Monday, March 7, 2011

CO2 Laser Use

 Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Over the past couple of months there have been a few good commentary articles on the use of CO2 laser us. 
The first one referenced below is a commentary by Dr. Scott J. Trimas on the treatment of facial acne scarring using CO2 laser abrasion.  He references his article from 10 years ago (2nd reference).  Full references are given to both articles below.
Over a 10 year period, Dr. Trimas, did 54 additional patients not included in his first article (the 2nd reference below) using full-face CO2 laser treatment for facial acne scarring. Their ages ranged from 16 to 74 years. Of those patients reviewed, 8 were male and 46 were female. He notes this population was similar to that of the original study. Most patients were followed for up to 2 years.
Dr. Trimas writes “notable improvement can be achieved with the use of the carbon dioxide laser, especially in the areas of the forehead, medial cheeks, and perioral region. Lesser improvement is noted in the areas of the lateral cheeks and temples. Nevertheless, substantial improvement is achieved in all areas.”
He also adds that one of the most substantial changes he has made is the addition of surgical excision of ice-pick scars prior to the laser resurfacing procedure. He performs the excision of the ice-pick scars at least 6 weeks prior to carbon dioxide laser abrasion.
The rationale for this excision technique was that some of the areas of the face did not seem to improve enough with just resurfacing, and I felt that ice-pick scars may have been the contributing factor. In fact, most ice-pick scars that were punch excised were in the lateral cheek regions.
That makes sense to me, as ice-picks scars are often too deep to be adequately treated by resurfacing procedures (laser or chemical peel) alone.
The other recent article (third reference below) covers the use of CO2 laser for more than simply acne scarring.  It was published in the February 2011 issue of the Plastic Surgery Practice.  In the article, Dr. Joseph Niamtu III, discusses his use of the CO2 laser, giving practical tips – both the traditional ablative and the newer fractional lasers.
Take for example his notes on “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."

I really appreciate how he is blunt with his patients regarding the recovery.  Patients need to hear this along with the expected results and risks.

1.  Facial Acne Scarring:  Ten Years of Treatment With the Carbon Dioxide Laser (Commentary); Trimas SJ; Arch Facial Plast Surg Jan/Feb 2011 2011;13(1):62-64.
2.  Carbon Dioxide Laser Abrasion: Is It Appropriate for All Regions of the Face?; Trimas SJ, Boudreaux CE, Metz RD;  Arch Facial Plast Surg. 2000;2(2):137–140, pmid:10925440
3.  Confessions of a Master Blaster:  How to use CO2 laster in a cosmetic facial surgery practice; Niamtu III, Joseph; Plastic Surgery Practice, February 2011

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