, marking lines must not be drawn on denuded skin. Along the borders of the cosmetic units (i.e. the edges of the eye sockets, nasolabial fold), grinding must be smoothing. When treating the entire face, the edges must be smoothed along the lower jaw to create a natural transition to the untreated skin of the neck.

Laser energy and power settings are much less important to monitor the depth of treatment with each pass than clinical considerations. With CO2 laser resurfacing, the skin turns pink after penetrating the papillary dermis. Most surgeons wipe away any remaining vaporized tissue with wet wipes between laser passes. With the Erbium laser, pinpoint bleeding is a marker of papillary penetration. As the dermis penetrates deeper, the pinpoint bleeding increases.

Since the pilosebaceous unit is an hourglass shape, the increase in pore diameter occurs as the ablation depth increases. Moreover, different skin thicknesses in cosmetic units require a given number of passes and given settings. Obviously, the thin skin of the eyelids allows for a smaller penetration depth than the thicker, more adnexal skin of the cheeks. Also, individual patient characteristics require a less aggressive approach on thin, dry skin compared to deep ablation of thick, oily skin. For example, the damaged skin of a 65-year-old woman will tolerate less laser energy than the skin of a 25-year-old man with acne scars. Very often, pathological changes (wrinkles or scars) extend deeper than the safe treatment zone. Another important goal of laser resurfacing, which usually determines the penetration of the reticular dermis, is the destruction of photodamage, wrinkles, or greater skin tightening.

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Complications of laser facial resurfacing

Temporary postoperative hyperpigmentation is common for 2-6 weeks after surgery. This darkening is caused by the sun and usually clears up well in the absence of sun exposure with hydroquinone, retinoic acid, and topical mild steroids.

On the other hand, hyperpigmentation can be long-lasting and unpredictable. This complication usually develops late, after several months. Fortunately, it occurs in only 10-30% of patients.

Scarring, which is the most feared problem, begins with persistent hyperemia that gradually becomes indurated and nodular. Local treatment with injectable steroids, steroid-impregnated dressings, or steroid ointments is highly effective. Certain areas of the face, such as the malar eminence, upper lip, and lower jaw, are prone to hypertrophic scarring.

The occurrence of viral infection is characterized by intense pain. It may develop despite prophylaxis with low doses of antiviral drugs. Infection is usually observed 7-10 days after the procedure, during the completion of re-epithelialization. Exacerbation of herpes requires intensive treatment with doses used for shingles. Bacterial infection can also cause pain and significantly increase the risk of scarring. Moreover, if the dressing is not changed for more than 24 hours or if the wound is not properly cleaned when changing the dressing, a secondary fungal infection can develop. Contact dermatitis to ointments such as Neosporin, Polysporin, and even Vaseline is much more common after laser resurfacing. Contact dermatitis requires discontinuation of the causative drug and topical application of medium-strength steroids, as well as systemic steroids. Close attention to the patient's skin type, treatment areas, and laser parameters can significantly improve the surgical outcome while minimizing potential side effects. Moreover, with careful and attentive monitoring in the postoperative period, almost all undesirable outcomes and complications can be anticipated and reversed. The most important action in the postoperative period is constant encouragement and reassurance of patients.

Post-operative care

As recognized by dermabrasion practitioners, semi-occlusive dressings such as Vigilon or Flexan have significantly reduced the time to re-epithelialization to 5-7 days by maintaining the moisture necessary for epithelial cell migration. These dressings have been shown to heal more quickly, with less pain, less scarring, and less erythema than open or desiccated wounds. Most surgeons change these dressings daily for 3-5 days. Wounds can also be managed open using liposoluble ointments.

After re-epithelialization is complete, sun exposure should be avoided until post-operative erythema has completely resolved (usually 2-3 months). Unscented moisturizers increase skin moisture while preventing contact sensitization. Topical class I and II steroids may also be used to reduce post-operative erythema. They should be used for short periods. Hypoallergenic, non-acne-causing makeup may be used to conceal unwanted redness after re-epithelialization is complete. The bright red color of post-operative erythema is usually neutralized with a green or yellow base.

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