Laser is not magic. This should be made explicitly clear from the start to the prospective patient who enters a practice, seeking a quick fix to his or her cosmetic problem.
Ellen S. Marmur, M.D., chief of the Division of Dermatologic Surgery at Mount Sinai Medical Center in New York City, shares her broad experiences with lasers, outlining the tips, tricks and pitfalls that the practitioner should be aware of when performing laser treatments.
"Cosmetic consultations must emphasize the benefits but also the possible pain and the healing time involved after laser surgery, as well as the need for multiple sessions separated by several weeks. The patient must understand fully that improvement is the desired goal, not perfection. If the expectations are clear, the patient will be much happier," Dr. Marmur says.
Be clear, concise
She lists several important points for a good consultation - the keys to success. It is crucial to be clear, realistic, patient-friendly and repetitive.
She says cosmetic consultations are unique. It is important for the patient to make the diagnosis. Dermasurgeons should not make suggestions unless specifically asked, even when pressured by the patient. Also, it is important to provide the patient with written information, including a list of the risks, which clearly must be discussed with the patient in detail.
Dr. Marmur says, "Consultations are often therapeutic. Laser and cosmetic patients often become emotional during the consultation, especially if they have never discussed their concern before. I encourage these patients to delay their first treatment until they have had time to process the information about the procedures. I also encourage first-time cosmetic patients to take things slowly and do one procedure at a time."
According to Dr. Marmur, it is paramount to document each consultation, using a template for each indication and for each laser system, as well as designing a consent form for each cosmetic procedure. This will help make the consultation clear, precise and to-the-point, banishing any possibility of eventual ambiguities for both practitioner and patient.
Common postoperative issues include: swelling, pain, pruritus, erythema, bruising, hyperpigmentation, crusting and bronzing. Dr. Marmur offers clinical pearls for common post-laser surgery complications:
"It is beneficial to spend extra time with the patient and explain what to expect over the next three weeks post-op. If you have documented these risks in the consultation, the patient will be more relaxed," she says. "It is also good for the patient to see post-op pictures of these complications and their resolution. Additionally, it is always good to offer to see the patient on a daily basis during the recovery time, if necessary."
For erythema, crusting, superficial blisters, bronzing and pruritus, Dr. Marmur has had good success with Aquaphor ointment (Eucerin), five to 10 times daily. For swelling, she uses ice packs, and for hyperpigmentation, Lustra AF (hydroquinone + retinol) (Canderm Pharma, Inc.) has shown very good results. This should be applied only after the epidermis is healed to prevent irritation.
Other uncommon post-operative issues include blisters, scars, hypopigmentation, infection, delayed healing and anesthesia complications. These unwanted complications are relatively rare, and naturally vary from patient to patient, but are a very real possibility that should be listed in the consent form and well understood by the laser surgeon.
Editor's note: Every month in Residents' Forum, a dermatologist in practice or academia discusses clinical and practice management issues affecting residents. If you're a resident and would like to see specific issues covered in this column, please e-mail the editor at firstname.lastname@example.org