Side Effects, Sequelae, and Complications of Carbon Dioxide Laser Resurfacing (2024)

Abstract

The benefits of laser resurfacing are now well-known and have been documented in numerous presentations at national meetings, as well as multiple publications in medical journals and book chapters.1–11 As experience accumulates on larger series of patients, it has been noted that there is a typical pattern of certain side effects and complications resulting from the procedure.6,12–14 As the depth of laser ablation is increased to remove rhytids, so is the likelihood that the patient will experience more side effects or complications. In an effort to decrease the maximum number of wrinkles, the surgeon may be increasing the postoperative pain and the duration and intensity of erythema, prolonging the recovery phase and subjecting the patient to changes in pigmentation (Figure 1).

Typical Sequelae of Laser Resurfacing

Certain sequelae or side effects are experienced by many patients as a result of laser resurfacing (Table 1). It should be explained to the patient that these sequelae will improve with time and proper care or treatment.

All patients experience postlaser resurfacing erythema that lasts for a variable period of time—usually 8 to 12 weeks. The erythema may vary in its intensity, ranging from a fiery red to a slightly reddish/pink appearance. There is usually gradual fading and blanching. This phase can be shortened and improved by use of a topical steroid cream on an intermittent basis. Temovate^® may be used on a “pulsed” treatment schedule: 7 to 10 days of use alternated with 7 to 10 days of nonuse.

At approximately 2 to 4 weeks, most patients experience pruritus. This symptom usually spontaneously diminishes. It can be relieved by cool compresses, iced facial mist with a plant mister, and occasionally a mild cortisone cream.

During the same period, many patients experience milia or fine “whiteheads.” The patient should be reassured that these usually spontaneously disappear. Standard acne gels or Retin-A^® and the use of a mildly abrasive skin cleaner such as a “Buf-Puf^®” can be very useful during this stage.

Patients may also experience a flare-up of previous acne as a result of the obstruction of the sebaceous glands by either occlusive dressings or oily or petrolatum-type topical ointments. Similarly, patients who have not had acne in the past may experience an acne breakout. These breakouts occur anywhere from 3 to 6 weeks after resurfacing, and may require intensive treatment with Retin-A^®, acne gels, and systemic antibiotics such as Minocin^® or tetracycline.

Patients often complain of a tight feeling in their skin about 2 to 4 weeks after resurfacing. This can be relieved by the use of skin hydrators, lubricators, or moisturizers. The line of demarcation that is apparent between the laser-abraded skin and normal skin will normally disappear between 2 and 12 weeks after the procedure. The line can be ameliorated during the original treatment by feathering the edges with gradually diminishing laser power, by use of a “paintbrush” or polka dot edge on the laser resurfacing, or by the use of 25% trichloroacetic acid (Figure 2). Time and camouflage will usually diminish this line of demarcation, but the patient should be cautioned ahead of time.

Any transient texture change of the skin is self-limited and may respond to glycolic acid application or peels. Some patients who are deeply tanned before the procedure may complain that the laser has removed their tan, causing the laser-treated area to appear abnormally pale compared with the rest of the skin. This can be easily treated with one of the topical artificial self-tanning creams.

Approximately 8% to 12% of patients will experience either persistence or recurrence of rhytids. This may be detected by the patient or may be observed by the laser surgeon. At approximately 12 to 16 weeks, it is possible to do a “touch-up,” relasering selected areas that have not had sufficient improvement of rhytids, with results that are often very satisfactory for the patient (Figures 3 to 5). Further treatment may be offered on a “no charge” basis to enhance patient satisfaction.

When the epidermis is removed by laser resurfacing and is replaced by new, thin epidermis, the patient may notice telangiectasia or mild rosacea that was present in the skin before treatment but was masked by thicker, more opaque epidermis. The new appearance of facial telangiectasia or rosacea can be effectively treated with the tunable dye laser.

Synechia, or abnormal adherence of deepithelialized skin edges, may produce abnormal creases in the skin (Figures 6 to 8). These can easily be manually separated. The denuded skin is lubricated to prevent readhesion.

Complications of Laser Resurfacing

Fortunately, true complications of laser resurfacing are very rare (Table 2). The most severe problem, and one that often results in scarring, is infection.13,14 Patients may be infected by a variety of agents. Herpes simplex infection may occur after laser treatment (Figure 9). It is often heralded by a tingly or burning feeling accompanied by small skin blisters. Patients with these symptoms should have a Tzanck stain for virus and be immediately started on high doses of antiviral agents. In addition, topical Zovirax^® ointment is effective. Systemic agents include Zovirax^®, Famvir^®, and Valtrex^®.

Bacterial infections may also be seen. The most common are Staphylococcus, Streptococcus, and Pseudomonas (Figures 10 to 12). Cultures should be obtained, and the patient should be treated with both topical and systemic antibiotics.

Suspected fungal or Candida organisms should be examined under a microscope and treated with Fluconazole^®. Similarly yeast infections can be diagnosed by microscopic examination and treated appropriately.

The routine use of antiviral and antibiotic agents has been debated. More than 50% of laser surgeons routinely treat their patients with antibiotics and antiviral agents before the procedure and continue these agents for at least 5 to 10 days. Such precautions may decrease the incidence of the above-mentioned infections.

Hypertrophie or keloid scarring may occur after laser resurfacing (Figure 13). The two most common causes are infection or lasing to a deep level extending into or through the reticular dermis. A very proactive regimen should be taken to detect the possibility of hypertrophie scarring. All patients should have the resurfaced skin area palpated at approximately 2 weeks. If there is any evidence of induration, or if redness is observed that is different in one area than an adjacent area, or if the patient states that they believe one area is thicker or has a burning feeling, a proactive approach should be taken because these areas may develop scarring (Figures 14 to 17).

The patient should be started on topical fluorinated steroids such as Temovate^®, as well as injected with intralesional steroids. The use of silicone gel sheeting or Cordran^® tape should be instituted as well. Outright keloid or hypertrophie scars should be treated actively with topical steroids in the form of Temovate^® cream or Cordran^® tape; intralesional injection of cortisone in the form of Celestone^®, Kenalog^®, or Triamcinolone^®; and the use of silicone gel sheeting. Silicone gel ointments (Kelo-Cote^®) may also be useful.

Various authors have recommended treatment with injected agents such as 5-fluorouracil or verapamil 2.5 mg/ml. Other treatments include cryotherapy, radiation therapy, tunable dye laser, and constant pressure bandaging.

Hyperpigmentation resulting from laser treatment may be a difficult problem for the patient but is fortunately always temporary (Figures 18 and 19). It is usually due to the fact that the patient has inadvertently gotten sun exposure on the freshly treated lasered area. Hyperpigmentation is also more common in patients with dark complexions and in certain ethnic groups such as Asians or Hispanics. The problem almost always completely disappears but may last as long as 6 to 9 months. It may be treated with bleaching agents such as hydro-quinone, Kojic acid, or a combination of Retin-A^® 0.1% cream, hydroquinone 5%, and steroid (Kligman's mixture). The same regimen may also be used 3 to 4 weeks before the surgery as a pretreatment.

Hypopigmentation as a result of laser resurfacing is permanent. It stems from resurfacing that has gone too deep into the reticular dermis and is seen more prominently in patients with hyperpigmentation or melanosis, including ethnic groups such as Hispanics and Asians. There is no treatment other than camouflage makeup for hypopig-mentation.

Patients who have had laser resurfacing are unusually sensitive to various topical agents or cosmetics (Figures 20 to 22). It is not unusual for a patient to report that the cosmetic that they had been using continuously for 20 years now makes their skin break out. Contact dermatitis is not usual. Topical antibiotics such as Bacitracin,^® Neosporin^®, or Polysporin^® have been known to cause significant contact dermatitis requiring systemic steroids and, in some cases, hospitalization. Sensitivity reactions to fabric softeners, astringents, and even aloe vera have been observed.

Tooth enamel injury may occur if a laser beam strikes the unprotected tooth. The enamel may be fractured by the impact of the laser, or by subsequent heat production. There is no treatment for this problem, but it can be avoided by the use of special mouth guards that are obtainable commercially. Alternatively, moist gauze may be placed over the teeth inside the lips whenever the laser is used in the perioral area. Patients who have had laser resurfacing of the lower eyelids may develop a scierai show or a temporary or permanent ectropion. Most of these ectropions will resolve with time, massage, and lubrication.

Patients who are having lower eyelid resurfacing should be carefully evaluated for tarsal adequacy. Any patient who is observed to have inadequate tarsal integrity should have a tarsal tightening procedure before, or in conjunction with, resurfacing of the lower eyelid. The eyes must be protected from inadvertent exposure to laser light. Corneal abrasions have occurred as a result of laser treatment. Laser-safe scierai eye shields or a special Jaeger plate should be used whenever the laser is used in the periorbital area.

References

© 1997 American Society for Aesthetic Plastic Surgery