The Gold Standard in Facial Resurfacing: The CO2 Laser and Future Directions

Transcription

1 Exploring Aesthetic Interventions The Gold Standard in Facial Resurfacing: The CO2 Laser and Future Directions The senior authors, Dr. Emil Bisaccia and Dr. Dwight A. Scarborough, are authors of the textbook The Columbia Manual of Dermatologic Cosmetic Surgery. BY DWIGHT SCARBOROUGH, M.D, LILIANA SAAP, M.D., AND EMIL BISACCIA, M.D. As many new technologies are developed to turn back the signs of aging, ablative resurfacing, in particular carbon dioxide (CO2) resurfacing, still remains the gold standard for erasing and smoothing out rhytids, photodamage and acne scars. In this article, we will briefly review the history of the CO2 laser and the most common applications of this laser in our cosmetic practice, as well as the possible complications and the best ways to avoid these. HISTORY OF THE LASER The term laser stands for light amplification by the stimulated emission of radiation. The concept of stimulated emission, introduced by Einstein in 1927, led to the development of a ruby laser by Maiman 1 in Several years later, in 1963, dermatologist Leon Goldman 2 became the first physician to test the effects Emil Bisaccia, M.D., F.A.C.P. Dwight Scarborough, M.D. of this laser on human skin. 3 The first published report of the CO2 resurfacing was for the treatment of actinic chelitis in However, it was not until the 1980s that the CO2 laser was used to treat wrinkles. 4 The first CO2 lasers operated on a continuous-wave (CW) mode. This means that, unlike the pulsed lasers, they did not operate on the principle of selective photothermolysis. The concept of selective photothermolysis, as conceived by Anderson and Parish in 1983, 5 refers to the concept of targeting a chromophore in a specific manner utilizing light energy to cause temperature mediated localized injury in a precise fashion as to avoid or keep to a minimum damage to the surrounding areas. 3 The CW CO2 lasers are not as specific in minimizing surrounding tissue damage. As such, they were initially used in an excisional mode for hemostatic capabilities or a vaporization mode to treat seborrheic keratosis, lentigines, actinic chelitis and other epidermal lesions. 3 More recently, superpulsed/ultrapulsed CO2 lasers have been developed, which follow the principle of selective photothermolysis. It is these new systems that have allowed lasers to be used for resurfacing of rhytids, photodamage and acne scarring. Since the inception of these lasers, continued use has also allowed us to create treatment parameters and wound care protocols that maximize the benefits of resurfacing while at the same time minimizing the risks, such as scarring, that were seen in the early days of CO2 resurfacing. THE IMPORTANCE OF PATIENT SELECTION AND PATIENT PREPARATION In obtaining the best results in CO2 laser resurfacing, it is imperative to pick the right patient. Patients that seem to do the best are patients with skin types I through III. Patients with darker skin types IV through VI have been treated, but run the risk of prolonged hyperpigmentation, up to 100%. 4 The risk of hypopigmentation is also a possibility in all patients. Some authors, however, feel 64 OCTOBER 2006 SKIN & AGING

2 that this risk is higher in patients with skin types I and II. 4 In addition to considering skin type, it s also very important to review medical history, medications, and history of scarring and prior cosmetic procedures. Patients expectations regarding degree of improvement, as well as the recovery time needed, should also be reviewed. Patients with prior history of dermabrasion or phenol peel may be at increased risk of hypopigmentation after ablative resurfacing. The need for antibiotic and antiviral prophylaxis prior to CO2 laser resurfacing is an important consideration as infection can cause scarring and delayed healing after laser resurfacing. Latent herpes reactivation is a clearly identified risk that occurs in about 2% to 7% of all laser resurfacing patients, even patients with no prior history of herpes simplex infection. 6 In our practice, valacyclovir 500 mg (Valtrex) twice a day is started 48 hours prior to resurfacing for a total of 10 days. The issue of prophylactic antibiotics is not as well established, since there are no controlled studies supporting the common practice of prescribing antibiotic agents to patients undergoing laser resurfacing. 3,7,8 Nevertheless, given the cosmetic nature of the laser resurfacing and the potential threat of scarring secondary to bacterial infection most laser surgeons do prescribe prophylactic antibiotics. 3 We often give patients 1 gm of I.V. cephalexin during the laser resurfacing procedure. Some laser surgeons also give fluconazole (Diflucan) to prevent candidal infection. 4 Currently there is no data to uphold the usefulness of topical preparation agents in preconditioning for laser resurfacing. 3 ANESTHESIA For laser resurfacing, several types of anesthesia can be used.these range from topical anesthesia, local anesthesia, regional anesthesia with nerve blocks, tumescent anesthesia, intravenous sedation to general anesthesia. In our experience, topical anesthesia is not effective for resurfacing beyond the epidermal level. Local anesthesia can be used for small cosmetic units, and nerve blocks can be used for larger cosmetic units. However, we have a preference for intravenous sedation and have found it ideal for CO2 laser resurfacing. A certified registered nurse anesthetist employs intravenous sedation, which consists of short-acting intravenous sedative agents such as propofol, fentanyl and midazolam. Twilight sleep provides for maximum patient comfort and laser efficacy. 9,10 Eye protection is also very important for laser resurfacing. Before starting resurfacing, we apply tetracaine drops (AK-T-Caine PF, Pontocaine) on the eyes followed by nonreflective laser eyeshields lubricated with ophthalmic ointment. CO2 APPLICATIONS It is important to be familiar and have a thorough understanding of all the parameters of CO2 laser resurfacing and how to vary them before starting, in addition to being familiar with the nuances of different anatomic sites, and possess the ability to use clinical findings in recognizing the clinical endpoint.the CO2 systems ordinarily vaporize 20 µm to 60 µm of tissue on the first pass, completely obliterating the epidermis. Following the first pass, each subsequent pass vaporizes lesser amounts of tissue owing to the effects of progressive dessication. But on average, most CO2 systems ablate down the papillary dermis after only two passes and reach the upper reticular dermis with three passes. In our office the most common uses of the CO2 laser are for full face resurfacing for rhytids (See Photos 1a and b, 1A 1B PHOTOS 1A-1B: 1A) Patient prior to CO2 laser resurfacing for rhytids and 1B) 6 weeks post CO2 laser resurfacing. OCTOBER 2006 SKIN & AGING 65

3 2A 3A PHOTOS 3A-3B: 3A) Patient prior to CO2 laser resurfacing for rhytids and 3B) 7 weeks post treatment. This patient also had a jawline tuck. 2a and b, and 3a and b), partial resurfacing after lower lid blepharoplasty and full or partial resurfacing for acne scarring (See Photos 4a and b, and 5a and b). We use the Ultrapulse CO2 laser (Lumenis) with the 8-mm computer pattern generator (CPG) scan at settings of 250 mj to 300 mj, 60W power, density of 5 and pattern of 29. Thinner and less involved areas of the skin that may be prone to scarring including the eyelids, malar region and mandible usually receive one or rarely two passes, while thicker and more involved areas of the skin, like the cheeks and forehead, may be treated with as many as three to four passes.this applies especially if the forehead and cheeks show signs of heavy photodamage or significant atrophic acne scarring but are otherwise healthy. In making multiple passes during resurfacing, it is our preference to use a pattern similar to dermabrasion, where the first pass may be vertical while the second pass is oblique, followed by a pass 2B PHOTOS 2A AND 2B: 2A) Patient prior to CO2 laser resurfacing for rhytids and 2B) 4 weeks post CO2 laser resurfacing. 3B that is horizontal. For the purpose of feathering of transition zones, in particular along the mandible and the preauricular region (especially when treated in combination with facial rhytidectomy), the laser beam is held at an oblique angle. 3 We often remove coagulated debris between passes, however in the case of severe wrinkling or acne scarring, prefer to leave the debris in favor of stacked pulses. POSTOPERATIVE CARE AND FOLLOW-UP After the final CO2 pass, we remove the eye shields and this time gently clean the debris remaining from the skin to decrease possible infection. Some laser surgeons prefer to leave the debris as a natural wound dressing.the next step in postoperative care is use of a postoperative dressing. A bland emollient dressing has the advantage of allowing closer follow-up for signs of infection, and decreased risk of infection, it is less expensive, and allows patients a sense of control over wound care. The patient s failure to apply enough emollient can result in dryness, crusting, bleeding and pain. On the other hand, excessive application can lead to acne, milia and increased risk for bacterial and yeast infections. 3 Pain management is also important in the postoperative period. In our experience the pain that patients experience is similar to a sunburn but usually subsides after the first few hours and is usually completely resolved by the third postoperative day.we encourage the use of nonsteroidal anti-inflammatory agents but also provide the use of an oral narcotic agent. If pain increases and does not improve, the patient should be seen to assess and culture for possible infection viral, bacterial or fungal. It is also imperative that the patient avoid sun for the first 6 weeks, use UVA and UVB blocking agents on a regular basis, use only a mild synthetic soap, moisturize with mild hypoallergenic emollients, avoid tretinoin products and alpha hydroxy acid for 3 weeks, and not start foundation makeup until skin reepithelialization is complete (usually by day 7 to 14). 3 AVOIDING POTENTIAL COMPLICATIONS Minor complications include acne, milia, contact dermatitis and prolonged erythema. The formation of acneiform pustules and milia is quite common after laser resurfacing and is due to a combination of the skin becoming hypersebaceous after the laser peel, as well as postoperative occlusive and emollient use. This can be improved by manual extraction of milia and the use alpha-hydroxy acid and tretinoin after the first 3 to 6 weeks. Contact dermatitis is also common and can be reduced by limiting 66 OCTOBER 2006 SKIN & AGING

4 regular use of topical antibiotics and products with perfumes and preservatives. It is preferable to use bland emollients after laser resurfacing. Sometimes a mild topical steroid or even a course of oral steroids may help with this complication. Prolonged erythema is usually related to either contact dermatitis or an infection and usually resolves if these two issues are addressed. Moderate complications include infections, severe, post-inflammatory melasma-like hyperpigmentation, and hypopigmentation. Infections can lead to scarring so it is important to recognize and treat infections early. These can be avoided by limiting the duration of occlusive dressings and avoiding 4A prolonged postoperative antibacterial prophylaxis. Once an infection is suspected, cultures and sensitivities should be done to isolate the responsible organism and treat it appropriately. Post-inflammatory hyperpigmentation can affect all patients, but significantly affects patients with skin types IV and higher. 4 To avoid this complication it s imperative to have patients follow strict sun avoidance and protection, and only do superficial CO2 laser (no more than one pass) in patients with darker skin tones. 11 However, even by limiting CO2 to one pass in darker skin tones the risk of hyperpigmentation is still very high. Once it does occur, the use of sunscreen, sun avoidance, hydroquinone, alpha-hydroxy acids and tretinoin help reduce its severity and duration. 3 Hypopigmentation can either be relative or true. Patients with extensively sun-damaged skin have damage on both their faces and necks. After resurfacing the face, it may appear lighter than the skin on the neck that is still sundamaged. PHOTOS 4A AND 4B: 4A) Patient prior to CO2 laser resurfacing for acne scarring and 4B) 2 months post CO2 laser resurfacing. 5A PHOTOS 5A-5B: Side view of above patient. 4B 5B True hypopigmentation is an epidermal loss of melanin. This can affect patients with all skin types but is more noticeable in patients with skin types III and higher. 3 It also tends to affect patients with prior history of dermabrasion and phenol peel. Should it occur, the treatment options are limited. Prevention is aimed at not being overly aggressive and limiting the number of CO2 laser passes as well as patient selection. The most severe complications are hypertrophic scarring and ectropion formation.these are rare in our experience and can be generally avoided with proper patient selection, care in selecting energy parameters and number of passes appropriate for the individual patient; and proper postoperative follow up to be able to diagnose and treat infections or other complications early. 3 THE FUTURE OF FACIAL RESURFACING Even as the CO2 laser has set skin rejuvenation standards high, increasing demands for 1) less down time, 2) the need for greater patient comfort, and 3) the application for darker skin types has given rise to incremental surfacing technology. Early attempts were fraught with an unpleasant (green) skin discoloration for hours or days, and presented serious pain management problems, leading to the application of potentially toxic topical anesthetic agents. 12,13,14 A newer approach has yielded preliminary breakthroughs in providing significant aesthetic results with requisite patient comfort.we currently employ an Erbium laser handpiece (the Palomar Lux 1540 Fractional handpiece in conjunction with the Starlux system) that operates using the principle of fractional photothermolysis. Using a 1.5 cm 2 focusing lens with 320 spots per cm 2,a 1064-nm wavelength creates a focal points of tissue coagulation, stimulating new collagen and epithelium to quickly fill in the damaged treatment zones (See Photos 6a and b). The contact cooling plate at 4 degrees Celsius provides temperature stability to prevent discomfort OCTOBER 2006 SKIN & AGING 67

5 6A PHOTOS 6A AND 6B: 6A) Example cross-section of treated area shows penetration of microbeams into deeper layers of skin and 6B) Magnification of microbeam grid generated by laser during treatment Images provided by Palomar Medical. 7A PHOTOS 7A-7B: 7A) Patient prior to nonablative resurfacing with the Palomar Lux 1540 Fractional handpiece and 7B) 1 week post treatment. during treatment, and also protects the melanin-rich epidermis from overheating during pulse transmission. As with any laser, appropriate care must be taken with regard to patient selection as well as laser safety and proper use. Multiple treatments are required for best results, however we have found that with one treatment alone (3 passes, 50J at 10 ms), significant results may be obtained in the periorbital, perioral and cheek zones (See Photos 7a and b).we are currently studying its applications for varying degrees of facial aging with wrinkle formation, photodamage in various vulnerable skin areas, and for acne scarring. STILL THE GOLD STANDARD The results of ablative resurfacing are often dramatic in reversing the effects of cutaneous aging and sun damage. Both physicians and patients are routinely 6B 7B elated with the outcomes. However, it is important to take care in selecting the right patient, and educating the patient thoroughly so that patient expectations are in line with postoperative healing time and realistic outcome goals. In addition, having thorough knowledge of preoperative considerations, using the CO2 laser and varying its parameters according to anatomic site, and instituting the best postoperative care are imperative to obtaining the best results. At the present time CO2 laser still remains the gold standard. With new technologies on the horizon, we are looking forward to lasers the can achieve close and even better results than the CO2 laser with decreased down time. Dr. Bisaccia is a practicing dermatologist and Clinical Professor of Dermatology at the Columbia University of Physicians and Surgeons in New York City. Dr. Saap is a fellow in dermatologic, cosmetic and Mohs micrographic surgery. Dr. Scarborough is a practicing dermatologist and Assistant Clinical Professor of Medicine, Division of Dermatology, at the Ohio State University Hospital in Columbus, Ohio. References: 1. Maiman TH. Stimulated optical radiation in ruby. Nature 1960; 187: Goldman L, Blaney DJ, Kindel DJ, et al. Effect of the laser beam on the skin. I Invest Dermatol 1963; 40: Bisaccia E, Scarborough DA. Laser surgery. In the Columbia Manual of Dermatologic Cosmetic Surgery. New York: McGraw-Hill: 2002; Rokhsar CK, Lee SS, Fitzpatrick RE. Laser Skin Resurfacing. In Procedures in Cosmetic Dermatology: Laser and Lights Volume 2. Philadelphia : Elsevier Saunders: 2005; Anderson RR, Parrish JA. Selective photothermolysis: Precise microsurgery by selective absorption of pulsed radiation. Science 1983; 220: Nanni CA, Alster TS. Complications of carbon dioxide laser resurfacing: An evaluation of 500 patients. Dermatol Surg 1998; 24: Horton S, Alster TS. Preoperative and postoperative considerations for carbon dioxide laser resurfacing. Cutis 1999;64: Hruza GJ. Wound care and prophylaxis after laser resurfacing. In Controversies and Conversations in Cutaneous Laser Surgery. AMA Press: 2002; Abeles G,Warmuth IP, Sequeira M, Swensen RD, Bisaccia E, Scarborough DA.The use of conscious sedation for outpatient dermatologic surgical procedures. Dermatol Surg Feb;26(2): Abeles G, Sequeira M, Swensen RD, Bisaccia E, Scarborough DA:The combined use of propofol and fentanyl for outpatient intravenous conscious sedation. Dermatol Surg 1999 July;25(7): Alster TS, Hirsch R. Single-pass CO2 laser skin resurfacing of light and dark skin: extended experience with 52 patients. L Cosmetic & Laser Ther. 2003; 5: Marra DE,Yip D, Fincher EF, Moy RL. Systemic toxicity from topically applied lidocaine in conjunction with fractional photothermolysis. Arch Dermatol Aug;142(8): The Associated Press. Anesthetic cream linked to deaths of 2 women. Tucson Citizen Newspaper. Monday, Feb. 7, Gagnon, Louise. Lay use of lasers fueling complications. Derm Times Jun OCTOBER 2006 SKIN & AGING