II. ADJUNCTIVE PROCEDURES

II.C. Laser Resurfacing

Cosmetic eyelid surgery does not correct or improve the fine wrinkling that can occur with aging. In this situation, laser resurfacing (or some other resurfac­ing procedure) may be the best option (Fig. 4).4 Skin is a living organ. Every day, thousands of cells die, fall off , and are replaced by new cells from below. This is a haphazard process that does not allow the skin to shed dark spots, sun damage, or a dull lifeless complexion.

Laser resurfacing is a procedure in which a carbon dioxide laser (as well as some other types of lasers) is used to remove the outer layers of skin. The purpose of laser resurfacing is to cause the even, controlled removal of several layers of damaged cells. This allows a new fresh layer of skin to grow, with a more even texture and color. Before the laser resurfacing proce­dure, the surgeon should prescribe a skin cream for the patient to begin at least 2 weeks before the procedure to prepare the skin. All patients should be prescribed an antibiotic and an oral antiviral medication to begin prior to surgery. This is to prevent the outbreak of bacterial infection or cold sores/fever blisters dur‑ing the healing phase. On the day of the procedure, patients are instructed to wear clothing that fastens in front or back. Patients are asked to avoid slipover sweaters, T-shirts, and turtlenecks and are instructed not to wear any earrings, makeup, or facial creams. Men should be closely shaven.

FIGURE 4. Laser resurfacing is especially effective around the eyes (A preoperative, B postoperative)

The patient is brought into the procedure room and placed in a reclining medical chair or table. Local anesthesia and intravenous sedation or general anes­thesia are used as determined prior to the procedure. The patient's face is cleansed to improve uniform uptake. The laser procedure is then performed. At the completion of the procedure, ointment is applied. Immediately after laser resurfacing, the resurfaced area will feel swollen, numb, and look slightly pink. It is normal to have significant swelling the night and morning after the procedure. This can be lessened by sleeping with the head elevated.

During days 7-30 after laser resurfacing, a patient's skin will look sunburned. It may take up to 3 months for the redness to completely disappear, but after 7 days a patient should look socially acceptable with makeup. Patients may now resume their normal ac­tivities with the exception of sun exposure.

As with all surgical procedures, there are potential side effects and complications associated with laser resurfacing. Pigmentary changes after laser resurfac­ing can cause areas of increased or decreased pig­mentation. This is more common in darker skinned individuals or those with a history of pigmented scars. The use of sunscreens and lightening gels will decrease the risk of these problems. Close follow-upand keeping all appointments with the doctor is im­portant so that these problems can be treated early when they occur.

Some redness may last for up to 3 months. This is managed with skin care regimens and strict sun avoidance. Also, makeup can be used to camouflage any redness during this time. Infection may occur as a result of herpes simplex or bacteria. Preventative medications are routinely prescribed for this and are generally quite effective. Any signs of infection should be recognized early and treated with additional therapy as indicated. Scarring is a rare complication of the wound created by the laser resurfacing proce­dure, but it remains a potential complication of any procedure that wounds the skin. Close follow-up and keeping all appointments with the physician is important so that these problems can be treated early when they occur.

Patients may occasionally require more than one resurfacing procedure to achieve their best improve­ment. For most skin types, one procedure is enough to achieve the desired improvements, but some skin problems, such as excessive pigmentation from preg­nancy or birth control pills, may require multiple procedures for maximum improvement. Everyone's skin is different, so each program is tailored to the individual's needs.

In the average resurfacing procedure, it takes 6-9 days to achieve complete re-epithelialization (growth of new, "revitalized" skin). During this time, the treated area will leak a straw-colored fluid. This is normal and typically stops within a week. It is most important during this phase for the patient to keep the area moist and avoid crusting.

Crusting delays healing, so the patient is instructed to apply liberal amounts of plain Vaseline. Using Vase-line that has been refrigerated may help further ease the discomfort or swelling. Patients may wash their face gently with a mild soap, but must not rub. Patients are instructed to gently pat their face with lather and splash with water. Any crusts should be gently soaked away with water or hydrogen peroxide on a gauze sponge. Patients should not rub or pick crusts. After washing, Vaseline may be liberally reapplied. Patients should avoid strenuous activity and sweating during the first week.

During healing, any pain can be easily controlled with medication. In most cases, ibuprofen, Tylenol, or Tylenol with codeine should be adequate to control any discomfort. Most people feel they look "strange" during the early healing phase, but if this is not a concern they can go out. However, they will not be able to be in the sun or do anything that would cause them to perspire heavily. It is of utmost importance for patients to wear sunscreen and strictly avoid the sun. Damage from UV rays can occur in winter, through car windows, and on cloudy days. For the best possible results, daily sunblock should be used for 6 months.

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