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Complications of laser resurfacing
Cosmetic Surgery Times
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Procedures come and go in the field of cosmetic surgery, and if a given modality makes it a decade, it probably has merit and is here to stay, pending a newer technology.

Laser resurfacing techniques are probably on a decline as a whole, but not because the laser is an ineffective modality. The modest decline probably represents the fact that the novelty has worn off, and that many people who are candidates for laser resurfacing, have already been treated. Those whom obfuscate this procedure point out increased complications and increased recovery, but for those who have endured the learning curve, there is no more effective procedure for given indications. I would bet that most of the clinicians that rebuke laser resurfacing do not own their own lasers and have had bad experiences with the procedure. Granted, there are easier procedures with less of a recovery period, but in my opinion, there is still no substitute for rhytide effacement in severely actinically damaged and aged skin.

As the world plugs along for a noninvasive alternative resurfacing, many of us continue to rejuvenate our patients with the CO2 laser. There is no doubt that laser resurfacing patients will have complications, but is there any cosmetic procedure that produces a result that has none? For the most part, the spectrum of complications associated with CO2 laser resurfacing are predictable and treatable. They can be anticipated and planned for.

Multiple studies have consistently documented laser resurfacing complications. Drs. Alster and Nanni (see for more information) reviewed 500 laser cases and listed the complications as follows:

One can observe that the most severe complications such as hypertrophic scarring and true hypopigmentation are indeed rare. Other complications such as hyperpigmentation and milia formation are, on the other hand, common.

The best means of dealing with a complication is to anticipate it. The informed consent process cannot be overstated.

Cosmetic patients cannot be overeducated about their prospective procedures. Merely having an informed consent may protect you in a court of law, but still lead to disgruntled patients that can dissipate negative marketing for your practice. A potential problem that is discussed preoperatively is a sequela, but when it is discussed postoperatively, it is a complication!

Following laser resurfacing, the patient developed significant hyperpigmentation at four weeks posttreatment.
Most of us perform cosmetic surgery every day, but for many patients this will be their first, and possibly, only procedure. This means that we often assume our messages about treatment and complications are loud and clear, because it is so repetitive in our practices. The patients on the other hand may be so overwhelmed with fear, anxiety, economics, recovery, etc. that their understanding process is actually disabled. For this reason, it is imperative to confront the informed consent process on multiple fronts.

In our office, we have every patient read and sign a witnessed informed consent. In addition, we provide them names of patients who have had similar procedures and can provide communication first hand.

An additional technique that has proven very valuable is to have every patient view an in-office PowerPoint show that details his or her procedures. These shows take only minutes to put together and are extremely useful.

Obagi skin products were used to clear the hyperpigmentation over a three-week period. (Photographs courtesy of Joseph Niamtu, III, D.D.S.)
From time to time we have a patient view the show and he or she cancels the procedure. Although no one wants to lose a patient, they are doing us a favor because this patient would be overwhelmed with a complication (or possibly with the basic procedure) and make your life miserable until it is resolved.

The final step of our informed consent process is to have the patient sign a separate form, which the surgeon reviews with the patient that, again, lists the possible complications.

This form is much less encumbered than the procedural informed consent and basically lists the 10 or 12 possible problems including overtreatment, undertreatment, demarcation lines, sun avoidance, etc. This multistep informed consent process has proven invaluable when dealing with postlaser complications. Again, it is important to remember that merely escaping a lawsuit is not a win if unhappy patients defame your reputation. Most cosmetic practices are about marketing, and negative marketing is a serious reality.

It is beyond the scope of this article to discuss all the complications of laser resurfacing, so we will focus on two of the more common problems, prolonged erythema and postinflammatory hyperpigmentation.

Prolonged erythema I have had some patients with excellent postlaser results, but then be unhappy because there is a demarcation line where the laser stopped.

Technically, this is relative hypopigmentation in that there is no actual melanocytic damage, but there exists a color difference between the rejuvenated face and untreated neck skin. It is very important to inform the patient that the laser must stop somewhere and traditionally it is the mandibular shadow.

We show them the lateral skin of their biceps, which is usually sundamaged and darker when compared to the medial biceps skin. This is usually more protected and like rejuvenated or younger skin, it is lighter.

Usually, this demarcation will fade and blend with the neck skin, but we also give the patient an option of simultaneous TCA neck peel to better blend the laser treatment.

Not a complication, but it still looks bad Prolonged erythema is not truly a complication, but is probably the most unpopular sequella of CO2 laser resurfacing. Postlaser redness can last weeks or months (average 2 to 4.5 months, and is frequently unnoticeable at 12 to 16 weeks).

Since the erythema is a healing response, one cannot do much to alter its course and some patients simply remain red longer than others.

I show my patients pictures of the extremes of erythema and if their redness resolves quicker, I am a hero and if it does not, "I told them so." I have been recently doing an informal trial of Carrasmart Gel wound dressing (Carrington Laboratories, Inc., Irving, Texas), which seems to decrease postoperative erythema. This product contains acemannan hydrogel and is used for burns and stasis ulcers. It is applied topically as a coating and replenished continually for protection.

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