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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…