Expert Articles
 
SHORT-PULSED CARBON DIOXIDE LASER RESURFACING OR THE WRINKLE LASER

Introduction:

The lay press and popular news has been devoting an inordinate amount of attention to a new medical device which reportedly is the latest surgical "fountain of youth". The rapidly-pulsed carbon dioxide lasers, of which there are a number of competing brands, work by burning or vaporizing the skin very quickly minimizing damage to skin or tissue that is not specifically being targeted. These devices, particularly in combination with computerized pattern generators, allow very precise delivery of the laser light in geometric patterns and are being used in the place of older methods to rejuvenate or resurface the skin, such as dermabrasion or chemical peels. They do offer distinct advantages and, as we are finding out, some distinct disadvantages over the old methods.

The use of such lasers to resurface the skin was originally conceived of and implemented by a dermatologist who had used older generation carbon dioxide lasers for various cosmetic and noncosmetic procedures. At the annual meeting of the American Society for Dermatologic Surgery (ASDS) held in May 1996 numerous papers were presented concerning the various uses for this truly remarkable device as well as its potential misuses. It is indeed extremely effective at removing benign growths from the skin and has advantages over traditional modalities because of its ability to precisely injure skin without nonspecific or unintentional injury of deeper structures or adjacent skin. In addition, its automated functions take some of the physician error out of the equation.

Dermabrasion:

Dermabrasion where a spinning diamond wheel is used to remove the outer layers of the skin requires a very skilled dermatologic surgeon who is experienced with this technique to obtain the best results. Despite the skill of the operator scarring and permanent color changes may occur with dermabrasion.

Chemical Peels:

Chemical peels, by their nature, are unpredictable and the results vary from patient to patient and they can produce a blotchy or irregular result. The skill and experience of the chemical peeler, the concentration and type of chemical used, how the skin is prepared before the peel and treated after the peel, and how much chemical is applied in any given setting all contribute to the final appearance. The results can be different from patient to patient and there can be variations even in the same patient from place to place.

Advantages Of Short OR Rapidly-Pulsed
Carbon Dioxide Lasers:

The short- or rapidly-pulsed carbon dioxide lasers minimize some of this variation by utilizing computer generated patterns with well-defined energy settings and parameters to standardize the injury with each pass of the laser light across the face with some limitations. The more passes across the face, the deeper the injury. This injury then is more uniform resulting in more pleasing and predictable results in many cases than chemical peels and dermabrasion. At the same time, it minimizes some of the risks of complications associated with the older techniques described above.

Risks:

Short- or rapidly-pulsed carbon dioxide lasers still produce an injury or burn, albeit a well-controlled burn, and thus they have the same risks that the other older procedures had and as more and more patients are treated with these devices, these entirely predictable complications are beginning to surface. A number of the presentations at the American Society for Dermatologic Surgery outlined a number of these complications and showed examples of scarring, displacement of the eyelid, permanent color changes, persistent redness after laser treatment lasting up to six months, infection and almost more importantly relatively inadequate results.

In some hands carbon dioxide laser resurfacing provides a result equivalent to a medium depth peel which would cost a fraction of the laser procedure. The apparent maximum depth of the injury from the laser may not allow the same kind of results that can be obtained with dermabrasion on severely sun-damaged patients since the dermabrader or diamond-studded wheel in experienced hands can render a deeper injury than the laser when used in the standard fashion.

Other Issues:

As physicians become financially pinched by managed care, declining reimbursement and capitated contracts, the appeal of cosmetic surgery can be irresistible. Lasers, particularly newer sophisticated lasers are deceptively easy to use and have, thus, been enthusiastically received by physicians in many different specialties. This includes physicians who are inexperienced in injuring the skin in such a fashion, i.e., those who have not performed chemical peels and dermabrasions in the past. This is problematic despite the relative ease of use of these lasers, because the management of these patients postoperatively is a significant part of the overall experience of laser resurfacing and is fraught with problems. If there is mismanagement postoperatively, as well as preoperatively, complications can result.

Despite the efforts of dermatologic surgeons, as evidenced by numerous well-done studies presented at the ASDS meeting evaluating the depth of injury of these various devices comparing different brands of lasers, comparing outcome of laser surgery vs. standard modalities, and other predictable conclusions from scientific and systematic evaluation of the new devices. There remains much to be learned about these lasers. Further areas of investigation will need to identify the best way to use these lasers, the best method of managing patients both pre- and postoperatively, and the best candidates for this particular method of resurfacing. The resurfacing laser represents only another modality, that will most likely compliment more tried and true methods available to the experienced dermatologic surgeon.

Summary:

Significant patient dissatisfaction from scarring, permanent color change, persistent redness or erythema and less satisfactory results than expected or promised has been noted and will continue to be noted as more and more patients are treated with this modality. The lay literature has contributed to the potential for dissatisfaction and possible litigation by painting this procedure as a foolproof and relative harmless way to cut years off one's appearance, which is far from the truth. Experienced laser surgeons and dermatologic surgeons must continually educate patients about the real risks, benefits and alternatives of this technique even though this may deflate patient's expectations and enthusiasm.




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