Section 4 Plastic and Reconstructive Problems

Richter et al

Fitzpatrick type IV skin and are contraindicated in phototypes V and VI because of the increased risk of dyspigmentation and scarring (occasionally keloidal). 4 Due to the side-effect profile of the ablative nonfractionated lasers, a more gentle approach using nonablative technology was developed. The nonablative nonfractionated lasers include the 1319-nm pulsed energy laser, the 1320-nm neodyminum-doped YAG laser (Nd:YAG), and the 1450-nm diode laser. These lasers have had slight improvement with skin resurfacing and good results with acne treatment. 1 There is mini- mal recovery required with these lasers, little ery- thema, and minimal peeling. The nonablative nonfractionated lasers often require serial treat- ment sessions (4–6 treatments) to obtain improve- ment but can be used safely in patients with dark skin because of decreased risk of scarring and dyspigmentation. 7 To more effectively treat the skin, nonablative fractionated lasers were developed to combine a more aggressive pulse and the safety of fraction- ation while still avoiding the epidermal loss incurred with ablative lasers. These include the 1410-nm laser, the 1440-nm Nd:YAG laser, the 1540-nm laser, the 1550-nm erbium laser, and the 1927-nm thulium fiber laser. These nonablative fractionated lasers frequently require several treat- ments (2–6), with moderate improvements in skin tone and texture with moderate downtime. 7 The targeting of tiny diameter and deep dermal pene- tration of each MTZ allows for stimulation of collagen formation while avoiding disruption of the epidermal barrier function. 9 These lasers can be used safely in dark phototypes with a small risk of temporary hyperpigmentation. The ablative fractionated lasers are the most recent addition to the laser family. These lasers were developed in an attempt to increase resur- facing effectiveness while still enjoying quicker healing with fewer complications compared with ablative nonfractionated resurfacing. These include the 10,600-nm fractional CO 2 laser, the 2940-nm fractional Er:YAG laser, and the 2790- nm fractional erbium-doped yttrium scandium gal- lium garnet (Er:YSGG) laser. These lasers target MTZs with ablation and vaporization of dermal and epidermal tissues. A series of sessions may give resurfacing results nearly comparable to the ablative nonfractionated lasers but with much improved safety profiles. 7 These lasers can improve skin laxity and mild rhytides, but due to the violation of the epidermal layer, there is a risk of infection, scarring, and dyspigmentation and should be used with caution in patients with Fitz- patrick type IV through VI skin. 7

Radiofrequency technologies achieve mildly improved facial skin tone and texture by dena- turing existing dermal collagen and stimulating new collagen through low temperatures and deep tissue penetration. This option decreases the risk of dyspigmentation and scarring, and pa- tient discomfort is minimal. 2,7 When choosing a laser for hair removal, the 1024-nm Nd:YAG is the safest choice in dark- skinned individuals because the wavelength is poorly absorbed by melanin, which reduces the damage to dark epidermal pigmentation. 2 In addi- tion, the pulse length can be adjusted to deliver the pulse over a longer period to facilitate cooling. Other laser choices for hair removal include the alexandrite and diode lasers at lower fluences and wider pulse widths. As with laser treatment of other skin disorders, multiple treatment ses- sions may be needed to achieve permanent re- sults. Risks of laser hair removal in Fitzpatrick skin types IV to VI include blistering and temporary dyspigmentation, with a low risk of permanent hy- perpigmentation or hypopigmentation. 2,3 In addition to using lasers with longer pulse duration and longer wavelength to decrease the risk of discoloration or scarring, periprocedural cooling should be considered to decrease thermal damage to surrounding tissues. 3 Contact and noncontact cooling have the added benefit of improving patient comfort during laser therapy while decreasing thermal damage to the epidermis without interfering with laser intensity and direc- tion. Options for contact cooling include skin moistening, application of ice or ice packs, and laser-specific cooling tips. 6 The importance of postprocedural planning and skin care cannot be overstated when managing patients after laser treatment. Because many of these treatments often require several sessions, reducing skin damage between treatments can optimize epidermal healing and dermal collagen regeneration. The skin is more sensitive than usual for a short time after laser treatment, and sun blockade and cooling agents should be used judi- ciously. Darker phototypes have more reactive and labile fibroblasts compared with skin types I to III, and further dermal injury should be avoided. 2 After laser treatment and depending on the type of laser used, mild erythema, edema, peeling, and flaking may occur and typically resolve over several days. 10 The period for full recovery de- pends on the exact type of laser treatment, and postoperative care must be tailored to the treat- ment administered. The postoperative skin care POSTPROCEDURAL CARE AND FOLLOW-UP