Heeding specific warning signs can help physicians avoid the problem of lower eyelid ectropion that can result from laser resurfacing procedures.
"Erbium:YAG lasers are better than CO2 in that they are absorbed by water molecules much more readily. Therefore, their energy is dispersed very quickly. This causes very little spread of thermal damage, providing more precise control with a purely ablative laser," says Daniel Rousso, M.D., a facial plastic surgeon based in Birmingham, Ala.
He particularly likes a model that mixes short- and long-pulsed lasers, which allows deep resurfacing when combined with the laser's ablative component. "In my hands, it gives improvement of moderate and severe wrinkles, acne scars, actinic changes and dyschromias with less potential for permanent hypopigmentation than CO2, at least when I'm being very aggressive with the laser," he says.
The combination of short and long pulses allows deeper penetration than erbium lasers normally achieve, Dr. Rousso says. "You can get some coagulation of the deeper tissues and therefore more tightening than we do with a superficial ablative erbium:YAG laser," he says, adding that in his hands, the laser produces impressive results that he cannot achieve with fractional lasers. "You certainly can get these results with a completely ablative CO2 laser. However, I have more problems with hypopigmentation" as a result of aggressive CO2 procedures, he says.
TREATMENT DETAILS For a typical treatment, Dr. Rousso employs a first pass with 80 microns of ablation, which requires the use of a smoke evacuator. "There's very little char because it all goes up in smoke," he says. Additionally, patients must wear corneal shields.
The laser's second pass combines 50 microns of ablation with 50 microns of coagulation. "Coagulation produces the tightening effect on the dermis," he says. "This is where I'm a little more careful now" than he was when he produced an ectropion complication more than two years ago. "If you begin to get significant retraction and pulling of the lower lid margin when you start to do your second pass with this laser, you must be more careful and less aggressive than you may be on patients who don't get that kind of retraction."
Under normal circumstances, patients' skin typically re-epithelilizes within 10 to 14 days, Dr. Rousso says. He recommends that patients use a topical ointment (EltaMD Moisturizer, EltaMD) because it creates fewer problems with erythema and irritation than the petrolatum products he's used in the past. "We also give all our patients oral cephalexin, acyclovir and prednisone postoperatively," he says. Patients can begin rinsing their skin with water one to two days after the procedure, then applying their own moisturizers as tolerated.
CASE STUDY Any resurfacing procedure can produce side effects including prolonged erythema, contact dermatitis, hyper- or hypopigmentation, scarring, milia, acne, textural changes and ectropion. The latter occurred in a 64-year-old female who Dr. Rousso describes as "a great patient" whose history included CO2 resurfacing eight years prior to seeing him.
Additionally, he had performed a facelift, an upper and lower lid blepharoplasty, a superficial musculoaponeurotic system (SMAS) lift and lip augmentation on the patient about three years before her laser procedure. She also maintained an aggressive at-home skincare regimen and was a regular visitor to his medical spa. "She had few wrinkles; she didn't really need very much, and I didn't want to do very much" in terms of additional treatments, Dr. Rousso says. "Yet she twisted my arm and wanted to have laser resurfacing done."
It's common to see some retraction of the lower lid immediately after the procedure, he says. The retraction can last a few hours, "But by the next day — and certainly within a week or so — the lower lid position goes virtually back to normal," he says. "Hers did not."
Although the patient had little conjunctival irritation or erythema, Dr. Rousso says that both she and he were understandably disappointed by this result.
Dr. Rousso says he tried massage and Kenalog (triamcinolone acetonide, Bristol-Myers Squibb) injections, to no avail. "I thought about placing a Frost-type suture to pull the lower lid up," he says.
Instead, about three weeks postprocedure, he tried to pull the lower lid up laterally with a lateral tarsal strip procedure. "It helped a little, but we didn't get as much movement of the central lower lid as I would have wanted," he says. Overall, Dr. Rousso says that her facial skin was "tight as a drum. It didn't want to give very much."
For the next three weeks, Dr. Rousso says he continued to try more massage, pulling of the lower lid with tape, and application of topical ointment to ensure that the patient's eye did not dry out. Ultimately, he says, "I decided that we needed to lift her entire midface or put a skin graft on. Those were the only other options I had."
He says that performing a fairly aggressive subperiosteal midface lift didn't sufficiently improve the ectropion. He and his staff continued with the conservative treatments, he says, "And within about 10 months we got her to a point where the lid just came up to where we were completely happy with it."
Although the midface lift and conservative treatments helped, he says, "We also did a lot of hand-holding. We saw her at least twice weekly during the initial healing process, then weekly until she got to a point where we were comfortable."
To avoid such problems, Dr. Rousso says, closer patient evaluation can help. "If a patient has a poor snap test or distraction test on the lower eyelid, I would certainly be careful," he says. The patient in question had normal lid tension and virtually no skin excess initially. "You couldn't even pinch a millimeter of extra skin on her lower eyelid preoperatively," he says, adding that the patient's prior peels and laser treatments also may have put her at risk.
EXTRA CARE As a result of this experience, "I've started to pay more attention to patients who are incredibly active in their own care at home, using exfoliants, light peels, spa treatments and microdermabrasion, because these all can add up," Dr. Rousso says. "If they present to you and their skin is already tight and you don't see very much wrinkling, be careful about how aggressively you're going to treat them. Use clinical judgment regarding the type of laser peel that you employ."
Specifically, Dr. Rousso says, "If I see a lot of lower lid retraction with the initial pass, I won't do a second pass."
Fortunately, the woman in question is once again a "devout patient" who appreciates how well Dr. Rousso and his practice treated her. "We took a potential disaster" and rescued the patient relationship through a concerted, caring effort, he says.
"I still believe that ablative skin resurfacing is the gold standard by which all other resurfacing methods are measured, whether it's a peel or laser. And I still like the erbium:YAG laser for that reason," Dr. Rousso says.
Dr. Rousso is a consultant for Lutronic
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