Expert Pointers on Maximizing Post-Laser Care
I’m sure all of you have seen your share of patients who want to improve upon their appearance. Be it leg vein removal, resurfacing of periorbital wrinkles or hair removal, cosmetic procedures performed with lasers are becoming some of the most popular procedures performed by dermatologists. With advances in technology and patient care occurring regularly, there’s a lot of information to digest and put into practice. In this article, we talked to some of the experts who perform laser cosmetic procedures, and we’ll share with you their insights for optimally managing patients before and after surgery. The patient side: before and after surgery “The post-operative management of the resurfacing patient is critical to the ultimate outcome,” says Roy G. Geronemus, M.D., of New York. He continues, “It’s essential that the physician and ancillary staff have a specific plan for the postoperative care, and the patient must understand that he or she will be fully engaged in this process.” An issue that goes hand-in-hand with patients understanding that they play a major role in their treatment is properly educating them about the procedure, as well as the results you expect and any potential complications the patient may experience. Harold A. Lancer, M.D., F.A.A.D., of Beverly Hills, CA, says that patient expectations are a very important aspect of laser surgery — even before you perform the procedure. “You have to have a feel for the patient emotionally, mentally and physically before embarking on a treatment because lasers are known as a repetitive treatment — if someone doesn’t have a realistic expectation of cost and results, then they’re always going to be unhappy,” he says. Educating and gauging a patient’s expectations will go a long way in making the treatment process flow smoothly. Answer any questions they may have throughout the process (about healing time, recovery, etc.) and you’ll help them avoid any disappointment or anger. Dr. Lancer also suggests starting all patients on a topical skin care regimen and following how their skin responds and how compliant they are. If they can’t follow a simple home treatment protocol, then they won’t be compliant for post-laser regimens. Stick to your plan Failure to follow your post-operative management plan can lead to complications including infection and scarring, which are significant for both you and your patient. This applies to many types of laser surgery but is most important when dealing with ablative procedures. According to Dr. Geronemus, “Post-operative management following resurfacing should focus on the prevention of infection (bacterial, viral and fungal), comfort of the patient and a rapid healing process.” Depending on the type of problem you’re treating and the type of method you use to treat that problem, you’ll typically choose from a myriad of post-laser care options. George J. Hruza, M.D., of St. Louis says that laser hair removal doesn’t require any significant post-laser care except for sun avoidance and a few days of using a moisturizer. Because some patients may experience stinging after undergoing this type of procedure, you should suggest that they use ice packs until the stinging dissipates. Another procedure that requires minimal post-laser care is leg vein removal. Dr. Hruza says that most patients undergo sclerotherapy but that the most promising procedure uses long pulse nd:YAG lasers. For that, he says, he likes patients to use gradual compression stockings following the procedure for 1 to 2 weeks. When treating patients for wrinkles around the mouth using an ablative laser, Dr. Hruza says that it takes from 7 to 10 days for the wound to heal. “During that time, I recommend bio-occlusive dressings, and for partial face treatments I recommend Vigilon dressings for the first 3 days because that’s when they’re most helpful in healing and reducing pain.” He recommends that patients use mild vinegar soaks several times per day for 3 days after the procedure to remove the debris that’s left on the skin and apply Aquaphor healing ointment until the skin is healed (for approximately 7 to 10 days). He says that once the skin is healed, it will continue to appear red to pink for 6 to 12 weeks, during which time he suggests that patients minimize direct sunlight and use a broad-spectrum sunblock. Says Dr. Geronemus, “Following the resurfacing procedure, the skin is abraded and healing may take place within 2 to 10 days, depending on the depth of the injury created by the laser. Post-op wound care regimens are either occlusive where a topical dressing is left on for a period of time or “open,” where topical ointments and soaks are used to cleanse the open wound.” Following the open technique, which involves frequent soaking with diluted acetic acid, normal saline or cool tap water, followed by a gentle debridement of the skin, Dr. Geronemus prescribes a topical antibacterial or hydrophilic ointment to minimize crusting and exudate formation as well as to provide symptomatic relief. He suggests accompanying all resurfacing procedures by a prophylactic antibiotic for a minimum of 5 days post-op and antiviral therapy started pre-op until reepithelialization is complete. Side effects and complications are common, but if you put together a plan of action ahead of time and stick to it, you should be able to minimize any chance of unexpected complications. As is always key, emphasize to your patients the importance of compliance with their post-op care in order to achieve the best results. Coping with Complications According to Dr. Hruza, complications with non-ablative lasers, if used as recommended, are rare. “With ablative lasers,” he says, “Significant complications, such as hypopigmentation, can be delayed 6 to 12 months after the procedure.” That’s why he usually treats the whole area (for example, the face), so you change the color of the skin at the same time instead of the patient ending up with lines of demarcation. Dr. Geronemus comments on this complication, saying that “Post-inflammatory hyperpigmentation can be seen particularly in those patients who have darker skin types and those exposed to ultraviolet light during the healing phase.” He recommends managing this complication by using hydroquinones and sunscreens. He also mirrors Dr. Hruza’s approach of minimizing the untoward effects of pigmentary loss through full face resurfacing as opposed to treating isolated cosmetic units. He also notes that this effect is usually less apparent in patients who have lighter skin. Dr. Hruza also warns that on rare occasions, patients may develop scars if the laser goes too deep or they may get an infection or have intrinsic difficulty with healing. Dr. Geronemus says that side effects following laser resurfacing are frequent and predictable and may differ between the carbon dioxide and Erbium:YAG lasers. “The most serious acute complication is infection,” he says. “Bacterial contamination may be seen following laser resurfacing particularly under occlusive dressings that are often left on for prolonged periods of time.” This is where Dr. Lancer’s suggested “test” of putting a patient on a topical skin care regimen to gauge compliance prior to surgery comes in handy. It’s imperative that you educate patients about the importance of changing their dressings to prevent any type of infection. Says Dr. Geronemus, “While an exudate is considered normal following the procedure, any excessive crusting or delay in healing from a resurfacing procedure should warrant a culture and sensitivity as well as possible change in antibiotic therapy.” For contact, irritant and perioral dermatitis during the healing phase, Dr. Geronemus suggests using topical corticosteroids and/or antibiotics to manage these complications. Dr. Hruza gives resurfacing patients an antibiotic starting the morning of the procedure and has them continue taking it for a week. He also gives them valacyclovir (Valtrex) starting the morning of the procedure and has them continue that for 10 days following the procedure to reduce the chance of getting cold sore breakouts. Final thoughts Many individuals have begun to recognize the harmful effects of the sun’s rays. That’s probably the most popular reason why patients come to you for skin resurfacing — to reverse the signs of sun-damaged and over-exposed skin. So remember, educate your patients, make sure they understand what has happened to their skin and how they can prevent future excessive damage. Emphasize the importance of their compliance and the possible side effects and complications that may come with their treatment. Now that you’ve seen what these practitioners do, compare it to your post-laser protocol to find out if you’re missing any important aspects of treatment.
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