CO2 Laser and the treatment of WRINKLES
In the last three years carbon dioxide lasers, which
target water in the skin, and now erbium YAG lasers have been developed
with very short "on" times called "ultrapulsing".
Carbon dioxide lasers are relatively old lasers that
are good at burning lesions, such as warts, small lumps and bumps around
the face, skin tags, etc. Newer versions of these lasers allow burning or
vaporization of skin with very little dissipation of heat or thermal
damage to surrounding tissues. What this means is that extremely thin
layers of skin can be peeled or burned off, allowing the physician to
precisely and uniformly injure the skin decreasing the risk of scarring or
color changes during the healing phase. The skin, once burned in this
fashion, will heal from oil glands and hair follicles. These procedures
have the same risks that deep chemical peels and dermabrasion have, such
as scarring and permanent color changes, as well as temporary blotchy
pigmentation. Scarring can be thick, red, cord-like scars most frequently
along the jaw and upper lip, or subtle white spots. Scars can develop that
pull down the eyelids, called ectropion, is a serious complication.
The current CO2 lasers have computers that will lay
down a pattern of laser pulses allowing the face to be blanketed in a very
uniform manner. Laser resurfacing is a tedious procedure which requires
some skill and experience on the part of the operator but much less than
that of dermabrasion where a spinning diamond wheel actually tears off
layers of skin. Thus, this laser has largely replaced dermabrasion and
deeper chemical peels. The deeper chemical peels used for wrinkles and sun
damage are unpredictable and can cause permanent color changes, as well as
sometimes leave the face with a thin, crepe-paper-like appearance.
The new CO2 lasers are less likely to produce these
problems when used properly. They offer the chance to truly remove 10 to
15 years of sun damage and weathering from the face. The laser must stop
at the jaw line since below that on the neck skin scarring is much more
common. The blood supply and oil glands allow the face to heal from such
injuries better than other parts of the body. While necks have been
treated, the risk of scarring is high. Necks and hands may be treatable
with the new erbium YAG lasers since these devices "burn" or vaporize only
very thin layers at a time. A combined approach with CO2 resurfacing for
the face and the new YAG for the neck and central chest may yield the best
results; however, further study is necessary. There can be a line of
demarcation between the treated site and the untreated site along the jaw
line or, in fact, along any untreated line. Thus, if a deep enough laser
peel is done there will be a change in appearance between the treated and
nontreated skin. The treated skin will be smoother and more youthful
appearing and the contrast between the jaw and the neck is sometimes
bothersome. While this can be hidden successfully with makeup, this could
possibly draw attention to the procedure. This line of demarcation usually
fades over time. This problem may be minimized by the combined approach
described above.
The main side-effect of laser surgery for wrinkles is
persistent redness of the face that can last for many months. It appears
similar to a bad sunburn. Thus, doing the entire face as a cosmetic unit
will yield a better result. If just the eyelids or lips are done, there
will be a line of demarcation between treated and nontreated skin. This
redness can be present for many months as the skin heals. The new YAG
lasers are reported to result in less redness but that may be more a
feature of depth in that erbium YAG lasers will not go as deep as CO2
lasers, as a rule, unless multiple "passes" are done. Each "pass" of one
of these lasers removes another layer of skin.
Other problems with laser surgery is that when done
aggressively it is a deep burn; in fact, it is a second-degree burn and
takes ten to fourteen days to completely heal, requiring the patient to
constantly bathe the face and put ointment on. There are risks of
infection with herpes virus, bacteria and yeast, which could lead to
disastrous scarring. The eyes, obviously, have to be protected during the
procedure to avoid burns, which could be disastrous. Metal contact lenses
are placed by most physicians to protect the eye from accidental injury
during the procedure.
The procedure can be done with local anesthesia in the
physician's office and it requires at least two hours to perform a
full-face laser peel. When the patient is asleep it is much easier for the
physician to perform the procedure quickly requiring 45 to 60 minutes of
lasing time which may decrease the physician's bill, but it will increase
the cost to the patient because of the general anesthesia and operating
room fees.
While laser resurfacing is not a panacea, it has
distinct advantages over older rejuvenating procedures such as deep
chemical peels and dermabrasion. The results of laser abrasion or a laser
peel depend upon the number of "passes" the physician makes over the skin.
Each "pass" with the laser burns to a certain depth. Deep laser abrasions,
with the CO2 lasers involve three to four passes, sometimes five around
the mouth for bad wrinkles depending upon the type of CO2 laser used.
Superficial laser abrasions involve one to two passes and while leading to
excellent improvement may not offer tremendous advantage over much less
expensive medium-depth peels. This may also be true of the new YAG lasers.
Physicians performing laser resurfacing should have
experience with such procedures including laser surgery, chemical peels
and dermabrasion. These physicians include dermatologists, dermatologic
surgeons, plastic surgeons, some ophthalmologists and ENT surgeons. While
technically the procedures are not particularly difficult to perform, when
compared to dermabrasion, practically speaking the physician performing
such services should be experienced managing these types of wounds and
their potential complications. Again, those same physicians that perform
chemical peels and dermabrasions and have used carbon dioxide lasers in
the past would be more than competent to manage such cases. That would not
exclude physicians who have, in good faith, gone to laser training courses
and have worked with experienced physicians to become competent in laser
resurfacing. Patients should make their decisions based on the trust and
faith they have in their individual physician but like all cosmetic
procedures one should "shop around" checking both the physician's
credentials and their fees for such procedures.
CO2 Laser reurfacing example
results
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