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Some surgeons unconvinced of benefits of oculoplastic lasers
Manufacturers promote new nonablative lasers for oculoplastic procedures.
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Lasers have been used in oculoplastic surgery for decades, but some surgeons remain unconvinced that lasers will ever replace knives and scalpels.
In 3 decades of practicing medicine, Richard L. Anderson, MD, FACS, said he has seen oculoplastic surgery evolve from the largely “part-time” domain of general ophthalmologists to an independent and fully realized subspecialty.
Also in that time, he said he has witnessed ups and downs of laser technology for oculoplastic procedures. He pointed to the carbon dioxide (CO2) diode laser as an example of a technology that has seen its popularity wax and wane during its history in oculoplastic surgery.
Since the CO2 laser entered the market in the 1970s, Dr. Anderson said its use has expanded from a tool for removing vascular lesions to a device for creating surgical incisions. In the past 10 years, he said, the CO2 was largely considered to be the “Cadillac of lasers,” and practitioners “from dentists to OB/GYNs” clamored to adopt it into their practices.
“I think there was a huge push in the ’90s that if you weren’t using lasers you were behind the times,” Dr. Anderson said. “My overall philosophy is that laser companies promoted lasers more than physicians.”
Laser “infatuation”
Dr. Anderson noted that both physicians and patients are “infatuated” by expensive treatments, but once physicians invest in costly equipment, they may feel obligated to use it to cover costs.
“Some of this technology falls into the hands of people who have no training in cosmetic surgery,” he said. “The controls on some of these devices [are] of some concern. The marketing of some of these devices is of concern.”
Like Dr. Anderson, David S. Felder, MD, said he has resisted using the CO2 laser in cosmetic procedures – with one exception. The laser, he said, is the “gold standard” for 70% to 80% of his blepharoplasty patients who need resurfacing and tightening of the skin after a transconjunctival blepharoplasty is performed on the lower eyelids.
While a scalpel is easier to use for excising upper eyelid skin and a Colorado needle is used for fat removal, a laser works best to tighten wrinkles that develop after the fat is removed, he said. “In my hands, I think the laser works very, very well,” he said, estimating that there is a 50% to 70% reduction in wrinkles with the CO2. “The results that I get are very reproducible,” he said.
Types of lasers
Laser technology falls into two categories: ablative (which include the CO2, erbium:YAG and long-pulsed erbium: YAG lasers) and nonablative. According to the American Academy of Dermatology, ablative lasers remove the epidermis and heat the papillary dermis, stimulating the regeneration of collagen. Nonablative lasers bypass the epidermis and treat only the papillary dermis.
Complications from using an ablative laser could include at least hyperpigmentation, which Dr. Felder estimated occurs in 10% to 15% of patients and is more common in patients with darker skin.
Other risks from lasers include perforated globes, cicatricial ectropion, diplopia (when injury occurs to extraocular muscles) and corneal burns, according to Dr. Anderson.
He noted that surgeons began using ablative lasers to make incisions in several cosmetic and reconstructive periorbital procedures in order to overcome issues of hemostasis and to reduce postoperative bruising.
“I like to precisely excise the tissue. If you do that with a hot modality, the fatty tissue just contracts in front of your eyes,” Dr. Anderson said. It then reappears later, he said.
He added that these lasers are also less precise than scalpels and cause more collateral damage.
“Surgery is a tactile as well as a visual experience. I think there’s no better instrument than cold steel,” he said.
Dr. Anderson added that a common misconception is that a laser procedure is easier to perform than traditional surgery. The opposite is actually true; surgeons must have greater knowledge of eyelid and facial anatomy when applying a laser to overcome the lack of “tactile feedback,” he said.
Newcomers
Laser manufacturers, meanwhile, have turned to nonablative lasers to capitalize on the growing demand for procedures with quicker recovery times, the primary advantage associated with this technology.
In addition, many surgeons who were initially interested in the CO2 laser soon realized that they did not have the appropriate ancillary staff to support the procedure, according to Dr. Felder.
“There is some hand-holding to the postoperative care for using CO2 laser,” he said. He added that his practice employs two full-time aestheticians to help patients with skin care and applying cosmetics during the recovery period. “I think a lot of [surgeons] didn’t have the necessary ancillary staff or didn’t want to deal with it,” he said.
Yet Dr. Felder noted that with nonablative lasers, patients might not see results for several months, and multiple treatments are often required. Even then, nonablative lasers may not produce a significant result, he said.
“My practice is result-driven,” he said. “I don’t want my patients coming back in 6 months saying, ‘I don’t see a difference.’ They’re paying to see a difference.”
Results with an ablative laser can last 4 to 5 years, Dr. Felder said.
Future considerations
The most common form of nonablative technology is known as “intense pulsed light,” a term that was patented by manufacturer Lumenis to describe high levels of light energy supplied in millisecond bursts.
While nonablative lasers are most effective at removing hair and vascular lesions, Dr. Anderson said it would be premature to say whether this technology will ever replace chemical peels, which he described as cheaper and more effective for pigment and wrinkles. No down time is an advantage of the lighter peels and intense pulsed light, he said.
The newest in nonablative technology is called LED (light-emitting diode), according to Dr. Anderson. It is said to increase collagen production and improve skin quality. These newer light treatments are not true lasers, he said.
Yet lasers also offer other advantages when used in skin resurfacing by achieving results “more dramatically, effectively and uniformly” than chemical peels, avoiding potential heart rhythm disturbances and preventing systemic phenol absorption and toxicity, according to the American Society of Ophthalmic Plastic and Reconstructive Surgeons.
Dr. Anderson said that research on light therapy is still needed to fully understand which lights and wavelengths benefit or damage skin, and to find other modalities for achieving the same results.
For Your Information:
- Richard L. Anderson, MD, FACS, can be reached at Oculoplastic Surgery Inc., 1002 East South Temple, Suite 308, Salt Lake City, UT 84102; 801-363-3355; fax: 801-533-9613; e-mail: oculoplasticsurgery@worldnet.att.net.
- David S. Felder, MD, can be reached at Cosmetic Eyelid and Laser Center of South Florida, 2021 E. Commercial Blvd., Suite 306, Fort Lauderdale, FL 33308; 954-771-1310; fax: 954-771-1950; e-mail: dsfelder@eyelidlaser.com.
References:
- The American Academy of Dermatology can be reached at P.O. Box 4014, Schaumburg, IL 60168-4014; 847-330-0230; fax: 847-330-0050; Web site: www.aad.org.
- The American Society of Ophthalmic Plastic and Reconstructive Surgery can be reached at 1133 West Morse Blvd., #201, Winter Park, FL 32789; 407-647-8839; Web site: www.asoprs.org.
- Anderson RL, Pratt DV, Patel BCK. Laser mania in medicine. Arch Ophthalmol. 1998;116:1657-1658.
- Felder DS, Mayl N. Peri-orbital carbon dioxide laser resurfacing. Semin Ophthalmol. June 1996;11(2):201-210.
- Felder DS. CO2 laser skin resurfacing in oculoplastic surgery. Curr Opin Ophthalmol. 1996;7:32-37.
- Mayl N, Felder DS. CO2 laser resurfacing over facial laps. Aesthetic Surg J. September-October 1997;17.