National report — As the armamentarium for cosmetic surgeons grows, using various technologies and products thoughtfully and harmoniously to achieve the best result is key, according to Tina Alster, M.D., director of the Washington Institute of Dermatologic Laser Surgery in Washington, D.C., and clinical professor of dermatology at Georgetown University Medical Center.
In particular, surgeons need to master how laser procedures are best used in combination with botulinum toxin, collagen fillers and other surgical and cosmetic techniques. It is especially important to learn how to incorporate these procedures with the reality of what people want, says Dr. Alster.
"People would like to have treatment of their photodamaged or scarred skin with virtually no recovery time or postoperative healing, even though the nonablative systems do not give as good a response clinically as the ablative carbon dioxide or erbium:YAG lasers."
Preoperative patient evaluation is one of the most important aspects of laser skin resurfacing, according to Elizabeth Tanzi, M.D., co-director of the Washington Institute of Dermatologic Laser Surgery in Washington, D.C. She says the ideal patient for carbon dioxide laser resurfacing has phototype I or II skin and laser-amenable lesions — non-movement-associated wrinkles and discoloration as well as moderate to severe acne scars.
Dr. Alster suggests that physicians:
"Movement-associated (dynamic) wrinkles have a high recurrence rate following ablative laser skin resurfacing, so I suggest using Botox concurrently with the resurfacing procedure," Dr. Tanzi says.
Patients with unrealistic expectations are not ideal candidates. "In patients with severe photodamage, we won't eradicate every line on their face, and that needs to be quite clear," she says. "Patients with previous treatments in the area — dermabrasion, for example — may also be less than ideal candidates because laser skin resurfacing may uncover hypopigmentation."
Patients who can't tolerate the seven- to 10-day recovery period also are not good candidates, says Dr. Tanzi.
Dr. Tanzi says that active skin infections are an absolute contraindication for both ablative and nonablative resurfacing treatments.
"Patients with keloids or hypertrophic scars on other areas are also not ideal candidates," she says. "For all patients, I perform a full skin exam and inspect prior surgical sites to see how well they healed."
The use of isotretinoin within the past six to 12 months is also contraindicated because of the increased risk of hypertrophic scarring.
Fair-skinned patients comprise 80 percent of Dr. Tanzi's facial ablative procedures.
"Dark-skinned patients are more prone to develop undesirable postoperative pigmentary changes," she says. "We tell dark-skinned patients to avoid excessive sun exposure and to use sunscreen for at least a month before the procedure. If they do develop postoperative hyperpigmentation, we use light glycolic acid peels, hydroquinone and tretinoin to help hasten resolution."
Preoperative evaluation for non-ablative procedures is less stringent than for ablative procedures, according to Dr. Tanzi.
"Candidates must have realistic expectations because results are not as dramatic as with ablative procedures." Although the popularity of ablative laser resurfacing procedures has decreased because patients seek procedures with no down time, nonablative procedures have yet to offer the degree of improvement seen with ablative procedures, Dr. Tanzi says. "Ablative procedures will continue to be useful, and patient education before treatment is paramount."
Supplemented topical anesthesia
Practitioners of ablative laser resurfacing have traditionally used general anesthesia, conscious sedation, regional nerve blocks, or a combination of topical, oral or locally injected anesthetics to increase patient tolerability, according to Suzanne Kilmer, M.D.