Laser resurfacing can effectively minimize post surgery scars

MIAMI – In his practice, Joel L. Cohen, MD, spends a good part of his day doing Mohs surgery, “with the goal of cancer removal, and after surgery, having the patient look good,” he said at the Orlando Dermatology Aesthetic and Clinical Conference.

“Having resurfacing in my practice has allowed me to treat not only wrinkles and etched lines, but also help skin cancer patients by blending and minimizing their skin cancer scars,” said Dr. Cohen, an aesthetic dermatologist and Mohs surgeon in private practice in Denver.

For example, one of his patients was a kindergarten teacher who had a large rotation flap scar on her cheek after excision of a melanoma in situ. The children asked her about it all the time during the 2 months after the surgery, and she decided to come in for some laser sessions. “With three ablative fractional laser sessions, she really looked great just 3 months later and wasn’t even interested in wearing makeup at that point.”

Resurfacing in his practice using a variety of lasers is very helpful, Dr. Cohen said. He published a study in November that compared pulse dye laser, CO₂ ablative fractional lasers, or a combination of both for modification of scars following Mohs surgery (J Drugs Dermatol. 2016 Nov 1;15[11]:1315-9).

The prospective, multicenter study revealed that although both monotherapy approaches were safe and effective, the combination of pulse dye laser and fractional ablative laser offered some synergy that was preferred by patients.

Reprinted with permission from J Drugs Dermatol. 2013.12:10;1172.

“We are definitely seeing patients earlier for scar minimization procedures whether it’s after skin cancer removal or a trauma like a laceration,” Dr. Cohen said. “I think there is a trend to treat scars earlier and earlier due to an increased awareness of some important new studies,” which included a split-scar study in which one-half of each patient’s scar was treated the same day as surgery with a fractional ablative laser, “and the treated half consistently came out better,” he noted (Arch Dermatol. 2011 Sep;147[9]:1108-10).

Perioral resurfacing possible

Beyond the world of treating scars, a typical cosmetic patient in Dr. Cohen’s practice presents with numerous lines around the perioral area. “When people think about rejuvenation of the lips, they only think of fillers. But fillers are not the only way to rejuvenate this area, and it is really about choosing the right tool for the right job – where resurfacing lasers are needed.”

Reprinted with permission from Journal of Drugs in Dermatology, 2016, 15:1, 112. Photo credit: Joel Cohen, Colorado Springs, CO

In one case, a woman came in concerned about her perioral lines because her grandchildren told her they made her look older. “I treated her with a neuromodulator a week before resurfacing. Then I did full-field erbium resurfacing, 150 micron times three passes, and went back and did some additional 30-micron passes for some persistent lines in that same session,” Dr. Cohen said. He also augmented her nasolabial folds with fillers, and the patient was happy with the overall outcome.

Set realistic expectations

Setting the right expectations for people is extremely important, Dr. Cohen said. “You can educate the patient that if you’re putting the needle into the lines, you’re only treating the larger lines that you can get a 30-g needle into, but there are often a host of other lines in that area – many of which are too small to get a needle into.”

As a starting point, neuromodulators can have a role in trying to prevent or delay etched-in lines from forming around the mouth in the first place. “These are the lines between the musculature, the ones you see when you ask the patient to purse their lips,” Dr. Cohen said. He typically injects a medium dose of one of three neuromodulators – such as 6-10 U of onabotulinumtoxinA (Botox), 6-10 U of incobotulinumtoxinA (Xeomin) or 14-18 U of abobotulinumtoxinA (Dysport). “Then somewhere between week 8 and 10, there is an attenuation of the effect, and I often will see patients back then for additional treatment with a neuromodulator,” he added.

“For our every day patient complaining of lots of etched perioral lines, we have laser resurfacing,” Dr. Cohen noted. He is a bigger proponent of full-field erbium treatment versus fractional ablative laser resurfacing for these prominent upper cutaneous lip lines because the results are much more impressive with a single treatment. He added that dermatologists could do fractional treatment around the rest of the face, and reserve the erbium resurfacing to improve the appearance of lines around the mouth and prominent creping skin around the eyes.

Realistic postprocedure expectations are especially essential in the days after erbium laser resurfacing – as it is a tough downtime procedure for patients, often taking 7-9 days to re-epithelialize. “Having photos to show patients what they will look like is really helpful,” Dr. Cohen said. He suggested showing patients a chronologic set of photos of the downtime period as well as the results – so they realize improvement occurs slowly over time. “Getting people to understand they are gong to look terrible for 1.5-2 weeks is superimportant.”

“I like to have them back in the office for a postprocedure check a few days after the bigger laser resurfacing procedures are done, just to check on them,” Dr. Cohen said. “A lot of hand holding is often needed, as there is significantly more healing time with the full-field ablative resurfacing than there is with fractional. Full-field resurfacing patients will experience postprocedure erythema for a few weeks or even months,” Dr. Cohen said. A prescription of topical steroids, and sometimes some brimonidine topical gel (Mirvaso) as well can help reduce the redness.