Carbon Dioxide Laser Skin Resurfacing Treatment & Management
- Author: Andrew Jacono, MD; Chief Editor: Gregory Gary Caputy, MD, PhD, FICS more...
Selecting a suitable patient for carbon dioxide laser resurfacing is essential to achieve the desired results. Pay specific attention to skin type and degree of photodamage.
At least 6 weeks before carbon dioxide laser skin resurfacing, start all patients on a daily skin conditioning regimen, which consists of the following medications:
- Retinoic acid 0.05-0.1% cream (0.5-1 g Retin-A) in evening
- Hydroquinone 2-4% cream (0.5-1 g Clear or Eldoquin Forte) twice per day, in morning and evening (author does not necessarily use hydroquinone on patients who are light white [Fitzpatrick phototype 1])
- Alpha-hydroxy acid 2-4% cream (0.5-1 g Exfoderm) in morning
- Sun protection (SPF 15 or higher, Sunfader or sunblock) applied in morning
Patients should wash their faces with an antibacterial soap the night and morning prior to laser treatment.
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Observe laser safety at all times.
- Carbon dioxide laser light can cause a fire. No flammable objects should be present in laser field (eg, dry hair, dry gauze, alcohol).
- Supplemental nasal cannula oxygen must be turned off during laser resurfacing.
- Proper eye protection for patient, physician, and assistants is mandatory.
- Use proper evacuation of vaporized tissue plume to reduce chance of airborne transmitted diseases.
Clean patient's face with antibacterial soap. If isopropyl alcohol or acetone is used, understand that these agents are flammable and take precautions. Chlorhexidine gluconate (Hibiclens) and hexachlorophene detergent cleanser (PHisoHex) can cause keratitis.
Coat metal eye shields with sterile ophthalmic petrolatum to reduce chance of corneal abrasion.
Cover periphery of face with wet cloths.
Protecting teeth with wet gauze under lips reduces chance of enamel damage.
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Topical anesthetics (eg, eutectic mixture of lidocaine/prilocaine [EMLA]) and local infiltration with lidocaine or tumescent anesthesia often does not lead to complete anesthesia, may distort existing wrinkles or scars, and may change laser-tissue optomechanical properties.
Regional nerve block combined with intravenous (IV) conscious sedation seems to be the preferred method of anesthesia among laser surgeons. Fourteen nerve blocks are required: supraorbital, supratrochlear, infraorbital, auriculotemporal, zygomaticofacial, mental, and cervical plexus.
IV sedation using propofol (Diprivan) is rapid and easily titrated. Midazolam (Versed) provides initial sedation as well as amnesia. Fentanyl (Sublimaze) is the primary analgesia, although some anesthesiologists also use ketamine. IV sedation requires the presence of an anesthesiologist, oxygen source, electrocardiogram and blood pressure monitors, pulse oximeter, IV access, and resuscitation cart.
Laryngeal mask airway combined with IV sedation and general anesthesia with endotracheal intubation are other acceptable methods of anesthesia. Cover endotracheal and laryngeal mask airway tubes with wet towels.
Carbon dioxide laser resurfacing technique
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Treatment parameters are set according to carbon dioxide laser device and are individualized for each patient according to the condition treated, skin type, and goal to be achieved.
By achieving tissue vaporization in a single laser pulse, vapor that is created absorbs most of the heat generated, with resultant minimal diffusion of heat into the skin.
Pulse stacking leads to cumulative thermal injury in the skin.
When using a single spot hand piece, move it across the skin carefully and activate the laser at a slow enough rate (4-10 Hz) to deliver single pulses with minimal overlap of subsequent pulses.
Avoid overlap of the edges of computerized pattern generator patterns.
Generally, the first laser pass results in the removal of the epidermis, leaving behind a narrow zone of thermal damage (10-30 µm). Skin appears white with desiccated debris composed of epidermal tissue remaining after water evaporation.
After the first pass, rehydrate skin with moist saline-soaked gauze, remove debris using gentle rubbing, then wipe treated area using dry gauze.
Perform second pass in the same manner as the first pass; however, pulses may be oriented at 90° to the direction used for the first pass.
In general, a third pass or subsequent passes can be applied more selectively to areas of advanced photodamage or scarring (shoulder of acne scars), often using a single spot handpiece.
Relationship between number of laser passes and tissue ablation/thermal damage is not linear.
The first laser pass significantly ablates more tissue than the second or subsequent passes; an ablation plateau is reached in 3-4 passes, limiting ablation depth to approximately 250 µm. However, thermal damage is cumulative with each additional laser pass, resulting in a wider zone of necrosis.
Perform laser resurfacing in a systematic fashion, beginning on the forehead and proceeding down the remainder of the face. Eyelid resurfacing often is performed last because eyelids are treated at lower pulse settings and densities and require additional care to avoid burning the eyelashes.
Resurfacing of a single area alone generally is not advised to avoid sharp demarcations. One alternative is to perform carbon dioxide laser resurfacing on the desired area, then treat surrounding nonresurfaced areas with a less aggressive procedure such as the blue peel (15-20% trichloroacetic acid [TCA] in a blue base). [9, 10]
Perform feathering of margin between resurfaced and nonresurfaced skin edges to prevent demarcation lines. Treating the band of skin between the resurfaced and nonresurfaced skin at lower fluences accomplishes the desired blending. Feathering into the hairline and jawline also can reduce demarcation lines.
Laser resurfacing endpoints are as follows:
- As with any resurfacing modality, depth control is essential in carbon dioxide laser skin resurfacing to avoid potential complications and obtain best results.
- Confine depth to the papillary dermis or upper reticular/midreticular dermis.
- In general, as depth of penetration increases, risk of textural changes, scarring, and permanent hypopigmentation or depigmentation increases.
- Cosmetic endpoint is the ablation of the target (eg, scar, wrinkle).
- Safety endpoint is the appearance of a "chamois" yellow skin color that persists after wiping with a saline-soaked gauze, even if treated lesion persists.
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Oral antibiotics (eg, cephalexin [Keflex]), antiviral medications (eg, acyclovir [Zovirax]), and oral analgesics (eg, ibuprofen [Motrin]) are prescribed routinely.
Some laser surgeons use oral anti-inflammatory medications (eg, nonsteroidal anti-inflammatory medications) or corticosteroids to manage postoperative swelling.
Oral anxiolytics (eg, lorazepam [Ativan], diazepam [Valium]) are helpful to relieve anxiety and improve sleep patterns.
Oral antipruritic (eg, hydroxyzine [Vistaril]) medications are administered as needed.
Remind patients to avoid picking at their skin and to avoid rubbing skin vigorously when cleaning it or while in the shower.
Dressings are used as follows:
- Care for the skin after laser resurfacing is similar to managing a second-degree thermal burn.
- Keeping the wound moist promotes faster reepithelialization.
- In general, 2 methods of wound dressing exist.
- Open technique: Apply an occlusive ointment (eg, petrolatum) to the resurfaced areas until reepithelialization is complete. Avoid use of topical antibiotics (eg, bacitracin [Baciguent]) because of increased risk of contact dermatitis. Advantages include its low cost, decreased rate of infections, use by patients at home, and suitability for regional resurfacing. Disadvantages are that it is more painful, it is messy, and it requires patient compliance.
- Closed technique: Apply semiocclusive biosynthetic dressing until reepithelialization is almost complete. A wide variety of these dressings are available, including polyurethane films (Silon II), hydrocolloids (Flexzan), and hydrogels (Vigilon). Advantages include that it is painless and faster healing occurs. Disadvantages are the increased cost, increased rate of infection, and need for frequent office visits.
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Closely monitor patients during the postoperative period. Have frequent follow-up visits at close intervals with patients to provide much needed support and to detect complications early in the course.
Recovery for full face laser resurfacing is 7-14 days depending mainly on depth achieved.
During the first week, the patient experiences variable degrees of oozing and crusting depending on the dressing used.
Apply dressings until complete reepithelialization takes place. Patient then can start applying a light water-based moisturizer for the next 2-3 weeks.
Begin postprocedure skin reconditioning early during the healing process. Reintroduce hydroquinone and retinoic acid 3-4 weeks postoperatively. Avoid alpha-hydroxy acids until stratum corneum is regenerated fully and skin tolerance has returned. Use sunscreens once reepithelialization occurs.
Evaluate patient at 2-3 days, 1 week, 3-4 weeks, 3 months, 6 months, and 1 year postresurfacing.
Similar to other resurfacing modalities, incidence of complications following carbon dioxide laser resurfacing primarily is related to depth attained.
Expected sequelae commonly are encountered after carbon dioxide laser resurfacing and must be clearly differentiated from true complications.
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Swelling: Postresurfacing swelling is expected. It peaks at days 2-3 and usually subsides by days 5-7. IV betamethasone intraoperatively and a course of oral prednisone postoperatively for 5 days can help significantly in decreasing the swelling.
- Erythema, to some degree, is observed in all patients who have been resurfaced to the level of the upper dermis with the carbon dioxide laser.
- It is related to increased blood flow, collagen remodeling, inflammation, and increased metabolic activity.
- Erythema is more obvious in patients with lighter skin complexion and in patients with flushing or blushing tendencies (eg, those with acne rosacea).
- While erythema is usually transient, it may persist for weeks to months, yet it generally can be camouflaged with green-tinted or yellow-tinted makeup.
- Do not use topical steroids to treat postresurfacing erythema since they reduce collagen synthesis.
- Carbon dioxide lasers that do not induce erythema have produced only superficial injury, and the procedure does not induce collagen remodeling.
- Differentiate diffuse erythema of laser resurfacing from focal, itchy, palpable, or persistent erythema that is a sign of developing hypertrophic scar or keloid.
Itching (pruritus): Itching is common after laser resurfacing, yet it may signal infection, contact dermatitis, or early scarring. In the absence of these conditions, pruritus responds to an oral antihistamine or midpotency topical steroid (eg, mometasone furoate 0.1% [Elocon]).
Acne flare/milia: Milia and acne commonly are observed 2-4 weeks after carbon dioxide laser resurfacing and partially are related to the use of occlusive ointments. Many of these patients are acne prone at the start, and their condition can be improved significantly by reintroducing retinoic acid and topical antibiotics to their postresurfacing regimen. Additionally, a 2- to 3-month course of oral antibiotics (eg, tetracycline) or oral isotretinoin (Claravis, Amnesteem, Sotret) usually is very helpful. Comedones and milia can be expressed manually using a comedone extractor.
- Hyperpigmentation after resurfacing is common, especially in patients with dark skin.
- It usually first is observed 14-21 days after the procedure and represents a postinflammatory hyperpigmentation phenomenon.
- Preconditioning the skin with retinoic acid and hydroquinone prior to carbon dioxide resurfacing decreases incidence, severity, and duration of hyperpigmentation. Resulting hyperpigmentation also may be more amenable to therapy.
- Aggressive postresurfacing skin reconditioning using hydroquinone 2-4% twice per day, retinoic acid (0.5-0.1%) every bedtime, and sun protection and sunscreen resolves this condition in 2-4 weeks.
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Infection (bacterial, viral, yeast, fungal)
- Typical presentation is a papulopustular eruption with itching or pain and delayed healing.
- Occasionally, infection presents as maceration and necrotic tissue in a previously healed area.
- Culture lesions using the appropriate medium (viral, bacterial, fungal).
- Begin appropriate topical and systemic medications as soon as possible.
- Irritant or allergic contact dermatitis can occur secondary to topical antibiotics (eg, neomycin, bacitracin).
- Dermatitis can be treated successfully with potent topical corticosteroids (eg, clobetasol propionate 0.05% [Temovate]).
- Systemic steroids rarely are needed.
- Occurrence of hypopigmentation certainly is related to depth of resurfacing and resultant thermal injury.
- It usually occurs in lighter skin types (Fitzpatrick phototypes 1-3) and is observed 6-12 months postresurfacing (see image below).
- This complication can be avoided by performing the following:
- Avoid regional resurfacing (especially in individuals with darker skin); instead, perform full face resurfacing.
- Limit resurfacing depth to the papillary dermis or upper reticular dermis.
- Stimulate skin to regenerate pigment in the epidermis by recruiting melanocytes in the adnexal structures. This can be attempted by using retinoic acid nightly.
Sharp demarcation lines: Avoid these by creating a transitional zone of resurfaced skin (ie, gradual change in depth of resurfacing between face and neck) and combining full face resurfacing with a light chemical peel such as the blue peel on the neck to create a less noticeable gradient zone between resurfaced face and neck/chest.
Hypertrophic scars and keloids
- Development of scars is mainly related to (1) depth of resurfacing achieved, (2) development of infection, (3) postoperative wound care, and (4) other patient-related factors (eg, excoriations).
- It is observed more commonly in nonfacial skin resurfacing.
- Localized persistent erythema with or without pruritus should be considered an evolving hypertrophic scar until proven otherwise.
- Aggressively treat with high-potency topical steroids (eg, clobetasol propionate 0.05% [Temovate]), intralesional steroids (eg, triamcinolone acetonide 10 mg/mL [Kenalog, Aristospan]), 5-fluorouracil (Carac, Efudex, Fluoroplex), or verapamil. Silicone gel sheeting and pulsed dye laser therapy are very helpful.
Ectropion and scleral show
- Ectropion usually is related to aggressive carbon dioxide laser resurfacing of the lower eyelids, preexisting laxity of the lower lids, previous skin excision during blepharoplasty, or development of an infection.
- It can be avoided by testing lid for laxity before resurfacing, by limiting depth of resurfacing on the eyelids to the papillary dermis, and by decreasing power settings.
- Use of eye lubricants to prevent drying, upwardly massaging lower eyelid 3-4 times per day, and using a potent steroid cream are helpful measures.
- In extreme cases a skin graft may be required.
Tooth enamel injury: This can be avoided by proper teeth protection.
Corneal abrasion/injury: This can be avoided by using the patient's eye shields properly, placing particular emphasis on choosing the correct size, and applying copious eye lubricants prior to inserting metal shields.
Outcome and Prognosis
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Results of laser resurfacing are good to excellent depending on the indication for which the procedure was performed.
Patient satisfaction is based on the delivery of natural results with minimal downtime and a low incidence of complications.
Actinic changes are improved to the greatest degree. Wrinkles typically are improved by 60-80%, while scars are improved to a lesser degree.
Improvement can be seen in deeper skin folds of the cheeks, forehead, and neck, malar bags, and even in the excess skin of the upper eyelid (pseudoblepharoplasty effect), but their improvements are less predictable.
Static lines are improved to a greater degree than dynamic lines. Treatment of these dynamic lines with botulinum toxin A provides significant improvement.
To best estimate degree of improvement after healing is complete, assess results at 6 months postresurfacing. Usually, some loss of early improvement and some recurrence of wrinkles can be observed as postoperative edema resolves.
Repeat treatments are possible but should be spaced approximately 6 months apart.
Laser skin resurfacing is a relatively new procedure, and long-term skin effects are largely unknown. A 2008 retrospective report of 47 patients identified hypopigmentation as the sole long-term adverse effect, aside from 1 case of hyperpigmentation, which resolved within 2 years.
Overall success in laser skin resurfacing is related to the following elements:
Proper patient and skin type selections
Attention to preoperative, intraoperative, and postoperative details
Aggressive management of emerging complications
Good patient-physician relationship
A study by Kohl et al of skin resurfacing with a fractional carbon dioxide laser indicated that the extent of wrinkle reduction achieved by the procedure varies by facial region but is most pronounced in the cheeks. The study involved 25 women, each of whom underwent three fractional carbon dioxide laser treatments. Pretreatment and posttreatment measurements were used to evaluate wrinkle size, depth, and width, in four facial regions. The treatments significantly reduced wrinkles in all four areas, with the greatest reduction of wrinkle size and depth found in the cheeks and the next greatest in the periorbital region.
Future and Controversies
In general, given the overall success and safety of carbon dioxide laser resurfacing, the demand for this procedure will continue to increase at a relatively notable speed.
Every resurfacing procedure (lasers, peels, dermabrasion) has specific indications to make it the procedure of choice. Each procedure has inherent advantages and disadvantages, complicating the decision to use one resurfacing procedure over another. Choice of resurfacing modality certainly depends on the physician's skills in that procedure and the patient's needs.
Furthermore, whether the long-term results of various resurfacing procedures differ if the depth achieved is equal is unknown. The advantage of carbon dioxide laser resurfacing over other resurfacing procedures is the precise control over the depth of tissue ablated.
Combined resurfacing modalities
Realizing that different regions of the face display various degrees of skin damage, often one needs to combine more than one resurfacing modality to achieve the best result possible.
A common example is a patient with deeper rhytides around the eyes and mouth but without many wrinkles on the rest of the face. To achieve good improvement in these wrinkles, a papillary or reticular dermis level of resurfacing is needed. However, subjecting the rest of the face to this same depth of resurfacing is not necessary; an upper papillary dermis level procedure or even epidermal exfoliation may be all that is needed in these areas. In this case periorbital and perioral carbon dioxide laser resurfacing can be combined with a more superficial TCA peel over the rest of the face. This helps to blend the results well and prevent any lines of demarcation.
While carbon dioxide laser resurfacing of undermined skin such as a rhytidectomy flap is controversial, carbon dioxide laser resurfacing can be performed safely on nonundermined skin and combined with a superficial TCA peel over the undermined skin flap if the depth of the peel is kept superficial. See before and after images below.
Newer resurfacing modalities
Three resurfacing modalities recently have emerged with claims of achieving faster healing and less potential for complications than carbon dioxide laser resurfacing.
Erbium:Yttrium-aluminum-garnet (Er:YAG) laser
- This laser has a wavelength of 2940 nm and a pulse duration of 250-500 microseconds.
- Because of greater water absorption, Er:YAG laser ablates less tissue per pass (approximately 4-5 µm) with a narrower zone of thermal necrosis (approximately 20-30 µm) than carbon dioxide laser.
- Er:YAG laser neither can induce the same collagen tightening nor impart the hemostasis commonly observed with carbon dioxide laser. It is most suitable for exfoliation (epidermis level) or papillary dermis level resurfacing (pinpoint bleeding as an endpoint) and may not be as effective when used to correct deeper wrinkles or scars.
Neodynium:YAG (Nd:YAG) laser
- This laser has a wavelength of 1320 nm.
- It can induce a certain degree of thermal collagen coagulation in the papillary dermis while generally sparing the epidermis (nonablative resurfacing). Coagulation necrosis in the papillary dermis leads to collagen contracture and subsequent neocollagenesis.
- This procedure is best suited for mild wrinkles.
- Multiple treatments are required over many weeks to achieve an optimal result.
Electrosurgical skin resurfacing (Visage)
- The manufacturer uses the term coblation to describe this procedure's selective lesional tissue damage by radiofrequency waves while inflicting minimal damage on adjacent structures.
- Ablation depth with this procedure is approximately 70-80 µm with collateral tissue damage that extends into the upper papillary dermis.
- Coblation differs from laser resurfacing by the almost complete lack of heat generated by the former, theoretically decreasing the likelihood of erythema and other postresurfacing complications.
- Little is known about this resurfacing modality, since clinical studies have not been performed.
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