A successful ablative resurfacing procedure begins with a thorough preoperative evaluation. This evaluation should pay careful attention to patient expectations, preoperative photographs, and counseling about the perioperative period. Medications are prescribed to minimize potential infection and include a prophylactic antibiotic (typically a first-generation cephalospo-rin), antiviral (acyclovir or valcyclovir), and antiyeast (fluconazole) medications. A non-steroidal anti-inflammatory agent and an analgesic are also prescribed to control postoperative discomfort. Patients are educated as to what to expect during the healing period; appropriate wound care for the first week is reviewed. Pre-operatively, patients apply topical anesthetic cream EMLA (eutectic mixture of lidocaine and prilocaine) with occlusion 2.5 h prior to the procedure time (Fig. 5.2). Forty-five minutes before the procedure, EMLA is reapplied with occlusion. The following medications are also provided by mouth: diazepam, hydroco-done or similar analgesic, and intramuscular ketorolac.
Fig. 5.2. EMLA with occlusion, preoperative
The first CO2 ablative laser pass is performed mainly to remove the epidermis and feather peripherally to minimize any demarcation with surrounding nontreated skin. The second laser pass, and, if used, a third pass is for heat deposition to promote tightening. Finally, the erbium laser (in the ablation mode) can be used to remove superficial thermal necrosis for further sculpting of deeper rhytides and/or acne scars.
When the UltraPulse CO2 laser specifically is used, the first pass is usually performed at a density of 7 for the main treatment areas. The previously described preoperative topical anesthetic technique leads to increased skin hydration and, consequently, allows the use of a higher density setting to more efficiently remove the epidermis. If no hydration is used, the first pass is performed at a density of 6. Hydration is mandatory, however, for treatment of the neck. When moving towards the jawline and hairline, the density is decreased to 6 and possibly 5 for higher risk patients. Progressing down the neck, density settings are decreased by one per row until the lowest setting of 1 is reached, allowing skip areas in the final row. The epidermis is then wiped free on the central face and other areas where a second pass is to be performed. The peripheral edges are usually left intact and the neck is never wiped.
The second CO2 laser pass is performed at a density of 4-5 depending on the tightening needed and the risk for the area. The upper eyelids and the central face are typically treated at densities of 5, whereas mid cheeks and some lower eyelids may be treated with densities of 4. Delivered energies are also decreased towards the periphery. A second pass is rarely done on the lateral cheeks unless acne scarring is present. A third pass may be done on acne scars and in perioral and glabellar regions to deliver additional heat to enhance tightening. When using the EMLA topical anesthetic technique, the face is typically treated in sections (Fig. 5.3). All passes in a given area are performed before moving on to the next section.
In cases where deep rhytides or acne scars persist, the erbium laser in the ablative (shorter-pulsed) mode is helpful to sculpt the edges or to remove the superficial coagulative
Fig. 5.2. EMLA with occlusion, preoperative
necrotic layer, which can hinder healing. The utilized erbium laser energy, and spot size, depends on the area to be treated, with a 3.5- to 5.0-mm spot size set at 1-2 J/cm2 most commonly used. Bleeding can occur in these areas as the thermal effect is insufficient to provide hemostasis.
When the erbium laser is the sole utilized system, the first pass is performed to most efficiently debride the epidermis. This is undertaken typically at 100 ^m of ablation with no coagulation. The ablation depth is decreased at the periphery to minimize the final demarcation between treated and untreated areas. For the second pass, erbium laser coagulative pulses or, alternatively, ablation with concomitant coagulation is used to provide the heat needed for the tightening effect. Finally, the third pass utilizes the ablation mode to remove superficial necrosis but can also include additional coagulation to enhance the thermal effect. To treat the neck, pure ablation is used with a graduated drop in setting to feather while proceeding lower and laterally on the neck. As with the pulsed CO2 laser, careful feathering to blend the treated and untreated areas is critical to ensure a natural and cosmetically pleasing result.
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