The standard surgical mask is not NIOSH approved and only effectively (99%) filters particles larger than 5 µm (vs 25% efficacy for 0.3-µm particles). Its main purpose is to protect the patient from the wearer.12
High-filtration masks, which capture particles as small as 0.1 µm, should be used instead. The surgical N95 respirator is a NIOSH-certified respirator and is recommended for use in cases when smoke management is necessary. The FDA does not test or certify these masks; it only clears them after reviewing manufacturer test data. Technically, to be called a surgical mask, it must be cleared by the FDA.12 The 95 of N95 indicates filter efficiency ratings of 95% when testing the filter efficiency using particles of approximately 0.3 µm in diameter (Table 2).13 Because 77% of surgical smoke particles are smaller than 1.1 µm, surgical masks and N95 respirators are never sufficient as stand-alone protection.14 An LEV system is much more important for safe surgical smoke management. However, recommendations call for the use of a smoke evacuator and a high-filtration mask together to obtain the most protection available.14
Fire Hazards
Fire hazards constitute another area of concern for the laser user and are seen with class 4 lasers. There usually are 2 types of fire hazards: electrical fires inside the laser (often faulty wiring) and flash fires (laser beam contacts flammable material). Flammable materials (eg, hair, hair products, makeup, fabrics, plastic, alcohol, chlorhexidine, aluminum chloride, elastic strap on safety goggles, gauze, drapes) should be identified and removed prior to laser use. CO2 and erbium:YAG lasers tend to pose the worst risk for flash fires.15
Precautions for fire control in the laser room should include fire extinguishers and/or fire extinguisher blankets, a water basin, and fire-resistant drapes available as needed. Flammable material such as gauze should be kept wet, or a nonflammable version should be used.3
Additional Safety Considerations
Whenever lasers are being used, it is important to cover any windows in the laser treatment area (LTA) to prevent the laser beam from passing through the glass window. Laser-blocking window covers are a requirement and are available from several vendors. Covers that block every laser class are available and come as a shade or a flat cover that is attached with Velcro or magnets. They also come with “Laser in Use” warning signs for additional safety. Access to the LTA when the laser is in use should be controlled and appropriate warning signs placed on the door to prevent inadvertent entry without proper PPE. Locking the door to the LTA while using the laser is an additional safety measure and can be included on a checklist.
For the dermatologist, the skin is a primary focus, and similar to the eye, can be at risk for injury. The most common type of injury resembles a sunburn, such as those seen in the UVB range, that appears as redness and sometimes blistering,15 which is an important consideration, and attention should be given to all those in the laser room.
Checklists
Checklists are ubiquitous throughout many occupations and many medical specialties. Their usefulness in preventing adverse events is well established. Any patient-provider encounter in which a series of sequential actions is required is a perfect situation for a checklist. In dermatologic laser surgery where the eye is uniquely susceptible to injury, a laser safety checklist is essential. Additionally, there are issues with LGACs and fire that are important to consider. Having protocols (ie, a checklist) in place that address these safety issues has been shown to reduce adverse outcomes.2 There are a number of templates available from various sources that can be customized to the laser treatment area. We provide a modifiable example (Table 3).
Conclusion
Laser usage in dermatologic surgery has increased. According to surveys from the American Society for Dermatologic Surgery, in 2012 there were approximately 2 million laser/light/energy-based procedures performed. By 2017, there were 3.27 million, up from 2.79 million in 2016, representing an approximate 1-year increase of 17%.16 Lasers have allowed interventions for skin, vascular, and aesthetic conditions that were once untreatable. As their use increases in number and broadens in scope, there also has been an increase in litigation alleging malpractice for misuse of the laser.17 Adverse events, which include photochemical or thermal injuries to the skin, pigmentation issues, scarring, plume-related issues, and fires, do occur. One solution to reduce the chance of an adverse outcome is to implement a checklist. Research using checklists has shown that adverse events are reduced when checklists are created and implemented properly. Improving checklist compliance also improves patient outcomes.17 The American National Standards Institute, in their ANSI Z136 series, and the World Health Organization provide checklist templates. We include our checklist for use in laser surgery (Table 3). Understanding that each laser treatment area is unique, the templates can serve as a starting point and can then be customized to suit the needs of each dermatologist.