Fractional CO2 laser can play a role in the ophthalmic practice

A surgeon says the procedure is useful for periocular rejuvenation and as an adjunct to surgical blepharoplasty.

Raminder K. Saluja

The gold standard for treating photodamaged skin, photoinduced facial rhytids, precancerous lesions, dyschromias and atrophic scars has been the carbon dioxide laser.

Ophthalmologists have used the CO₂ laser for periocular rejuvenation in the past. This laser, along with the Er:YAG laser, ablates the epidermis to the mid-papillary dermis. The thermal effect of the CO₂ laser acts on dermal collagen stimulating neocollagenesis and tightening of facial skin. Another method of decreasing thermal damage while promoting collagen stimulation is combination therapy with CO₂ laser followed by Er:YAG laser.

The final result of laser ablation is dramatic; however, recovery time may take weeks, and there is a risk of fungal, viral and bacterial infections as well as prolonged edema, erythema, dyspigmentation and scarring. Re-epithelialization can take 5 days to 14 days, and postoperative erythema can last for many months.

Development of fractional lasers

Due to the extreme side effect profile, carbon dioxide ablative resurfacing has fallen out of favor in recent years and has been replaced by minimally invasive procedures with rapid healing times. Unfortunately, most minimally invasive procedures lead to minimal results. The current consensus among patients is to embrace a treatment modality that delivers maximum results with minimal downtime. This desire has led to the development of fractional lasers that treat a percentage of the skin while leaving the intervening areas untreated.

Initially, fractional lasers were introduced in non-ablative technology, which was developed to overcome the homogenous thermal damage typically created after treatment with standard CO₂ and/or Er:YAG laser. The idea was to create microscopic thermal wounds that spare the tissue surrounding each wound. Results were visualized with this modality, with a 2.1% linear shrinkage of periorbital rhytids noted at 3 months. Unfortunately, non-ablative lasers do not perform well for improving significant photodamage. There is still a place for non-ablative lasers, and the indications would be for patients who desire improvement of their photodamage but cannot accept downtime and are willing to undergo four to six treatments before their results are clinically visualized.

More recently, fractional photothermolysis is being applied to ablative lasers, allowing for a more aggressive treatment option. This development allows for a percentage of skin to be treated, while leaving intervening areas untreated, which allows for dramatic results associated with quicker healing times and less postoperative sequelae.

As an ophthalmologist and cosmetic surgeon, I have seen a shift in practice regarding periocular rejuvenation. The shift is toward less surgery and greater corrective procedures involving lasers, which address textural issues of the skin as well as laxity. Our fractional CO₂ laser (Affirm CO₂, Cynosure) has been the laser that has generated the greatest volume of patients.

Fractional CO₂ procedure

Patients who are candidates for fractional CO₂ laser have a Fitzpatrick skin type of 4 or less. Although the literature now shows that Fitzpatrick skin type 5 patients can undergo fractional CO₂ without the complications of post-inflammatory hyperpigmentation, I remain conservative regarding treatment of Fitzpatrick skin type 5.

During consultation, before and after procedures are shown to patients to allow them to visually appreciate downtime. They are given prescriptions for acyclovir and Keflex (cephalexin, MiddleBrook Pharmaceuticals), which they begin 1 day before the procedure and continue for 1 week postop.

Lidocaine 5% ointment is applied topically for 1 hour. Ativan (lorazepam, Biovail Pharmaceuticals) and Lortab (acetaminophen and hydrocodone, UCB) are then given orally.

Ocular shields are placed over the cornea before the procedure.

Depending on the level of rhytids, dyschromia or textural issues (acne scarring), energy from 20 W to 25 W is selected for the first pass. The dwell time (pulse duration) and pitch (density of microthermal spots) are selected based on the level of treatment indicated. This is followed by a second pass at lesser settings.

A cool air blower (SmartCool, Cynosure) is utilized during the procedure for patient comfort.

After the procedure, cool compresses are applied for 10 minutes followed by Aquaphor. Patients are instructed to continue with cool compresses for 5 minutes every 30 minutes for the rest of the day. They are to wear Aquaphor for 4 days and may return to their sunscreen and makeup on day 5 after they have re-epithelialized.

Dyschromia and textural irregularity are improved by week 1. The real neocollagenesis is appreciated after 10 weeks.

Patients have been satisfied with the procedure, and many have recommended it to their friends.

I think that fractional CO₂ has a role as a standalone modality for periocular rejuvenation and as an adjunct to surgical blepharoplasty.

References:

• Alster TS, Garg S. Treatment of facial rhytides with a high-energy pulsed carbon dioxide laser. Plast Reconstr Surg. 1996;98(5):791-794.
• Fitzpatrick RE. Laser resurfacing of rhytids. Dermatol Clin. 1997;15(3):431-447.
• Fitzpatrick RE, Goldman MP, Sotur NM, Type WD. Pulsed carbon dioxide laser resurfacing of photo-aged skin. Arch Dermatol. 1996;132(4):395-402.
• Goldman MP. Carbon dioxide and erbium:YAG laser ablation. In: Cutaneous and Cosmetic Laser Surgery. St. Louis: Mosby; 2006:162.
• Goldman MP. Laser-tissue interactions. In: Cutaneous and Cosmetic Laser. St. Louis: Mosby; 2006:5.
• Goldman MP, Manuskiatti W, Fitzpatrick RE. Combined laser resurfacing with the ultrapulse carbon dioxide and Er: Yag lasers. In: Fitzpatrick RE, Goldman MP, eds. Cosmetic Laser Surgery. St. Louis: Mosby; 2000.
• Goldman MP, Marchell N, Fitzpatrick RE. Laser skin resurfacing of the face with a combined CO₂/Er:YAG laser. Dermatol Surg. 2000;26(2):102-104.
• Greene D, Egbert BM, Utley DS, Koch RJ. The validity of ex vivo laser skin treatment for histological analysis. A prospective controlled study. Arch Facial Plast Surg. 1999;1(3):159-164.
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• Hobbs ER, Bailin PC, Wheeland RG, Ratz JL. Superpulsed lasers: minimizing thermal damage with short duration, high irradiance pulses. J Dermatol Surg Oncol. 1987;13(9):955-964.
• Lowe NJ, Lask G, Griffin ME, Maxwell A, Lowe P, Quilada F. Skin resurfacing with the Ultrapulse carbon dioxide laser. Observations on 100 patients. Dermatol Surg. 1995;21(12):1025-1029.
• Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med. 2004;34(5):426-438.
• Manuskiatti W, Fitzpatrick RE, Goldman MP. Long-term effectiveness and side effects of carbon dioxide laser resurfacing for photoaged facial skin. J Am Acad Dermatol. 1999;40(3):401-411.
• Ratner D, Tse Y, Marchell N, Goldman MP, Fitzpatrick RE, Fader DJ. Cutaneous laser resurfacing. J Am Acad Dermatol. 1999;41(3 Pt 1):365-89.
• Saluja R, Khoury J, Detwiler SP, Goldman MP. Histologic and clinical response to varying density settings with a fractionally scanned carbon dioxide laser. J Drugs Dermatol. 2009;8(1):17-20.
• Tan KL, Kurniawati C, Gold MH. Low risk of postinflammatory hyperpigmentation in skin types 4 and 5 after treatment with fractional CO₂ laser device. J Drugs Dermatol. 2008;7(8):774-777.

• Raminder K. Saluja, MD, can be reached at Presbyterian Cosmetic and Laser Center, 17810 Statesville Road, Suite 321, Cornelius, NC 28031; 704-895-5394; fax: 704-895-5399; e-mail: rksaluja@novanthealth.org. Dr. Saluja has given lectures for Cynosure in the past for which she has been paid. She has no financial interests in the laser or other products.