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In the simplest sense, ablative laser skin resurfacing describes the process of removing the epidermal and superficial dermal layers of the skin to reduce cutaneous signs of photoaging. Other indications for ablative laser skin resurfacing include scarring, actinic keratoses, seborrheic keratoses, and facial wrinkles. This activity outlines and describes ablative laser options and their current uses in skin resurfacing. The differences between fractional and non-fractional lasers are highlighted, with consideration given to appropriate patient selection. Objectives: Outline the physiology of ablative laser resurfacing. Describe the equipment, personnel, preparation, and technique required for ablative laser resurfacing. Recall the potential complications of ablative laser resurfacing. Outline the importance of care coordination amongst interprofessional team members to enhance the delivery of patient care and improve clinical outcomes. Access free multiple choice questions on this topic.

In the simplest sense, ablative laser skin resurfacing describes the process of removing the epidermal and superficial dermal layers of the skin to reduce cutaneous signs of photoaging. Other indications for ablative laser skin resurfacing include scarring, actinic keratoses, seborrheic keratoses, and facial wrinkles. The use of lasers for ablating and resurfacing is based upon the concept of selective thermolysis of the epidermal and dermal layers of the skin through the delivery of light energy.[1][2] Light energy emitted by the laser is absorbed by the skin's two main chromophores, melanin, and water, which then emit thermal energy, destroying the surrounding tissue. Laser resurfacing technology has benefited from a number of breakthroughs in the last few decades, with the use of continuous-wave carbon dioxide (CO2) lasers beginning in the 1980s.[3] The implementation of pulsed delivery of CO2 laser energy and the subsequent development of the erbium-doped yttrium aluminum garnet (Er:YAG) laser, which gained popularity in the late 1990s, further improved the precision and depth of cutaneous ablation and reduced the incidence of adverse effects.[4] Additional refinement in skin resurfacing occurred in the early 2000s with the advent of fractional lasers, which are lasers that use narrow, microscopic columns of light to treat a specific portion of the skin. This less destructive modality further reduced the incidence of adverse events and increased the degree of therapeutic control while still seemingly providing comparable results to non-fractional modalities.[5] Depending on the indication, the technician may choose to employ a specific ablative laser (e.g., CO2 or Er:YAG) with a multitude of different settings, including fractional versus non-fractional, to achieve the desired result and, more importantly, minimize laser-associated complications such as scarring, persistent erythema, and dyspigmentation. All in all, ablative lasers represent a safe and effective tool for skin resurfacing, some nuances of which will be discussed herein.

Ablative laser resurfacing represents a safe and effective technique associated with a low-risk profile and a high satisfaction rate. Complications are associated with all types of laser therapy, including full-field and fractional lasers. Fractional laser resurfacing tends to produce a reduced severity and frequency of complications, including:[26] Persistent erythema Hyperpigmentation/hypopigmentation Infections (viral, bacterial, fungal) Scarring Acneiform eruptions Milia Ectropion

The key to maximizing outcomes and patient satisfaction is beginning with a thorough history and physical examination of the patient and a discussion of the patient's expectations. Reviewing the anticipated outcome, recovery period, and potential risks are essential before planning ablative laser therapy. The success of the procedure depends on efficient cooperation among the interprofessional team members, including a physician, a physician assistant, and/or a nurse or technician. A team consisting of personnel who are comfortable and well-trained to provide quality peri-procedural monitoring and care is the cornerstone of effective ablative laser treatment. Post-procedural care and close follow-up are required to evaluate the patient for possible complications such as infection or dyspigmentation. Patient education regarding proper care for the procedural site during convalescence is essential to minimize adverse outcomes and maximize patient satisfaction. [Level 5]

The appearance of edema and exudate are expected within the first few days after treatment, and patients should be informed of this during pre-procedure counseling. The use of cooling compresses, saline/water soaks, and head elevation will help minimize edema and keep the skin moist, promoting rapid wound healing. Skin cleansing and application of ointment should be performed routinely until crusting resolves (3 to 4 days for fractional, 7 to 10 days for full-field laser resurfacing). Pain associated with the post-procedure period can typically be managed with acetaminophen with or without stronger oral analgesic agents. Patients must be counseled to avoid scratching or rubbing the skin and engage in photoprotective activities, including avoidance of the sun and use of sunscreen to minimize the risk of persistent hyperpigmentation. Occasionally, pruritus may occur, and the patient should be monitored and provided with topical corticosteroids to apply twice daily for several days if needed. The use of topical steroids, hydroquinone cream, retinoids, or peeling agents has been employed to reduce the development of postinflammatory hyperpigmentation and to accelerate its resolution. Scarring can be managed with topical or intralesional steroids as well as nonablative fractional lasers. Patients can generally return to work 14 to 21 days following a full field face CO2 laser resurfacing and 3 to 8 days following a full field Er:YAG laser skin resurfacing. Fractional CO2 lasers generally require a 4 to 10 day recovery period, while only 1 to 3 days off work are recommended after fractional Er:YAG laser resurfacing. Patients should be informed of the expected recovery timeframe and regularly monitored by the interprofessional healthcare team to ensure normal healing.

Close follow-up during the initial post-procedure period to monitor for signs or symptoms of infection, pruritus, and other issues is imperative to reduce adverse outcomes and maximize the therapeutic benefit of ablative laser therapy. Many patients may require three or more treatments to achieve the desired results, particularly with fractional therapy; therefore, longitudinal follow-up and discussion will maximize the chance of favorable clinical outcomes.