14.2.4 Postoperative Care

Reepithelialization post-laser resurfacing is enhanced with the use of occlusive dressings, which are thought to maintain humidity and subsequently enhance fibroblast function and migration. These dressings must be changed daily for the first 3–7 days. Ointments may be used, but care must be taken to avoid contact dermatitis that can occur as a result of continued exposure to these agents. After reepithelialization is complete, the patient may begin to use mild, hypoallergenic makeup to help conceal the underlying erythema. Moisturizers that are fragrance-free should be utilized to improve hydration. The most important aspect in postoperative care is complete sun avoidance. This should be followed for at least 2–3 months or until all postoperative erythema has resolved. Exposure to sunlight during this healing period may be associated with melanocyte activation and increased pigmentary abnormalities.

14.3 Complications

Infection is always a concern with any surgical procedure, especially one with a wound as large as the entire face. Much has been written about viral infections, but both bacterial and fungal etiologies should be considered. Viral infections are typically marked by pain that occurs at the latter portion of the reepithelialization process. These outbreaks can occur despite the use of antiviral medication and should be treated with antiviral doses typically used to treat zoster infections. Bacterial infections are also associated with pain and are also concerning, because they may result in profound scarring. Fungal infections are more likely when dressing changes are not performed frequently enough or when exudate is not completely removed with the dressing change.

All patients experience some degree of transient hyperpigmentation that lasts for 1–2 months. Hyperpigmentation that persists beyond this time may be treated with hydroquinone, retinoic acid, mild topical steroids, and, most importantly, continued avoidance of sunlight [8]. Nearly all patients will also experience some degree of hypopigmentation

Fig. 14.3 (a) Patient with postoperative hypopigmentation demonstrated at line of demarcation between treated and untreated skin. (b) Patient is able to disguise line of demarcation with makeup (Photos courtesy of Shan R. Baker, MD)

post-procedure. This occurs in 10–30% of patients. The implications of this effect can be minimized with feathering of the treated and non-treated skin (Fig. 14.3). Unfortunately, this effect is permanent and unpredictable, although there is an association between the degree of rhytid improvement and hypopigmentation. Patients may camouflage the line of demarcation with makeup.

The most troublesome and feared complication of laser resurfacing is scarring. This can be minimized by adopting a conservative approach to help decrease the likelihood of deep dermal penetration [14]. Treatment typically consists of steroids and vascular lasers [1, 9].

14.4 Discussion

The carbon dioxide and erbium lasers provide improved precision and more consistent results compared to chemical peels and have less risk of aerosolized particles compared to dermabrasion. Further technological advances are likely to continue to improve these treatments leading to safer and more effective treatment of rhytids and solar damage of the face.

One key technology not discussed in this chapter is non-ablative rejuvenation, which promises shorter recovery times by treating the dermis and avoiding injury to the overlying epidermis [1, 15, 16]. This results in neocollagen production and secondary dermal remodeling. Many new treatments are available that target different chromophores within the dermis [1].

An additional technology that bears mention as a promising new method is the fractionated technique of thermolysis. This technique works by emitting light of 1,500 nm in tiny zones, which when applied to skin targets water and creates microscopic thermal injury “cylinders” surrounded by healthy, non-injured tissue. The treated cylinders are rapidly reepithelialized by the surrounding non-injured tissue resulting in a recovery time of approximately 24 h. Multiple treatments are required, but patients enjoy the benefits of shorter recovery time with improvement in rhytids and solar injury [17–20].

14.5 Conclusions

The laser is a valuable tool in the facial plastic surgeon’s armamentarium. The ideal laser treatment for facial resurfacing will be one that allows improvement in facial rhytids and solar aging with short recovery time and less pain. The rapid improvements in technology that occurred over the past 10–15 years are expected to continue into the next decade and beyond. This time will be an exciting one for those involved in the care of patients who desire improvement in the appearance of their facial skin as new technologies are discovered that maximize results while minimizing side effects and recovery time.

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