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| FACIAL AESTHETICS | PEER-REVIEW New lasers have the capacity to perform a number of


levels of treatment by using traditional and newer fractional platforms. This gives both health professional and patient an increasing number of treatment options to suit and balance the damage with customised recoveries. Fractional laser skin resurfacing has shown promise for a more user-friendly procedure, but to this point it cannot rival the results of traditional, aggressive CO2 resurfacing quality and results. Ultimately, the CO2


laser skin laser


can also serve as a surgical adjunct for bloodless tissue incision in blepharoplasty and other eyelid surgeries, lesion removal, and even in resection of tumours. Laser technology alone or in combination with


botulinum toxin and hyaluronic acid fillers may give very promising results. Although


improvement is less than with traditional CO2


the degree of laser


treatment, the recovery is much shorter and tolerable, and the complication rate is lower. However, traditional CO2


lasers are the workhorse of


cosmetic facial surgery practice; a single minimally-invasive fractional laser treatment (cannot compare to the level of rhytide effacement and


improvement in dyschromia seen with a traditional CO2 laser device. There is no doubt that the recovery is much easier, but in order to get significant results, the patient may have to undergo up to five treatments. In the authorÕs clinic, superficial ablative treatments are not used. Superficial fractional laser treatments, on the other hand, can frequently be performed without sedation, which is a huge advantage for practitioners. The majority of these patients are treated with a topical anaesthetic only, while the remainder will request full sedation. The procedure is performed by degreasing the face


and applying a generous coat of BLT (benzocaine, lidocaine and tetracaine) topical anaesthesia. A single pass is made over the patientÕs entire face. Generally, 100 mJ with a density of 2 is used for facial treatments. The entire procedure can be completed in 10–20 minutes on an awake, topically-treated patient. In the authorÕs clinic the use of the CO2


laser is not


limited to skin resurfacing, but is also used in laser-assisted blepharoplasty procedures (Figures 2–5), as a bloodless incisional modality is preferred. This treatment modality is easier, and better results can be achieved by using the CO2


laser in the majority of eyelid surgeries such as ptosis,


ectropion and entropion, and in xanthelasma (Figure 8). A 0.2 mm laser handpiece with an 8 W setting is used in


incisional surgeries. Additionally, the handpiece is used at normal focal length to incise the skin and orbicularis, as well as the septum, while for melting and reshaping of the fat tissue it is preferred to de-focus the laser in order to increase the spot size to shrink fat. Although the laser is excellent for small-vessel haemostasis, it is less valuable for larger-vessel haemorrhage, as the CO2


chromophore is


water and the small beam loses its ability to coagulate in a pool of blood. For lower-lid surgery, it is possible to use both the


transcutaneous or transconjunctival approach. If the latter is used, the conjunctiva and capsulopalpebral fascia are incised to access the prolapsed lower fat pads. The


References


1. Coleman SR, Grover R. The anatomy of the aging face: volume loss and changes in 3-dimensional topography. Aesthet Surg J 2006; 26(1S): S4–9


2. Coleman SR. Structural Fat Grafting. St. Lois MO: Quality Medical Publishing, 2004


3. Gosain AK, Klein MH, Sudhakar PV, Prost RW. A volumetric analysis of soft-tissue changes in the aging midface using high-resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg 2005; 115(4): 1143–52


4. Reid RR, Said HK, Yu M, Haines GK 3rd, Few JW. Revisiting upper eyelid anatomy: introduction of the septal extension. Plast Reconstr Surg 2006; 117(1): 65–6


5. Erdogmus S, Govsa F. The arterial anatomy of the eyelid: importance for reconstructive and aesthetic surgery. J Plast Reconstr Aesthet Surg 2007; 60(3): 241–5


6. Biesman BS. Anatomy of the eyelid, forehead and temporal region. In: Biesman BS. ed, Lasers in Facial Aesthetic and Reconstructive Surgery. Philadelphia: Lippincott Williams and Wilkins, 1998


7. Fitzpatrick R, Geronemus R, Goldberg D, Kaminer M, Kilmer S, Ruiz-Esparza J (2003) Multicenter study of noninvasive radiofrequency for periorbital tissue


tightening. Lasers Surg Med 33(4): 232–42


8. Ross E, Naseef G, Skrobal M, Grevelink J, Anderson R. In vivo dermal collagen shrinkage and remodeling following CO2 laser resurfacing. Lasers Surg Med 1996; 18(suppl 8): 38


9. Janik JP, Markus JL, Al-Dujaili Z, Markus RF. Laser resurfacing. Semin Plast Surg 2007; 21(3): 139–46


10. Alexiades-Armenakas MR, Dover JS, Arndt KA. The spectrum of laser resurfacing: nonablative, fractional and ablative laser resurfacing. J Am Acad Dermatol 2008; 58(5): 719–37


11. Walsh JT Jr, Flotte TJ, Anderson RR, Deutsch TF. Pulsed CO2 laser tissue ablation: effect of tissue type and pulse duration on thermal damage. Lasers Surg Med 1988; 8(2): 108–18


12. Nanni CA, Alster TS. Complications of carbon dioxide laser resurfacing. An evaluation of 500 patients. Dermatol Surg 1998; 24(3): 315–20


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prime-journal.com | January/February 2013 ❚ Key points


periocular surgeries such as blepharoplasty, ptosis, entropion and ectropion, and xanthelasma excision are discussed in this article


n The benefits of using the CO2


laser in n CO2 laser systems


have the advantage of both cutting the skin and for rejuvenation of the skin


the gold standard


n Skin resurfacing has evolved rapidly over the past two decades, but the CO2


laser remains


incision is made approximately 4 mm inferior to the lower tarsus from the canthus to the lacrimal punctum. A subciliary incision is made if the transcutaneous method is preferred. In some patients upper-lid blepharoplasty with lower-lid resurfacing is performed, providing very good results (Figures 3–4). However, it is essential to select patients carefully as laser resurfacing should not be performed if there is laxity at the lower eyelid, as this will increase the risk of post-surgical ectropion.


Conclusions The benefits of using the CO2


laser rather than a cold-steel


scalpel in periocular surgeries such as blepharoplasty, ptosis, entropion and ectropion, and xanthelasma excision are discussed in this article. Reduced operation time, less bleeding, superior intraoperative visibility, less bruising and swelling, as well as less pain and discomfort, and a shorter healing period, are some of the benefits of using the laser as a surgical tool. Furthermore, the CO2


laser can be used in laser


resurfacing treatments for photodamaged skin and acne scars. The efficacy and safety have been demonstrated with this technique since its first introduction 20 years ago. Thermal ablation vaporises superficial layers of tissue providing the tissue rejuvenation. Thermal activation causes immediate tissue contraction and new collagen production to reduce wrinkles and tighten the skin. Patient selection and appropriate preoperative planning and postoperative care are essential for successful outcomes. Despite the advances in technology and the


introduction of alternative methods for skin resurfacing, the CO2


laser continues to deliver the most consistently


effective improvement in skin tightening and wrinkle reduction, thus remaining the gold standard for skin resurfacing.


 Declaration of interest None  All figures ç Rengin Griffin


39


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