Figure 1A shows traditional high-density full laser skin coverage. Figure 1B shows the subtotal laser coverage of fractional treatment, in which the lasered regions are spaced between nontreated skin.

The CO2 laser is a workhorse in the contemporary cosmetic facial surgery practice. New lasers are capable of performing various levels of treatment by using traditional and newer fractional platforms. This gives the surgeon and patient an ever-increasing number of treatment options to suit severity of damage—and balance it with customized recoveries.

Fractional laser-based skin resurfacing has shown promise for a more user-friendly procedure, but to this point it cannot rival the results of traditional, aggressive CO2 laser skin resurfacing. Progress in this area will surely occur.

Ultimately, the CO2 laser can also serve as a surgical adjunct for bloodless tissue incision in blepharoplasty and lesion removal, as well as precise endoscopic dissection for brow and forehead lift.

Most of the people reading this article have witnessed several paradigm shifts in their training or practice life. A true paradigm shift occurs when change happens and influences the way things are done from that point forward. Laser technology, Botulinum toxin, and hyaluronic acid fillers are examples that most of us lived without at one time. After the shift happens, it is difficult to think about the way you did something before the technological advances.

Progress can shorten the memory. For example, at one of my recent lectures someone asked me why I kept calling my PowerPoint presentations “slides.” That sort of thing makes you feel old. As today’s children can’t fathom using a printed encyclopedia or even the Yellow Pages, younger surgeons may not realize how much lasers have improved cosmetic facial surgery.

Prior to the advent of CO2 laser technology, facial resurfacing pretty much meant chemical peel, dermabrasion, and blepharoplasty, and was certainly a more bloody surgery prior to the early 1990s.

Flash-forward to today: Laser technology continues to provide benefits for patients and surgeons and also continues to blossom in terms of progress. Although some cosmetic surgeons do not embrace laser technology, I can’t imagine my current practice without my CO2 laser. Along with my ultrapulsed CO2, I also have a 532- and 940-wavelength as well as an IPL. Although the latter are useful, my CO2 laser is my workhorse. I refer to it as my “Swiss army knife,” as its applications are broad to contemporary surgery.

Feeling the Burn

Figure 2. This patient was treated with three high-fluence, high-density nondebrided passes with the CO2 laser.

Facial skin resurfacing has undergone many changes over the past 15 years. Basically, physicians went from aggressive high-fluence, high-density, multipass resurfacing to more gentle fractional treatments. I think this is both good and bad. The new fractional treatments are superb for minor rejuvenation with minor recuperation.

Traditional high-power, high-density, ablative CO2 treatment produced a burn of the entire skin surface, which is analogous to painting a wall with a paint roller—the entire area gets treated. Fractional laser treatment, on the other hand, is a subtotal treatment and leaves untreated regions of normal skin next to micro columns of burned skin. The fractional treatment would be like painting a wall with polka dots instead of the paint roller (Figure 1). Since the entire skin surface is not treated, the entire recovery process is easier and re-epithelialization is faster.

Although the degree of improvement is manyfold less than the traditional CO2 aggressive laser treatment, the recovery is much shorter and tolerable, and the complication rate is lower.

I use Lumenis Inc’s ActiveFX (superficial ablative fractional) resurfacing in two main scenarios: younger patients who do not have much aging and damage, and older patients who cannot or will not tolerate extended aggressive CO2 recovery. Although I think that this level of minimally invasive resurfacing has merit, I also think it has been tremendously overhyped by media and corporate entities. We so badly want to steer patients away from the traditional 2-week aggressive CO2 laser recovery, we have gotten the cart in front of the horse.

I personally think that the anticipated results of fractional laser are overstated. Granted, a single treatment will provide a mild-to-moderate result with 3 to 5 days of downtime. My problem? I continually hear physicians and media types calling this the new gold standard, which is simply not true. A single minimally invasive fractional laser treatment (regardless of company, wavelength, etc) can’t hold a candle to the level of rhytid effacement and dyschromia improvement with an “old school” CO2 laser device. There is no doubt that the recovery is much easier, but in order to get really noticeable results, the patient may undergo three to five treatments, which in my opinion is a rawback—a single aggressive CO2 treatment will heal quicker (do the math) and with better results.

Figure 3. The CO2 laser provides a bloodless incision modality for upper and lower blepharoplasty.

In my practice, I use the superficial ablative treatment mostly for those patients who laugh in your face if you suggest a 12-day recovery. The fact that females make up the majority of cosmetic surgery patients—and that many of them are in the workforce and want to look better but have to work—is a good platform for this lighter degree of treatment. My biggest caveat is that you should not overpromise the result, which is a common mistake made by many physicians.

Superficial fractional laser treatments can frequently be performed without sedation—a huge advantage for companies and some practitioners. This is useful for practitioners who do not have the training, privileges, or facility to perform IV or general anesthesia with a laser treatment.

I treat 99% of these patients with IV sedation, but will do the occasional patient who insists on topical anesthetic only. The procedure is performed by degreasing the face with acetone and applying a generous coat of BLT topical anesthesia. Most local pharmacies will compound this using 20% lidocaine, 6% benzocaine, and 4% tetracaine. This is left in place for about 45 minutes. A single pass is made over the patient’s entire face (and neck, if desired). Typically, I use 100 mJ with a density of 2 for facial treatment and reduce the power to 50 mJ and a density of 2 for the neck region (Figure 4). The entire procedure can be done in 10 minutes on a sedated patient and in about 20 minutes on an awake, topically treated patient.

Figure 4. This patient is shown immediately after superficial fractional laser using topical anesthesia only.

Deep Resurfacing

In discussing fractional laser treatment, the second type of fractional resurfacing I perform is deep fractional ablative CO2 resurfacing (DeepFX). Although I have not done nearly as many of these treatments as I have traditional aggressive laser, I think it holds promise for situations in which we just cannot use regular ablative CO2. Examples include scar and wrinkle treatment on darker skin types and the treatment of burn and traumatic scars of the body. Jill Waibel, MD, of Miami has been a leader in using this technology for burn patients, and I believe that this platform will continue to open new doors.

Whereas the superficial fractional treatment is frequently confined to the epidermis, the deep ablative fractional treatment drills the laser beam much deeper into the skin and can penetrate well over a millimeter, although 450 to 600 microns are the most common desired depths.

Treating the entire skin surface with full-surface deep penetration would result in overtreatment, but the fractional nature of the Lumenis DeepFX platform allows normal skin bridges next to deep penetrating laser burns. Again, this subtotal coverage allows for faster healing.

One could say that I have “failed to adapt” in terms of technology, as I am one of those practitioners who still perform a significant amount of “old school,” aggressive, high-fluence, high-density, multipass CO2 laser resurfacing. I remain convinced that this platform remains the true gold standard for wrinkle and scar improvement, as well as dyschromia treatment. Granted, this type of treatment will cost the patient almost 2 weeks of recovery, but to reverse a half a century of aging I still think this is not too much to ask.

When it comes to lasers, you get what you pay for, not in terms of fee but in terms of recovery time. There is no doubt that this traditional type of laser resurfacing is harder on practitioner and patient. The wound care is more intense, and postlaser erythema is inevitable. Complications such as hypopigmentation, burns, scars, and texture changes are definitely a greater possibility. For this reason, many surgeons have abandoned this level of treatment and settle for lesser clinical results. On the contrary, I am doing more of this level of treatment than ever before and have undertaken numerous steps to make the entire process easier on me, my staff, and, of course, the patient.

Figure 5. This patient underwent facelift and aggressive laser over the central oval of the face, with lower-density CO2 resurfacing over the undermined facelift flaps and neck. The laser enhances the facelift and vice versa.

These changes have included not debriding the eschar between laser passes and allowing the char to serve as a biologic dressing, which speeds recovery, reduces pain, and lessens postlaser erythema. Additionally, I only use open wound care—all the patient does for the first week of recovery is use petrolatum or Aquaphor. This makes life easier for patient, physician, and staff. Employing technology that is a spin-off of treating Iraq war mustard gas injuries with an amino acid complex oxygen mist also improves postlaser comfort and speeds re-epithelialization.

Figure 5 depicts a case of aggressive, high-fluence, high-density, multipass CO2 skin resurfacing. When lasering over undermined facelift flaps, I use various options. In general, I treat the central oval (nonundermined regions) with traditional aggressive settings, but greatly respect the undermined flaps. Whereas I may do three passes of 80 mJ and a density of 6 on the central oval, I will use the same fluence but drop to a density of 4 over the flaps. Alternately, I sometimes elect to drop the power to 40 mJ and up the density to 6.

I have performed hundreds of facelifts with simultaneous laser resurfacing. I have not had increased problems with flap viability. The CO2 laser is also very useful for treating surgical and traumatic—as well as acne—scars, and I use it frequently for that purpose.

Bleph Treatments

My use of the CO2 laser is not limited to skin resurfacing. I have performed thousands of laser-assisted blepharoplasty procedures. I have always preferred a bloodless incisional modality, such as Ellman radiowave surgery or CO2 laser, and I believe that using the CO2 laser provides many advantages to the procedure.

We measure Intraoperative bleeding on four eyelids with a Q-tip. There is virtually no hemorrhage when using CO2 laser incision. Less bleeding means less swelling, less bruising, less postop pain, and faster healing.

I use a 0.2-mm laser handpiece with an 8-watt setting. The skin is excised by following preoperative markings. Generally, I also use the laser to remove an approximately 5-mm strip of orbicularis oculi muscle, and also to incise the orbital septum to access the fat pads in the upper lid. The prolapsed fat can be easily reduced or recontoured using the laser beam without blood loss (see Figure 3 above).

I use the handpiece at its normal focal length to incise the fat and defocus the laser in order to increase the spot size to contract and shrink fat. Although the laser is excellent for small-vessel hemostasis, it is less valuable for larger-vessel hemorrhage, as the CO2 chromophore is water and the small beam loses its ability to coagulate in a pool of blood. I always keep a radiowave micro forceps on the tray in case of gross hemorrhage.

For lower-lid surgery, I employ a retroseptal transconjunctival approach and incise the conjunctiva and capsulopalpebral fascia to access the prolapsed lower fat pads. The incision is made about 4 mm inferior to the lower tarsus from the canthus to the lacrimal punctum (see Figure 3 above).

Additionally, the CO2 laser can be utilized in endoscopic brow and forehead lift. A long laser waveguide attaches to the straight handpiece and allows extreme precision in incising tissue in the endoscopic optical pocket. I primarily use the laser waveguide to incise the supraorbital periosteum and disrupt the procerus, corrugator muscles, and lateral orbicularis muscles.

Joseph Niamtu III, DMD, FAACS, is a board-certified cosmetic surgeon in Richmond, Va. He can be reached at .

Postlaser Wound Care—Past and Present

If there is one drawback in employing traditional CO2 ablative laser resurfacing, it is the area of postlaser wound care. It adds extra layers of work (and sometimes frustration) for the patient, surgeon, and staff. If the process and experience of postlaser wound care could be ultimately simplified, the promoting of traditional CO2 treatments would be much easier.

I know several experienced laser surgeons who have abandoned the procedure because of the intensity of the wound care and the hand-holding required to get the patient through it successfully.

Inducing an intentional and controlled second-degree facial burn removes the entire epithelium and part of the dermis. This is obviously a giant insult to the normally intact integument. Patients who undergo fully ablative, high-fluence, high-density, multipass CO2 laser resurfacing have to understand in the preop period that this treatment will be their hobby for 4 to 6 weeks. I am very blunt with my patients who are considering this type of laser treatment, and I do not sugarcoat the recovery.

Incidentally, for new practitioners, understating a recovery from laser treatment—or any procedure, for that matter—can really come back and bite you in the foot. In an era of new “miracle” treatments and surgeries emerging daily, some surgeons feel compelled to downplay the patient-recovery phase of treatment in hopes of “selling” a procedure. There is no better way to infuriate a patient then to tell them that a 2-week recovery is 1 week, etc. Not only does it upset them, it can cost them in other ways, such as missed work and other scheduled events, and disrupt family life in general.

I tell my patients that they won’t like me for a week, that they will need about 2 weeks before they can get back in makeup, and that they will be pink for several more weeks. If I tell them the recovery is 14 days and it takes only 10 days, I am a hero. If I tell the inverse, I am a zero.

Understating a recovery is unethical and promotes negative marketing. I have seen too many instances in which a physician says 1 week for a 2-week recovery, then tries to squirm out of it by blaming the patient for “not healing well.”

My Life With Wound Care

As an early adopter of CO2 laser resurfacing, I have walked the entire gamut of wound care.

When I first started doing CO2 laser resurfacing, full-face coverage with Flexan Topical Wound Dressing was popular. The patient’s face was covered with an opaque membrane and Tubegauze dressing for several days to a week. They looked like a mummy. It was impossible to observe the skin surface, and the dressings were very intimidating for all involved. When I first experimented with open dressings, I used another popular treatment at the time, Catrix, which is a collagen derived from bovine trachea. This was a rather messy cream that provides adequate protection for healing.

I undulated between open and closed dressings in search for the best option. Silon transparent membrane was applied similarly as the Flexan dressings, but was much thinner (like cellophane wrap) and easier to apply. This was also retained with Tubegauze dressing, and its transparency allowed direct wound observation. I think this dressing is superior to other closed dressings and advanced re-epithelialization by an average of 24 to 48 hours. I also experimented with hydrogel dressings that are used to treat burns. These were very soothing and allowed wound observation, but were expensive and cumbersome.

Having observed this, the drawback of wearing a “mask and net” was still too intimidating for my patients and me. This led to my total crossover to open wound care. I experimented with multiple treatments, including Crisco, mineral and olive oil, and other petrolatum-based products.

For ease of application, affordability, and convenience, I currently use Vaseline or Aquaphor on most patients—messy and greasy, but they do a good job without having to put the patient in a mask.

Some practitioners advocate platelet-rich plasma with or without surgery or lasers. I swear that this impressively speeds re-epithelialization and decreases erythema. Currently, I am experimenting with amino acid complex delivered via oxygen mist. This promising treatment has been used to treat military mustard gas burns. Numerous companies market postlaser kits, of which I have recently been impressed with the kit from SkinMedica Inc. It has received very positive reviews from patients and appears to make healing easier.

Postlaser wound care certainly leaves a lot to be desired by doctors, patients, and staff. It is the number one drawback for promoting traditional ablative CO2 laser resurfacing. I don’t think fractional laser treatment is the answer. Yes, the recovery is much shorter, but the results, in my experience and that of many other veteran laser surgeons, don’t hold a candle to “old school” treatment.

I am hopeful that we will either be able to tame the laser beam or find the elusive “miracle postop treatment.” The person who invents that should probably get the Nobel Peace Prize!