ANAHEIM, CALIF. Ablative laser resurfacing offers perhaps the most effective means for smoothing wrinkles and acne scars, but its success depends on the "five Ps": prepared patients, a good preop evaluation, pain control, a perfectly done procedure, and postop diligence, Suzanne L. Kilmer, M.D., said at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.
Requiring just a single treatment, ablative laser resurfacing removes the epidermis in a first pass, thereby eliminating epidermal lesions and helping to decrease the risk for actinic keratoses and basal cell carcinomas.
To achieve the best possible outcome, however, it's important to pay attention to the details included in the five Ps, said Dr. Kilmer of the department of dermatology at the University of California, Davis.
Prepared Patients
"The consult is critical," Dr. Kilmer said. "Educated patients are going to be much better prepared for what they will be dealing with and will have more realistic expectations."
To help alleviate fear, Dr. Kilmer said she shows patients a video of the procedure (supplied by the manufacturer), along with typical before-and-after photosand not just the best cases. "I'll even show my worst," she said. "I'll also show photos to give them an idea of how they can expect to look in a couple of days, a couple of weeks, and as time goes on."
In addition to the informed consent form, patients receive handouts describing the procedure (including preop preparation and postop care) and risk/benefit options.
Preoperative Evaluation
Because hyperpigmentation is one of the most common problems in ablative laser resurfacing, patients' skin type should be checked for that tendency, Dr. Kilmer said.
If patients have acne or other scars, the shallow, dish-shaped scars tend to respond the best, although the treatment significantly improves most acne scars, she said.
Photos of patients should be taken preoperatively and at 1 week, 6 weeks, 36 months, and 1 year. Full-face shots as well as close-ups of all anatomical units should be taken with good lighting and consistent settings.
"I can't emphasize enough the need to document with photographs in various stages," Dr. Kilmer said. "It's amazing how often patients won't see much improvement or will say some spot wasn't there and you can look back and show them that it was."
Pain Medications
Dr. Kilmer recommended EMLA with hydration for pain control. Not only does it enhance comfort, she said, but it also enhances safety, with less superficial coagulative thermal damage and less prolonged erythema. Redness has a much shorter duration, and the tendency for hyperpigmentation decreases, she added.
Dr. Kilmer instructs her patients to begin with hot, soapy soaks for 15 minutes at home and then immediately apply the EMLA and cover with a plastic wrap. A second tube is applied when they come to the office.
Patients who have previously had cold sores receive antiviral medications, and they also get antiyeast pills because persistent itching and redness can represent a low-grade yeast infection.
Valium (510 mg) and oral nonsteroidals are also given around the clock for the first few days to relieve pain.
Perfectly Done Procedure
Dr. Kilmer said she typically treats in quadrants, with a first pass using slightly higher intensity because the epidermis is so hydrated. Feathering peripherally in the first pass is also important to prevent a stop and start line.
She advises wiping everywhere except the neck, jaw line, and hairline, and giving a lighter treatment to fair or thin-skinned patients, who should never be wiped on the lateral third of the cheek.
Treatment of the neck can have good results and helps blend the entire treatment area nicely, Dr. Kilmer said, but she emphasized that EMLA should be used for extra protection from thermal damage and the neck should never be wiped.
Postop Diligence
Dr. Kilmer emphasized the need to stay on top of any potential problems, such as contact dermatitis from unexpected sources. "Fabric softening agents and dryer sheets … tend to have perfume and dyes, which can really be a problem," she said. Use of topical steroids can help in such situations.
If scarring is suspected, treatment should be given right away. A bubbly reaction seen on the skin texture signals a scarring problem, and she advises physicians to consult with others and seek help.
Likewise, treatment of hyperpigmentation cases should be swift, and patients should get zinc oxide right away, with hydroquinones and Retin-A at about a month after treatment.
In the thousands of cases she's done, Dr. Kilmer said she's never seen hyperpigmentation become permanent. EMLA and hydration help provide a greater margin of safety, making ablative laser resurfacing a highly effective tool, she noted.