Responsible Patients Fare Better Before and After CO2 Laser Surgery
Since instituting a month-long preoperative skin care regimen and a strict postoperative wound healing protocol, W. Grant Stevens, M.D., has had scar free results in 945 full-face resurfacing with the CO2 laser. Dr. Stevens is a clinical instructor of plastic surgery at the University of California – Los Angeles.
"Preoperatively, all patients use peel and bleach cream (P&B) for a minimum of 4 weeks before resurfacing. I make no exceptions to this rule. We also do at least two Bio-Medic MicroPeels on every patient. Certain patients cannot tolerate this month of pre-treatment. I've found this regimen clearly determines the patient's overall commitment and weeds out the not fully compliant patients."
Because using a laser is easy – anyone can do it, he says. "What is crucial is whether the patient is going to be compliant postoperatively," Dr. Stevens adds.
A patient scheduled for laser resurfacing is assigned to an aesthetician and a nurse. The patient can talk with them at any time. The lengthy pretreatment period facilitates patient bonding with clinicians and with Dr. Stevens. It also accustoms patients and their families to seeing other patients in different phases of resurfacing.
"This policy has enabled me to survive an onslaught of phone calls, and it improves the quality of life for both my patients and myself," says Dr. Stevens.
A month of pretreatment with P&B (Retin-A 0.5%, hydroquinone 4%, hydrocortisone 1%) prepares the skin for optimal results. Dr. Stevens evolved the regimen from a study that compared pretreated with non-pretreated CO2 laser resurfacing patients. Detailed written instructions included washing the face with mild soap or soap substitute and waiting 15 to 20 minutes until the skin is completely dry before applying a thin coat of P&B to the entire face or areas to be treated. Next, the skin is hydrated using a moisturizer with an SPF of 15 or higher. To acclimate the skin, patients are instructed to begin applying cream on alternate nights and work up to nightly applications.
According to Dr. Stevens, postoperative treatment is as equally important. "I'm firmly convinced that wound care and dressings matter. Skin becomes and stays edematous without dressings. You can also minimize some of the nursing care with Flexzan dressings, which accelerate wound healing, and improve final results overall.
Patients are seen on the first postoperative day and on two or three subsequent visits during the first week. Dr. Stevens likes the splinting effect of Flexzan dressings and reapplies them to most patients on post-operative day one, rarely removing them until day three, when open skin treatment begins.
Patients self-administer cool soaks or refrigerated 75% water and 25% vinegar solution to the open skin, changing them frequently. Because Resurfix (shark oil) cleanser and ointment may irritate the skin after the laser procedure, patients apply petroleum jelly postoperatively to a dry face for the first few days and then switch to Resurfix BID until days five to seven. At day seven, patients return to the aesthetician, who instructs them in make-up and home care.
Dr. Stevens' written instructions included a warning not to remove the dressing for any reason. The instructions contain a final paragraph that states, "My postoperative treatment care has been explained to me and I understand my responsibility for properly fulfilling the aftercare instructions." There also are spaces for the signature of the patient and a witness.
Sun avoidance is paramount postoperatively, emphasizes Dr. Stevens, since hyperpigmentation will develop if patients expose skin to the sun too quickly. "To avoid hyperpigmentation, we'll often put people right back on Retin-A 0.1% and hydroquinone 4% if they can tolerate it, and reiterate skin care and sun precautions."
Another important factor is successful outcomes is carefully screening patients. "Patient selection is crucial," stresses Dr. Stevens. "Absolute contraindications are type five skin, the unstable patient, the unreliable patient, and the noncompliant patient in the pre-operative phase. If they can't maintain the program pre-operatively, they won't do it postoperatively.
When to Laser
Indications for laser resurfacing are wrinkles, sun damage, irregular pigmentation, and scars.
Dr. Stevens treats patients with skin types one through 3 unless there is a clear medical contraindication. Type 4 skin is relatively contraindicated. "I am treating some patients with type 4 skin but I give it a lot of thought first."