Section 4 Plastic and Reconstructive Problems

Fitzpatrick type IV skin and are contraindicated in

phototypes V and VI because of the increased

risk of dyspigmentation and scarring (occasionally

keloidal).

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

POSTPROCEDURAL CARE AND FOLLOW-UP

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.

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.

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

Richter et al