Fig. 19.14 One-hundred and eight days post op

op appointments is reduced (Figs. 19.11–19.14), daily sunblock is used, and camouflage makeup can be applied as needed to conceal postoperative color variations.

19.5Complications

The most difficult aspect of laser skin resurfacing is the postoperative care and recognizing the signs of complications. For the surgeon beginning laser skin resurfacing, a preceptorship or formal partnership with an experienced surgeon is invaluable. Avoiding complications is the goal, but complications do occur and can be managed successfully with proper treatment and patience.

A herpes simplex infection is a potentially serious complication which can arise during the first 2 weeks of

postoperative healing. This can be challenging to identify during the early stages of healing because these infections usually present with epithelial changes, and the epithelium is absent during this stage.

In the following photos, the evolution and treatment of a herpetic infection can be seen (Figs. 19.15–19.21). This patient was treated with a relatively light skin laser ablation to improve the skin quality of the lower lid and reduce periocular rhytids. Healing typically occurs relatively quickly, with re-epithelialization at 7–10 days. At 3 days, the wound looked appropriate (Figs. 19.15 and 19.16).

But at 7 days after laser skin resurfacing (Fig. 19.17), the lack of healing indicated a problem. The patient was instructed to increase the concentration of the vinegar in her soaks to help with the removal of the exudate on the lower lid. The patient was seen daily at this point and on postoperative day 13 (Fig. 19.18), the presence of only a border of healed epithelium (suboptimal epithelialization) gave the indication of a secondary factor influencing wound healing. The wound was cultured for bacterial and fungal elements, but the strong suspicion was for a herpetic infection, and the dose of Valtrex® was doubled from 1 g per day to 2 g per day.

The patient was followed up daily. The preliminary microbiologic cultures came back without growth, and the dose of Valtrex® was again increased to 3 g per day. At this point, the wound started to improve slowly (Fig. 19.19). By day 22, the wound was healing nicely (Fig. 19.20).

As the wound continued to heal, it was confirmed that the poor healing was due to the herpes simplex virus. The patient was continued on 3 g of Valtrex® until the skin was fully epithelialized and was then tapered off over 2 weeks. The patient healed well without scar formation (Fig. 19.21).

Other possible infections which occur in the first 1–2 weeks following laser treatment include a bacterial cellulitis and fungal infection. Bacterial infections typically present

with redness, pain, exudates, and foul odors. Culturing these wounds is paramount. Antibiotics including intravenous administration, should it be warranted, may be given depending on the severity of the infection. When infections do occur, a polymicrobial nature can be seen. Some typical pathogens include pseudomonas, staphylococcus, and streptococcus. Some surgeons propose prophylaxis with antibiotics to aid in prevention of these infections.

Fungal infections, such as Candida, usually appear as soft white plaques on an erythematous base. Satellite lesions can be seen and diagnosis with a KOH preparation can help identify and differentiate these infections. Some surgeons treat with antifungal medications as prophylaxis against these infections as well.

Acne eruptions are possible after resurfacing and can be treated with an oral tetracycline. Milia can present in the first month and may be treated with glycolic acid peels and low dose retinoic acid.

Pigmentary changes can occur after laser treatment. Postinflammatory hyperpigmentation typically presents in the first month. It is more likely to occur in those patients with Fitzpatrick skin types III–VI. Treatment options include observation as many resolve over 4–6 months, topical bleaching with hydroquinones, topical retinoids, topical steroids, and the use of sun avoidance and sunblock. If a patient is in the skin types at risk, some surgeons preand posttreat with topical hydroquinones and retinoids.

Hypopigmentation is less commonly seen. When present, it is typically a pseudo-hypopigmentation. This laser procedure causes a relative reduction in the normal age related pigment deposition in the skin. This would normally lead to a transition zone of relatively lighter (treated) skin to darker (untreated) skin. However, this finding is diminished by the use of decreasing laser energies in the border region around the heavily treated skin. Decreasing the level of ablation in a

graded fashion around the central treatment area creates a transition zone which blends the clinical effect and pigment changes between the treated and adjacent untreated skin.

Absolute hypogimentation is rare. When present, this may be due to thermal injury to the deep melanocystes of the skin. Excimer lasers have been used to stimulate the melanocytes in these cases and have been helpful, but a more simple treatment involves the use of camouflage makeup.

Erythema is normally seen during the first 12 weeks after treatment and then decreases over time. If erythema persists, mild topical steroids can be helpful. Makeup can be used to camouflage the erythema.

Scarring and ectropion are rare complications after laser skin resurfacing, and are usually preventable with proper intraoperative technique and postoperative care. In the treatment of festoons described in this chapter, the authors have not experienced scarring or ectropion in over 15 years of experience. Subdividing the lower lid into a more superficially treated zone from the eyelid margin to the orbital rim and a more aggressively treated zone adjacent and distal to this area probably mitigates these complications.

As described in this chapter, to treat festoons, multiple laser applications are needed. Treating other portions of the face with this approach is aggressive, may lead to scar formation, and is not recommended. If scars from laser skin resurfacing do form, the surgeon must recognize and treat them with steroids, anti-metabolites, and/or vascular lasers. In certain stable scars, surgical excision may be indicated. Careful patient selection, safe laser technique, and attentive postoperative management mitigate the risk of scars after surgery.

As mentioned above, we have not seen ectropion after laser application. This is most likely related to our laser application technique (graded zoned treatment), and a thorough preoperative evaluation identifying patients with eyelid

laxity who are at risk of post-laser eyelid malposition. If permanent post-laser ectropion were to develop, appropriate surgical management is needed.

Performing laser treatment of festoons, its postoperative care, and the management of possible postoperative compli-

cations can seem daunting. However, with proper adherence to the technique described in this chapter practitioners can perform the procedure safely and effectively.

Preand postoperative results of our technique can be seen in Figs. 19.22–19.24.