Article For Cosmetic Dermatology In The Complications Corner Labeled Post Laser Pigment Dyscromia
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Case history: a 38-year-old caucasian female had facial laser resurfacing for rejuvenation of photo aging skin. A CO2 laser was used for resurfacing and the patient healed in an uncomplicated fashion. Postoperatively, there was a noticeable hypopigmentation which was especially evident over the jawline in direct contrast to the tan dyscromic coloration of the neck. This bothered the patient because of its unnatural appearance and was referred for treatment.

Discussion, Prevention and Treatment

The unnatural appearance of a laser resurfaced in contra distinction to the photo aging color and texture of neck skin is an unnatural appearance that is not acceptable today. Thought in past decades when deep chemical peeling was in vogue, this was an acceptable difference for which makeup was necessary. In today's society, there is a demand for a natural blended appearance when cosmetic surgery is performed. Our patients are intolerant of an "operated look" or an artificial juncture from on portion of the skin to another. It is therefore necessary to evaluate the exposed neck, chest, and shoulders of a patient who requests resurfacing for photo aging facial skin. These areas must be addressed for either simultaneous blending procedures or a second procedure to solve the problem of facial resurfacing demarcation lines.

It is best to address the neck issues during the facial resurfacing procedure. Though neck skin cannot tolerate deep laser resurfacing, it, though, can be treated with less aggressive superficial procedures, manual dermasanding, or erbium yag laser. These are epidermal resurfacing procedures that can blend color change and have a softening affect on photo aging skin texture of the next and chest. During consultation the patient must be informed that the changes that will occur in the neck and chest are not as dramatic as though which can be achieved in facial skin that has been resurfaced. In my hand, the procedure of choice if superficial chemical peeling of the chest, shoulders, and neck, along with dermasanding at the jawline juncture descending and blending to the upper third of the neck. This creates a gentle transition from chest to vertical neck to the junction of neck and jawline where deeper resurfacing is present. Neck skin in the upper third can tolerate mild medium depth resurfacing while vertical neck, lower neck and chest will only tolerate superficial resurfacing procedures. If one is too aggressive in these areas, scar formation and pigmentary hypopigmentation will be a consequence. The correct blending of these areas, though, will achieve natural results without demarcation problems.

All patients should be pre-treated with tretinoin, sunscreen protection, and in skin type III-VI, or those with a history of pigmentary dyscromia, a 4-8% hydroquinone bleach in a cream base. These pharmaceutical preparation should be instituted at least three weeks prior to treatment and then restarted approximately 2 - 3 weeks after the surgical procedure when reepithalialization is complete and erythema is decreased. Superficial peeling agents most appropriate for this procedure in clue Jessner's Solution, 70% glycolic acid solution, 15 - 25% TCA, and 20% lactic acid solution. Manual dermasanding is accomplished with 180 - 220 grit silica carbide sand paper or wall sheeting paper. This method will remove epidermal dyscromias and have a very mild textural change near the jawline to blend facial skin.

To treat this patient who has a demarcation line with neck hyperpigmantation and dyscormia, is a commitment to repetitive superficial chemical peeling, cosmesutical agents, dermal sanding, and, in some cases, laser treatments. It is much more difficult to correct this abnormal pigmentary separation than to prevent it. Treatment instituted should begin with cosmesutical agents including trentinoin and 4 - 8% hydroquinone. Repetitive light chemical peeling with salicylic acid will lighten the dysromic pigmentation and gradually blend the demarcation line. With resistant cases, more aggressive peeling with Jessner's or TCA can be instituted but with caution. Similarly, dermasanding and erbium yag laser can be an added procedure to blend the pigmentation.

The question arises as to whether the hypopigmentation seen in facial resurfacing is a true hypopigmentation from the laser treatment or pseudohypopigmentation in contrast tot he dyscromic hyperpigmentation. In either event, it is an unnatural, poorly tolerated postoperative result that most patients will complain about. It is, therefore, prudent for the cosmetic surgeon to address the neck issue early on when he is planning his facial procedure.

This will be submitted with the photographs to cosmetic surgery.