Short term and long term complications of laser resurfacing surgery

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Complications of Laser Surgery

Complications of laser surgery can generally be divided into short term and long-term side effects. The short term side effects include transient erythema, pruritus, milia formation, acneiform pustules, transient scarring, and long-term problems, such as hypopigmentation and, occasionally, permanent scarring.

Short Term Effects

(redness of skin)

The laser-treated areas have a distinctive redness, which is much more vivid than untreated areas. The laser treated area takes at least 7-10 days for re-epithelializing. The redness is seen in the epithelial tissue due to increased blood flow from healing and inflammation. The redness starts fading with the new growth of the superficial tissue. Erythema may take months to fully resolve, depending on the depth of resurfacing. The deeper the tissue injury, the more persistent is the erythema associated with it.


This is very common and varies from person to person. Most patients’ skin swells moderately after laser treatment, but in some patients the swelling is more severe. Significant post-treatment swelling and soreness may persist for 10–14 days. The skin may feel tight for some weeks following treatment partly due to the edema, but also from the tightening effect of the procedure. Treated areas usually heal in approximately 1 week, and the post-treatment inflammation resolves over the following 6 weeks, but can take up to 6 months

Postoperative, long-lasting erythema following a CO2 laser treatment is a major drawback. As a consequence of the procedure, the transient erythema discussed above is the result of the natural healing process, but persistent erythema the other hand is a troublesome complication both for the patient and laser surgeon.

The intensity of erythema increases with increasing pulse energy and the number of laser passes. Focal persistent erythema may lead to hypertrophic scarring or permanent hypopigmentation if it persists for 6–12 months after the procedure.

The condition can be treated with silicone gel, potent topical steroids, intralesional steroids, or flash lamp pulsed dye treatment.

Allergic reactions

Allergic reactions or irritation in response to some of the medications or creams may also develop. An increased sensitivity to wind and sun may occur, but is temporary and clears as the skin heals.

Diffuse, persistent facial erythema in some patients may also be due to allergic or irritant contact dermatitis and may cease after discontinuation of mupirocin or other topical antimicrobials. The antimicrobials which are mainly iatrogenic should be avoided.

Hyper pigmentation
(increased skin color)

This side effect is seen generally in those who have dark complexions, Fitzpatrick skin types IV, but in almost all cases it is temporary.

Ideally, the patient’s skin needs pre-operative care with the regular use of sunblock prior to the resurfacing procedure to prevent this side effect. The hyperpigmentation as a result of a post-inflammatory phenomenon can be easily prevented by treating with alternating hydroquinone and tretinoin preparations and glycolic acid peels, starting shortly after complete healing.

Patients who are prone to hyperpigmentation (the ones who turn brown in areas of scratches or injuries) can be treated with topical preparations and full ultraviolet A (UVA) protection using a high content zinc oxide sunblock to prevent further exacerbation of the hyperpigmentation.

Milia formation
The injudicious or indiscriminate use of moisturizers is likely to result in acne and milia formation in laser treated skin, and the injudicious use of irritant cleansers may lead to the breakdown of the skin and hypertrophic scar formation. Stopping or changing the useage of these products usually resolves the problem.

Bacterial infection can usually be recognized as an adherent yellow crusting, pustules, or by increased pain and delayed wound healing. Herpes simplex virus typically has clustered vesicles but can have an unusual presentation within the denuded epidermis within a few weeks time post surgery (the time of reepithelialization).

Yeast infections may be subtle and only promote increased erythema or itching, which can be confused with contact dermatitis.

Infections with herpes simplex and Candida can be treated with an increase in aciclovir dosage and the initiation of an antiyeast cream as soon as they are recognized, in order to avoid textural changes.

Long Term Side Effects

(decreased skin color)

Some hypopigmentation also results from removal of sun-damaged skin and returns you to your natural lighter color, similar to areas on your body that have not had long-term sun exposure (i.e., underarms). This form of hypopigmentation is usually of little concern and is often regarded as a benefit of treatment.

Significant long term hypopigmentation can be a major side effect of the procedure though it is generally not very common. When present it is usually related to the depth of treatment, it can occur even when the procedure has been performed properly.

Hypopigmentation can also be observed due to the aggressive ablation of thin areas (such as the neck) where the depth the laser treatment has penetrated to has been more than was required. This type of hypopigmentation due to tissue injury during the procedure can be easily avoided by using a lower density application of the laser for the neck areas and other areas where the skin is thinner.

Delayed hypopigmentation can also take a form of permanent scarring and pigmentary alteration (hypopigmentation). Pigment loss or the change in these areas is generally permanent and has resulted due to injury to the deep follicular melanocytes. Both of these side effects are becoming less pronounced with the introduction of the new CO2 laser technology.

There is some hypopigmentation that may reach 16-18% which gradually worsens with time. This is a late complication which has been seen to occur in skin areas that have been previously abraded with other modalities.

The use of heavy emollients during the recovery period after laser treatment greatly increases the likelihood of acne eruption. This can be generally improved upon discontinuation of heavy topical agents, and transition to less occlusive moisturizers.

Aquaphor® is more water-based and should be used for those with acne-prone skin. Oral antibiotics may be started in conjunction with a topical regimen in order to minimize the acne flare. Isotretinoin should not be used in this setting because of the likelihood of scarring in newly laser treated skin.

Scarring or keloids
Scarring is a possible consequence not only of the laser re-surfacing procedure, but also any procedure in which the surface of the skin is removed. This usually occurs because of some secondary factor that interferes with healing, such as infection, irritation, scratching, or poor wound care.

Scarring from infection, irritation, or scratching does blend and ordinarily disappears in a few months, but some scarring may be permanent if it occurs. Hypertrophic scars or keloids in susceptible people may suddenly appear. Most of these respond to injections or special creams, though some scarring could be permanent.

The development of these long-lasting complications can be avoided when the laser resurfacing procedures are performed by experienced hands and the treated skin is properly cared for.

The use of optimal laser settings that avoid excessive collagen denaturation, and occlusive dressings that facilitate wound healing, also helps to avoid most complications.

Patient education, good pre and post operative care and early recognition of future problems by the cosmetic surgeon during the initial consultation are some of the factors which can play important role in minimizing the side effects.

Laser resurfacing is the modality of the future, be informed about it and take its advantage.

  1. E. Papadavid,and A. Katsambas, “Lasers for facial rejuvenation: a review”, 2003, The International Society of Dermatology, 42, 480–487
  2. D. Railan, and S. Kimlmer, “Ablative treatment of photoaging”, Dermatologic Therapy, Vol. 18, 2005, 227–241

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