Laser Resurfacing

background. Cutaneous laser resurfacing with high‐energy, pulsed and scanned carbon dioxide (CO2) lasers has become popularized for the treatment of a variety of cutaneous indications, but potential complications and side effects remain a large concern. Despite the recent boom in cutaneous laser resurfacing procedures, there remains a relative paucity of written information documenting laser complication rates. objective. The purpose of this study was to identify and report the complications that occurred after cutaneous CO2 laser resurfacing within a large patient population. methods. A retrospective analysis and chart review was performed in 500 consecutive patients who underwent cutaneous laser resurfacing of 1589 facial regions with the UltraPulse CO2 laser by a single operator. Side effects and complications relating to infection, postoperative healing, pigmentary changes, and scarring were tabulated. results. The most common complication observed was postoperative erythema, which occurred in all patients, lasting an average of 4.5 months. Hyperpigmentation was seen in 37% of patients with a higher rate in darker skin phototypes. Acne flares, milia formation, and dermatitis occurred in 10–15% of patients. Postoperative infection with herpes simplex virus (HSV) was observed in 7.4% regardless of prior HSV history. Hypopigmentation, scarring, and other local or disseminated infections occurred in <1% of this study population. conclusions. Cutaneous CO2 laser resurfacing is a relatively safe procedure with a low complication profile. Proper laser treatment protocol and postoperative management is important in reducing side effects and complications.

background Carton dioxide (CO2) laser resurfacing has become a very popular method of rhytide and scar removal in the recent past. Preliminary studies have been published describing the method, histology, and clinical results of CO2 laser resurfacing. However, none of these studies has dealt with long‐term follow‐up results. objective To review all side effects resulting from CO2 laser resurfacing with regard to both short‐ and long‐term effects. method Retrospective analysis of 104 patients who have undergone CO2 laser resurfacing for either facial rhytides and/or scarring with follow‐up periods of 4‐23 months (average, 8.2 months). results The incidence of side effects are generally very low for CO2 laser resurfacing, including scarring, postinflammatory hyperpigmentation, and infection. However, there is a significant and previously unreported risk of hypopigmentation in an area of the population who often seek improvement in the appearance. conclusions CO2 laser resurfacing of facial rhytides and acne scars can be a very safe procedure by an experienced laser operator. However, careful patient selection, thorough patient instruction, and proper aesthetic analysis of treatment sites must be followed to insure the most favorable outcomes with CO2 laser resurfacing.

IMPORTANCE Despite expert wound care and assiduous management with traditional therapy, poor cosmetic outcomes, restricted motion, and symptoms such as pain and itch are a pervasive problem of disfiguring and debilitating scars. The advent of ablative fractional photothermolysis within the past decade and its application to the treatment of traumatic scars represents a breakthrough in the restoration of function and cosmetic appearance for injured patients, but the procedure is not widely used. OBJECTIVE To provide a synthesis of our current clinical experience and available literature regarding the laser treatment of traumatic scars with an emphasis on fractional resurfacing. EVIDENCE REVIEW Eight independent, self-selected academic and military dermatology and plastic surgery physicians with extensive experience in the use of lasers for scar treatment assembled for a 2-day ad hoc meeting on January 19 and 20, 2012. Consensus was based largely on expert opinion, but relevant literature was cited where it exists. FINDINGS After consensus was appraised, we drafted the manuscript in sections during the course of several months. The draft was then circulated among all panel members for final review and comment. Our consensus is that laser treatment, particularly ablative fractional resurfacing, deserves a prominent role in future scar treatment paradigms, with the possible inclusion of early intervention for contracture avoidance and assistance with wound healing. CONCLUSIONS AND RELEVANCE Laser scar therapy, particularly fractional ablative laser resurfacing, represents a promising and vastly underused tool in the multidisciplinary treatment of traumatic scars. Changes to existing scar treatment paradigms should include extensive integration of fractional resurfacing and other combination therapies guided by future research.

background With proper technique and instrumentation, laser resurfacing for facial wrinkles has been found to be highly effective and relatively safe. Most, if not all, of the noninfectious complications such as pigmentary changes, scarring, and persistent erythema can either be avoided or managed with appropriate therapy. Postoperative injections, on the other hand, may develop despite proper technique and instrumentation. Without proper management, they may cause significant physical morbidity and psychological distress defying the expected benefit of the procedure. objective To quantify the incidence and to study the characteristics of infections arising after laser resurfacing for facial wrinkles with pulsed carbon dioxide laser treatment. METHOD. A retrospective study was carried out by reviewing the records of all patients undergoing laser resurfacing for facial wrinkles from January 1, 1995 to April 30, 3996. An infection is defined as a positive culture in the presence of signs or symptoms of an infection. results Over 16 months, 395 procedures were performed and 17 cases of. culture‐proven infection recorded, an incidence of 4.3%. All patients had symptoms starting between days 2 and 10 after the operation. Over half of the patients had multiple infections with two to three microorganisms. Pseudomonas aeruginosa was the most common causative agent, found in 41 % of all infected cases, followed by Staphylococcus aureus (35%), S. epidermidis (35%), and Candida species (24%). Multiple drug‐resistant, gram‐negative bacteria were found in four cases, implicating the possibility of hospital‐acquired infections. Almost all isolates of gram‐positive bacteria were resistant to both erythromycin and penicillin, but not oxacillin. With proper treatment, most patients healed normally. Only one patient had persistent, multiple atrophic scars due to locally disseminated herpes simplex infection despite proper prophylaxis and treatment. conclusions Postoperative infection is uncommon and manageable with early recognition and proper treatment. The types of infectious agents being found are very similar to those reported in burn patients. This complication has been found to be much more common in patients undergoing full face resurfacing and those using a bio‐occlusive dressing postoperatively. With comprehensive preventive and management measures, it is likely that this type of uncommon, yet distressful, complication can be avoided and more successfully treated. Recommendations are made for prevention and management of suspected postoperative infections.

BACKGROUND Melasma is a facial dyspigmentation which is a common complaint in patients with darker skin tones. Many current therapies used for this condition are ineffective and can cause significant adverse effects. OBJECTIVE The purpose of this study was to evaluate the role of erbium:YAG laser resurfacing in the management of refractory melasma. METHODS Ten female patients with melasma unresponsive to previous therapy of bleaching creams and chemical peels were included in this study. Full face skin resurfacing using an erbium: YAG laser (2.94 microm) was performed using 5.1-7.6 J/cm2 energy. Clinical evaluations using the Melasma Area and Severity Index (MASI) and melanin reflectance spectrometry measurements were taken preoperatively and at 0.5, 1, 1.5, 3, and 6 weeks and 3, 5, and 6 months postoperatively. Adverse effects after laser resurfacing such as prolonged erythema, infection, and hyperpigmentation were recorded. RESULTS There was marked improvement of the melasma immediately after laser surgery using the parameters outlined; however, between 3 and 6 weeks postoperatively, all patients exhibited post-inflammatory hyperpigmentation. Decreased MASI and melanin reflectance spectrometry measurement scores were noted after biweekly glycolic acid peels and at the end of 6 months, significant clinical improvement in the melasma was seen compared to the preoperative evaluation. CONCLUSION Erbium:YAG laser resurfacing effectively improves melasma; however, the almost universal appearance of transient post-inflammatory hyperpigmentation necessitates prompt and persistent intervention. The use of this laser therapy is recommended only for refractory melasma.

OBJECTIVE To quantitatively examine the dynamics of molecular alterations involved in dermal remodeling after carbon dioxide (CO(2)) laser resurfacing of photodamaged human skin. DESIGN Serial in vivo biochemical analyses after laser therapy. SETTING Academic referral center, Department of Dermatology, University of Michigan, Ann Arbor. Subjects Volunteer sample of 28 adults, 48 to 76 years old, with clinically evident photodamage of the forearms. Intervention Focal CO(2) laser resurfacing of photodamaged forearms and serial biopsies at baseline and various times after treatment. MAIN OUTCOME MEASURES Reverse transcriptase real-time polymerase chain reaction technology and immunohistochemistry were used to assess levels of type I and type III procollagens; matrix metalloproteinases (MMPs) 1, 3, 9, and 13; tropoelastin; fibrillin; primary cytokines interleukin 1beta and tumor necrosis factor alpha; and profibrotic cytokine transforming growth factor beta1. RESULTS Production of type I procollagen and type III procollagen messenger RNA peaked at 7.5 and 8.9 times baseline levels, respectively, 21 days after treatment and remained elevated for at least 6 months. Increases in messenger RNA levels of several cytokines (interleukin 1beta, tumor necrosis factor alpha, and transforming growth factor beta1) preceded and/or accompanied changes in collagen levels. Marked increases in messenger RNA levels of MMP-1 (39 130-fold), MMP-3 (1041-fold), MMP-9 (75-fold), and MMP-13 (767-fold) were noted. Levels of fibrillin and tropoelastin rose in a delayed fashion several weeks after treatment. CONCLUSIONS The biochemical changes seen after CO(2) laser resurfacing proceed through a well-organized and highly reproducible wound healing response that results in marked alterations in dermal structure. These quantitative changes may serve as a means for comparison as other therapeutic modalities meant to improve the appearance of photodamaged skin are evaluated.

BACKGROUND The recent development of high-energy pulsed CO2 lasers that minimize thermal injury to uninvolved adjacent structures has revolutionized the manner in which atrophic facial scars are recontoured. Significant improvement of atrophic scars with laser resurfacing has clearly been demonstrated; however, the exact timing for assessment of skin for further treatment has varied due to the unknown amount of time needed after laser scar resurfacing to effect maximal collagen formation and remodeling. OBJECTIVE The aim of this study was to determine the immediate and long-term (12-18 months) histologic and clinical effects of atrophic acne scars after CO2 laser resurfacing in order to provide physician guidelines for postoperative clinical assessment for retreatment. METHODS Sixty patients (50 women, 10 men, mean age 38 years, skin types I-V) with moderate to severe atrophic facial scars were evaluated. Nineteen patients received regional cheek treatment and 41 patients received full-face resurfacing with a high-energy pulsed CO2 laser. Independent clinical assessments of treated scars were performed at 1, 6, 12, and 18 months and blinded histologic analyses were made of skin biopsies immediately prior to and after laser resurfacing, and at 1, 6, 12, and 18 months postoperatively in six patients. RESULTS Significant immediate and prolonged clinical improvement in skin tone, texture, and appearance of CO2 laser-irradiated scars was seen in all patients. Average clinical improvement scores were 2.22 (69%) at 1 month, 2.1 (67%) at 6 months, 2.37 (73%) at 12 months, and 2.5 (75%) at 18 months. Continued collagenesis and subsequent dermal remodeling were observed on histologic examination of biopsied tissue up to 18 months after surgery. CONCLUSION Continued clinical improvement was observed as long as 18 months after CO2 laser resurfacing of atrophic scars, with an 11% increase in improvement observed between 6 and 18 months postoperatively. We propose that a longer postoperative interval (12-18 months) prior to assessment for re-treatment be advocated in order to permit optimal tissue recovery and an opportunity for collagen remodeling.

BACKGROUND Fractional carbon dioxide laser resurfacing (FxCR) has shown considerable efficacy in reducing wrinkles, although complications such as scarring and prolonged erythema are more common and down‐time is longer than with nonablative laser treatment. Platelet‐rich plasma (PRP), a high concentration of platelets in a small volume of plasma, is known to enhance tissue healing. OBJECTIVE To evaluate the benefits of PRP in the wound healing process after FxCR. MATERIALS AND METHODS Twenty‐five subjects were treated with FxCR on the bilateral inner arms. PRP was prepared from 10 mL of whole blood and applied on a randomly allocated side, with normal saline being used as the contralateral control. Transepidermal water loss (TEWL) and skin color were measured on both sides. Skin biopsies were also taken from five subjects on day 28. RESULTS Significantly faster recovery of TEWL was seen on the PRP‐treated side. The erythema index and melanin index on the PRP‐treated side were lower than on the control side. Biopsy specimens from the PRP‐treated side showed thicker collagen bundles than those from the control side. CONCLUSION Application of autologous PRP is an effective method for enhancing wound healing and reducing transient adverse effects after FxCR treatment. The authors have indicated no significant interest with commercial supporters.

BACKGROUND Transient hyperpigmentation is the most common complication seen following cutaneous carbon dioxide (CO2) laser resurfacing. OBJECTIVE The purpose of this study was to determine whether the use of a topical skin lightening regimen prior to cutaneous laser resurfacing reduces the incidence of post-laser resurfacing hyperpigmentation. METHODS One hundred consecutive CO2 laser resurfacing patients (skin types I-III) were randomized to receive preoperative treatment with 10% glycolic acid cream twice daily (n=25), hydroquinone 4% cream qHS and tretinoin 0.025% cream twice daily (n=25) or no pretreatment (n=50, control) for at least 2 weeks. Clinical and photographic assessments were performed prior to laser resurfacing and at 4 and 12 weeks following treatment. RESULTS There was no significant difference in the incidence of post-CO2 laser resurfacing hyperpigmentation between subjects who received pretreatment with either topical glycolic acid cream or combination tretinoin/hydroquinone creams and those who received no pretreatment regimen. CONCLUSION It is postulated that reepithelialization after cutaneous laser resurfacing includes follicular melanocytes that have not been affected by topical pretreatment. When instituted as a component of the skin care regimen postoperatively, topical hydroquinone, tretinoin and/or glycolic acid preparations may be helpful in reducing post-laser resurfacing hyperpigmentation.

Background and Objective: With the increasing use of laser resurfacing, concerns have arisen about the biological hazards associated with the procedure. This study analyzed the potential bacterial and viral exposure to operating room personnel as a result of the laser smoke plume in CO2 laser resurfacing.