Note: Laser Resurfacing is being replaced by other procedures that are often a better alternative. If you are considering laser resurfacing, please talk to one of our consultants about our alternative procedures.

The CO(2) laser, long the darling of dermatologists, is opthalmology's biggest comeback story of the year. From all accounts, skin resurfacing and laser versus cold-steel cutting techniques were the topics that sparked the most debate, controversy, and interest among opthalmologists at the annual American Academy of Ophthalmology meeting in Atlanta.

Those who swore they’d never do another bloody blepharoplasty were seduced by the claims of bloodless incisions. Others fell in love with the laser’s ability to erase seemingly untreatable fine lines and wrinkles. But these exquisite postoperative results put forth by laser proponents aren’t the only reason for the surge of interest.

‘Opthalmologists need to understand that the facial rejuvenation industry is a $60 billion per year business in the United States,’ said Brian Biesman, MD, in an interview with Ophthalmology Times.

If the unabashedly enthusiastic response of AAO attendees who swarmed to the various lectures, presentations, and live surgical procedures highlighting the CO(2) laser is any indication, then it is clear that the point is well taken.

Some in attendance asked why they should invest in the new technology.

‘We’ve been doing dermabrasion and chemical peels for decades,’ Dr. Biesman said. ‘The concept of trying to give skin a younger appearance is nothing new. This has garnered great public interest for many years.’

He said using the new CO(2) laser to eradicate fine lines is a ‘new procedure with a well-known modality that offers the benefit of skin resurfacing without some of the problems associated with chemical peeling.’

The technique has a great potential upside, but as with any new procedure, there is a significant learning curve associated with it,’ said Dr. Biesman, director of the eye plastic and orbit service at the New England Eye Center, and assistant professor, Tufts University School of Medicine, Boston.

Marc Werner, MD, agrees that opthalmologists need to educate themselves before embarking on a CO(2) laser career.

‘The technology is in a constant state of change, so continual education is important,’ he said.

For example, surgeons in the 1980’s were using the CO(2) laser as a scalpel for blepharoplasties and other cosmetic surgeries. Back then, the technology was far from perfect and many physicians raised legitimate criticisms over wound healing and scarring.

‘It was determined that due to scarring the laser was unsuitable for cosmetic surgery. That’s not the case with today’s new generation of lasers,’ said Dr. Biesman, who has performed skin resurfacing on 30 to 40 patients with the Coherent laser.

Dr. Biesman has taught several laser resurfacing courses at Tufts University, has lectured about the technology, and has given instructional courses around the country.

He and Dr. Werner, who has used the Sharplan laser at the Manhattan Eye and Ear Infirmary in New York, believe the laser has some clear advantages over cold steel techniques.

‘There is relatively less bleeding and bruising with the laser. Whether the skin heals quicker is debatable, but patients definitely bleed less and look better sooner,’ Dr. Biesman said.

‘Relative disadvantages include concerns over energy being delivered into the wrong anatomic plane,’ he said. Surgeons who are used to using a scalpel will have to master a learning curve before they have as much control with a laser as they already have with a scalpel, he said.

The downside also includes the cost of the machine, which ranges from $40,000 to $130,000. Smoke evacuators, maintenance contracts, training, and protective gear all add to the cost.

‘For some, this will be prohibitively expensive compared to chemical peels,’ Dr. Werner said.

So why should opthalmologists spend the time and money on a CO(2) laser when they could use chemical peels for skin resurfacing?

Because the laser offers a level of control that is difficult to achieve with other techniques, say Dr. werner and Dr. Biesman.

The whole idea behind this technology is that the laser energy is applied to the skin in very short frequencies and very high energy bursts.

‘The laser vaporizes the outer layers of the skin while causing a minimal amount of damage to the deeper adnexal structures,’ said Dr. Werner, who has a plastic and reconstructive surgery practice in New York.

The advantage of the laser over a chemical peel is that the surgeon can visually judge the effect of the treatment as it is performed. That is, the physician can see the depth of treatment and therefore titrate the amount of treatment to the individual patient.

‘It is easier to titrate the depth of treatment with the laser because tissue is removed layer by layer. That means you can see the extent of the treatment and the tissue reaction as you treat,’ Dr. Werner said.

Surgeons who do successful chemical peels and have a good feel for the depth of penetration may not want to switch to a laser, Dr. Biesman said.

But, he adds, it is more difficult to judge the depth of treatment with the chemical peel than with the laser.

‘The surgeon knows the amount of energy applied and the tissue effect of the laser. For example, it’s possible to perform a midpapillary dermis treatment and a more superficial treatment. If the surgeon decides deeper treatment is necessary, then another pass with the laser can be made,’ Dr. Biesman said.

Proponents say the laser is excellent in correcting fine lines and wrinkles, but others ask if the treatment is really necessary since the defects are so minimal.

That depends on the patient, the surgeons said.

‘Many patients are not happy even after a good blepharoplasty because of residual fine wrinkles on the lower lids. Often patients have what many surgeons would consider an exquisite blepharoplasty and they’re still not happy. In the past, we relied on chemical peels, but unless surgeons do a lot of the procedures, they can be very difficult. For example, if the chemical remains on the lower eyelid too long, lower lid retraction and ectropion can occur,’ Dr. Biesman said.

One of the most intriguing areas of laser resurfacing is in conjunction with a transconjunctival lower lid blepharoplasty. The laser is not indicated at the same time a facelift or external blepharoplasty procedure is performed due to concerns over a potentially compromised blood supply, Dr. Werner said.

One of the most important caveats stressed by both Dr. Werner and Dr. Biesman is that patient selection is critical in determining success.

The best candidates for the procedure are people with finely wrinkled, lightly complected skin (Types I and II). But people with very deep wrinkles or Type III skin will have significant improvement, Dr. Biesman said.

Some people are relatively contraindicated - for example a patient with an active herpetic infection should not be treated. Some doctors will treat their patients with preoperative acyclovir (Zovirax) to prevent herpetic lesions, he said.

Fungal disease of the fingernails is another contraindication. Laser resurfacing should be postponed until the infection is cured.

‘We’re creating a de-epithelialization, a superficial dermal wound, and that puts the patient at some risk for infection,’ Dr. Biesman said.

He hastened to add that infection after the procedure is uncommon.

‘Patients must realize that their skin will be bright red and oozing and that they will look bad for at least 1 week and crusting. That means there is a great deal of hand-holding in the first postoperative week,’ Dr. Biesman said.

In other words, don’t perform the procedure on very anxious patients.

‘Those surgeons who pick appropriate patients find the transition into this technique a comfortable one, while those who pick very anxious patients can start off on the wrong foot because they require tremendous amounts of counseling and advice,’ he said.

‘That’s why it’s very important to provide adequate preoperative counseling. I tell opthalmologists that they should rework their office schedules so they can spend 30 to 45 minutes in their preoperative evaluation of each of these patients,’ Dr. Biesman said.

And it doesn’t end there. Postoperative counseling is also intensive. But, Dr. Werner said, oculoplastic surgeons are used to that. ‘Our patients tend to be more bruised, so we’re perhaps more attuned to extensive hand-holding.’

Satisfaction is also related to patient personality. Expectations may be somewhat higher in a young professional, ‘but it is possible to achieve satisfactory results in these individuals because their wrinkles usually are not as deep,’ said Dr. Biesman. Older patients with deeply wrinkled skin can see significant improvement, although their wrinkles will not completely disappear, he explained.

Also, laser resurfacing is a ‘very personal decision. What is a very fine line to one patient is a chasm to another,’ Dr. Werner said.

Candidates who may not achieve optimal results are those with dark pigmentation or deep facial scars, Dr. Biesman said. Conversely, those with barely visible lines are not reasonable candidates either. ‘The best candidate is somewhere in between,’ he said.

Preoperative counseling is crucial to making sure a patient has reasonable expectations, Dr. Biesman said.

‘I want someone who comes in with a specific complaint,’ he said, citing as an example someone who is unhappy with a wrinkle on their upper lip. Patients who come to him with a general unhappiness about their appearance are unlikely to be as satisfied with the results, he added.

‘The technique is not applicable in every situation, and the surgeon must feel comfortable in knowing what he’s doing and that what he does can make an improvement or achieve the desired results. If that’s not the case, then the surgeon shouldn’t proceed,’ Dr. Werner said.

Preoperatively, patients are given prophylactic antibiotics to protect against bacterial infection. All patients are treated with acyclovir two days preop and take the drug until the skin is healed, about 5 to 7 days after treatment.

Patients are also treated with tretinoin (Retin-A) to prepare the dermal structures. Patients apply a preparation of 0.025% tretinoin for 2 weeks before surgery. Patients with Type III skin also are treated with hydroquinone (Solaquin Forte), a bleaching agent that helps prevent hyperpigmentation.

‘It’s important to treat these patients with a bleaching agent because hyperpigmentation is a real concern. It can occur months after surgery,’ Dr. Biesman said. ‘There is a 30% incidence of hyperpigmentation in this group. Although the discoloration usually resolves, it can take many months and may require bleaching agents. I make this complication very clear to these patients.’

He said a reasonable amount of correction per patient is ‘50 to 60% improvement. Studies that examined the depth of wrinkles preoperatively compared with postoperatively found that objective improvement, as judged by skilled observers, is 50 to 60% after one treatment session.’

The patient’s face is divided into aesthetic units for treatment. the forehead is considered one unit, the lower lids and crow’s feet another, and the upper lip and chin another. Because most of the upper lid is hidden by the eyelid fold, it is not treated with the laser. In cases of wrinkling or redundant skin, excision is the procedure of choice here.

Local anesthetic is required and may be combined with intravenous sedation, depending on the patient and the amount of surgery to be performed.

‘We find the majority of patients prefer a small amount of sedation. For a full face treatment, it’s definitely helpful to have an IV,’ the doctors say.

Local anesthetic is given in a combination of nerve blocks and local infiltration, depending on how much of the face is treated. A small area is easily infiltrated. The forehead, upper lip, and chin can be regionally blocked. The lower lids and cheeks should be infiltrated, Dr. Biesman said.

The patient can be prepped with povidone iodine (ACU-dyne, Aerodine, Betadine, et al) or the skin may be wiped off and dried. The approved drape for the CO(2) laser is a wet towel. Eye protection is provided by wet sponges if treatment is delivered away from the eye. When treating eyelids or periorbital tissue, a laser-safe eye shield is used. Dr. Werner and Dr. Biesman recommend anodized bone plates and metal laser-safe contact lenses.

‘The Coherent laser has two hand-pieces that can be used to deliver the beam, one delivers a 3-mm round spot from a collimated handpiece. This means the handpiece can be held at almost any distance from the patient, and the same energy will be delivered,’ Dr. Biesman said.

Not all brands of CO(2) lasers offer a collimated beam, however. ‘Most other lasers are engineered so that the operator must work at a fixed distance from the handpiece. If it is moved closer or farther away from the skin, then different effects are achieved,’ Dr. Werner said.

Some surgeons don’t think collimated beams are critical because the surgeon’s hand is usually in a stable position when applying energy, he continued.

The Coherent laser offers another handpiece, Dr. Biesman said, which applies a specific pattern of energy. A computer in the handpiece provides differently shaped grids.

‘Instead of applying individual spots with the 3-mm handpiece, this [hand-piece] lays down spots in rectangular, circular, or triangular grids using a pattern generator. This option speeds up the procedure.

‘Also, rather than relying on the surgeon to place each spot in exactly the correct location, the computer pattern generator places the spots at a distance determined by the computer, which can be adjusted by the operator,’ he said.

For example, spots that are very close together have a greater tissue effect than those far apart.

‘When treating the lower eyelid, the surgeon may not want the spots as close as if they were treating the cheek or forehead. Eyelid skin is thinner than other areas, and the surgeon will want to be more gentle here,’ Dr. Biesman said.

‘This is another advantage over chemical peels; we can overlap the spots to varying degrees to achieve very precise effects,’ Dr. Werner said.

Each pass of the laser removes 50 to 70mm of tissue. The surgeon will see white spots indicating tissue vaporization. They are cleaned with wet gauze.

‘In effect, the epithelium is wiped away,’ Dr. Werner said.

They both warned that excessive treatment on the lower lids will cause the same complications as if the surgeon misuses the chemical peel.

‘I tell all my patients that I would much rather undertreat than overtreat them. I offer additional treatment for which I don’t charge if it is deemed necessary,’ Dr. Biesman said.

Clearly, how to titrate the treatment is a matter of surgical judgement, gained, these surgeons say, only by experience.

Simply put, the laser is applied to different areas of the face, while the surgeon continually judges the depth of treatment by removing the ablated tissue with a wet sponge.

Dressing the wound is not an established regimen. Some surgeons apply an occlusive dressing because they think the skin will re-epithelialize sooner, others simply use ointments.

‘Most things work,’ Dr. Biesman said. ‘The question is what works the best.’ Both doctors use occlusive dressings.

Dr. Biesman said that he always sees his patients on the first post operative day, and may also see them on the second, third, or fourth day, depending on the amount of oozing.

‘The occlusive dressing is removed on the fifth day when the epithelium is mostly healed,’ Dr. Biesman said.

‘Although they have very little discomfort, their skin is still very red, and that means they require some hand-holding,’ he continued.

Aquaphor Natural Healing gel, available over the counter, is prescribed.

The jury is still out on how long the treatment will last. Dr. Biesman and Dr. Werner say it depends on a variety of factors including heredity and patient behaviors such as smoking, alcohol consumption, and sun exposure.

So where does the interested ophthalmologist get the education and experience to begin treating the 30-something and older discriminating cosmetic surgery patient?

We recommend attending at least one laser course, because they are excellent in teaching the basics of laser safety and the parameters of treatment,’ Dr. Biesman said. ‘We also recommend visiting with a skilled laser preceptor who has a good volume of patients.’

Neither doctor has a financial interest in the products mentioned.

Suggested Reading & References

Fulton, J. (1995). Variety of uses found for glycolic acid combinations. Dermatology Times, 16(3), 35-36.

Fulton, J. (1994). Facial skin peels. International Journal of Aesthetics and reconstructive Surgery, 2(2), 125-130.

Kincade, K. (1995). New procedures push tissue studies beneath the surface. Laser Focus World, 31(8), 57.

Kotler, R. (1992). Chemical rejuvenation. St. Louis, MO: Mosby-Year Book, Inc.

LeRoy, L. (1991). The role of the esthetician with the cancer patient. Les Nouvelles Esthetiques, 6(11), 63-66.

LeRoy, L. (1997). Laser resurfacing, the nurses role. Cosmetic Dermatology, 9(3), 173-175.

Lewis, S.M., & Collier, I.C. (1983). Medical-surgical nursing: Assessment and management of clinical problems. New York: McGraw-Hill.

Megenity, J.S., & Megenity, J. (1982). Patient teaching: Theories, techniques and strategies. Bowie, MD: R.J. Brady.

Ristow, B. (1994). Aesthetics in the plastic surgeon’s office. Dermascope, 5, 35-38, 62.