Section 4 Plastic and Reconstructive Problems

Richter et al

Table 3 Classes of lasers and clinical outcomes

Laser

Outcomes

Risks

Ablative nonfractionated 10,600-nm CO 2 laser 2940-nm Er:YAG laser Combined CO 2

Oozing, bleeding, and crusting (100%) 7 ; acne, transient hyperpigmentation and hypopigmentation (IV) (55%– 68%) 7,8 ; scarring and poor wound healing, permanent skin hypopigmentation 4,7 Minimal, few hours of erythema, no scaling or peeling, no abnormal pigmentation 7

Dramatic improvement in wrinkle reduction, alleviate acne and atrophic scars 7

Er:YAG laser

Nonablative nonfractionated 1319-nm pulsed dye laser 1320-nm Nd:YAG laser 1540-nm diode laser

Improvement scar severity (29%) 3 ; improvement acne scars (10%–50%) 2,9 ; atrophic scarring and acne-induced PIH (III–VI) (51%–75%) 5 ; limited wrinkle improvement 2 significant improvement in acne scarring (51%–75%) 3,5 and overall appearance: excellent (30%), significant (59%), moderate (11%) 3,9 ; safe in dark skin types because of limited tissue damage and melanocyte stimulation 7 Moderate resurfacing power for mild skin laxity and rhytides 2 ; moderate improvement in photodamage, scars (37%), and dyspigmentation 2,7 Moderate improvement in texture and wrinkles 4 ;

Nonablative fractionated 1410-nm laser 1440-nm Nd:YAG laser 1540-nm laser 1550-nm Er laser 1927-nm thulium fiber laser

Moderate downtime; moderate pain 5 ; postinflammatory hyperpigmentation (III, IV, V) (3%, 12%, 33%, respectively) 5 ; acne (2%) 8,10 ; herpetiform eruptions (2%) 8,10

Ablative fractionated 10,600-nm fractional CO 2

Moderate downtime, moderate complications 8 ; postinflammatory hyperpigmentation (II–V) (44%) 3 ; use with caution in skin type VI 2

laser

2940-nm fractional Er:YAG laser 1790-nm fractional Er:YSGG laser

Abbreviation: PIH, post-inflammatory hyperpigmentation. Data from Refs. 2–5,7–10

combination with intralesional steroid injections. 4 The pulsed dye laser has been shown to decrease erythema, improve pain and pruritus, decrease lesion height, and improve hypertrophic scar pliability. These effects may facilitate intralesional steroid injection. However, the pulsed dye laser can target epidermal pigmentation and must be used with caution in patients with dark skin. Ke- loids may also be treated with the 1064-nm Nd:YAG laser with moderate results of mild ke- loids. The lesion is injected with intralesional triam- cinolone 10 mg/mL up to 3 mL before starting therapy with regular laser treatments (fluence 13– 18 J/cm 2 , 2000 pulses) for 6 weeks. 2 After 7 weeks, the lesion may be reevaluated and treatment repeated if necessary. PREPROCEDURAL PLANNING: MEDICAL OPTIMIZATION Before embarking on laser rejuvenation of facial skin, it is important to emphasize routine skin

distinguish between melasma and postinflamma- tory hyperpigmentation when considering laser therapy. 4,7,11–13 Options for laser treatment of dyschromia include the Nd:YAG laser and frac- tional nonablative devices. 7

Laser Hair Removal

The use of lasers for hair removal relies on melanin absorption within the hair follicle ( Fig. 3 ). Laser hair removal may be complicated in patients with dark skin because of unintended epidermal overheating leading to blistering, crusting, and subsequent pigmentary changes. 4 With this in mind, longer- wavelength lasers (1064-nmNd:YAG) with lower flu- ences and skin cooling may be used successfully in darker skin types for the treatment of hypertrichosis. 2

Keloids and Hypertrophic Scarring

Keloids and hypertrophic scars occur more commonly in dark-skinned individuals. Laser treat- ment of thickened scars may be considered in