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S C I E N T I F I C F O R U M

Aesth etic CO 2 Laser Surgery:

Evaluation of 9 7 Patients

Thomas L. Rob erts III MD; Cyn thia Wein stein MD; John K. Alexa ndrid es MD; and

Karen M. Yokoo MD

Resurfacing the skin to improve skin quality is an important concept in aesthetic plastic

surgery. Altho ugh time-honored metho ds (e.g., dermabrasion and chemical peel) are

available for this purpose, they have several disadvantages. A n ewe r meth od w ith a high-

energy pulse d carbon dio xide laser provides a m ore controllable and m ore predictable

method of resurfacing facial skin.

In our study of 907 patients, monitored up to 2 years, 868 laser resurfacing procedures

were done for facial wrinkles. Eight hundr ed two o f 868 (92.4 ) achieved very goo d to

excellent results (>75 removal of wrinkles in 92.4 of cases). Forty-six of 61 (75.4 )

patients with ache scars also obtained very good to excellent results. Most patients with

selected skin lesions (rhinophyma, actinic cheilitis, epidermal nevi, seborrheic keratoses,syringomas , xanthelasm as, a nd postsurgical scars) achieved goo d to excellent results,

although these are adm ittedly mor e difficult to quantify.

Major complications were uncomm on. One hundred one of 907 (11.1 ) patients had

development of tempora ry hyperpigmentation, which resolved in an average o f 2.6

weeks. Thirty-four of 907 (3.8 ) patients had development of mild perma nent hypopig-

mentation. Eight of 908 (0.9 ) patients had development of som e induration that

resolved w ith use o f intralesional steroids. M os t o f these (5 of 8) were in the perioral

area. Three of 907 (0.3 ) patients had developm ent o f a small persistent scar. Seven of

316 ( 2 ) patients undergoing periorbital resurfacing had development o f some mild

scleral show . Early in our experience one patient dev eloped ectro pion tha t required sur-gical correction.

We conclude that the new generation high-energy pulsed carbon dioxide laser is safe and

effective for resurfacing facial skin. However, this procedure is very technique dependent

and requires a com bination of didactic and ha nds-o n training, conservative surgical

judgment, and diligent patient follow-u p to obtain optima l results with minim al compli-

cations.

i n t roduct i on

Rejuvenation of th skin is an imp orta nt aspect of aesthet ic facial surgery. M any patients

Thomas L. Roberts is an associate

clinical professor of surgery at the

Medical U niversity of South

Carolina at Spartanburg, SC.

Cynthia Weinstein is a senior con-

sultant dermatologist at the

University of Melbourne,

Melbourne , Australia. Jo hn K.

Alexand rides is a resident in the

Departme nt o f Plastic Surgery,

University of Miami School of

Medicine, Miami, FL. Karen M.

Yokoo is an assistant professor of

plastic surgery at the University of

South Carolina, Columbia, SC.

Subm itted for publication A ugus t

11, 1997; accepted September 9,

1997.

Reprint requests: Thomas L.

Roberts III, MD, 100 E. Wood St.,

Suite 100 , Spartanburg, SC

2 9 3 0 3 .

Copyright 9 199 7 by the American

Society for Aesthetic Plastic

Surgery, Inc.

1 9 0 - 8 2 0 X / 9 7 / $ 5 . 0 0 + 0

7 0 1 8 5 8 9 3

A E S T H E T I C S U R G E R Y J O U R N A L ~ S E P T E M B E R O C T O B E R 1 9 9 7 93



Table

Breakdown of laser procedures

Resurfacing for fac ial wr ink les 868Numbers of each aesthet ic uni t

Per ioral 482

Per iorbi ta l 316

Total face 62

Forehead 35

Cheeks 15

Resurfacing with other fac ial aesthet ic surgery

Blepharoplasty and per iorbi ta l resurfacing 271

Face lif t and regional resurfacing (not cheeks) 27

Endoscopic brow lif t and forehead resurfacing 18

Resurfacing for acne scarr ing 61

Other les ions & ear ly surgical scars 51

These numbers total more than 907 because some patients had

more than one procedure.

requi re impr ovem ent in f acia l sk in qua l i ty in addi t ion to

a l te ra t ion in quant i ty or pos i t ion o f the sk in . This is pa r -

t icu la rly t rue for pa t ien ts w i th f ine to m odera te wr inkles

resu l t ing f ro m ac t in ic damage and p i t ted acne sca rs .

Carb on d ioxide la se rs , emi t t ing l igh t a t 10 ,600 nm, have

b e c o m e a n im p o r t a n t t o o l i n d e r m a to lo g y a n d , m o r e

recently, in aesthetic plastic surgery. 1-6 Because the car-

bon d ioxide la se r beam is predominant ly absorbed by

water , i t has become a useful tool in resurfacing the skin

(90 of the ep ide rmal content i s wa te r ) . 7

Cont in uous-w ave CO 2 la ser s have been ava i lab le for

more th an a decade but never gained wide acceptance for

resur fac ing the sk in because of the long dura t ion of expo-

sure , a l lowing thermal diffusion of the laser energy into

t i ssue , which causes an u nacceptab ly wide zone of the r -mal damag e . The t ime needed for reduc t ion of tempera -

ture a t any s i te by 50 i s kno wn as thermal relaxation

time and for the superf ic ia l layer of skin is estimated at

700 to 1000 gsec. A familiar example of this is that if

one passes a f inger through a candle f lame fast enough,

there is no burn , and in fact , no h eat is fel t . Th us if a

CO 2 la ser could deve lop enough ene rgy to vapo r ize sk in

in less than 9 00 btsec , the targe t skin cou ld be vaporized ,

caus ing only minimal the rmal damage to the ad jacent

underlyin g skin. *-19 This conc ept led to the deve lopm ent

of the new genera t ion o f h igh-energy pulsed la se rs , wi thpulse w idths of less than 900 btsec . The f irst laser to

Table 2

Rating system

Percent of improvement in

Rating w r i n k l e s l l es i o n s l c n e l s c r s

Excellent _>95

Very good 75 to 94

Fair 50 to 74

Poor <50

achieve this was the Ultrapuls e (Coherent, Inc . , Palo

Alto, CA), which is the laser used by the authors of this

repor t . Othe r CO 2 la ser s a re ava i lab le today , each having

different operating systems and physical character ist ics.

Ou r experience is l imited to the Ultrapuls e laser , and

because of the d i f fe rences among la se r s , it i s unk now n a t

present whe the r our da ta and resu l ts can be appl ied to

other devices.

One of the ma jor advantages of f ac ia l sk in re sur fac ing

with the C O 2 laser is the im med iate visible dermal t ig ht-

ening. This gives visual assessment of the degree of sur-

face cor rec t ion , adding an e lement of cont ro l and

predic tab i l i ty not ava i lab le wi th any chem ica l peel or de r -

m a b r a s io n .

Pat ients and Methods

Nine h undred seven pa t ien ts underwen t CO 2 la ser r esur -

facing . The pa t ien ts e lec ted the procedures show n in

Table 1.

There were 814 females and 93 males r anging in age

f rom 3 to 86 yea rs . The eva lua t ion of a ll pa t ien ts was

ca r r ied ou t wi th prede te rmined c r i ter ia (Table 2) and

inc luded rev iew of cha r ts and preopera t ive and pos toper -

ative sl ides and/or an interview in person. Eighty percentof a ll patients in the American ser ies were evaluated in

person.

A r a n d o m su b g r o u p o f t h e A m e r i c an p a t ie n t s w h o u n d e r -

went ope ra t ion by one of the au thors (T. L . R . ) was

asked to ra te the i r ow n sa t i s fact ion wi th the i r r esu l ts .

These re sponses were repor ted to one of the o the r

authors (J . A.) , who was not involved in the surgery or

pos topera t ive ca re .

Anesthesia

All pa tien ts undergoing CO 2 la se r b lepharoplas ty a ssoci -

w 9 4 A E S T H E T I C S U R G E R Y J O U R N A L ~ S E P T E M B E R / O C T O B E R 1 9 9 7 VolumeIT Number5




Tabl e 3

Results at 5 to 4 months

N

Resurfacing for wrink les

All facial areas 868

Perioral 482

Periorbital + laser blepharoplasty 27 1

Forehead 17

Acne scarring 61

Lesions/surgical scars 51

Excellent

566 (65.2 )

412 (85.5 )

181 (66.8 )

5 (29.4 )

17 (27.9 )

39 (76.5 )

Very good Fair Poor

236 (27.2 ) 65 (7.5 ) 1

66 (13.7 ) 4 (0.8 ) 0

82 (30.3 ) 8 (3 ) 0

6 (35.3 ) 6 (35.3 ) 0

29 (47.5 ) 15 (24.6 ) 0

11 (21.5 ) 1 (2 ) 0

a ted wi th pe r iorb i ta l r e sur fac ing were g iven in t ravenous

seda t ion wi th a combina t ion of midazolam, fen tanyl ,

and/or propofol . Direc t loca l anes the t ic inf i l t r a tion o f the

upper and lower eye lids was p e r forme d wi th l idoca ine

(Xylocaine ) or Xyloca ine and bupivaca ine (Marca ine ),

both wi th ep inephr ine . Te t raca ine eyedrops were a lso

used . Pa t ien ts undergoing resur fac ing requi red a combi-

nation of nerve blocks and local inf i l tra t ion.

L a s e r S a f e t y

Dur ing b lepharoplas ty , the g lobe was pro tec ted by use ofa sandblas ted David-Baker c lamp (upper eye lid), o r

Jaeger sta inless steel pla te ( low er eyelid) , and a sta inless

steel shie ld for the contrala teral eye. During resurfacing,

the eyes were pro tected w ith e ither wet gau ze ( if resurfac-

ing was not near the eyes) or sandblasted sta inless steel

eye shields. To minimize the r isk of f ire f rom an

unplanned t r igge ring of the la se r , the pa t ien t ' s head was

sur rounded wi th e i ther c rumpled s te r ile a luminum fo il

( to diffuse the beam) or wet ster i le towels ( to absorb the

beam) . Oxy gen cannula or endotrachea l tubes , i f used ,

were wrapp ed w i th s te r ile a luminu m fo i l .

Prepara t i on

All pa t ien ts were washed wi th aqueous chlorhexid ine or

benza lkon ium chlor ide (Zephiran) . Use of vola t ile so lu-

tions, such as acetone or a lcohol, were avoided.

Laser Se t t i ngs

Carbon Dioxide Laser Blepharoplasty

For laser blepharoplasty, the laser was set in the continu-

ous-wave mode a t 5 to 8 W, except when making theupper l id skin incision, for which the laser was set in the

pulsed mode a t 15 mJ and 4 W. A 0 .2 mm spot s ize was

used in the focused mode for inc is ion and de focused

mod e for hemostas is . In the ea r ly phase of th is s tudy,

resur facing of the sk in was pe r fo rmed wi th the Coherent

Ul t rapulse la ser wi th a 3 mm col l ima ted handpiece . At

f i rs t , ma xim um energy ava i lab le on the machine was 250

mJ pe r pulse . In the la s t yea r of the s tudy, an upgrade to

500 mJ pe r pulse became ava i lab le and was used rout ine -

ly af ter this t ime. An effor t was made to overlap the spots

by appro xima te ly 20 to avoid gaps be tween spots . In

the la s t 6 months of the s tudy, the scanner ( com pute r ized

pa t te rn genera tor ) became ava i lab le , and i t was used a t

similar f luence (300 mJ through i ts 2.25 mm spot size) .

This scanner delivers 81 pulses o ver 120 m m z in 0.3 sec-

onds , inc reasing the uni form i ty and speed of the proce -

dure . The scanner was set a t a density of 5 to 7 (c linically

apparen t ove r lap of spots of 20 to 30 ) .

Periorbital Region

Early in the study, 250 mJ per pulse a t 2 to 3 W was

used. Later 500 mJ per pulse was used, and f inally, with

the scanner a t 300 mJ, density 5 to 7. On the eyelid, one

comple te pass was made . I f a second pass was necessa ry ,i t was a lways m ade a t ha l f the ene rgy or ha l f the dens i ty .

On the c row's f eet , two or three comple te passes were

made depending on the depth of the wr inkles .

All Other Facial Aesthetic Units

In the ear ly study, we used 250 mJ per pulse a t 2 to 5 W,

wi th the 3 mm spot s ize . La te r 500 m J pe r pulse was used

at 3 to 10 W. The scanner was used at equivalent f luence

during the last 6 months (300 mJ, density 5 to 7) .

Techni que

Pa t ien ts wi th wr inkles or acne sca r r ing underwen t t r ea t -

Aesthetic CO2 Laser Surgery: Evaluation o f 9 7 A E S T H E T [ C S U R G E R Y J O U R N A L - S E P T E M B E R / O C T O B E R 1 9 9 7 ) 9 5

Patients



igure 1. Appearance o/ fema le patient before left) and 6 monthsafter undergoing total facial laser resurfacing right).

Figure 2 Appearance of female patient preoperatively left) and 6months followi ng total facial laser resurfacing right).

men t of a complete aesthet ic unit. Sp ot resurfacing was

only perfo rme d for small isolated skin lesions or scars.

In the ea r ly phase of the s tudy, when the manua l 3 mm

handpiece was used, the complete cosmetic unit was

treated by resurfacing perpendicular to the wrinkle l ines

or scar. On the first pass, 10 to 20 overlap was

achieved.

The vaporized epide rmal debr is was then rem oved wi th

gauze soaked in sal ine solut ion. The skin was not

al lowed to d esiccate during the proc edure. A fter the first

pass, only abnorm al a reas were t rea ted on subsequent

pas~es. Th e laser beam was again passed across wrinkle

l ines or acne scars with 20 to 30 overlap. Feathering

at the edges of laser-treated areas was performed on each

pass by decreasing the fluence with the m anual hand-

piece. After the intro duct ion of the scanner, i t was rarely

necessary to work the individual wrinkle shoulders and

valleys. Instead, addit ion al passes were made w ith the

larger pat terns in the areas where wrinkles remained.

Postoperative ressing

All laser-treated areas were dressed with a semipermeable

dressing with non conf luent adhesive (Flexzan Dow -

Hickman, Sugarland, TX). Dressings were changed when

necessary, usually after the first 24 hours. Subsequently, the

dressing adhered to the treated area and lifted when reepithe-

lialization was complete (approximately 7 to 10 days,

depend ing on the depth of the resurfacing). No antibiotic

ointm ents wer e used because of the high incidence of conta ctdermatitis wh en app lied to the healing skin.

Postoperative Medication

All pat ients wer e given oral cephalospo rin for 5 days.

After the ini t ial phase of our study revealed a 3 inci-

dence of acute herpes simplex, even in pat ients w ith no

prior history, we began requiring a 10-day course of acy-

clovir 400 mg three t imes dai ly administered by mo uth

for a l l pat ients, beginning 2 days befo re operat ion.

Patients who had ful l facial resurfacing were given dex-amethasone (Decadron 8 mg in t ravenous ly dur ing and

af te r opera t ion fo l lowed by an ora l Decadro n taper . A

mild analgesic was used, if necessary, for pain.

When reepithel ia l izat ion was complete , topical steroid

cream (clobetasol prop iona te [Temovate-E| twice dai ly

was used intermit tently (10 days on and 4 days off) for

two or three cycles to reduce eryth ema. If hyperp igmenta-

t ion occurred a f te r opera t ion , 4 hydroq uinone and gly-

colic acid or 0.1 re t inoic acid was used twice dai ly

unti l c leared. A sunscreen was used by al l pat ients fo r 3

months after operat ion to decrease the risk of hyperpig-

menta t ion .

Results

Table 3 shows the results for a l l pat ients. Very good to

excellent results , that is >74 impro vem ent, were

obtain ed in 92.4 of a l l pat ients t reated for facial wrin-

kles (Figures 1 and 2). Perioral and periorbi ta l areas

respon ded best (99.2 and 97.1 , respectively) (Figures

3 and 4). Only 67.4 of pat ients with forehead wrinkles

achieved this degree of improv emen t. Because all fore-head wrinkles are dynamic (produced by muscle act ivi ty)

9 6 A E S T H E T I C S U R G E R Y J O U R N A L S E P T E M B E R / O C T O B E R 1 9 9 7 VolumelT Number3




igure 3 Appearance of male patient before top) and 6 months afterundergoing four-lid laser blepharoplasty lower lid transconjunctival,upper lid transcutaneous) and total facial laser resurfacing bottom).

igure 4 Appearance of female patient before top) and 6 monthsafter undergoing total facial laser resurfacing bottom).

and tend to be deeper, i t is not surprising that the results

in this region were not as good.

Patients with ache scarring obtained very good to excel-

lent results in 75.4% of cases (Figure 5). As expected,

superfic ia l acne scars respond ed bet ter tha n deeper scars,

a l though al l of the cases showed significant improvem ent.

With selected facial skin lesions ( rhinop hym a, act inic

cheil i tis , syringomas, xanthelasm a, epidermal nevus,

act inic keratoses, hemang ioma, seborrheic keratoses, and

dermatosis papulosa nigra), a l l pat ients but one achieved

very good to excellent results (Figure 6). Patients with

actinic cheilitis obtained excellent results with quicker

healing (average 3 to 4 weeks) than with the older con-

t inuous-wave or superpu lsed CO 2 laser. Pat ients with

rhinophyma responded be t te r a f te r t rea tment wi th the

continuous-w ave mode. All pat ients with postsurgicalscars ob tained very good to excellent results wh en CO 2

laser resurfacing was used 6 to 8 weeks after the ini t ial

surgical procedure. This was visible as blurring of the

surgical scar and blending with surrounding skin.

Complications

Erythema

All pat ients had some degree of erythema. T he scale

ranged f rom a p ink color ( mi ld e rythema) to a ve ry

intense red color ( severe erythema). Non e of the

pa t ients had severe e rythema. Erythema was moder-

ate in 16% (145/907) of pat ients and mild in 83.8 %

(760/907). No erythema was noticeable in 0.2% (2/907)

of pat ients. The mean du rat ion of the erythema was 11

weeks.

Pain Discomfort

Mild discomfort was more comm only repor ted than t ruepain. No ne of the pat ients required strong analgesia ,

Aesthetic CO2 Laser Surgery: Evaluation of 9 7 A E S T H E T I C S U R G E R Y . J O U R N A L S E P T E M B E R / O C T O B E R 1 9 9 7 gig

Patients



igure5. Appearance of male patient before top) and 7 months afterundergoing total facial laser resurfacing for acne scarring bottom).

igure 6. Appearance of male patient before top) and after undergo-ing laser resurfacing for dermatosis papulosa nigra bottom).

97.5% (886/907) of patients required no analgesia, 2.3%

(21/907) of patien ts required mild analgesia, and 0.2 %

(2/907) of patients required moderate analgesia.

yperpigmentaUon

A significant numb er of patients (11%, 100/907) had

development of transient (defined as less than 120 days

after operation) hyperpigmentatio n. Only 0.1% (1/907)

of patients had persistent (greater than 120 days) hyper-

pigmentation. Hyperpigmentation was treated with topi-

cal hydr oquin one and /or retinoic acid.

ypopigmentation

Transient ( less tha n 120 days after operation) hypopig-

men tation occurred in 2% (18/907) of patients, whereas

persistent (greater than 120 days) hypop igmen tation was

observed in 3.7% (34/907) of patients. All cases of

hypo pigme ntation were less severe than the porcela in

white hypopigmentation that has been observed afterphenol peels.*

Pruritus

Seventeen percent of patients repo rted mild pruritus,

which generally resolved within 2 weeks after operation.

Antihistamines or ice compresses were used in some

patients.

SynechiaThese small epithelial bridges were observed in 0.8%

(7/907) of patients an d occurre d 3 to 11 days after opera-

tion, during reepithelialization.

Induration

Mos t cases of induration occurred on the upp er lip. This

problem was noted in 0.9% (8/907) of patients.

Scar

Three patients h ad development of small scars. These

*After completion of this study, longer-term follow-up suggests that

the incidence of hypopigmentation is approximately 10 .

F298 AESTHETIC SURGERY JOURNAL SEPTEMBER/OCTOBER 1997 Volume17 Number5



occurre d on the lower eyelid, lip (Figure 7), and cheek.

The la t ter pat ient underwent a cheek laser resurfacing

combined with a face l i ft with wide subcutaneous under-

ming.

cute Herpes Simplex

Before the administra t ion of prophylact ic acyclovir

(Zovirax| the incidence was 3 , but with the prop hy-

laxis the incidence was reduc ed to less than 1 .

Scleral Show

Trans ient (less than 120 days after op erat ion) scleral

show was observed in 2.5 (8/316) of pat ients.

Persistent (greater than 120 days after operat ion) scleral

show, less than 1 ram, was observed in 1.9 (7/316) of

patients. Persistent scleral show, greater tha n 1 mm, wasobserved in 0.3 (1/316) of pat ients.

Ectropion

Ectro pion was observed in one pat ient (0.3 , 1/316) in

wh om preopera t ive lid laxity was over looked. Ec t ropion

resolved after a la teral canthal suspension procedure was

performed.

cne

One patient (0.1 , 1/907) had developm ent of act ive

acne under the dressing.

Milia

Milia was observed in 7.2 (68/907) of pat ients and was

treated by unro ofing the lesions.

P a t i e n t S a t i s f a c t i o n

Patients were asked to judge their results 5 to 24 months

after operat ion , using the same cri teria we used (Figure

8). Ninety-thr ee percent of pat ients with resurfacing of

various facial units and 91 of pat ients with periorbi ta l

resurfac ing be lieved tha t more than 74 improvem ent

was achieved with this laser proced ure. Te n of the

patients had a previous chemical peel (t richloroacetic

acid or phenol). All 10 of these pat ients preferred the

laser t reatment over chemical peel because of bet ter

results , less hypopigm entat ion, and/or less discomfort .

Di scuss i on

Although t ime-honored methods a re currently ava ilable

for resurfacing skin, these have som e disadvantages.

Dermabrasion is a bloody procedure, making i t difficul t

to visual ize end points . Th e greatest disadvantage o f der-mabrasion is the potentia l for the blood aerosol to

igure 7. Appearance o f female patient before top) and after under-going aggressive laser resurfacing for deep wrinkles and small scar nod-ule bottom). No tice also moderate hypopigmen tation of facial skincompared with neck.

remain in the a ir for as long as 48 hours after the proce-

dure. 2~ This places the operat ing roo m personnel and

other pat ients a t risk of contract ing human immunodefi-

ciency virus, hepatitis B, and h epatitis C. 21 Mo reo ver ,

derm abrasion is technical ly difficult to learn and teach,

and few surgeons would risk dermabrasion on the eye-lids. 22

Chemical peel ing with pheno l and trichloroacetic acid is

essentia l ly a bl ind technique. Th e end result depends on

mult iple variables, and, con sequently, can be inconsis-

tent . Factors such as pretreatm ent with re t inoic acid, ace-

tone, o r glycolic acid, numb er of applicat ions, heaviness

of applicat ion, and postoperat ive taping may influence

the fina l res ult . 23-25

Phenol may cause sys temic toxic i ty and comm only pro-

duces postoperat iv e pain an d h ypop igmen tat ion. 23Trichlo roacetic acid in higher concen trat ions, tha t is ,

Aesthetic CO2 Laser Surgery: Evaluation o[ 9 7 A E S T H E T I C S U R G E R Y J O U R N A L ~ S E P T E M B E R O C T O B E R 1 9 9 7 9 9

Patients



100%-

80 -

60 -

40 -

20 -

0%-Facial Laser

Resurfacing lepharoplasty

PeriorbitalResurfacing

igure 8 Patient satisfaction a t S to 24 months postoperatively.

[] Very G o o d

I I Excellent j

>40%, has a poor sa fe ty margin and can cause sca r -

r ing. 26 In add it ion to this , tr ic hloroace tic acid is not very

effective against deep per ioral wrinkles.

CO 2 la se rs have been used for more than three decades

and have mo re recent ly been of va lue in some inc is iona l

cosm etic surg ery, espec ially bl eph aro pla sty . 13-19,27

How ever , the con t inuous -wave and superpulse C O 2 la ser

were l imi ted by the i r th e rmal e f fec ts . Improve ment s in

la se r technology by use o f the theory of se lec t ive pho-

to the rmolys is h ave enabled the use of pulsed la se r sys-

tems which minimize the rmal damage to noninvolved

tissue.28 , 29

The Ul t rapulse CO 2 la se r produces ex t rem ely shor t (600

to 1000 gsec) high-energy pulses, which ablate target t is-

sue more rap id ly than hea t and can be conduc ted to sur -

roun ding skin. z8-3~ Clean abla tion is possible becau se the

pulse dura t ion i s shor te r than the ta rge t t i ssue the rmal

relaxation t ime. Because the laser procedure is accurate

and re la tive ly b loodless , the ope ra tor can readi ly v isua l -

ize the d esir ed end po in t. 31-33

To achieve this c lean t issue ablation, a cr i t ical power

dens i ty for sk in must be exceeded . The c r i tica l power

density for CO 2 laser surgery in sk in is 4 to 5 Joule/cm,

vapor iz ing to a depth of approximate ly 100 pm, and pro-

ducing only a 20 to 50 btm zone of thermal damage.

When abla t ion i s a t tempted a t le ss than opt ima l power

density, overheating and signif icant charr ing and/or scar-r ing result . This can be a voided by use of the C O 2 laser

at power densit ies greater than the cr i t ical value 2 5 0 m J

for the 3 mm spot manua l handpiece and 150 mJ for the

scanner ' s 2 .25 m m spot ) . This is the oppos i te to wha t

one may init ia l ly believe, but use of too low an energy

result s in an on t ime of the la se r beam of grea te r than

the the rmal r e laxa t ion t ime , a l lowing i r r eve rs ib le the rmal

dam age to adjacent t issue. Superpu lse C O 2 lasers pro-

duced h igh peak po wer but r ap id decay and a longer ta i l

of lower ene rgy . 8 The newer rad io f requency-s t imu la ted

CO 2 lasers, such as the Ultrapulse CO 2 laser used in this

s tudy , produce sus ta ined h igh peak power , r e su l ting in

signif icantly greater en ergy per pulse .

Use of a 3 mm spot size , c lean charless ablation requires

a s ingle la se r impac t ene rgy wi th a mini mum of 150 mJ

to vaporize the targeted skin before signif icant heat is

conduc ted to sur rounding s t ruc tures . Normal t i ssue i s

ab le to adequ a te ly cool down be tween pulses so hea tbuildup will not occur .

Wi th a focused hand piece, the C O 2 laser can cut t issues

wi th a marked reduc t ion in b leeding , making i t e specia l ly

useful for surger ies on highly vascular areas such as the

eyelids and scalp. Laser-assisted blepharoplasties have

consequent ly b ecome inc reas ingly popu la r a s a r e su l t o f

reduction in bleeding, bruising, and a decrease in opera-

tiv e tim e. 34-37

Wh en eva lua t ing a pa t ien t for lower l id r e surfac ing , we

recom mend ca re fu l eva lua t ion of lower l id margin lax i ty ,by s t rong dow nwa rd t r ac t ion on the l id for 5 seconds. I f

3 0 0 A E S T H E T I C S U R G E R Y J O U R N A L S E P T E M B E R / O C T O B E R 1 9 9 7 Volume17 Number5



mor e than 3 to 4 seconds is required for the l id margin to

contact the globe, la teral canthal tendon suspension or

othe r l id tightening procedure should be pe rformed pro-

phylact ical ly a t the t im e of the eyelid resurfacing and/o rblepharoplasty. In the defocused m ode, CO 2 lasers are

used to vaporize t issue so that the skin can be con toured ,

for ex amp le, rhi nop hym a. 38,39

Optimal results w ith the high-energy pulsed C O 2 laser

are achieved with sta t ic wrinkles o f the face, actinic dam-

aged skin, pi t ted (but n ot ice pick) acne scars, exophy tic

skin lesions, act inic cheil it is , and some p ost traum atic

scars. Resurfacing can be used alone or in combination

with a brow l ift (endoscopic or coronal), laser blepharo-

plasty , and face li f t. How ever , we do not recom mend

synchronous laser resurfacing over a subcutaneous

undermined skin flap. Resurfacing may be done on the

forehead when a subperiosteal brow l ift is performed at

the same t ime, because this is an ex tremely vascular and

thick flap. When there is much redundant skin, the com-

bination of the laser and an incisional proced ure can give

good, mutua l ly com pl imenta ry resul ts .

One end point , the re la t ive fla t tening of the abn orm al

con tou r of wrinkles, can be readily visualized. Entry from

papil lary dermis to re t icular dermis can be seen by

change in the surface collagen pat tern from smooth tocoarse and irregular col lagen bundles and a characteristic

yellow color. The num ber of passes with the laser was

determin ed by whichev er end poin t app ears fi rst; the dis-

appearance of the wrinkles/acne scars or the appearance

of a yel low color that persists after wiping with a wet

gauze. Althou gh the autho rs frequen tly wen t to a deeper

level , indicated by the app earance of a chamois yel low

color, i t is s trongly recommended that surgeons in their

first 6 to 12 m onth s of laser experience stop at the first

appeara nce o f a pale yel low color that persists after wip-

ing with a wet gauze. The chamois-yel low color manda-tory end po int is difficult to judge, and continuing deeply

wil l virtual ly guaran tee an unaccep tably high risk of

hyper troph ic scarring. It is safer to be conservative on the

first t reatme nt an d reevaluate the pat ient in the future f or

a second session o f C O 2 laser resurfacing, i f necessary.

By resurfacing dow n to the level of the upp er re t icular

dermis, new collagen forma tion wil l occur evenly

throughout the dermis, producing long-last ing t ightening

of the skin. In addit ion to this , dermis contains s tructural

proteins including elastin and collagen. Althou gh elast in

is extre mely heat stable, co llagen (typ e 1) microfibrils will

change their s tructure arrangement a t temperatures of

500 to 600 C, shortening by as much as one third of their

length. 4~ This collagen shorten ing is believed to be

responsible for the immediate t ightening seen cl inical ly

with the CO 2 laser.

Acne scarring, on the other h and, is caused by focal col-

lagen abnormali t ies an d so requires a different t reatment.

The shoulder of acne scars needs to be resurfaced more

deeply than the surrounding normal sk in to achieve max-

imum benefit . Because acne scars often extend deeply

into the dermis, 100 impr ovem ent is rarely achieved in

these extremely deep scars without destruct ion of

appendages. 44 Addit ion al co mp limen tary procedu res,

such as derm al graft ing, p unch graft ing, or fi l l ing agents,

may need to be used.

Early post traumatic and surgical scars may be rendered

less noticeable by laser resurfacing to blend them into the

surrou nding t issues, especial ly whe n perf orm ed 6 to 8

weeks after the injury. Althoug h there is no clearly

defined scientific reason for resurfacing during this peri-

od, i t is bel ieved that on e can optimize collagen remodel-

ing during this t ime. Syringomas and xanthelasmas that

are si tuated in the upper dermis can be sui tably removed

with the resurfacing techniques. Th ey are replaced with

new collagen. Recurrences, however, may occur a t the

edges of the treated area.

Indurat ion must be careful ly looked for, both visual ly

and by feeling the skin with the fingertips, as it heralds

the potentia l for hypertrophic scarring. It may appear as

early as 3 weeks, most commonly in the upper l ip. When

discovered, it is t reated im mediately and biweekly with

intra lesional inject ion of a di lute solut ion o f Kenalog 5

mg/ml unti l softening begins. Early treatmen t with the

8 nm pulsed-dye laser may also be used.

Synechia or adhesions are most common in the lower

eyelids and rarely the nasolabial fold or labiomentalcrease. Care m ust be tak en to pull the skin taut to e l imi-

nate any creases or folds when the adhesive dressing is

being applied to minimize this problem . Synechia appear

as l inear white l ines or creases. Inspection under magnifi-

cation reveals an epithelial tunnel. If identified early (1 to

2 weeks), the adhesion can be simply pulled apart by

tract ion between two cotton-t ipped applicators. If over-

looked, i t may present as an inflamed area with re tention

of epidermal debris . Treatm ent is to lyse the epithel ia l

bridge with fine pointed scissors under magnificat ion.

The subsequent natural t ightening wil l general ly smooth

out the crease.

Aesthetic CO2 Laser Su;~gery: Evaluation of 9 7 A E S T H E T I C S U R G E R Y J O U R N A L ~ S E P T E M B E R O C T O B E R 1 9 9 7 3 1

Patients



Hyperpigm enta t ion was more com monly seen in the

darker skin types Fitzpatrick types IV to VI) ra ther th an

those with fa ir skin. One black-skinned pat ient

Fitzpatrick type VI) underwent laser blepharoplasty andperiorbi ta l resurfacing after 8 weeks preparat ion with

re t inoic ac id and hydr oquino ne and hea led normal ly

wi thout any hyperpigmenta t ion or hypopigmenta t ion .

From our c l inical results , we conclude th at the new gen-

erat ion high -outp ut CO 2 lasers used in this study are

ideal for resurfacing fine to m odera te facial wrinkles,

t ightening the facial skin, and im proving acne scars, exo-

phytic skin lesions, rhinop hym a, act inic cheil i tis , and

postsurgical scars because of their abi l i ty to rem ove

abnormal t issue with minimal thermal damage to sur-

rounding normal skin. This is in accordance with the

results of oth er authors. 45-47 This cann ot be ex trapola ted

to the co ntinuo us-w ave or superpulse C O 2 lasers because

the power dens i ty i s not equivalent. Wh en co mpared

wi th o lde r re surfac ing methods such as de rmabras ion

and chemical peel , CO 2 laser resurfacing is a go od al ter-

nat ive because of the fol lowing:

1. Laser resurfacing is re la t ively bloodless, therefo re

direct visual izat ion o f the desired end point is possi-

ble.

2. Precise depth can be contr ol led by laser energy,

power, densi ty, and number of laser passes.

3. Th e small spot size and precision faci l i tates t reatment

of finer details.

4. Use o f the C O 2 lasers in the peri ocul ar region s is suc-

cessful in removin g wrinkles right up to the eyelashes.

Both upper and lower eyelids may be resurfaced.

5. With a dequ ate smo ke evacuation, the risk of spread-

ing unw anted viruses in the plume is minimal. As

ment ioned previous ly , the ae rosol ized b lood f r om

dermabras ion may pe rs i s t for up to 48 hours a f te r theprocedure .

6. The laser has no systemic toxici ty, whereas chemical

phenol peels are absorbed and may cause cardiac or

renal to xici ty or a l lergic react ions.

7. Wh en the laser is turne d off, there is no ongo ing t is-

sue injury. At the co nclusion of a chemical peel , a

toxic chemical remains in the skin, penetrat ing into

the subcutaneous, muscular, and lymphatic t issues,

causing massive swelling.

8. Medium deep and deep chemical peels often damagemelanocytes, result ing in skin that may be porcelain

whi te. Hypo pigmen ta t ion occurs infrequent ly wi th

conservative laser resurfacing, b ut w hen i t does, i t is

mild and rarely sharply demarcated. This is probably

due to the fact that the m elanocytes below the levelof resurfacing are undamaged, whereas the deep

chemical peel penetrates the entire thickness of the

skin.

9 . The hea t prod uced by the CO 2 la se r on surrounding

and underlying dermis may be responsible for the

immediate t ightening of the skin permit t ing immedi-

ate assessment of the degree of impro veme nt. This

gives m ore co ntrol to the surgeon, a benefi t not avail-

able with chemical peel or dermabrasion.

10. Th e risk of hyp ertrop hic scarring with the laser is less

than for comparably deep trichloroacetic acid peels .

11. When laser resurfacing is comb ined with incisional

plast ic surgery, especial ly endoscopic b row l ift , both

the cause of the wrinkles and the wrinkles themselves

can be sim ultaneously treated, yie lding a result that is

bet ter and longer last ing than ei ther metho d by i tself.

We believe that the n ew gen erat ion high-energy pulsed

CO 2 laser is a safe an d effective tool for aesthetic plastic

surgery. How ever, this proced ure is very technique

dependent and requires a combination of didact ic and

hands-on tra ining, conservative surgical judgment, anddil igent pat ient fol low-up to obtain optimal results with

minimal complicat ions, n

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Presented at the annual meeting of the American Society

of Plastic and Reconstruc tive Surgeons Montre al

Canada October i995 .

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