SCIENTIFIC FORUM

Continuing Medical Education Examination-Facial

Aesthetic Surgery

Side Effects, Sequelae, and

Complications of Carbon Dioxide
Laser Resurfacing

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David B. Apfelberg, MD

Learning Objectives:
The reader is presumed to have a broad understanding of plastic surgery procedures and
concepts. After studying this article, the participant should be able to:

1. Identify expected sequelae of laser resurfacing and suggested treatments.

2. Identify potential complications of laser resurfacing, methods to avoid or reduce the

incidence of complications, and suggested treatments.

Physicians may earn 1 hour of Category 1 CME credit by successfully completing the
examination based on material covered in this article. The examination begins on page
373.

The benefits of laser resurfacing are now well-known and -documented. As larger series
of patients are being treated and followed, a typical pattern of side effects and complica-
tions is being observed.

Normal sequelae or side effects include temporary skin problems such as erythema,
tightness, or drying of the skin. Milia or acne may occur at the 2- to 4-week interval.
David D. Apfelberg is the director
Inadequate removal of rhytids may necessitate touch-up treatment, as may the appear- at Atherton Plastic Surgery Center
ance of telangiectasia or rosacea. Hyperpigmentation and lines of demarcation often dis- and an assistant clinical professor
of Plastic Surgery at Stanford
appear with time and conservative treatment. University Medical Center in
Stanford, CA.
Complications include infection by bacterial, viral, yeast, or fungal organisms and may
Accepted for publication Nov. 13,
result in hypertrophic or keloid scarring. Unusual hypersensitivity reactions are not 1997.
uncommon. Hypopigmentation is permanent. Ectropion and tooth enamel injury may Reprint requests: David B.
also be permanent. Apfelberg, MD, 3351 EI Camino
Real, Suite 201, Atherton, CA
94027.

Copyright ©1997 by the American

T
he benefits of laser resurfacing are now well-known and have been documented Society for Aesthetic Plastic
Surgery, Inc.
~n num~ro~s presentations at national meetings, as ~ell as multiple publications
III medICal Journals and book chapters. 1-11 As experIence accumulates on larger 190-820X/97/ $5.00 + 0

series of patients, it has been noted that there is a typical pattern of certain side effects 70/1/87471

A EST H E TIC 5 u R G E R Y J 0 URN A L - Nov E M B E RID E CE: M B E R 1 9 9 7 365

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l' depth J, wrinkles Table 1

laser ablation i pain Side Effects and Sequelae of 206 Patients and 295
i erythema
Locations
- i
i
pigmentation
recovery phase
No. %

adapted from Sasaki

- Herpes
Hyperpigmentation
2/76
6/206
2.6%
2.9%
Inadequate/touch-up 15/206 7.3%
Figure 1. Balance between complete removal of rhytids and increased Temporary ectropion 5/77 6.5%
postoperative problems and prolonged recovery. (Reproduced with per-
mission, W.B. Saunders, OP Tech in Oto, Head and Neck Surgery, Milia/acne 30/206 14.6%
1997;8:29). Temporary tightness 100/206 48.5%

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Erythema 206/206 100%
Line of demarcation 206/206 100%
Loss of tan 5/206 2.4%
Telangiectasia 6/206 2.9%

should be explained to the patient that these sequelae will

improve with time and proper care or treatment.

All patients experience postlaser resurfacing erythema

that lasts for a variable period of time-usually 8 to 12
weeks. The erythema may vary in its intensity, ranging
from a fiery red to a slightly reddish/pink appearance.
There is usually gradual fading and blanching. This phase
can be shortened and improved by use of a topical
steroid cream on an intermittent basis. Temovate® may
be used on a "pulsed" treatment schedule: 7 to 10 days
of use alternated with 7 to 10 days of nonuse.

At approximately 2 to 4 weeks, most patients experience

pruritus. This symptom usually spontaneously diminish-
Figure 2. Methods of feathering to diminish line of demarcation. es. It can be relieved by cool compresses, iced facial mist
with a plant mister, and occasionally a mild cortisone
cream.

and complications resulting from the procedure. 6,12-14 As
the depth of laser ablation is increased to remove rhytids,
so is the likelihood that the patient will experience more
side effects or complications. In an effort to decrease the
maximum number of wrinkles, the surgeon may be
increasing the postoperative pain and the duration and
intensity of erythema, prolonging the recovery phase and
subjecting the patient to changes in pigmentation (Figure
1).
Typical Sequelae of Laser Resurfacing
Certain sequelae or side effects are experienced by many
patients as a result of laser resurfacing (Table 1). It
During the same period, many patients experience milia
or fine "whiteheads." The patient should be reassured
that these usually spontaneously disappear. Standard
acne gels or Retin-A® and the use of a mildly abrasive
skin cleaner such as a "Buf-Puf®" can be very useful dur-
ing this stage.
Patients may also experience a flare-up of previous acne
as a result of the obstruction of the sebaceous glands by
either occlusive dressings or oily or petrolatum-type topi-
cal ointments. Similarly, patients who have not had acne
in the past may experience an acne breakout. These
breakouts occur anywhere from 3 to 6 weeks after resur-
facing, and may require intensive treatment with Retin-

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Figure 3. Preoperative appearance of pel'ioml rhytids, Figure 4. Appearance 3 months after initial procedure. Note minor
persistence of some lines.

Table 2
Complications of 206 Patients and 295 Locations

No. %
Hypopigmentation 6 2.9
Prolonged erythema (>12 weeks) 16 7.8
Bacitracin® allergy 3 1.5
Allergic reaction 4 1.9
Infection 1 0.5
Hypertrophic scar
Upper lip (n = 3)
Chin (n = 1) 4 1.9
Synechiae 1 0.5
Permanent ectropion 0
Dental injury 0 Figure S. Final result after re-do or touch-up with complete elimina-
tion of all lines.

A®, acne gels, and systemic antibiotics such as Minocin®
or tetracycline.
Patients often complain of a tight feeling in their skin
about 2 to 4 weeks after resurfacing. This can be relieved
by the use of skin hydrators, lubricators, or moisturizers.
The line of demarcation that is apparent between the
laser-abraded skin and normal skin will normally disap-
pear between 2 and 12 weeks after the procedure. The
line can be ameliorated during the original treatment by
feathering the edges with gradually diminishing laser
power, by use of a "paintbrush" or polka dot edge on the
laser resurfacing, or by the use of 25% trichloroacetic
acid (Figure 2). Time and camouflage will usually dimin-
ish this line of demarcation, but the patient should be
cautioned ahead of time.
Any transient texture change of the skin is self-limited
and may respond to glycolic acid application or peels.
Some patients who are deeply tanned before the proce-
dure may complain that the laser has removed their tan,
causing the laser-treated area to appear abnormally pale
compared with the rest of the skin. This can be easily
treated with one of the topical artificial self-tanning
creams.
Approximately 8 % to 12 % of patients will experience
either persistence or recurrence of rhytids. This may be
detected by the patient or may be observed by the laser
surgeon. At approximately 12 to 16 weeks, it is possible
to do a "touch-up," relasering selected areas that have
not had sufficient improvement of rhytids, with results
that are often very satisfactory for the patient (Figures 3

Side Effects, Sequelae, and Complications of AESTHETIC SURGERY JOURNAL - NOVEMBER/DECEMBER 1997 367
Carbon Dioxide Laser Resurfacing
 SCIENTIFIC
Figure 6. Synechia of right lower eyelid.
Figure 7. Manual release of synechia.
to 5). Further treatment may be offered on a "no charge"
basis to enhance patient satisfaction.
When the epidermis is removed by laser resurfacing and
is replaced by new, thin epidermis, the patient may notice
telangiectasia or mild rosacea that was present in the skin
before treatment but was masked by thicker, more
opaque epidermis. The new appearance of facial telang-
iectasia or rosacea can be effectively treated with the tun-
able dye laser.
Synechia, or abnormal adherence of deepithelialized skin
edges, may produce abnormal creases in the skin (Figures
6 to 8). These can easily be manually separated. The
denuded skin is lubricated to prevent readhesion.
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Figure 8. Final smooth result.
Figure 9. Herpes simplex virus infection of chin. From Apfelberg DB.
Peri-operative considerations in laser resurfacing. IntJ Aesthetic Restor
Surg 1997;5:21-8. By permission.
Complications of Laser Resurfacing
Fortunately, true complications of laser resurfacing are
very rare (Table 2). The most severe problem, and one
that often results in scarring, is infection. 13 ,14 Patients
may be infected by a variety of agents. Herpes simplex
infection may occur after laser treatment (Figure 9). It is
often heralded by a tingly or burning feeling accompa-
nied by small skin blisters. Patients with these symptoms
should have a Tzanck stain for virus and be immediately
started on high doses of antiviral agents. In addition, top-
ical Zovirax® ointment is effective. Systemic agents
include Zovirax®, Famvir®, and Valtrex®.
Bacterial infections may also be seen. The most common
1997 Volume 17, Numb er 6
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Figure 10. Staphylococcus infection of left cheek 3 days after laser
resurfacing.
Figure 11. Staphylococcus paronychia of multiple fingers as source of
fa cial infection.
are Staphylococcus, Streptococcus, and Pseudomonas
(Figures 10 to 12). Cultures should be obtained, and the
patient should be treated with both topical and systemic
antibiotics.
Suspected fungal or Candida organisms should be exam-
ined under a microscope and treated with Fluconazole®.
Similarly yeast infections can be diagnosed by microscop-
ic examination and treated appropriately.
The routine use of antiviral and antibiotic agents has
been debated. More than 50 % of laser surgeons routinely
treat their patients with antibiotics and antiviral agents
before the procedure and continue these agents for at
Side Effects, Sequelae, and Complications of AESTHETIC
Carbon Dioxide Laser Resurfacing
FORUM
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Figure 12. Com plete resolution of infection after antibiotic treatment.
Figure 13. Keloid scar of upper lip From Apfelberg DB. Peri-
operative considerations in laser resurfacing. I ntJ Aesthetic Restor Surg
1997;5:2 1-8. By permission.
least 5 to 10 days . Such precautions may decrease the
incidence of the above-mentioned infections.
Hypertrophic or keloid scarring may occur after laser
resurfacing (Figure 13). The two most common causes
are infection or lasing to a deep level extending into or
through the reticular dermis. A very proactive regimen
should be taken to detect the possibility of hypertrophic
scarring. All patients should have the resurfaced skin area
palpated at approximately 2 weeks. If there is any evi-
dence of induration, or if redness is observed that is dif-
ferent in one area than an adjacent area, or if the patient
states that they believe one area is thicker or has a burn-
ing feeling, a proactive approach should be taken because
these areas may develop scarring (Figures 14 to 17).
SURGER Y JOURNAL - NOVEMBER / DECEMBER 1997 369
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Figure 14. Perioral rhytids before resurfacing.
Figure 15. Appearance 4 days after procedure with topical ointment.
The patient should be started on topical fluorinated
steroids such as Temovate®, as well as injected with
intra Ie siona I steroids. The use of silicone gel sheeting or
Cordran® tape should be instituted as well. Outright
keloid or hypertrophic scars should be treated actively
with topical steroids in the form of Temovate® cream or
Cordran® tape; intralesionalinjection of cortisone in the
form of Celestone®, Kenalog®, orTriamcinolone®; and
the use of silicone gel sheeting. Silicone gel ointments
(Kelo-Cote®) may also be useful.
Various authors have recommended treatment with
injected agents such as 5-fluorouracil or verapamil2.5
mg/ml. Other treatments include cryotherapy, radiation
therapy, tunable dye laser, and constant pressure bandag-
mg.
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Figure 16. Residual red firm area of chin 6 weeks after treatment
heralding impending hypertrophic scar.
Figure 17. Final appearance of chin scar.
H yperpigmentation resulting from laser treatment may
be a difficult problem for the patient but is fortunately
always temporary (Figures 18 and 19). It is usually due
to the fact that the patient has inadvertently gotten sun
exposure on the freshly treated lasered area.
Hyperpigmentation is also more common in patients
with dark complexions and in certain ethnic groups such
as Asians or Hispanics. The problem almost always com-
pletely disappears but may last as long as 6 to 9 months.
It may be treated with bleaching agents such as hydro-
quinone, Kojic acid, or a combination of Retin-A® 0.1 %
cream, hydroquinone 5 %, and steroid (Kligman's mix-
ture). The same regimen may also be used 3 to 4 weeks
before the surgery as a pretreatment.
Hypopigmentation as a result of laser resurfacing is per-
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Figure 18. Hyperpigmentation after sun exposure 6 weeks after resur-
facing.
Figure 20. Appearance of cheek rhytids before treatment.

Figure 19. Resolution of hyperpigmentation with Kligman's topical Figure 21. Contact dermatitis from use of makeup.
mixture of Retin-A® 0.1 %, hydroquinone 5%, and steroid.

manent. It stems from resurfacing that has gone too deep

into the reticular dermis and is seen more prominently in
patients with hyperpigmentation or melanosis, including
ethnic groups such as Hispanics and Asians. There is no
treatment other than camouflage makeup for hypopig-
mentation.

Patients who have had laser resurfacing are unusually

sensitive to various topical agents or cosmetics (Figures
20 to 22). It is not unusual for a patient to report that the
cosmetic that they had been using continuously for 20
years now makes their skin break out. Contact dermatitis
is not usual. Topical antibiotics such as Bacitracin,®
Neosporin®, or Polysporin® have been known to cause
significant contact dermatitis requiring systemic steroids Figure 22. Eventual resolution with time and topical steroid and sili-
and, in some cases, hospitalization. Sensitivity reactions cone gel sheeting.

Side Effects, Sequelae, and Complications of AESTHETIC SURGERY JOURNAL - NOVEMBER/DECEMBER 1997 371
Carbon Dioxide Laser Resurfacing
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to fabric softeners, astringents, and even aloe vera have
been observed.
Tooth enamel injury may occur if a laser beam strikes the
unprotected tooth. The enamel may be fractured by the
impact of the laser, or by subsequent heat production.
There is no treatment for this problem, but it can be
avoided by the use of special mouth guards that are
obtainable commercially. Alternatively, moist gauze may
be placed over the teeth inside the lips whenever the laser
is used in the perioral area. Patients who have had laser
resurfacing of the lower eyelids may develop a scleral
show or a temporary or permanent ectropion. Most of
these ectropions will resolve with time, massage, and
lubrication.
Patients who are having lower eyelid resurfacing should
be carefully evaluated for tarsal adequacy. Any patient
who is observed to have inadequate tarsal integrity
should have a tarsal tightening procedure before, or in
conjunction with, resurfacing of the lower eyelid. The
eyes must be protected from inadvertent exposure to
laser light. Corneal abrasions have occurred as a result of
laser treatment. Laser-safe scleral eye shields or a special
Jaeger plate should be used whenever the laser is used in
the periorbital area .•
References
1. Apfelberg DB. Ultrapulse carbon dioxide laser resurfacing and facial
cosmetic surgery. Can J Plast Surg 1995;3:133-6.
2. Apfelberg DB. The Ultrapulse carbon dioxide laser with computer pat-
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FORUM
tern generator automatic scanner for facial cosmetic surgery and resur-
facing. Ann Plast Surg 1996;36:522-30.
3. Apfelberg DB, Smoller B. Ultrapulse carbon dioxide laser with CPG scan-
ner for de-epithelialization: clinical and histological study. Plast
Reconstr Surg 1997;99:289-95.
4. Apfelberg DB. Adjunctive considerations for laser resurfacing. Operative
Techniques in Otolaryngology - Head and Neck Surgery 1997;8:25-30.
5. Apfelberg DB. A critical appraisal of high-energy pulsed carbon dioxide
laser facial resurfacing for acne scars. Ann Plast Surg 1997;38:95-101.
6. Rosenberg G, Apfelberg DB, Chernoff G, Seckel B. Treatment of post-
laser resurfacing complications. Aesthet Surg J 1997;17:119-23.
7. Apfelberg DB. Ultrapulse carbon dioxide laser with CPG scanner for full
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face resurfacing for rhytids, photo-aging, and acne scars. Plast Reconstr
Surg 1997;99:1817-26.
8. Jewell ML, Apfelberg DB, Roberts TL, Rubin MG, Weinstein C. Skin
resurfacing with the Ultrapulse carbon dioxide laser. Aesthet Surg Q
1995;15:4-9.
9. Weinstein C, Alster TS. Skin resurfacing with high- energy, pulsed car-
bon dioxide lasers. In: Alster TS, Apfelberg DB, eds. Cosmetic laser
surgery. New York: Wiley-Uss, 1995:9-27.
10. Chernoff WG, Schoenrock LD, Cramer H, Wand J. Cutaneous laser
resurfacing. Aesthetic Restorative Surg 1995;3:57-68.
11. Fitzpatrick RE, Goldman MP, Satur NM, Tope WD. Pulsed carbon dioxide
laser resurfacing of photo-aged facial skin. Arch Dermatol
1996;132:395-402.
12. Roberts TL, Lettieri JT, Ellis LB. CO 2 laser resurfacing: recognizing and
minimizing complications. Aesthet Surg Q 1996;16:142-8.
13. Bernstein U, Kauvar ANB, Grossman MC, Geronemus RG. The short
and long-term side effects of carbon dioxide laser resurfacing. Dermatol
Surg 1997;23:519-25.
14. Sachal S, Fitzpatrick RE, Goldman MP, Smith SR. Infections complicat-
ing pulsed carbon dioxide laser resurfacing for photoaged facial skin.
Dermatol Surg 1997;23:527-36.
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