Preoperative anesthesia and postoperative considerations in laser resurfacing

A Novel Macrophage-Activating Gel Improves Healing and Skin Quality After CO2 Laser Resurfacing of the Chest

BACKGROUND

After laser resurfacing, it is imperative that an appropriate postoperative regimen is followed for optimal wound healing. There is currently no consensus about which agents should be used.

OBJECTIVE

To evaluate the safety and efficacy of a novel macrophage-activating gel in a Phase 2B trial to be used after fractionated ablative laser resurfacing of the chest.

MATERIALS AND METHODS

Forty-two adults who received fractionated CO2 laser resurfacing of the chest were randomized (active or placebo) for 5 consecutive days after procedure. Skin quality at baseline and follow-up was assessed by a blinded evaluator using the Fitzpatrick-Goldman Wrinkle Scale. Subject satisfaction with skin healing and quality was also assessed.

RESULTS

At 28 days according to the Fitzpatrick-Goldman Wrinkle Scale, 85% of subjects achieved an improvement of at least 33% for the active group versus 50% in the placebo group (absolute difference 35%; p = .04). Similarly, 75% of subjects achieved an improvement score of at least 33% in elastosis in the active group versus 35% in the placebo group at 28 days (40% absolute difference; p = .011).

CONCLUSION

This study confirms the potent effects of the novel macrophage-activating gel for optimization of skin healing and quality after laser resurfacing of the chest.

Recognizing and Managing Complications in Laser Resurfacing, Chemical Peels, and Dermabrasion

Skin resurfacing techniques allow improvement of skin texture and color. This includes the effacement of wrinkles, signs of photoaging, and the softening of scars. Laser resurfacing, chemical peels, and dermabrasion are associated with overlapping risks of complications. The most common of these include infection, hypopigmentation, hyperpigmentation, and scarring. Patient evaluation helps provide treatment that gives the maximal benefit with a minimization of risks. This includes understanding the extent of each patient's issues (Glogau scale) and Fitzpatrick type. A thorough knowledge of potential risks will reduce their incidence and optimize early recognition and treatment of these complications when they do occur.

Anesthesia methods in laser resurfacing

Laser resurfacing technology offers the ability to treat skin changes that are the result of the aging process. One of the major drawbacks of laser resurfacing technologies is the pain associated with the procedure. The methods of anesthesia used in laser resurfacing to help minimize the pain include both noninvasive and invasive procedures. The noninvasive procedures can be divided into topical, cryoanesthesia, and a combination of both. The invasive methods of anesthesia include injected forms (infiltrative, nerve blocks, and tumescent anesthesia) and supervised anesthesia (monitored anesthesia care and general anesthesia). In this review, the authors summarize the types of anesthesia used in laser resurfacing to aid the provider in offering the most appropriate method for the patient to have as painless a procedure as possible.

Current lasers in skin resurfacing

Lasers are a useful tool to combat signs of aging, photodamage, and environmental effects on the skin. This article reviews the history, basic science, indications, clinical considerations, and procedural techniques of various ablative lasers.

Lasers in dermatology: four decades of progress

Advances in laser technology have progressed so rapidly during the past decade that successful treatment of many cutaneous concerns and congenital defects, including vascular and pigmented lesions, tattoos, scars, and unwanted hair-can be achieved. The demand for laser surgery has increased substantially by patients and dermatologists alike as a result of the relative ease with which many of these lesions can be removed, combined with a low incidence of adverse postoperative sequelae. Refinements in laser technology and technique have provided patients and practitioners with more therapeutic choices and improved clinical results. In this review, the currently available laser systems with cutaneous applications are outlined, with primary focus placed on recent advancements and modifications in laser technology that have greatly expanded the cutaneous laser surgeon's armamentarium and improved overall treatment efficacy and safety.

Current lasers in skin resurfacing

Because of its cosmetic implications in the treatment of photoaging and facial rejuvenation, CO2 and Er:YAG laser resurfacing has raised a lot of interest. It has replaced dermabrasion and medium and deep chemical peels in many clinical settings. The best technique or combination of techniques for any given treatment will depend on the judgment and experience of the skilled clinician. Treatment results have been impressive. As laser technology is refined, the side effect and complication profiles of laser resurfacing continue to improve.

Development of multiple warts after skin resurfacing with CO2 laser

BACKGROUND

Skin resurfacing with CO2 laser is a common surgical procedure to improve photodamaged skin. Many complications may occur after this procedure, however, common warts is relatively rare.

OBJECTIVE

To report a case of multiple warts after CO2 laser resurfacing and discuss the complete involution of these lesions.

METHODS

A 78-year-old woman with multiple warts after CO2 laser resurfacing is described.

RESULTS

The patient developed multiple common warts on the face after resurfacing with CO2 laser. Retinoic acid was introduced and complete involution of the lesions was observed after 5 days with no scars.

CONCLUSION

Although emphasis is placed on the hazards of the laser plume to the medical staff, one should be aware of this complication. We believe that the regression of the lesions was spontaneous rather than induced by the retinoic acid.

Cutaneous laser resurfacing

Cutaneous resurfacing with the new generation of carbon dioxide and erbium lasers has recently come into favor for the treatment of facial rhytides, photodamage, and scarring. The precise control of these resurfacing lasers over the extent of tissue vaporization minimizes thermal damage to the skin while maximizing therapeutic efficacy. Proper use of resurfacing lasers is contingent upon a complete understanding of their clinical, histologic, and ultrastructural effects, as well as an appreciation of the principles of laser safety. An organized approach to the preoperative, intraoperative, and postoperative management of the patient undergoing laser resurfacing will be provided, including a discussion of prevention and treatment of postoperative side effects and complications. (J Am Acad Dermatol 1999;41:365-89.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the clinical, histologic, and ultrastructural effects of resurfacing lasers and be able to discuss the preoperative, intraoperative, and postoperative management of patients undergoing laser resurfacing.

Depth of vaporization and the effect of pulse stacking with a high-energy, pulsed carbon dioxide laser

BACKGROUND

Laser resurfacing of photodamaged skin has become popular, but questions regarding its safety with regard to the risks of scarring have arisen.

OBJECTIVE

This study was designed to investigate the depth of vaporization and residual thermal necrosis of single-pulse vaporization and multiple passes versus pulse-stacking and multiple passes. The potential significance of operator technique and laser parameters is considered.

METHODS

Skin samples from surgical excisions were treated by means of a Coherent Ultrapulse carbon dioxide laser at 250 mJ per pulse and 500 mJ per pulse with a 3 mm collimated beam and a repetition rate of 10 Hz. A total of 70 treatment areas were performed. Blinded analysis of the histologic effects of single-pulse, double-pulse, and triple-pulse vaporization after 1 through 10 passes was undertaken.

RESULTS

A plateau of vaporization was observed after 3 passes at both 250 and 500 mJ whether single-, double-, or triple-pulse vaporization was used. This plateau occurs at approximately 100 to 250 microm from the skin surface. Thermal necrosis is well controlled only with single-pulse vaporization. There is a direct linear increase in the depth of thermal necrosis both with the number of pulses stacked and the number of passes.

CONCLUSION

Pulsed carbon dioxide laser resurfacing is a safe and self-limited procedure if a pulse width of less than 1 msec is used with single-pulse vaporization and fluences of 3.5 J/cm2 and 7.0 J/cm2. There appears to be little justification for performing more than 3 or 4 passes. Pulse stacking may significantly increase residual thermal necrosis, thereby increasing the risk of scarring. Operator technique may be significant in avoidance of this occurrence.

Incidence of postoperative infection or positive culture after facial laser resurfacing: a pilot study, a case report, and a proposal for a rational approach to antibiotic prophylaxis

BACKGROUND

Laser skin resurfacing (LSR) has emerged as a popular procedure for facial rejuvenation; however, there are no clear guidelines regarding systemic antibiotic prophylaxis.

OBJECTIVE

We attempt to provide practical guidelines for antibiotic prophylaxis in LSR based on our experiences, pharmacology, and a review of the literature.

METHODS

In a pilot study, four consecutive full-face LSR patients were treated without oral or topical antibiotics. The next four patients received oral prophylaxis with a narrow spectrum antibiotic. We also report the case of a severe gram-negative infection after LSR.

RESULTS

For full-face LSR, 2 of 4 consecutive patients without antibiotic prophylaxis experienced focal Staphylococcus aureus infection. The next 4 consecutive patients, who had received gram-positive oral prophylaxis, were all culture negative after 2 days. All test sites (5 of 5) were culture negative despite the absence of systemic or topical antibiotics. One patient not in the pilot study receiving gram-positive antibiotic prophylaxis experienced a gram-negative infection.

CONCLUSION

We recommend narrow-spectrum gram-positive oral antibiotic coverage for full-face and regional LSR.

Laser resurfacing of rhytides

A discussion of the pathologic findings found with aging and photodamage is used to formulate a rational preoperative regimen, treatment technique, and maintenance regimen. Details of laser treatment technique, anesthesia, and postoperative care are given. Possible contraindications are discussed, as are the pros and cons of early versus late treatment.