Aesthetic Surgery Journal

http://aes.sagepub.com/ Outcomes of Fractional CO2 Laser Application in Aesthetic Surgery: A Retrospective Review
Keith C. Neaman, Marissa E. Baca, Rocco C. Piazza III, Douglas L. VanderWoude and John D. Renucci Aesthetic Surgery Journal 2010 30: 845 DOI: 10.1177/1090820X10386930 The online version of this article can be found at: http://aes.sagepub.com/content/30/6/845

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Cosmetic Medicine
Aesthetic Surgery Journal 30(6) 845 852 2010 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www .sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X10386930 www.aestheticsurgeryjournal.com

Outcomes of Fractional CO2 Laser Application in Aesthetic Surgery: A Retrospective Review

Keith C. Neaman, MD; Marissa E. Baca, BS; Rocco C. Piazza III, MD; Douglas L. VanderWoude, MD; and John D. Renucci, MD

Abstract Background: Despite the effectiveness of ablative CO2 laser resurfacing for facial rejuvenation, its application has been limited owing to an undesirable side-effect profile, including prolonged hyperemia and potential pigmentary changes. However, newer fractional CO2 laser technology has reduced the recovery time and led to decreases in postprocedural hypo- and hyperpigmentation. Objectives: The authors investigate the application and outcomes of ablative fractional technology in a private cosmetic surgery practice. Methods: In this retrospective cohort study, the charts of patients who received fractional CO2 laser resurfacing between March 2007 and May 2008 were reviewed. Data regarding patient demographics, pretreatment regimens, detailed operative data, and posttreatment findings were obtained. The length of hyperemia (less than five weeks, five to eight weeks, and more than eight weeks), complication rates, and revision rates were analyzed. A satisfaction survey was also sent to all patients. Results: Throughout the 19-month study period, 97 patients received 101 treatments with an average follow-up of 4.5 months. Full-face laser resurfacing was performed in 81.1% of patients, with 64.3% receiving their treatment under local anesthesia without sedation. Length of hyperemia was less than five weeks in 93%, five to eight weeks in 5.9%, and more than eight weeks in 0.9% of patients. Hyperpigmentation (9.9%), milia (6.9%), acne breakout (5.9%), and transient ectropion (0.9%) were less common. Patient satisfaction surveys revealed that a majority of patients were satisfied with their results. Conclusions: New fractional CO2 laser skin resurfacing is associated with shorter periods of hyperemia, resulting in shorter recovery time in comparison with older ablative technology. The side-effect profile is minor and infrequent. This new technology provides significant clinical improvement with high patient satisfaction. Keywords facial rejuvenation, CO2 fractional laser, ablative laser, skin resurfacing Accepted for publication January 4, 2010.

According to the American Society for Aesthetic Plastic Surgery, there has been a 270% increase in laser skin resurfacing procedures over the past decade.1 This increase is likely the result of patients seeking facial rejuvenation without the high risk and recovery time associated with standard surgical procedures. Lasers rely on differing techniques to produce thermal damage to the epidermis and dermis, resulting in tissue ablation and collagen proliferation. Each laser varies in intensity of treatment, efficacy, and side-effect profile. Ablative laser treatment has resulted in excellent facial rejuvenation, but it has been plagued by a wide range of side effects. However, nonablative lasers, although they have a reduced risk of side effects, have resulted in decreased efficacy. Carbon dioxide (CO2) lasers target water by emitting a 10,600-nm light pulse that leads to vaporization of intraand extracellular water, resulting in tissue ablation. Depending on the duration and intensity of exposure, the

depth of dermal ablationas well as damage to surrounding tissueis varied. This treatment pattern results in a zone of homogeneous thermal damage (termed bulk heating) and, depending on the depth of dermal ablation, may result in persistent erythema leading to prolonged
Dr. Neaman is a plastic surgery Resident, Dr. Piazza is plastic surgery Resident, Dr. VanderWoude is Clinical Associate Proffesor, and Dr. Renucci is Assistant Program Director at the Grand Rapids Medical Education and Research Center, Michigan State University, Grand Rapids, Michigan. Ms. Baca is a third-year medical student in the Michigan State University-College of Human Medicine, Grand Rapids, Michigan. Corresponding Author: John D. Renucci, MD, 220 Lyon St NW, Suite 700, Grand Rapids, MI 49503, USA. E-mail: johnrenucci@yahoo.com

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recovery times. Furthermore, the side effects include scarring, infection, postinflammatory hyperpigmentation, and delayed hypopigmentation.2-5 As a result, fully ablative nonfractional ablative CO2 lasers, once considered the gold standard for treatment of facial rhytids and photodamaged skin, have fallen out of favor. In 2004, Manstein et al described fractional photothermolysis, a novel method for cutaneous remodeling.6 This technique formed microscopic columns of thermal injury surrounded by viable tissue. This method has been applied for a wide variety of lasers, both ablative and nonablative, with alteration in the density, depth, and pattern generation of these microscopic treatment zones. Numerous reports have shown decreased recovery times and a narrow side-effect profile, likely the result of these preserved areas of intact tissue.7-12 With this new fractional technology, there has been a resurgence in the application of ablative therapies for facial rejuvenation. Here, we investigate the outcomes of ablative fractional technology in a cosmetic surgery practice.

Patient Satisfaction Questionnaire (Scale: 1-5) 1. Where you satisfied with your CO2 laser treatment? 2. Would you recommend the procedure to your friend? 3. Would you have the procedure again if you needed? 4. How much improvement did you notice in your skin following the laser treatment? 5. Were the results of the treatment worth the time and cost invested? 6. The most significant improvement in my skin after the laser treatment was: color smoothness (lines/wrinkles) improved tone/tightness 7. Did you experience any problems with the procedure?

METHODS
A retrospective chart review was performed on 97 consecutive patients who received 101 treatments with a nonsequential fractional ultrapulse CO2 laser (Ultrapulse Encore, Active FX, Lumenis Ltd., Santa Clara, CA) between March 2007 and May 2008 for the purpose of aesthetic skin resurfacing. The average length of follow-up was four months (range, two weeks to 19 months). Patient demographics, Fitzpatrick skin type, aesthetic units of the face with laser parameters, and the number of passes, types of anesthesia, pre- and posttreatment care, complications, and side effects were recorded. The length of hyperemia was classified as follows: five weeks, five to eight weeks, or more than eight weeks. All data points were analyzed as possible risk factors for complications. All patients were sent a follow-up survey investigating the level of patient satisfaction (Figure 1).

Figure 1. Patient satisfaction survey. Responses were scored on a five-point Likert scale, with 5 being the highest.

Laser Treatment
Patients were instructed to discontinue retinoids two weeks prior to the procedure. Each patient began a course of valacyclovir two days pretreatment and continued it for eight days posttreatment. Procedures were performed under local anesthesia or under conscious sedation starting with topical anesthetic cream applied 45 minutes before the procedure. The patients face was cleansed and sensory nerve blocks were performed, targeting the supraorbital, infraorbital, and mental nerves. Patients receiving treatment of isolated facial aesthetic units (eg, perioral) were anesthetized appropriately. The laser settings were determined and problem areas received a double and/or triple pass, as dictated by the surgeon. When multiple passes were performed, the epidermis was debrided with a tongue

blade between each pass. By performing multiple passes with a density greater than three, the epidermis is completely ablated, leaving an intact dermis with microscopic treatment zones. Theoretically, this procedure would provide a more aggressive treatment while taking advantage of the reduced downtime associated with fractional photothermolysis secondary to intact dermal bridging. The range of laser settings and frequency of passes for each aesthetic unit are depicted in Table 1. In general, the entire face was treated with feathering onto the neck and down to the clavicles with lighter settings. When treating the periocular region, eye protection was provided with metal eye shields. Of note, CO2 resurfacing was not performed on skin that was being concurrently undermined secondary to an adjunct procedure such as a rhytidectomy. Posttreatment, patients were seen weekly for four weeks and then every other week for an additional six weeks. A kit with detailed posttreatment instructions was provided to each patient. Early posttreatment dressings consisted of an occlusive ointment (eg, Vaseline) for approximately seven days followed by a recovery complex cream that was semi-occlusive (paraffin based) for an additional four to seven days. Patients were instructed to wash frequently with a gentle cleanser. Areas of skin that exhibited fibrous exudates were treated with Vaseline, while areas that were reepithelialized were treated with a paraffin-based moisturizer. Most patients were able to resume a regimen of daily moisturizer, sun block, and/or cover-up makeup by posttreatment week four or at the time of stable epithelialization. Retinoids were resumed at that time as well. Some patients did receive a methylprednisolone dose pack if swelling was determined to be severe.

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Table 1. Treatment Areas, Laser Settings, and Number of Passes Area treated Perioral Periorbital Cheeks Forehead Double pass, n (%) 45 (44.6%) 4 (4.0%) 12 (11.9%) 3 (3.0%) Energy(mJ) 100-50 80-125 80-150 70-150 Frequency(Hz) 100-500 75-150 75-150 75-200 Shape 3-7 3 3 3 Size 5-8 4-8 5-7 5-7 Density 3-6 3-6 3-6 3-6

Table 2. Medical History Medical history Chronic sun exposure Previous acne Acne scarring Herpes simplex virus Tobacco abuse Hypertension Hypertrophic Scarring Keliod n (%) 48 (47.5%) 38 (37.6%) 29 (28.7%) 22 (21.8%) 13 (12.9%) 9 (8.9%) 5 (5.0%) 3 (3.0%)

Table 4. Physical Exam Results Pretreatment physical exam findings Perioral lines Uneven pigmentation Crows feet Acne scars Hyperpigmentation Sun damage Smile lines Mannequin lines n (%) 47 (46.5%) 34 (33.7%) 24 (23.8%) 21 (20.8%) 16 (15.8%) 15 (14.9%) 11 (10.9%) 6 (5.9%)

Table 3. Previous Facial Aesthetic History Nonsurgical Retinoids Botox Fillers Light peel Medium peel Heavy peel n (%) 63 (62.4%) 41 (40.6%) 46 (45.5%) 27 (26.6%) 17 (16.8%) 6 (5.9%) Surgical Nonfractional CO2 Facelift Endo-brow Blepharoplasty Medlite V-Beam n (%) 18 (17.9%) 17 (16.8%) 13 (12.9%) 33 (32.7%) 25 (24.8%) 17 (16.8%)

Table 5. Fitzpatrick Skin Type Type I II III IV V Table 6. Areas Treated n (%) 6 (5.9%) 27 (26.7%) 49 (48.5%) 17 (16.8%) 1 (1.0%)

RESULTS
The average patient age was 53 years (range, 17-76). Ninety-five percent of patients were female (97% Caucasian, 3% Asian). Significant medical history is described in Table 2. A majority of patients had undergone previous surgical and nonsurgical treatments, as depicted in Table 3. Patients typically presented with pretreatment findings of perioral lines, uneven pigmentation, and crows feet (Table 4). Fitzpatrick skin types are listed in Table 5. Local anesthesia was administered in 65.3% of procedures. Those patients receiving their laser resurfacing in conjunction with other cosmetic procedures were typically given general anesthesia (n = 17; 16.8%). The entire face was treated 82.2% (n = 83) of the time, followed by the treatment of isolated facial aesthetic units (Table 6). Typically, those patients who did not receive full-face resurfacing underwent additional facial cosmetic procedures (eg, facelift) at the time of their resurfacing. A majority of patients received feathering onto the neck and chest region. Posttreatment hyperemia is shown in Table 7. Ninetythree percent of patients had less than five weeks of erythema posttreatment. One patient had more than eight weeks of erythema secondary to a contact dermatitis. Fifteen patients had less than five weeks of follow-up. All

Area Full face Eyes Perioral Cheek Forehead Nose Table 7. Duration of Hyperemia Duration Less than five weeks Five to eight weeks More than eight weeks
a

n (%) 83 (82.2%) 11 (10.9%) 3 (3.0%) 1 (1.0%) 1 (1.0%) 1 (1.0%)

n (%) 94 (93.1%) 6 (5.9%) 1 (1.0%)a

Patient had severe contact dermatitis.

Table 8. Posttreatment Complications Complication Hyperpigmentation Milia Acne Transient ectropion n (%) 10 (9.9%) 7 (6.9%) 6 (5.9%) 1 (1.0%)

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Table 9. Survey Results (Questions 1-7) Response to question 1 Question #1 Question #2 Question #3 Question #4 Question #5 4 (6.1%) 4 (6.1%) 10 (15.2%) 7 (10.6%) 7 (10.6%) Response Question #6 Question #7 Improved tone / tightness (48.5%) Yes (27.3%) 2 6 (9.1%) 6 (9.1%) 6 (9.1%) 11 (16.7%) 9 (13.6%) 3 12 (18.2%) 16 (24.2%) 14 (21.2%) 15 (22.7%) 14 (21.2%) 4 16 (24.2%) 11 (16.7%) 13 (19.7%) 21 (31.8%) 21 (31.8%) 5 28 (42.4%) 29 (43.9%) 23 (34.9%) 12 (18.2%) 15 (22.7%) Median 4 4 4 3.5 4

of these patients had minimal-to-no residual hyperemia at their last visit and were categorized as having less than five weeks of hyperemia. Posttreatment complications were minor and included transient hyperpigmentation, milia, and acne (Table 8). Anecdotally, patients with hyperpigmentation tended to be those who were noncompliant with the posttreatment skin regimen, failing to apply sun block with early sun exposure. Hyperpigmentation generally occurred three to four weeks posttreatment and lasted, on average, 5.7 weeks (range, two to 12). The laser settings for these patients were not significantly different from those of other patients, but the skin types were statistically higher (III-V). All cases resolved with application of hydroquinones. One patient with a history of multiple lower lid blepharoplasties did experience a transient ectropion. She was treated with the following settings: energy of 125 mJ, frequency of 150 Hz, shape of three, size of seven, and density of six. Her ectropion did not result in any exposure keratitis and was edema related. It resolved after four weeks of treatment with eye lubricants and gentle massage. No patients experienced posttreatment hypopigmentation or herpes outbreaks. Four patients went on to receive additional laser treatments during the study period because of the severity of their underlying rhytids. In general, these patients were pleased with their results and, initially, the need for multiple treatments was discussed. Representative clinical cases are depicted in Figures 2 through 4. Sixty-six patients responded to the five-point Likert scale satisfaction survey (Figure 1), equating to a response rate of 68%. Table 9 outlines the responses to individual questions. The following posttreatment complaints were recorded: intraoperative pain (n = 4), as well as pigmentary changes, visible patterns, length of recovery time, ocular irritation, and acne outbreak (all n = 2). All of these reported complications were transient in nature.

DIScUSSION
This study describes the experience of one cosmetic surgery practices application of ablative fractional CO2 lasers for the purpose of nonsurgical facial rejuvenation. For

years, nonfractional ablative CO2 lasers have been the standard for facial resurfacing. However, as patients seek shorter recovery times and less-invasive procedures, plastic surgeons have worked to develop newer modalities. Fractional CO2 lasers serve as an excellent adjuvant to surgical procedures in providing safe, efficacious, predictable, and positive clinical outcomes for challenging treatment areas. These lasers focus on the outer skin envelope by addressing texture, color, elasticity, fine-line wrinkles, and deep rhytids, whereas issues such as jowling and neck redundancy are best addressed surgically. On this point, education is a key component of the pretreatment evaluation. We strongly reinforce that laser resurfacing will not replace surgical treatments focused on altering volumetric changes as a result of aging. Posttreatment erythema lasting up to four months has been reported with nonfractional ablative CO2 lasers.5 In our study, over 93% of patients had less than five weeks of erythema. Other reports have echoed these findings, with anywhere from two days to three weeks of posttreatment erythema being reported.8-9,11-13 The variability is related to the depth of treatment as a result of the energy selected. Some authors have employed lower settings with multiple treatments, whereas others treat more aggressively. Initially, we elected to treat with lower settings, resulting in less dermal penetration. However, as our experience has grown, we are now treating more aggressively with slightly longer recovery times, resulting in significant improvement in rhytids. Despite the length of erythema, patients usually return to work two to three weeks posttreatment and are able to apply makeup. One advantage of fractioned CO2 lasers is the ability to treat patients under local anesthesia,8 which is generally well tolerated. However, of those patients who reported experiencing difficulty with the procedure, intraoperative pain was the most common complaint. Hence, we offer both local anesthesia and conscious sedation to all patients and encourage sedatives for those patients who express anxiety with regard to the pain associated with the procedure. Pigmentation changes following CO2 resurfacing are a major concern. In our cohort, 10 patients experienced postinflammatory hyperpigmentation (PIH), which was

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Figure 2. A, C, E, This 62-year-old woman presented for facial rejuvenation. She had a Fitzpatrick II skin type and a history of chronic sun exposure and dyschromias. B, D, F Six months after full-face treatment with the fractional CO2 laser under general anesthesia.

transient and controlled with bleaching agents. Tan et al recently reported no episodes of PIH in seven patients (skin types IV and V) treated with a fractional CO2 laser.14 This finding is in direct contrast to the experience of Nanni et al, who reported temporary hyperpigmentation in 37% of his patients who underwent traditional ablative CO2 resurfacing.5 Our preference is to pretreat patients with glycolic acids, tretinoin, and hydroquinone four to six weeks prior to their CO2 treatments. This pretreatment, in conjunction with decreased sun exposure and prompt resumption of a skin care

regimen approximately four weeks posttreatment, is a primary contributor to our low rate of PIH. In addition to hyperpigmentation, delayed postoperative hypopigmentation is a frequent occurrence following conventional CO2 laser treatment, with rates up to 16.3% in some studies.3 We had no cases of hypopigmentation in this study. However, it is difficult to draw any long-term conclusions, given our short length of follow-up and the reported occurrence of hypopigmentation up to 10 months posttreatment.5 Case reports of hypertrophic scarring in the neck following ablative

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Figure 3. A, D, G, This 63-year-old woman presented for facial rejuvenation. She had a Fitzpatrick III skin type and a history of chronic sun exposure and acne. She had undergone numerous chemical peels and Botox injections prior to presenting at our clinic, secondary to actinic changes and facial rhytids. B, E, H, One week after a full-face treatment with the fractional CO2 laser performed under local anesthesia, with double passes in the cheek and perioral regions. C, F, I, 19 months posttreatment.

fractional CO2 treatments, usually the result of deep treatments, have also been reported.15, 16 This side effect did not occur in our series, which may be related to our sequential moderate treatments spaced over four to six months for safer outcomes.

Disclosures
The authors declared no conflicts of interest with respect to the authorship and publication of this article.

REFErENcES
1. American Society for Aesthetic Plastic Surgery (ASAPS). 2005 Cosmetic Surgery National Data Bank Statistics. Statistics. http://www.surgery.org/press/statistics-2005.php. 2. Prado A, Andrades P, Danilla S, et al. Full-Face carbon dioxide laser resurfacing: A 10-year follow-up descriptive study. Plast Recon Surg 2008; 121:983-993. 3. Bernstein LJ, Kauvar AN, Grossman MC, Geronemus RG. The short and long term side effects of carbon dioxide laser resurfacing. Dermatol Surg 1997; 23:519-525.

CONcLUSIONS
The fractional CO2 laser is an excellent, less-invasive tool for skin resurfacing, with shorter recovery times and limited side effects. It serves as a safe and reliable method of restoring the outer skin envelope. When patients undergo laser resurfacing as an adjuvant to surgical procedures, maximum facial rejuvenation can be obtained safely, predictably, and efficaciously, resulting in excellent clinical outcomes.

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Figure 4. A, C, E, This 53-year-old female presented for facial rejuvenation. She had a Fitzpatrick III skin type with actinic changes and severe facial rhytids. Prior to her first treatment, this patient had undergone numerous facial cosmetic procedures, including Botox injections, chemical peels, four-lid blepharoplasty, and several rhytidectomies. B, D, F, 14 months after the second full-face treatments performed under local anesthesia with double passes in the perioral and cheek areas. The two treatments occurred seven months apart.

4. Alster TS, West TB. Resurfacing of atrophic facial acne scars with a high energy, pulsed carbon dioxide laser. Dermatol Surg 1996; 22:151-155. 5. Nanni CA, Alster TA. Complications of carbon dioxide laser resurfacing. Dermatol Surg 1998; 24:315-320. 6. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med 2004; 34:426-438. 7. Chapas AM, Brightman L, Sukal S, et al. Successful treatment of acneiform scarring with CO 2 ablative fractional resurfacing. Lasers Surg Med 2008; 40: 3 81-386.

8. Clementoni MT, Gilardino P, Muti F, Beretta D, Schiamchi R. Non-sequential fractional ultrapulsed CO2 resurfacing of photoaged facial skin: Preliminary clinical report. J Cosmet Laser Ther 2007; 9:218-225. 9. Christiansen K, Bjerring P. Low density, non-ablative fractional CO2 laser rejuvenation. Lasers Surg Med 2008; 40:454-460. 10. Alster TS, Tanzi EL, Lazarus M. The use of fractional laser photothermolysis for the treatment of atrophic scars. Dermatol Surg 2007; 33:295-299. 11. Tannous ZS, Astner S. Utilizing fractional resurfacing in the treatment of therapy resistant melasma. J Cosmet Laser Ther 2005; 7:39-43.

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12. Geronemus RG. Fractional photothermolysis: Current and future applications. Lasers Surg Med 2006; 38:169-176. 13. Fisher GH, Geronemus RG. Short-term side effects of fractional photothermolysis. Dermatol Surg 2005; 31(9 Pt 2): 1245-1249. 14. Tan KL, Kurniawati C, Gold MH. Low risk of postinflammatory hyperpigmentation in skin types 4 and 5 after treatment with fractional CO2 laser device. J Drugs Dermatol 2008; 7:774-777.

15. Fife DJ, Fitzpatrick RE, Zachary CB. Complications of fractional CO2 laser resurfacing four cases. Lasers Surg Med 2009; 41:179-184. 16. Avram MM, Tope WD, Yu T, Szachowicz E, Nelson JS. Hypertrophic scarring of the neck following ablative fractional carbon dioxide laser resurfacing. Lasers Surg Med 2009; 41:185-188.