Biomedical Engineering Reference
In-Depth Information
post-care routine
Gentle post-care is of paramount importance. In our practice,
we supply our patients with a skin care kit to be used during
their laser treatment series. It consists of a gentle cleanser, non-
occlusive moisturizer, thermal water spray, and a physical sun-
block. Post-care instructions are reviewed verbally with the
patient after treatment and they are also sent home with writ-
ten instructions. The patient is instructed to cleanse the treated
area twice a day with the cleanser and immediately apply the
moisturizer. The broad spectrum sun protection must be
applied before exposure to sunlight and reapplied as necessary.
Patients can also apply cool compresses or cold packs and
spray their face with the thermal water spray as needed to help
reduce swelling and discomfort. Narcotic pain medication is
rarely necessary, but over-the-counter acetaminophen can be
taken if needed. Patients should sleep with their head elevated
for the fi rst few nights to help diminish swelling. They should
avoid vigorous exercise or activity while swollen or red.
They should avoid smoking and excessive alcohol consump-
tion. Strict sun protection must be observed using a broad
spectrum SPF of 30 or greater. Direct sun exposure should be
avoided for 3 months after treatment. Topical products
and medications can usually be restarted 3-7 days after treat-
ment depending on the level of treatment and sensitivity of the
patient. Those patients prone to PIH or who are being
treated for melasma will restart a topical hydroquinone cream
1-4 days post-procedure.
recommended. For darker skins types or patients prone to
hyperpigmentation, pre- and post-treatment with a hydroqui-
none bleaching cream are recommended and strict sun protec-
tion is discussed with all patients.
treatment preparation
To prepare for NAFL treatment, patients are asked to remove
all jewelry and makeup and cleanse their skin with a mild
cleanser. Consents are reviewed and signed. Premedication
with an oral antiviral for patients with a history of herpes
simplex virus is documented. Pretreatment standardized
photographs are taken. Our practice uses the Canfi eld Omnia
system and the Vectra 3D system (Canfi eld Scientifi c Inc.,
Fairfi eld, New Jersey, USA). The Visia™ system (Canfi eld Sci-
entifi c Inc.) can be used for fi ner textural changes and wrinkle
assessment. The treatment area is wiped with 70% isopropyl
alcohol and allowed to dry. A moderately thick (a quarter
inch) application of a topical anesthetic is made. We use com-
pounded topical anesthetic with 15% lidocaine and 5% prilo-
caine in an ointment base for the treatment of the face or
localized body area. A two-treatment area restriction should
be considered when using these stronger, compounded topi-
cal anesthetic agents. Lidocaine overdose is possible and lido-
caine toxicity has been reported during NAFL treatment (18).
The fractional laser consensus panel recommends to limit the
area to 300-400 cm
2
to minimize potential lidocaine toxicity
(19). If larger skin surfaces are to be treated, a standard topi-
cal anesthetic cream can be used like lidocaine 5% cream
(L.M.X. 5, Ferndale Healthcare Inc., Ferndale, Michigan,
USA). The topical anesthetic should be blended into the
perimeter of the anticipated treatment area to ensure com-
fort. After 60 minutes, the topical anesthetic is removed
with a dry gauze pad. Chapter 16 details topical anesthesia.
Use of eye protection for the patient, practitioner, and sup-
port staff is mandatory during the NAFL treatment. If the
eyelid skin inside the orbital rim is to be treated, intraocular
metal eye shields should be inserted. Handpieces are sanitized
with Sani-Cloth® (Professional Disposables International,
Inc., Orangeburg, New York, USA) before each treatment.
Laser system tests are performed to ensure a properly per-
forming laser. A paper test strip is available for use with the
Fraxel laser systems (Fig. 8.5B).
When treating the patient with any NAFL, divide the treat-
ment area into smaller cosmetic units. For example, the cos-
metic units of forehead, cheeks, nose, lip, and chin are treated
as separate areas. These units can be customized to the prefer-
ences of the individual practitioner. Completely treat one
cosmetic unit at a time. Be careful not to overlap treatment
between the individual cosmetic units that could cause over-
treatment. In our practice, we use forced cold air during the
treatment, which has been shown to reduce pain but can also
affect the thermal laser injury (20). After the NAFL treatment
is concluded, patients are treated with a light-emitting diode
treatment (Gentlewaves, LLC., Virginia Beach, Virginia, USA)
to reduce the intensity and duration of post-treatment ery-
thema (21). They are also treated with topical thermal water gel
and spray (Avene Thermal Water, Pierre Fabre Dermo Cosmé-
tique USA, Parsippany, New Jersey, USA) to alleviate discomfort
and a physical sunblock is applied before they leave the offi ce.
The next treatment is scheduled in 3-6 weeks.
complications
Complications are a possibility with any NAFL treatment, even
though the potential for and the incidence of serious side effects
are exponentially less than with traditional and ablative resur-
facing. Nonablative skin resurfacing has a low complication rate.
Most side effects are transient in nature. Possible side effects
include erythema, swelling, blistering, scarring, infection, pig-
mentary changes, herpes reactivation, and acne fl are-up. Tran-
sient erythema and swelling are to be expected and the patient
should be instructed to expect these. In a review of short-term
adverse effects from 1550-nm NAFL treatment by Fisher et al.,
all patients displayed post-treatment erythema and edema was
present in 82% of patients (22). Prolonged erythema, massive
swelling, blistering, and subsequent scarring can occur if aggres-
sive treatment parameters were used and overheating of the skin
occurs. These side effects can be easily avoided with a prudent
selection of treatment parameters. Infection is rarely seen
with nonablative fractional resurfacing. Hyperpigmentation
defi nitely occurs and is more prevalent with darker skin types
(IV-V). This can be reduced with pre- and post-treatment with
hydroquinone bleaching agents and strict sun protection. Also,
treatment densities and fl uencies must be lowered to reduce this
side effect. Reactivation of herpes simplex is a real side effect.
Patients who are prone to herpes simplex should be pretreated
with oral antivirals. There have also been three cases of herpes
zoster along the trigeminal nerve, which have been reported
after NAFL (23). Acneiform eruptions can also occur. If patients
are prone to acne, they can be treated with oral antibiotics, like
minocycline or doxycycline and/ or a topical antibiotics, such as
clindamycin. The nonablative resurfacing complication rate has
been studied over several years (24-26). A retrospective study of
961 nonablative 1550-nm laser treatments recorded a 7.6%
