Ablative and non-ablative lasers have different effects on the skin.
Various postoperative treatments have been used, e.g., topical agents and/or dressings (open vs closed techniques).
Additional research is needed to determine the optimal postoperative care after laser procedures.
Introduction
The non-ablative lasers use longer wavelengths to infiltrate deeper into the dermis, however their efficacy compared to ablative techniques is not as significant. Thermal injury to the dermis after laser procedures results in the normal cellular and molecular cascade associated with injury. Varying degrees of erythema, swelling and crust formation are associated with thermal injury. |
Laser procedures have increased drastically in the past decade. Advancing technology coupled with increasing environmental stressors, such as higher UV levels due to ozone depletion, have resulted in a large increase in laser procedures.1 Lasers are an appealing form of therapy for acne scars, photodamage, wrinkles, and discoloration of the skin.2 Ablative lasers (carbon dioxide – CO2 and erbium:YAG) have been used effectively for years however with concerns of potential side effects and/or complications, the demand for ablative procedures has decreased with non-ablative techniques dramatically on the rise. The non-ablative lasers use longer wavelengths to infiltrate deeper into the dermis, however their efficacy compared to ablative techniques is not as significant.3 With the rapid advances in laser technology there is a need to better examine the effects of these new devices on skin as well investigate optimal postoperative regimens. Since there are more complications with ablative techniques, we will focus the below discussion on ablative postoperative care.
In the skin, lasers function through basic photothermolitic principles.4 With conventional ablative lasers, since water is the targeted chromophore, there is usually ablation of the entire epidermis with subsequent effects on the papillary dermis. Thermal injury to the dermis during this process results in the normal cellular and molecular cascade associated with injury. As part of this cascade, collagen is denatured, resulting in collagen shrinking and tightening of the tissue.5 As a result, the treated skin regains some of its youthful elasticity and firmness.6 Generally, lasers that can employ selective photothermolysis with minimal tissue damage are the most desirable.
Although multiple types of lasers are frequently employed using various pulsing techniques and cooling strategies, all skin rejuvenation procedures carry with them some risk of side effects, even in the hands of experts.7 Most, if not all, laser procedures result in varying degrees of erythema, swelling and crust formation associated with thermal injury.8 Dependant on the extent of ablation of the epidermis, pain can result due to exposed nerve endings. As with any surgical procedure, viral and bacterial infections are possible, particularly, early in the recovery process. Scarring, hypo-, and hyper-pigmentation also occur, although these effects are fairly uncommon.9
Available Postoperative Treatments
Open techniques use topical agents only Closed techniques use occlusive dressings (with or without topicals) Moist wound healing is important for optimal healing Ideal dressing or topical agent for post surgical care should: (1) stimulate healing, (2) reduce pain, (3) be easy to apply, (4) provide optimal cosmetic results |
Various treatment options are available post laser therapy and these include occlusive, semi-occlusive dressings and/or the use of various topical agents. The use of topical agents only is commonly referred to the “open” technique, where the use of occlusive dressing is considered the “closed” technique. It has been well established that keeping wounds moist with an occlusive dressing allows faster epithelization, maintains growth factor viability, alleviates pain, and can reduce scar formation.10 – 16 Different postoperative treatments can affect the quality of healing and an ideal dressing or topical agent for post surgical care should: (1) stimulate healing, (2) reduce pain, (3) be easy to apply and (4) provide optimal cosmetic results.17 Because of the possibility of severe infection or disfiguration of the patient, postoperative therapy should be separated into phases based on the most immediate risks (Table 1). Care should be taken immediately after completion of the procedure to minimize the probability of scar formation and bacteria or viral infection. This is usually accomplished by using various cooling techniques to avoid the necrotic progression usually associated with thermal injury. Anti-inflammatory and antibiotics/antivirals can be used early in the recovery process to promote healing. Within the first 48 h, this can be accomplished by using cold water, corticosteroids, and water-soluble antibiotics. After 72 h, gentle moisturizers can be incorporated into the treatment regimen to enhance water retention in the healing tissue and to minimize the probability of scar formation. One week post-surgery, patients can begin using gentle cleansers to remove any crust or necrotic tissue which may remain in order to limit the nutrient available to pathogens. During the same time period, patients can begin using hypoallergenic make-up to cover any residual erythema. After the third week of recovery, patients can begin focusing on sun protection and conditioning masks to promote skin hydration. Treatment and make-up for residual erythema can be continued or intensified if needed. One month post-procedure, pigment correction can begin for either hypo- or hyper-pigmentation. Sun protection should be continued and scar treatment can begin, should it be necessary.18
Table 1
Treatment schedule and indications for post-operative recovery
Time post operation | Treatment | Indication |
|---|---|---|
0–48 h | Topicals/dressings Anti-inflammatory Antiseptic Cooling | Enhance healing Swelling Infection prevention |
72 h–1 week | Moisturizers Antibiotics Antivirals | Minimize scarring Infection prevention |
1–2 weeks | Cleansers Make-up Anti-erythema | Remove crusting Cover and treat erythema |
3–4 weeks | Sunblock Anti-erythema | Sun protection Residual erythema |
>4 weeks | Vitamins, colorants or bleaching agents | Pigmentation conditions |
Immediate Post-operative Treatment (0–48 h)
Immediately after completion of the procedure, ice packs can be applied to a patient to alleviate the burning sensation that is commonly experienced. Petrolatum can be applied to the treated area within 2 h of completion of the procedure.19 Petrolatum provides some cooling and a moist environment conducive to proper healing. It is interesting to note that Eaglstein and Mertz found that vehicles, including different lots of petrolatum, can have a varied effect of the healing of acute partial thickness wounds.20 It is also likely that different brands of petrolatum (or other moisturizers) may have varied effects after laser procedures. Petrolatum is sometimes replaced by the addition of an antibiotic cream. Gentamycin ointment is frequently recommended and sometimes combined with prednisone, or other corticoids, to reduce inflammation.1 Antiseptic washes can be used to remove any remaining eschar and as a prophylactic. Dilute vinegar or chlorhexidine can be used to gently wash the area several times daily to prevent infection and to remove debris.10 Interestingly, the rate of postoperative infections has also been shown not to be influenced by the use of prophylactic oral and/or intravenous antibiotics in the peri- or post-operative period.21 Cautious use of antibiotics is suggested in high-risk patients, certain anatomic locations and the presence of infection.22
Anti-inflammatory Agents
Corticoids – Corticosteroids play a major role in the stress response of the body. They serve to modulate the immune system and various inflammatory mechanisms. Corticoids can be used to suppress the inflammatory response due to laser injury but should be used with caution. Although, they have potent anti-inflammatory action, some corticoids can inhibit healing through their interactions with inflammatory cytokines, which are essential of adult mammalian healing.23
Alpha bisabolol – Alpha bisabolol is a cyclic monosaturated sesquiterpinic alcohol isolated from the horse chestnut. The compound is more of an anti-irritant than an anti-inflammatory although it does have some anti-inflammatory activity.24 The agent is highly vasoactive (constrictive) and reduces vessel permeability.1 These activities are attributed to blockage of 5-lipoxygenase and cyclooxigenase in the arachadonic acid pathway.25
Enoxolone (glycyrrhetinic acid) – Enoxolone has been used to reduce inflammation by ancient civilizations since the third century B.C. Evidence of its use has been found in China, Greece, Rome, and Egypt.26 It is isolated from licorice root and was first described, in modern times, as a potent anti-inflammatory in 1958.27 The compound functions as a non-steroidal anti-inflammatory but at high doses may induce swelling, redness, and edema by inhibiting 11-hydroxy-steroid-dehydrogenase.15 At low concentrations, enoxolone has been shown to interfere with steroid metabolism in renal tissues, resulting in global anti-inflammatory action.28
In addition to topical agents, various dressing materials have been used post operative for laser resurfacing. Occlusive dressings can provide a moist environment, protect the wound from bacterial invasion and depending on their composition influence the micro environment.29 – 32 The fear of infection which is often associated with the use of occlusive dressings has made many practitioners avoid their use. However, studies have shown lower infection rates with wounds which are covered with certain types of occlusive dressings.33 When used properly, dressings can enhance patient discomfort, simplify postoperative wound care and do not increase the risk of infection or contact dermatitis.34
Optimal postoperative treatment regimens have not been clearly defined. In studies conducted with partial thickness excisional wounds in swine, we found that in order to promote optimal epithelization using an occlusive polyurethane film, the dressings need to be applied within 2 h after wounding and should be kept in place for at least 48 h for optimal healing effects.20 Whether this is true for laser procedures that have different effects on the tissue, remains to be seen. In another study, we have found that laser sites (porcine model) covered with different dressing materials all epithelized faster than untreated control sites. However, sites which had the least amount of inflammation, also had a “better” histologic appearance which may correlate to a better cosmetic result.17 Below is a list of various dressing materials with a brief description and mention of potential benefits and disadvantages (Table 2).
Table 2
Dressings available after laser procedures
Dressing | Description/benefits/disadvantages | Example |
|---|---|---|
Transparent films | Polymer sheets (most common – polyurethane) Easy to observe area through dressing Does not absorb exudate | Opsite, Tegaderm, Silon TSR |
Foams | Foamed polymers (most common – polyurethane) Adheres to normal skin, absorbs exudate Cannot see through dressing material | Flexzan, Revitaderm |
Hydrogel | Hydrophillic polymers (cross linked) Cooling effect for patient’s pain Enhances healing of burn wounds Not adhesive to normal skin | Second skin, Vigilon |
Polymer mesh | Partially transparent polyethylene or silicon polymers allow the passage of blood and fluids. Semi-occlusive Can be adhesive or non-adhesive to normal skin Does not provide optimal moist environment | N-Terface, Mepitel |
Hydrocolloids | Estomeric, adhesive and gelling agents Absorbs exudate well and adheres to normal skin Cannot see through dressing material | DuoDerm |
Alignates | Derived from seaweed – hydrophilic gel Absorbs exudate, hemostatic Can be difficult to remove | Kaltostat |
Early Post-operative Treatment (72 h to 1 Week)
During the first week of recovery, a darkening of the skin may be observed mostly due to remnant epidermal debris. While it is essential for optimal healing, the debris may provide a readily available nutrient source for bacteria. Therefore, antibiotic treatment should be continued to prevent infection. The treatment can be combined with moisturizers in order to soften the residual epidermal tissue and provide a moist environment for healing.
Moisturizers
Squalene oil (olive oil) – Olive oil, high in squalene content has been used for centuries to treat burns and wounds in Mediterranean countries. Squalene is a triterpene and an intermediate in cholesterol biosynthesis.35 Squalene-rich olive oil has been shown to have antioxidant properties and protect skin lipids from oxidation by UV radiation. High olive oil consumption is thought to play a role in the reduced rate of various types of cancers in Mediterranean societies.36 In addition to its anti-cancer properties, squalene-rich olive oil has been implicated in accelerated wound healing.1
Hyaluronic acid – Hyaluronic acid is a naturally occurring component of the skin. Higher amounts of hyaluronic acid in the skin, such as in the developing fetus,37 have been associated with scarless healing or reduced scar formation.38 The compound’s structure provides it unique hygroscopic, rheological, elastic properties which contribute to the effects it has on the skin. As part of the extracellular matrix of skin, hyaluronic acid helps maintain moisture and elasticity.39 Both characteristics may play essential roles in healing and in the relief of itching sometimes associated with laser procedures. Increases in the elasticity of the treated skin may result in enhanced results.
Bovine mucopolysaccharide-cartilage complex (MCC) – Preparations of MCC have been used for over 25 years to treat chronic wounds originating from pressure, trauma, vascular insufficiency, or venous stasis. MCC has been shown to reduce inflammation and edema and enhance wound healing.40,41 Cartilage is made primarily of collagen which, in a wound, provides a scaffold for chemotactic and cellular factors. The scaffolding allows migration and stabilization of granulocytes, macrophages, and fibroblasts, all of which play major roles in cutaneous healing.42 A comparison of MCC to standard of care for Er:YAG treated skin showed a consistent reduction in the severity of erosion, edema, and inflammation in the MCC treated skin.43
Silicone ointment –Related posts:
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