Thursday, 28 March 2013




Sometimes a well marketed laser procedure creates a reputation for itself in the public domain that goes beyond what experienced clinicians think of it.
Fraxel can be a very useful laser procedure, but there is no doubt that some people who don't need it are being treated aggressively with it and aren't always happy with the outcomes.

For the lucky ones, it may have just been a waste of money without any permanent physical or psychological harm.
For some less fortunate, unnecessary (albeit well intentioned) laser procedures create issues that horrify those of us asked to correct them.
One such patient I met recently who appeared to attend for advice about a facial related issue, only to open up at the end of the consult with the real reason.

This isn't an unusual thing in the field of cosmetic medicine.  After all, it takes a while to establish rapport and trust when you've had a horrendous experience previously.

In this case, the patient had travelled interstate for Fraxel resurfacing to her face, neck and chest area about 9months previously.  It had appeared to go according to plan initially, in that she had woken from the general anaesthetic with some moderate discomfort on all areas, and then healed quickly on the face, but the chest was a different story.
Having returned to her home in Melbourne within 24 hrs, the patient reports very slow healing of the chest, with horrendous scarring initially appearing after 2 weeks, especially in the central/sternum area, which has steadily worsened over the next 6months.

I'm rarely lost for words, or ideas on how to fix a problem, but in this case I really did feel her pain and distress.
Her entire chest is covered in thick, contracted keloid scarring from one side to the other, from top to bottom.

I wish I could show you her photo, if only to warn you that some areas of the body are particularly prone to keloid scarring and the chest is probably the greatest example of that.

Here is an example, it is NOT of the patient described above.  This was apparently one that formed from a mole having been excised, and is not one of my patients, but is a good example of the keloid scarring that can result from even a minor surgical procedure on the chest.

I have a keloid scar on my own upper chest.  Fortunately it is only about 0.5cm diameter.  It developed 2 years ago after I was bitten by a mosquito there.
I'm highly allergic to mosquito saliva, as is my son, so I took antihistamines to suppress the inflammation and made sure not to touch the bite or scratch at it.  Despite these measures, the inflammatory response was so strong in this area that I have developed a hypertrophic scar that really does extend beyond the location of the original bite, hence is a genuine keloid scar.  I suppose if it really worried me I would have some cortisone injected it, but so far I've just left it alone, hoping that with time it will settle. 

If a mosquito bite can give me a keloid scar, it just goes to show how sensitive and keloid prone that part of our body really is.  Whenever someone asks me to perform an unnecessary (in my opinion) procedure on their chest area, I always show them my keloid scar, and explain how I got it.  Sometimes people just need to weigh up the risk/benefit ratio a little more carefully before diving in to a procedure that may have inherent risks no matter who is doing the procedure.  I guess that affects my income at times.  Big deal.  I would rather sleep well than lie awake stressing that some gorgeous previously confident woman has now had to undergo psychiatric assistance and adapt her entire wardrobe because I had given her a keloid scar that would be the envy of any Masai warrior in Africa.

Some laser procedures should never be done on areas off the face.  Others can be done, but very very carefully...especially in the central chest area.  

I NEVER encourage patients to have any laser or any injectable procedure done under a general anaesthetic or even "twilight sedation".  It is much safer to have a mentally alert (albeit somewhat anxious) patient able to give verbal feedback on what she is experiencing (ie feeling) as far as pain is concerned, than to have someone rendered incapable of providing this valuable feedback.  Very anxious patients can safely use an inhalation anaesthetic like Penthrox if necessary, without it impacting on their ability to liase during their treatment.  

Early recognition of a laser burn is essential if gross complications such as keloid scarring are to be prevented.  The best way to recognise a laser burn early is to have the patients awake at the time of the procedure, and to have them attend for follow up within 2 weeks of the procedure.  It's hard to do that if you're going interstate or overseas for your treatment, so think again before deciding that the only factor worth considering in the choice of your treatment is the price.

After all, any burnt patient will tell you that it hurts like hell being truly burnt by a laser..and it's a very different sensation compared to the normal fleeting mild-mod pain experienced during most routine laser treatments. 

Our pain fibres provide very valuable information to the doctors treating us.  But only to those who actually want to know about it.

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