POSTOPERATIVE CARE
Because superficial resurfacing procedures generally do not extend beyond the epidermis, the dermal wound healing mechanisms are not activated. In contrast, medium-depth and deep resurfacing procedures stimulate the following four stages of dermal wound healing (see Ch. 141): (1) inflammation and coagulation; (2) re-epithelialization; (3) fibroplasia and matrix formation; and (4) collagen remodeling.
Because the pronounced edema following medium-depth and deep resurfacing procedures may minimize the appearance of scars, rhytides and other irregularities, the patient’s initial perception of his or her improvement may be exaggerated. As swelling subsides postoperatively, patients should be reassured and advised that collagen remodeling continues for several months and leads to further clinical improvement. At some point in the postoperative course, patients often want to know when another resurfacing procedure can be performed if it is necessary. The presence of persistent postoperative erythema may indicate continued collagen remodeling and may serve as a warning that a similar resurfacing procedure performed prematurely could produce scarring. To assure their safety, patients undergoing mediumdepth resurfacing should not undergo another medium-depth or deep procedure for the next 3 to 9 months. An individual having a deep resurfacing procedure should avoid another one for at least 12 months postoperatively. Touch-up procedures for revision of a prior suboptimal outcome are also best avoided during these time periods, especially if erythema is still present.
Healing time is generally proportional to the depth of the resurfacing procedure. Superficial resurfacing procedures cause minimal downtime and necessitate little postoperative care. They usually produce mild erythema and desquamation that last from 1 to 4 days depending on the wounding agent and the techniques used. Regular washing with a mild cleanser and the use of routine moisturizers and sunscreens are generally sufficient during the healing period.
Following medium-depth resurfacing procedures, there is a considerably longer healing time and more intensive postoperative care is necessary. Follow-up visits are scheduled regularly to monitor the patient’s postoperative course. After a medium-depth chemical peel, occlusive dressings are not necessary because the epidermis, which is not removed intraoperatively, functions as a biologic dressing until peeling occurs. Because areas of medium-depth peeling which have been enhanced by manual dermasanding do not possess residual epidermis, occlusive dressings may be used on these areas during the first 3 postoperative days.
The patient is instructed to soak the areas four times daily with warm compresses and to apply an emollient after each soak and during the inter-vening periods as necessary. A solution of 0.25% acetic acid (one tablespoon of white vinegar added to one pint of warm water) is preferred for the soaks because the mild acidity is physiologic for healing granulation tissue. It is also a mild debridant and has antibacterial effects, especially against Pseudomonas spp. and other Gram-negative organisms. Occlusive emollients, such as petrolatum, Aquaphor® or Eucerin® ointment, speed the process of re-epithelialization and lessen the tendency for delayed healing. These emollients are also helpful in wound debridement and in the prevention of crust formation and infection. Showers, soaks, and emollients are continued for a week postoperatively.
Following medium-depth resurfacing, edema begins to appear almost immediately and progressively worsens during the first 48 hours. It can even be severe enough to close the eyelids and impair the patient’s visual fields. If tolerated, aspirin or other NSAIDs can be administered, preoperatively and during the first 24 hours postoperatively, to alleviate discomfort and reduce swelling. After a medium-depth chemical peel such as the Jessner’s–35% TCA peel, there is initially a brawny, dusky erythema which is followed by the formation of a brownish crust that begins to separate from the skin surface between days 4 and 8 postoperatively. Although the initial darkening can be disturbing to the patient, it represents an expected separation of the epidermis. The underlying, newly formed epithelium is brightly erythematous but fades to a pink color that resembles a sunburn (see Fig. 154.6D). By postoperative day 7 to 10, re-epithelialization has occurred and the erythema can be camouflaged with cosmetics. Within 2 to 4 weeks after the procedure, the erythema usually resolves fully, and retinoids and sunscreens can be restarted as tolerated.
Deep resurfacing procedures, such as the Baker–Gordon phenol peel or dermabrasion, require a follow-up visit the next day, several visits during the first week, and very close monitoring thereafter. At each visit, instructions for wound care are reviewed with the patient and any questions are answered. The immediate postoperative course after deep resurfacing is similar to that following medium-depth procedures, except that edema and erythema may be even more severe and persistent. NSAIDs can provide some relief, but an intramuscular corticosteroid injection is often administered on the day of surgery, even though its effects on wound healing are not completely understood. Pruritus may occur during the healing phase following a resurfacing procedure of any depth but is particularly prevalent after deeper resurfacing. This problem can be alleviated by the use of emollients, ice packs, NSAIDs, and antihistamines until the pruritus spontaneously resolves. Milia formation, which commonly occurs 3 to 4 weeks after deep chemical peeling or mechanical resurfacing, is easily managed with needle extraction.
Patients undergoing deep mechanical resurfacing with either motorized dermabrasion or manual dermasanding can have an occlusive hydrogel biosynthetic dressing (e.g. Vigilon®, 2nd Skin®) applied immediately after the procedure. In patients undergoing a Baker– Gordon phenol peel, occlusive tape or a biosynthetic dressing is usually utilized postoperatively. Occlusive tape dressings must be removed on the first postoperative day and this procedure may require analgesia and sedation. For this reason, the authors prefer untaped phenol peels with application of ointment or bio-occlusive dressings. Whenever a biosynthetic dressing is used, it must be removed daily and replaced with a new one for the first 2 or 3 days postoperatively so that the face can be gently debrided with saline soaks and moistened cotton tips. The patient should be instructed to regularly apply an occlusive ointment to areas around the mouth, eyelids, and hairline that are not adequately covered by the dressing. Occlusive biosynthetic dressings have been shown to enhance collagen synthesis and hasten re-epithelialization in superficial wounds. They also minimize the amount of discomfort and obviate the need for repeated soaks by the patient during the first few days after the procedure.
By the third day following deep mechanical or chemical resurfacing, the patient begins open wound care with 0.25% acetic acid soaks four to six times daily and regular applications of an occlusive ointment. By the 7th to the 14th day postoperatively, re-epithelialization is usually complete and the ointment is replaced by a heavy moisturizer. The marked edema and erythema typically seen after dermabrasion or dermasanding generally resolve after several weeks. The erythema resulting from deep peeling may be more persistent but is rarely present beyond 2 to 4 months. Strict sun avoidance is critical for 3 to 6 months after dermabrasion or deep chemical peeling. The patient typically restarts sunscreens and retinoid therapy within a couple of weeks of re-epithelialization, as tolerated.