Single-pass-CO2-Laser-Skin-Resurfacing-of-Light - Washington ...

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j Cosmetic & Laser Ther 2003; 5: 39-42
© j Cosmetic & Laser Ther. All rights reserved ISSN 1476-4172
001: 10.1080/14764170310000835
Single-pass CO2 laser skin
resurfacing of light and dark skin:
t. Taylor&Francis
• healthsciences 39
extended experience with 52 patients
Tina S Alster & Ranella J Hirsch
Authors:
T S Alster
R J Hirsch
Washington Institute of
Dermatologic Laser Surgery,
Washington, DC, USA
Received 30 July 2002
Accepted 11 December 2002
Introduction
The goal of cutaneous resurfacing is to render the skin as
smooth as possible. While there are many different
treatments available to achieve this goal, the carbon
dioxide (C02) laser remains the gold standard of laser
Correspondence: Tina S Alster, MD, Washington Institute of
Dermatologic Laser Surgery, 2311 M Street, NW Suite 200, Washington,
DC 20037, USA.
Tel: (+ 1) 202 785 8855; Fax: (+ 1) 202 785 8858;
E-mail: talster@skinlaser.com
BACKGROUND: Multiple-pass carbon
dioxide (C02) laser skin resurfacing
has been a favored treatment modality
for photodamaged and acnescarred
skin over the past several
years. Its association with numerous
side effects and complications, particularly
prolonged erythema and
dyspigmentation, however, has dampened
the initial enthusiasm reserved
for its use. By reducing the laserassociated
tissue ablation depth and
degree of thermal necrosis, it is
possible that the incidence of these
side effects can also be reduced.
PURPOSE: To evaluate the clinical
efficacy and side effect profile of
single-pass CO2 laser skin resurfacing
in a large series of patients.
MATERIALS AND METHODS: A total of
52 consecutive patients (skin phototypes
I-VI) with mild facial rhytides,
atrophic scars, or infraorbital hyperpigmentation
underwent single-pass
treatment with a high-energy, pulsed
CO2 laser. Side effects to treatment
were closely monitored and tabulated.
Clinical improvement using a quartile
grading scale was assessed
independently by two masked medical
evaluators at 1, 3, 6, and 12
months postoperatively.
RESULTS: Significant clinical improvement
was seen in all patients, with
peak improvement scores noted at
12 months. Greater clinical improvement
was seen in patients with
darker skin tones despite the near
universal incidence of transient
postoperative hyperpigmentation in
these patients.
CONCLUSIONS: Single-pass CO2 laser
skin resurfacing can improve the
appearance of fine rhytides, mild
atrophic scars, and infraorbital
hyperpigmentation in all skin types.
The severity and duration of side
effects and complications are
reduced with this technique (compared
with multiple-pass procedures)
and may offer a possible solution to
the problem of treating patients with
darker complexions. J Cosmetic & Laser
Ther 2003; 5: 39-42
skin resurfacing.l " With a wavelength of 10600 nm, the
CO2 laser is well suited for cutaneous resurfacing because
of the strong absorption of its infrared wavelength by
water-containing tissue in the skin. Such tissue comprises
70% of total skin volume.
The success of CO2 laser skin resurfacing was historically
limited by the emission of light in a continuous wave mode
that produced zones of thermal destruction ranging from
200 p.m to 2 mm beyond the target tissue, resulting in
unintended scarring and fibrosis. With the application of
the modern theory of selective photothermolysis, as first

40 TS Alster & RJ Hirsch
Original Research
'0,1
described by Anderson and Parrish in 1983,4 controlled
destruction of target tissues could be achieved while
limiting unwanted thermal damage to the surrounding
skin. This is accomplished in part by limiting the pulse
duration to a time shorter than the thermal relaxation time
of the target. Consequently, when short pulsed « 1ms)
CO2 lasers were introduced in the mid-1990s, vaporization
of very thin layers of skin (20-30 pm per pass) was made
possible.c"
Cutaneous resurfacing with the CO2 laser has since been
shown to be highly effective in the treatment of
photodamaged and acne-scarred skin, as well as for
removal of a variety of epidermal and dermal lesions. 7 - 15
Despite its high clinical satisfaction rate, CO2 laser
resurfacing has been associated with multiple side effects
and complications, ranging from prolonged erythema to
fibrosis and scarring. 16,17 One of the most common
postoperative sequelae is transient cutaneous dyspigmentation.
Over one-third of all patients who undergo CO2 laser
resurfacing develop moderate hyperpigmentation lasting
several months, with a near universal occurrence in patients
with darker skin photo types (Fitzpatrick type III or
greaterj.l" Hypopigmentation is a far less frequent side
effect and tends to be permanent. Patients must be clearly
motivated to tolerate the extended recuperation from CO2 laser resurfacing, which includes 7-10 days of intense
erythema, edema, crusting, and discomfort. Viral, bacterial,
and fungal infections can be seen during the first
postoperative week before full re-epithelialization has
been effected. Prompt, aggressive intervention with an
emphasis on prevention is mandatory.
The depth of ablation and residual thermal necrosis seen
in the dermis correlates directly with the number of laser
passes perrorrne c d. 56", 18 19 W'Ith mcreasmg . . dept h and degree
of thermal damage, the risk of pigmentary alteration
rises. 20 - 23
It stands to reason that limiting the ablation
depth and extent of residual thermal necrosis would
lower the incidence of postoperative side effects and
complications.
The purpose of this study was to evaluate the clinical
efficacy and associated complication rates of single-pass
CO2 laser resurfacing in a large series of patients with light
and dark skin and to compare the results with those
previously reported in the literature for traditional multipass
CO2 laser treatment.
Materials and methods
A total of 52 consecutive patients (47 females, 5 males; aged
15-67 years, mean 52 years) with mild to moderate
rhytides, infraorbital hyperpigmentation, or atrophic scars
were included for study evaluation. Skin phototypes I-VI
were represented (Table 1).
Cutaneous anesthesia was obtained with appropriate
facial nerve blocks using 1% lidocaine with 1:200000 units
epinephrine. For full-face procedures, intravenous anesthesia
was administered by a certified nurse anesthetist
using a combination of propofol, Versed®, fentanyl, and
ketamine.
Skin type No. of Facial Infraorbital Atrophic
patients rhytides hyperpigmentation scars
I 5 3 2 0
II 34 24 6 4
III 10 5 3 2
IV 1 0 0 1
V 1 0 1 0
VI 1 0 1 0
Table 1
Patient characteristics.
The entire treatment area received adjacent nonoverlapping
8 mm laser scans with a high-energy, pulsed
CO2 laser (UltraPulse; Coherent Laser, Ine., Palo Alto, CA,
USA) at 300 m] of energy, 60 watts of power, and a CPG
density of 5 by a single operator (TSA). Treatment edges
and 'skip' areas were finished with single 3 mm spots
(300 m] of energy, 5 watts of power). Partially desiccated
tissue was left intact to serve as a biologic wound dressing
(rather than being removed with saline or water-soaked
gauze). Concomitant chemical peeling of the adjacent neck
skin was performed in all patients undergoing full-face laser
treatment using 25% trichloracetic acid (TCA) to achieve a
light frost (2 minute acid application followed by cool
water rinse).
Immediately following treatment, healing ointment
(Aquaphor; Beiersdorf, Ine., Norwalk, CT, USA) was
applied to the irradiated skin. Each patient was instructed
to perform gentle facial rinses with cool water several times
daily, followed by liberal ointment application. Ice packs
and round-the-clock acetaminophen were prescribed
during the first 24-48 hours postoperatively to reduce
swelling and discomfort. Full-face laser patients received a
prednisone taper for 5 days. All patients were prescribed
twice daily oral prophylactic antiviral treatment (valacyclovir
500 mg) beginning on the day of surgery and
continuing for 10 days. No other antibiotic prophylaxis was
used. Patients were followed closely in the first postoperative
week, during which time any residual coagulated
debris was removed with dilute acetic acid compresses. Side
effects and complications of treatment were monitored and
treated as appropriate. All patients were able to apply
camouflage makeup by 7-10 days postoperatively.
Clinical response to treatment was documented by
sequential digital photographs using identical camera
settings, lighting, and patient positioning. Assessments of
treated areas compared with baseline pretreatment photographs
were performed by two masked medical evaluators
preoperatively and at 1, 3, 6, and 12 months postoperatively
using a quartile rating scale (0 = 75% improvement).
Results
Significant improvement in skin tone, texture, and
appearance of skin was noted in all patients. Average
-

" I
Singl~-pass C02 laser skin resurfacing 41
clinical improvement scores peaked at 12 months regardless
of skin type (Figure 1).
Greater clinical improvement was seen in patients with
darker skin tones (phototypes III-VI) (Figure 2). Postoperative
erythema was rated as mild and lasted an average
of 3.5 weeks (range 2-5 weeks). Hyperpigmentation was
the most common side effect (average incidence of 46%,
mean duration of 12.7 weeks), with 100% incidence in
patients with skin phototypes III or darker, and was the
reason for lower early clinical improvement scores in these
patients (Table 2).
Bacterial infections were observed in five patients (9%)
within 3-5 days of the procedure. Four patients cultured
positive for Staphylococcus aureus and one patient had
superficial Enterococcus. All infections cleared on a 7-day
course of appropriate oral antibiotics without sequelae. No
herpetic or other infections were seen.
Discussion
By utilizing a single-pass CO2 laser technique without posttreatment
removal of desiccated epidermal debris, a
biological (tissue) wound dressing is created. Ross et al
previously reported speedier re-epithelialization in a pig
model when partially desiccated tissue was left intact.r' The
results of our study support this observation, with patients
demonstrating complete re-epithelialization within 5-7
days postoperatively (compared to 7-10 days following
multi-pass CO2 laser resurfacing procedures). In addition,
the severity and duration of postoperative erythema seen in
our patients was less than that typically observed after
multi-pass CO2 and erbium:YAG laser procedures - a
finding also reported by others. 18,22,23In our study,
erythema was more pronounced in patients with paler
skin tones and lasted for a longer period of time,
presumably due to the fact that it was easier to observe,
rather than because of any differences in the extent of
thermal damage.
Postoperative pigmentary changes remain a dreaded side
effect of laser resurfacing, particularly in patients with
darker complexions. As a consequence, individuals with
dark skin phototypes have often not been considered to be
suitable candidates for laser skin resurfacing procedures?4-27
Analysis of our treatment series indicates that
single-pass CO2 laser resurfacing may offer a possible
solution to this problem. While the incidence of
Original Research
Skin type Total no. of Hyperpigmentation Onset Duration Infection Onset Organisms Duration
patients (n) (n) (weeks) (weeks) (n) (postoperative day) cultured (days)
I 5 1 4 4-6 1 4 5. aureus 5
II 34 10 4 3-6 2 3-5 5. aureus Enterobacter 4
III 10 10 3 6 2 2 5. aureus 7
IV 1 1 3 5 0
V 1 1 4 9 0
VI 1 1 5 9 0
Table 2
Incidence of side effects and complications.
• Daric skin (SPT 11I-VI. n = 13)
o Light skin (SPT I-II, n = 49)
Figure 1
Clinical improvement scores (0= 75% improvement).
Figure 2
(A) Patient with infraorbital hyperpigmentation (skin phototype V)
before laser treatment; (8) 6 months after single-pass CO2 laser
resurfacing (clinical improvement score=2).
(A)
(8)

42 TS Alster & RJ Hirsch
Original Research
'~I
hyperpigmentation remained high in our patients with
dark skin tones, its intensity and duration were less than
that reported after multi-pass CO2 laser procedures (3-6
months). In contrast to the findings reported by Ross and
colleagues.l" where increased hyperpigmention was
observed in periorbital regions (compared with perioral
, areas), no differences in the rate of hyperpigmentation were
seen in different facial areas in this study.
References
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resurfacing. Clin Plast Surg 2001; 28: 37-52.
2. Alster TS. Carbon dioxide laser skin resurfacing In:
Alster TS, eds. Manual of cutaneous laser techniques, 2nd
ed. Philadelphia: Lippincott, Williams & Wilkins, 2000:
119-34.
3. Alster TS. Cutaneous resurfacing with the CO2 and
erbium:YAG lasers: preoperative, intraoperative, and
postoperative considerations. Plast Reconstr Surg 1999;
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4. Anderson RR, Parrish JA. Selective photothermolysis:
precise microsurgery by selective absorption of pulsed
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5. Alster TS, Nanni CA, Williams CM. Comparison of four
CO2 resurfacing lasers: a clinical and histopathologic
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','
Conclusions
Single-pass CO2 laser skin resurfacing can improve the
appearance of fine rhytides, mild atrophic scars, and
infraorbital hyperpigmentation in all skin types. The
severity and duration of side effects and complications
are reduced with this procedure compared with those
previously reported for multi-pass CO2 laser procedures.
15. Boyce S, Alster TS. CO2 laser treatment of epidermal
nevi: long-term success. Dermatol Surg 2002;
28: 1-3.
16. Alster TS, Lupton JR. Prevention and treatment of side
effects and complications of cutaneous laser resurfacing.
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laser resurfacing. An evaluation of 500 patients.
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versus multiple-pass Er:YAG laser resurfacing in the
treatment of rhytides: a comparison side-by-side study
of pulsed CO2 and Er:YAG lasers. Dermatol Surg 2001;
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19. Burkhardt BR, Maw R. Are more passes better? Safety
versus efficacy with the pulsed CO2 laser. Plast Reconstr
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20. Ross EV, Domankevitz Y, Skrobal M, Anderson RR.
Effects of CO2 laser pulse duration in ablation and
residual thermal damage: implications for skin resurfacing.
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21. Ross EV, Mowlavi A, Barnette D et al. The effect of
wiping on skin resurfacing in a pig model using a high
energy pulsed CO2 laser system. Dermatol Surg 1999; 25:
81-8.
22. Ruiz-Esparza J, Barba Gomez JM. Long term effects of
one general pass laser resurfacing: a look at dermal
tightening and skin quality. Dermatol Surg 1999; 25:
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23. Ruiz-Esparza J, Barba Gomez JM, Labastida Gomez De
La Torre 0, David L. Erythema after skin laser
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24. Horton S, Alster TS. Preoperative and postoperative
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25. Ho C, Nguyen Q, Lowe NJ et al. Laser resurfacing in
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