September/October 2008Circulation 20,000www.miinews.com

For many years carbon-dioxide (CO2) lasers dominated laserresurfacing technology. Consumers were thrilled with the signifi-cant results, however, the associated risks and lengthy downtimewith this highly ablative treatment modality led to a decrease ininterest. The patient’s desire for less invasive treatments has influ-enced the skin rejuvenation field as a whole and skin resurfacingis no exception. Lutronic, Inc. (Princeton Junction, N.J.) has com-bined the ablative properties of a CO2 laser with fractional andscanning technology to create their eCO2 device. This uniquecombination provides a wide variety of treatment options and con-siderably reduces adverse effects.

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In July 2008 eCO2 received FDAclearance to treat wrinkles, furrows, finelines, textural irregularities, pigmentedlesions, vascular dyschromia and variousother skin conditions for total skin resur-facing. Its ability to adjust depth penetra-tion along with Controlled Chaos scan-ning technology has resulted in a highlevel of efficacy with decreased discom-fort, positioning it as a top player amongmulti-functional fractional CO2 laser plat-forms on the market.

“Ability to adjust penetration depth isan important feature but not all lasers offerit,” said Mark G. Rubin, M.D., assistantclinical professor of dermatology at theUniversity of California, San Diego anddermatologist in Beverly Hills, Calif. “Posttreatment healing with fractional CO2 pro-cedures is dramatically improved andmuch faster than previous ablative tech-niques. Up to this point, we have notobserved any infections, scars or loss ofpigment after eCO2 treatments. If they’retreated on Monday, patients are healedby the end of the week and have very fewissues, if any.”

“Healing time is what truly distinguish-es fractional technologies from traditionallaser therapies,” stated Dr. Rubin. Insteadof full ablation, the eCO2 lays down apattern of tiny ablative wounds. The skinbetween each wound is left undamaged,allowing new, healthy skin cells to spreadmore rapidly to the injured areas. In addi-tion, bulk heating is reduced, whichlessens treatment discomfort and decreas-es downtime to just days.

In contrast, traditional ablative CO2laser resurfacing produces mass thermalinjury and completely removes an entirelayer of skin. Downtime is measured inweeks and the risk of complications suchas scarring, infection, or hypopigmenta-tion is much greater. Physicians must relyon topical anesthesia, nerve blocks orsedation to control the pain during treat-ment and discomfort during recovery isalso greater.

“Basically, the technology behindeCO2 fills a niche we’ve been tryingto fill for years,” Dr. Rubin advised.“Patients with significant wrinkling havedesired resurfacing treatments, howeverthey were wary of the risks and disad-vantages associated with full-on ablativelasers and therefore elected not to under-go resurfacing procedures. We can nowoffer an attractive technology to themwhich has had a very positive impact onour practice.”

eCO2 features Controlled Chaos Tech-nology (CCT) which sets it apart from thecompetition. “Unlike most other devicesthat deposit microscopic wounds in a linearpattern, eCO2 laser pulses are deposited

“We have not observedany infections, scars orloss of pigment aftereCO2 treatments. Ifthey’re treated onMonday, patients arehealed by the end of theweek and have very fewissues, if any.”

eCO2 Merges Traditional CO2 withModern Fractional Technology for Improved ResultsBy Lara G. Owens and Kevin A. Wilson, Contributing Editors

THE Aesthetic Guide September/October 2008 www.miinews.com

Mark Rubin, M.D.Dermatologist, Beverly Hills, CAAssistant Clinical Professor ofDermatologyUniversity of California, San DiegoSan Diego, CA

Before Tx One month after second eCO2 Tx

Photos courtesy of J. David Holcomb, M.D.

in a seemingly random fashion,” explainedJeffrey Rapaport, M.D., of Cosmetic Skinand Surgery Center in Englewood Cliffs,N.J. “This technology actually chooses thefarthest point from the last wound, thusdecreasing thermal damage and reducingpain. That’s what I want – a unit I can usewithout nerve blocks or sedation that pro-vides effective treatment.” eCO2 is alsocapable of laying down wounds sequen-tially, depending on physician preference.

According to J. David Holcomb, plasticsurgeon in Sarasota, Fla. and past presi-dent of the Florida Society of Facial Plasticand Reconstructive Surgery, eCO2’sdynamic mode is another unique aspect ofits versatility. “In this mode, if the patientfeels discomfort, the user can simply turndown the speed that spots are being laiddown at instead of having to changeparameters, which can have a detrimentaleffect on the overall results. Treatment timeincreases a little but it reduces discomfortwithout disturbing efficacy.” Conversely itsstatic mode provides the ability to repeat-edly stamp patterns in the treatment area,with a spot size of up to 14 mm x 14 mm.

Dr. Rubin finds the dynamic mode espe-cially beneficial in finessing treatment toreduce the checkerboard look seen manytimes with traditional stamping modes thatother devices rely on. “eCO2’s dynamicmode is like spray painting. We use it forblending more than traditional therapy. Thisdevice is one of the few fractional devicesthat allows the option of either mode.”

Another useful feature of the eCO2 isits automatic total density counter which

enables greater treatment consistency. “Thisensures exact amounts of treatment, notonly between different facial regions butacross different patients, which enhancesreproducibility.”

eCO2 also features selectable continu-ous or pulsed operating modes; random-ized or regular beam patterns; and skinsensor technology which prevents thehandpiece from discharging when not incontact with the skin. Initial biopsy studiesindicate that the laser can penetrate asdeep as 2.4 mm into the dermis at a 120micron wound diameter. Parameters canbe set for minimum or maximum ablationand three different treatment tips areoffered, including a point beam tip for inci-sion, excision and vaporization of skin tagsand pigmented lesions. “Tips connect mag-netically so they’re easy to attach anddetach,” said Dr. Holcomb. “Lutronic’s instru-ments are equipped with recognition soft-ware so their devices have interchange-able treatment tips. Users can apply a lowprofile tip to enable a more ergonomictreatment, I use that one for eyelids and itmakes a big difference.”

Patients with photodamage are benefit-ing from eCO2 therapy because of the pos-itive effect the procedure has in the deepdermis. According to James H. Carraway,M.D., of the Aesthetic Skin Care Center inVirginia Beach, Va., “We lack the appro-priate experience to comfortably handledarker pigmented skin so we only treat skintypes I through III. We’re focusing on photo-aged skin with fine wrinkles and a thin der-mis. The eCO2 reaches the deep dermisand stimulates new collagen to thicken theskin and tighten to some extent.”

“As a plastic surgeon, my goals are dif-ferent from those of a dermatologist,” Dr.Carraway continued. “I can operate on apatient for two hours, and they will have

“Lutronic’s instruments areequipped with recognitionsoftware so their deviceshave interchangeabletreatment tips. Users canapply a low profile tip toenable a more ergonomictreatment, I use that onefor eyelids and it makes abig difference.”

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Jeffrey Rapaport, M.D.Cosmetic Skin and Surgery CenterEnglewood Cliffs, NJ

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dramatically tighter skin. I often tightenwith a face-lift, then follow-up with eCO2to enhance the overall effect, but it alldepends on power, density and how muchdowntime a patient is willing to accept. Itell my eCO2 patients the same thing I tellmy face-lift patients: the more comprehen-sive result we achieve, the more downtimeyou’ll have. Let the patient get involved intheir care. They can tell you how muchdowntime they can manage.”

“Fractional lasers produce approxi-mately 10% to 15% less wrinkle reductionthan traditional CO2 ablative lasers,” Dr.Rubin reported. “That’s still very impres-sive. In addition, results have been spec-tacular for color and textural improvementand everyone believes fractional CO2lasers are the treatment of choice for acnescars today.”

Dr. Rapaport also added that, “scarsare a traditionally difficult to treat indica-tion that necessitate eCO2 therapy ratherthan popular non-ablative devices. Unlikemany other physicians my practice isabout 70% acne scars and 30% photo-aging.” When treating acne scars, “abla-tion is superior to non-ablation for threereasons: greater depth, better remodelingand improved tightening. Acne scars con-tain more collagen and elastin fibers thanother tissue, making it more difficult to getthrough ablatively, let alone non-ablative-ly. Generally, acne scar patients are morewilling to tolerate downtime than wrinklepatients because they’ve dealt with disfig-urement for so long. So far I haven’t need-ed to perform a second treatment.”

“Certain types of acne scars respond bet-ter than other types of acne scars,” Dr.Rapaport continued. “The eCO2 worksvery well for boxcar scars, pits and shallowscars. Atrophic scars are the only limitationbut nothing works terrifically on them.”

Dr. Holcomb uses the eCO2 to treat alot of dyschromia, skin laxity on the face,neck and arms, acne scars and othertypes of scars. “You obviously have to becareful about the energies. I use low den-sities and moderate energies. After evalu-ating many different non-ablative fraction-al devices, results with eCO2 are by fargreater and patient satisfaction is high.”

“Patient feedback has only been posi-tive,” Dr. Rubin agreed. “Everybody justloves it. It’s like botulinum toxin – youhave to search long and hard to find anunhappy patient. I don’t think we’ve treat-ed one person with eCO2 who hasn’tcome back thrilled with their skin.”

Dr. Carraway has found results to besimilarly noteworthy, even in patientswho had received previous treatmentwith comparable devices. “After oneeCO2 treatment they could really see achange, and that’s the key. In order tofeel an enthusiasm towards treatment,patients need to see a change and knowa bigger transformation is coming.”

“After evaluating manydifferent non-ablativefractional devices, resultswith eCO2 are by fargreater and patientsatisfaction is high.”

J. David Holcomb, M.D.Plastic SurgeonSarasota, FL

Photos courtesy of Jeffrey Rapaport, M.D.

Before Tx Three weeks after eCO2 Tx

Since the eCO2 device is still new to themarket and collagen remodeling takes fourto six months to fully occur, future resultscould potentially be even better as cliniciansperfect their technique. “Patients we treatedfive or six months ago are very happy withtheir results, but I think we are more aggres-sive with treatment than we were back thenowing to our continued training,” explainedDr. Rubin. “I’m sure that our current patientswill achieve even better results than thosewe saw with our first patients.”

Dr. Rubin also shared the two opposingparadigms for achieving the best result infractional resurfacing: deep penetration ona small percentage of skin versus moresuperficial penetration on a higher per-centage of skin area. “We’re moving moretowards deeper treatment with low density,but we have quickly realized that we canbe more aggressive than we were initiallycomfortable with. You can easily reach800 or 1,000 microns in a small percent-age of skin and get significant improve-ment in wrinkling and tightening. If you’retreating just pigmentation or areas off theface, don’t go too deep. You can use verylow energies and low densities.”

“Another reason I like eCO2 is that I cantreat my patients with 30% topical lidocaineonly. I am able to be pretty aggressive withmy settings even without sedation,” notedDr. Rapaport. “Here in New Jersey, thereare a lot of regulations for pain manage-ment medication and nerve blocks cancause bruising which could take longer toresolve than laser induced erythema.”

Dr. Carraway manages treatment dis-comfort with intra-muscular Versed fromHoffman-LaRoche, Inc. (Nutley, N.J.), whichtakes effect more rapidly than many alter-natives. “We also use topical anestheticsbut 3 mg to 4 mg of Versed relaxes thepatient just enough to get them through

the laser procedure. Since I also use it forvarious surgery procedures, I have experi-ence with it.”

“Hydroquinones may be appropriatewith eCO2,” Dr. Rapaport noted. “Forany skin type higher than type II, we willstart that from day one. If they’re dark,we’ll give them 8% hydroquinone.”

The group agreed that post treatmentcare is limited mostly to moisturization buteach physician had their own preferredprotocol. Dr. Rubin sends his patient’shome with Aquaphor healing ointmentfrom Eucerin-Beiersdorf (Wilton, Conn.)for the first day and then replaces it witha less greasy moisturizer to reduce thechance of post treatment acne outbreaks.“We also have patients apply cool com-presses several times a day for three orfour days. Most people are completelyhealed and ready to face the world byday five, but we encourage them to setaside seven days just in case,” he said.

Dr. Carraway added that the need forantibiotic prophylaxis with eCO2 is less thanwhat is required for traditional resurfacing.“We only use pre-operative antibiotics ifsomeone has a history of recurrent infec-tions. Post-operatively we routinely admin-ister anti-virals for all laser work around themouth. We also like to prepare the skinwith tretinoin and vitamin C. Antibacterialointments have the potential to incite aller-gies so we don’t use them.” He also putspatients on a low-starch diet to reduceswelling, which contributes to post treat-ment discomfort. “Usually after five days,patients can wear make-up again.”

“Patients we treated fiveor six months ago arevery happy with theirresults, but I think we aremore aggressive withtreatment than we wereback then owing to ourcontinued training. I’msure that our currentpatients will achieve evenbetter results than thosewe saw with our firstpatients.”

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James H. Carraway, M.D.Aesthetic Skin Care CenterVirginia Beach, VA

Nine weeks after eCO2 Tx

Before Tx

Photos courtesy of Mark Rubin, M.D.

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As with any laser therapy, there is arisk of burns or post-inflammatory hyper-pigmentation, but this is extremely lowwith eCO2 therapy. “Anytime you createa wound you have to be prepared for thepotential adverse events,” Dr. Rubinadvised. “With eCO2’s fractional tech-nology, the healing is much faster and theinjuries are less traumatic than they werewith the old lasers, therefore ensuingproblems are much less frequent.”

Dr. Holcomb agreed that adverseeffects have not been an issue. “With anydevice you have to be careful aboutemploying too much energy in a shortperiod of time, but I have had no prob-lems, even with the darker skin types.”

Fractional technology is not new, andneither are the procedures associatedwith it, which facilitates easy integration.“Integrating eCO2 into a practice is notdifficult, especially for those with laserexperience,” Dr. Rubin stated. “There is alearning curve for setting it all up, but itreally only takes a few days to get youroffice up to speed. The paperwork,including consent forms and other patientinformation sheets are the real issue,which is normal.”

According to Dr. Rapaport, eCO2 pro-vides an alternative for his older patientswho, due to the extent of their photodam-age, previously only had the option of tradi-tional CO2 resurfacing. “Now with maybetwo eCO2 treatments we will see resultsequal to one traditional CO2 treatment.Additionally, the price of eCO2 is lowerthan similar devices for both the patient andthe physician and there are no disposables.Therefore fewer treatments are required tosee the return.

“Cost is a major factor,” agreed Dr.Carraway. “Plastic surgeons and derma-tologists need to be able to afford thesemachines. Quite honestly, I am alwaysaverse to offering patients expensive pro-cedures, so if I can present somethingmore affordable I feel good. eCO2 givesme the opportunity to provide a moreaffordable treatment with the confidenceof obtaining a good result and less down-time. Moreover, Lutronic’s technical sup-port and service have been excellent.”

According to Dr. Rubin, the full capabil-ities of eCO2 and fractional CO2 technol-ogy are still being explored. “There areactually more features on the eCO2 that Ihave not experimented with yet, but I likethe idea of having a device that doesmore than I need. Oftentimes you canenhance treatment when you have moreparameters available. This is more thanjust science. As we gain experience wecan advance further toward the artisticside of cosmetic surgery. Having an eyefor aesthetics is what separates goodpractitioners from great ones and eCO2definitely plays a role in this.”

“With eCO2’s fractionaltechnology, the healing ismuch faster and theinjuries are less traumaticthan they were with theold lasers.”

Before Tx Ten days after eCO2 Tx

Photos courtesy of Jeffrey Rapaport, M.D.