ABSTRACT
PATIENT SELECTION FOR FRACTIONAL ABLATIVE LASER RESURFACING Although there are reports that ablative fractional laser resurfacing is safe in a variety of skin types, the author limits this indication to skin types I to III, as there have been reports of hypopigmentation with ablative fractional laser resurfacing. Post-inflammatory hyperpigmentation may also ensue but is generally reversible. The author also limits the treatment to facial areas and prefers non-ablative fractional laser resurfacing for non-facial areas, especially with the introduction of dual non-ablative fractional laser wavelengths of 1550 and 1927 nm in a single treatment. Finally, “blended” AFR and NFR treatments are the most common indication, where more aggressive treatments with AFR is performed on perioral and periorbital areas and the rest of the face is treated with non-ablative fractional laser resurfacing. Patients prefer this modality as there is considerably less recovery and risks ( Fig. 29.1 ).
PATIENT PREPARATION, TREATMENT, AND POST-TREATMENT CARE FOR FRACTIONAL ABLATIVE LASER RESURFACING All patients are advised to discontinue topical retinoids and exfoliating agents one week prior to treatment. Prophylaxis for oral herpes simplex is indicated for all patients and extended if the patient gives a documented history of oral herpes simplex. A short course of a broad spectrum oral antibiotic is also given in the peri-operative period as well as a single dose of oral diflucan to prevent candidal outbreaks. The greatest challenge in ablative fractional laser resurfacing is pain control. With mild settings, topical anesthesia and nerve blocks are usually adequate. However, with aggressive settings more aggressive pain control is necessary. Tumescent anesthesia has been used, as well as the use of intravenous sedation with the presence of an anesthesiologist. The technique of ablative fractional laser resurfacing is absolutely critical, particularly when using aggressive settings or treating off the face. Care must be taken to deliver the energy without significant overlap to avoid bulk heating. Lower fluencies and lower treatment densities are advisable off the face. Treating anatomic units in sequence is recommended. If treatment is performed on eyelids and the periorbital area, nonreflective metal corneal shields need to be placed. Immediately following the treatment the patient will experience oozing, pinpoint bleeding, and crusting. A petrolatum-based ointment is recommended to be used multiple times a day to keep the wound moist. Dilute vinegar and water soaks are also recommended. The erythema and edema becomes most pronounced at 24 to 48 hours, but shows a rapid resolution within 3 to 5 days ( Fig. 29.2 ). Emolliation should be continued until re-epithelialization is complete, and should be followed with a mild unscented moisturizer. Strict photoprotection is also indicated during the recovery phase. The most critical time for healing is within the first few days so any sign of infection should be noted and immediately addressed to prevent adverse sequelae. If there is greater than expected erythema or textural change, close follow-up should be performed to prevent the development of scarring.
