DRESSING AND POSTOPERATIVE WOUND CARE:
After complete removal of desiccated skin a saline-soaked gauze is applied to all laser-treated areas. This dressing is transparent and thus allows direct observation of the wound base throughout the healing process. Meticulous care is given to ensure that every square millimeter of laser-treated skin is covered by dressing.
For full-face treatments, the dressing is secured with a 4 x 75-inch stretch bandage around the most peripheral aspects of the dressing. The patient is instructed on meticulous care of the dressing to ensure that all laser-treated areas remain covered around the clock. The dressing is removed after seventy two hours. Wound care after treatment is directed toward gentle debridement of serous exudate and necrotic tissue by frequent soaking (four times a day or more) with tap water containing 2% acetic acid (white vinegar, 1 tsp. per cup of water) and maintenance of a moist tissue surface with continuous application of a nonsensitizing ointment (Vaseline). The prophylactic antibiotics and antiviral medications should be continued for ten days.
The preconditioning program should be restarted two to four weeks following the procedure, after healing and re-epithelization is complete or evidenced by lessened sensitivity, resolution of oozing and complete scar separation. The program (sunscreen, retionic acid 0.025%, AHA 10%, Hydroquinone 4%, cleanser, toner, moisturizers) should continue for six to twelve months and a program of maintenance and protection may be necessary for life. The pre and post procedure programs have revolutionized the results of both laser and chemical resurfacing. This will lead to better results with less complications and happier patients.
COMPLICATION OF LASER RESURFACING:
Prolonged erythema: The most common causes are:
- Cutaneous infection
- Contact dermatitis: cosmetics, fabrics
- Sun exposure
- Unknown origin
To minimize the risk of severe or prolonged erythema, patients are routinely instructed to avoid the use of fabric softeners with any clothing or linens and to be attentive to any worsening of erythema after applying any skin care products or cosmetics and to immediately discontinue the use of such products should this occur. This is an important point because of the higher incidence of postinflammatory hyperpigmentation in these patients with prolonged erythema associated with inflammation. Patients are also instructed to avoid exposure to ultraviolet light by:
1. Remaining indoors as much as possible for the first seven postoperative days.
2. Wearing a wide brimmed hat during this first week if they must be outdoors.
3. Wearing sunscreen after this week that contains block for both ultraviolet A and B wavelengths.
Staphylococcus aureus: Each of the S aureus infections occurred in patients who either had a known prior history on infection (recurrent vestibulitis or furuncles) or had family members who become involved in their wound care who were otherwise at high risk.
The staphylococcus aureus infection is characterized acutely by yellow mucoid plaques with associated increased pain in all affected areas. Treatment consists of :
- Wound culture followed by appropriate antibiotics for a minimum of three to four weeks.
- Local wound care with diluted hydrogen peroxide to debride plaques.
- Topical petroleum jelly as a moisturizer.
- Elimination of all contaminated cosmetic moisturizers.
- Patient education to avoid contamination of products.
Pseudomonas: The infection was characterized by acutely green mucoid plaques that emitted a sweet aroma. The patient experienced increased pain in involved areas and comparatively increased erythema and temporary reduction in skin thickness in areas involved by plaques. The infection is resolved within four days of using oral Ciprofloxacin combined with local wound care using white vinegar (2% acetic acid), one tsp per cup of water. No notable long-term changes (dyschromia, pain) were noted.
Fungal: Identified by culture as Candida species and successfully treated with a combination of oral Sphoronox (Itraconazol) and local wound care with diluted vinegar and Daktarine. Erythema lasted from four to eight weeks and spotty dyschromia may follow. The dyschromia usually resolved within six weeks with the use of topical pigment gel.
Herpes simplex: Characterized by marked increased pain. The prophylactic dose of Valvacyclovir or Famir is doubled and continued until resolution of the infection.
The following prophylactic means should be followed:
- Dressing ideally should be transparent to afford direct view of the entire wound base.
- Any increased pain postoperatively should be considered infection until proven otherwise and the patient should be evaluated.
- Patient should be seen frequently (at least every third day) during the period of pre-epithelialization.
- Patients should be placed prophylactically on antiviral agents and anti-staphylococcal antibiotics. the author also recommends PHisoHex shampoo and facial wash on the eve of surgery. A detailed history to rule out any previous infections with S aureus, Herpes or Pseudomonas should be taken and patient treated with extra caution appropriately.
Dyschromia: Dyschromia is hyperpigmentation or hypopigmentation plays an important complication in patients of skin type IV, V, or VI. Dyschromia will distort the quality of any laser or chemical resurfacing procedure results. The most common type of problem is hyperpigmentation. The onset of hyperpigmentation usually occurs between the 14th and 20th postoperative days. Treated skin initially takes on a bronze tone which if untreated, progresses over the next two weeks into a golden brown to dark brown colour.
- Patients of Fitzpatrick classification IV through VI have a higher propensity than those in groups I through III. Patients with severe skin aging who receive more aggressive treatment are similarly more prone.
- In cases of prolonged or more severe postoperative inflammation, particularly related to hypersensitivity reactions or infection by S aureus or Herpes, a higher incidence of hyperpigmentation was observed. This phenomenon is believed to be due to postinflammatory hyperpigmentation mechanisms.
- Postoperative sun exposure may also play a significant role. Each of UVA and UBV types of ultraviolet light stimulate melanogenesis. Thus, patients are instructed to use sunscreen that protects against both and are provided with the names of specific brands of sunscreen.
- Hypopigmentation is due to the entire epidermis (melanocytes) being vaporized by the laser or destroyed by the chemical peeling agent.
- A variety of topical pigment gels are available that are effective in blocking the enzymatic oxidation of tyrosinase in the conversion of tyrosine to melanin (Hydroquinone 4% – Kojic acid 2%). The effects of these preparations when used postoperatively are slow, requiring two to six months for resolution and are occasionally completely ineffective. It is believed that persistent spotty hyperpigmentation is due to postinflammatory dermal melanosis and specifically address these with alexandrite or ruby laser treatment. The emotional consequences of prolonged hyperpigmentation may be significant. Thus, early treatment with pigment gels in higher risk patients is a standard. Great care is given to avoid infection.
- Sunscreens are strongly emphasized. Lastly, considerable time is spent in patient education on this subject.
Scarring: Scarring or keloid formation are caused by deep laser or chemical peel that reach the adnexal structure at the deep reticular dermis. Therefore, thorough knowledge of the colour effects and number of passes required for each facial zone are mandatory before using the laser. In addition, history of tendency for hypertrophic scar and keloid formations should be ruled out.
- Tooth thermal injury
- Scleral show / ectropion
- Corneal abrasion / injury
- Local antibiotic cream allergy
Again, laser resurfacing should be considered with caution in patients from the Middle East and Asia. Skin pre-conditioning and prolonged post-conditioning programs are mandatory. It is advisable not to exceed the greyish colour effects in patients skin type IV, V and VI, in order to avoid scarring and permanent pigmentations.