Q11

2 CO2 laser

applications: new fractional and

traditional CO2 laser resurfacing and CO2 laser blepharoplasty

Brooke R. Seckel

Key points

What is photothermolysis? How does the CO2 laser remove wrinkles and

tighten skin?

What is fractional laser skin resurfacing? What are the contraindications to laser skin

resurfacing and blepharoplasty?

What are the advantages of CO2 laser blepharoplasty?

What are the crucial steps in post laser skin resurfacing wound care?

CO2 laser skin resurfacing

The technique of CO2 laser skin resurfacing (LSR) for the removal of photo-aging skin pathology, including wrinkles and solar lentigines, and skin tightening is based on the concept of photothermolysis. Utilizing CO2 laser light (photo) energy which is highly

absorbed by water, the skin is irradiated with the laser beam, intracellular water is heated (thermo) to a point where cell rupture (lysis) occurs. With CO2 and 2940 Er:YAG lasers, the lasers most highly absorbed by water, sufficient cellular injury occurs to actually ablate or remove photo-damaged epidermal cells and

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damaged superficial dermis. In addition, the cellular injury in the dermis causes residual thermal damage (RTD) which initiates an intense inflammatory cascade. This results in the production of new collagen in the dermis to replace the actinically damaged dermal collagen.

The new dermal collagen and wound healing response result in wrinkle removal and skin tightening (Seckel et al 1998). The ablation of photo-damaged skin by CO2 LSR provides superior wrinkle removal and skin tightening compared to non-ablative LSR which only heats, but does not remove, photo-damaged skin (Figure 2.1). However traditional flat-beam ablative LSR is followed by 23 weeks of recovery time and often months of prolonged erythema, and long term hypo-pigmentation is common.

Fractional CO2 laser skin resurfacing

The prolonged recovery and attendant morbidity have dampened enthusiasm for traditional flat-beam CO2 and erbium laser resurfacing in spite of the ability to achieve significant results with these techniques. Recently, new technology called fractional laser skin resurfacing (LSR) has been developed which has dra-matically shortened recovery time and lessened the occurrence of complications.

With fractional laser resurfacing the laser beam is broken up or fractionated, into many small micro-beams. These micro-beams are separated and thus, when they strike the skin surface, small areas of the skin between the beams are not hit by the laser and are left intact. These small areas of untreated skin

promote a much more rapid re-epithelialization, recovery and healing with less risk of complications. The small areas treated by the fractional micro-beams, called micro-treatment zones (MTZs), cause sufficient laser injury deep in the dermis to promote new colla-gen production and resultant facial skin rejuvenation. Early fractional LSR devices were non-ablative. They heated but did not ablate the tissue in the MTZs. Although the non-ablative LSR lasers are effective at plumping the skin and removing pigment, they are less effective for wrinkle removal than traditional flat-beam ablative LSR lasers. During the past year, frac-tional ablative CO2 and erbium lasers have been developed which ablate columns of skin as deep as 1600 microns (Figure 2.2). The Reliant Fraxel re:pair and the Lumenis UltraPulse Encore DeepFX are two of the most commonly used ablative fractional CO2 lasers.

CO2 laser blepharoplasty

CO2 laser blepharoplasty using the 0.2 mm incisional hand piece on the Lumenis UltraPulse CO2 laser, is a very precise, atraumatic technique for incisional upper and transconjunctival lower blepharoplasty. The CO2 laser blepharoplasty provides superior hemo-stasis, accurate control of incisional margins and reduced operating time in a bloodless field (Box 2.1). The safety and efficacy of the CO2 laser blepharoplasty have been well documented (Seckel et al 2000). The benefits of combined periocular CO2 LSR and trans-conjunctival orbicularis oculi muscle and septal tight-ening have dramatically improved cosmetic results in eyelid and periocular skin rejuvenation.

Figure 2.1 Diagrammatic representation of skin changes before, after non-ablative LSR and after ablative LSR.

Dermis

Sun Damaged Skin Non-Ablative Skin Resurfacing Ablative Skin Resurfacing

Epidermis

Subcutaneous layer

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Patient selection

CO2 LSR is best limited to patients with fair skin because of the risk of post LSR hypo-pigmentation and demarcation lines between treated and untreated skin. Therefore I limit CO2 LSR to patients with Fitzpatrick Type 1, 2, and 3 skin. Although many physicians have successfully treated darker skin types, I do not because of the risk of hypo-pigmentation.

Contraindications to CO2 LSR include active infection, prior use of Accutane within the past 612 months, skin atrophy from previous laser resurfacing or chemical peel, significant psychopathology, unreal-istic expectations, non-compliant patient, active pus-tular acne or skin infection, deficient wound healing, and use of anticoagulant medication (Box 2.2).

CO2 laser blepharoplasty can be done on any patient who is an appropriate candidate for incisional upper and transconjunctival lower blepharoplasty. Contraindications to blepharoplasty include uncon-trolled hypertension, Graves disease, proptosis greater than 3 millimeters, uncontrolled glaucoma, serious retinal disease, dry eye syndrome, acute blepharitis, and blepharochalasis (Box 2.3).

Indications

CO2 LSR is indicated for the treatment of skin photo-aging pathology including wrinkles, solar lentigines, diffuse superficial hyperpigmentation, multiple widespread actinic keratoses, sebaceous hyperplasia, rhinophyma, and acne scarring. These are accepted indications for traditional flat-beam CO2 LSR. Frac-tional CO2 LSR is indicated primarily for wrinkle and pigment removal and acne scarring. Efficacy for treat-ment of actinic keratoses and exophytic skin lesions has not yet been established for fractional ablative lasers.

Indications for CO2 laser blepharoplasty include dermatochalasis, excess upper eyelid skin causing hooding of the eyes, herniation of the infraorbital fat

Figure 2.2 Diagram comparing depth of skin penetration of traditional flat-beam LSR, non-ablative fractional LSR and ablative fractional LSR.

Ablative Resurfacing(CO2 & 2.94 Er:YAG)

10200 microns

Non-Ablative Fractional Resurfacing

6001000 microns

Ablative FractionalResurfacing

6001000 microns

Superficial FractionalAblative Resurfacing(CO2 & 2.94 Er:YAG)

1070 microns

Box 2.1 Advantages of laser blepharoplasty

Less bleedingLess operative timeMore preciseLess trauma to tissuesEarly recovery of the patientLess painLess swelling

Box 2.2 Contraindications to laser peel

Active herpes simplex infectionPsychoneurosis - active abuse of drugs and alcoholHistory of hypertrophic or keloid scarHistory of hyperpigmentation or hypo-pigmentationUse of Accutane in previous 6 monthsUnrealistic expectationsThe non-compliant patient

Box 2.3 Contraindications to cosmetic blepharoplasty

Uncontrolled hypertensionGraves diseaseProptosis >3 mmUncontrolled glaucomaSerious retinal diseaseDry-eye syndromeAcute blepharitis or blepharochalasis

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causing puffiness or bags on the lower eyelids, and skin excess or photo-aging changes on the lower eyelid skin. A new indication for lower eyelid blepharoplasty is the arcus deformity which is also called the dark circle under the eye. The arcus deformity is caused by the attachment of the arcus marginalis to the under-side of the lower lid combined with skin laxity and herniation of lower eyelid fat. The arcus deformity can be corrected with a transconjunctival laser lower blepharoplasty with arcus release and fat repositioning or fat grafting onto the orbital rim.

Operative technique

Pre-operative preparation

Pre-operative preparation for all patients includes a thorough history and physical examination, preferably performed 10 days to 2 weeks before CO2 laser resur-facing or CO2 laser blepharoplasty. Screening for con-traindications to LSR is essential. If CO2 LSR or CO2 blepharoplasty of the lower eyelids is contemplated, lid laxity must be evaluated using the Jelks lid snap test. Several predisposing factors, especially laxity of the lower eyelids, can increase the risk of ectropion following LSR or blepharoplasty (Box 2.4).

At the pre-operative visit, patients undergoing CO2 LSR are given prescriptions for oral antibiotics such as Duracef (500 milligrams twice a day) or Eryc (500 milligrams daily) beginning the day of the procedure. I also prescribe the antiviral Valtrex (500 milligrams twice a day for 10 days) beginning one day before the procedure. For patients who are having the CO2 LSR under topical anesthesia I prescribe Percocet (1 tablet) and diazepam (5 milligrams) to be taken 1 hour prior to the procedure. For patients who have, or are at risk for, hyperpigmentation I also prescribe a bleaching regimen to begin 36 weeks prior to LSR.

This consists of a uniform mixture of 4% hydroqui-none, 0.1% Retin A, and 1% hydrocortisone cream which are to be mixed in the hand and applied to the facial skin one to two times a day and to be discon-tinued a day before LSR.

Reliant Technologies recommends clobetasol pro-pionate 0.05% cream applied twice daily starting the day before the Fraxel re:pair fractional CO2 LSR pro-cedure. Benadryl 25 milligrams is also prescribed at bedtime starting the night before the procedure and for 23 nights after the procedure. I also have patients acquire Aquaphor ointment, gauze sponges and normal saline solution for post-operative wound care. Patients who are having CO2 blepharoplasty are given Lacrilube and erythromycin ophthalmic ointment for use after surgery as well as the prophylactic antibiotics listed above.

Traditional flat-beam CO2 LSR with the CO2 UltraPulse laser

Good results and avoidance of complications require knowledge of laser skin interactions, skin micro-anatomy, wound healing response and the depth of laser injury caused by the particular laser in use. These details cannot be covered here and the reader is referred to a detailed coverage of these variables described below for the Coherent Ultrapulse 5000 CO2 laser (Seckel 1996), the most widely available CO2 laser in use for LSR today. Users of the new Lumenis Ultrapulse Encore are referred to the users manual for adjustment of the settings for the new ActiveFx and DeepFX pattern generator hand piece in order to achieve the energy and coverage listed below. It is essential that laser fire precautions be observed. Eye protection is mandatory for the patient and all personnel. Smoke evacuation of the laser plume is crucial throughout the procedure.

Most full face CO2 LSR procedures are done under general anesthesia. Prior to starting the procedure the skin is de-greased, rinsed with saline and dried. The depths of wrinkles, rhytides and acne scars are marked with a surgical marker so that progression of ablation can be observed during treatment. The sub-mandibu-lar border is marked symmetrically by observing the mandible from below so that symmetrical demarca-tion zones are achieved. Protective stainless steel scleral shields (Oculo-Plastik, Montreal, Quebec) are placed over the eyeball.

Box 2.4 Conditions associated with an increased risk of ectropion

Hypotonicity of lidMalar hypoplasiaShallow orbitGraves ophthalmologyUnilateral high myopia (long eyeball)Large eyeSecondary blepharoplasty

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The CO2 Ultrapulse Laser with the CPG scanning hand piece is set at 300millijoules, 60 watts, packing density 5, pattern 3, and size 69. The first pass is done over the entire face avoiding the eyelids, making certain the ablation patterns are adjacent or with a 5 % overlap to avoid skip areas. The gray char is removed with saline soaked gauze sponges revealing a pink de-epithelialized skin surface. A second, and usually, a third pass are done. If the skin develops a yellowish chamois cloth appearance it is an indication of injury into reticular dermis and no further pass should be done. In patients with very deep rhytids individual passes with a smaller pattern can be done on the hillock or shoulder of the wrinkle as long as the chamois cloth appearance has not developed. More than three passes does not achieve improvement in results and can extend the depth of injury to an unsat-isfactory level.

The laser is then de-powered to 150 millijoules and 30 watts and a blending pass is done at the demarca-tion line on the mandible to blend the transition between treated and untreated skin. The eyelids are only one-sixth of the thickness of the facial skin and must not be treated as deeply as the remainder of the face. I use one to two passes at 300 millijoules 60 watts with a packing density of 5 on eyelid skin of average thickness. Thinner skin is treated with 150 millijoules and 30 watts. A smaller pattern 3 size 23 is used on the eyelids.

Closure

I apply a mask of Xeroform gauze on the facial skin and cover this dressing with thick layer of bacitracin ointment for the first post operative night. I cover the lower eyelid with a supportive Flexan occlusive dress-ing and simply apply bacitracin to the upper eyelids. Some practitioners prefer other occlusive agents such as Aquaphor or Vaseline due to risk of contact allergy with topical antibiotic ointment. Percocet tablets are used for pain management.

Operative steps

Place intra-ocular shields De-grease skin Three passes facial skinone to two passes eyelid

skin

Cleanse between passes

Apply Xeroform dressing with bacitracin or other occlusive agent

Flexan supportive lower eyelid dressing Remove intra-ocular shields.

Fractional CO2 LSR with the Reliant Fraxel re:pair procedure

The Fraxel re:pair LSR procedure is done under topical or local nerve block anesthesia. Pre-operative prepara-tion has been covered above. I use a topical anesthetic consisting of benzocaine 12%, tetracaine 8%, and lidocaine 4%, compounded by University Pharmacy in Salt Lake City, Utah, which is applied 1 hour prior to the procedure. This compound should not be used on large areas like the leg or body because of potential toxicity; however, use on the face is safe for individuals who do not have sensitivity to these agents. The topical anesthetic is removed only from the treatment area currently being treated leaving the anesthetic on the areas which will be treated later. Other topical anaes-thetics such as Pliaglis (Galderma Labarotories, Ft. Worth, TX) have been introduced that provide excel-lent topical anesthesia. The face is prepped with sterile solution and then the skin cleansed and de-greased. As in the traditional flat-beam CO2 LSR procedure above, laser fire precautions, eye protection for patient and staff, and constant smoke evacuation of the laser plume are mandatory laser safety procedures.

I use stainless steel intra-ocular shields when doing ablative CO2 LSR, although if the eyelids are not to be treated, external shields may be used. The Fraxel re:pair laser settings below are recommended in the Reliant user manual and are customized accord-ing to skin type and anticipated depth of treatment required. Depth of penetration is determined by pulse energy which can be set from 20 millijoules to 70 millijoules. The second parameter to consider is the percentage of skin surface area coverage of the fractional laser beam which, for the face, is usually set from a low of 25% to a high of 60%. The neck should not be treated with over 35% coverage. Eyelids are thinner than facial skin. Thus the eyelid skin should be treated with lower settings, a maximum of 20 millijoules and no more than 40% surface area coverage. While higher settings of depth and surface area coverage will provide more effective wrinkle removal, higher settings will also increase post LSR erythema and delay recovery.

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The Fraxel re:pair is new technology, and you will experience a definite learning curve. For mild to mod-erate rhytides and/or pigmentation, I use a 25% surface area coverage and 40 millijoules and four passes, two horizontal and two vertical over the same area at 90 degrees to the prior pass. For acne scarring and deeper rhytids a 40% surface area setting and 50 to 60 milli-joules will produce better results, but also prolong erythema time. The Fraxel re:pair hand piece is a marvellous technological achievement. The two rollers glide easily over the skin, delivering the fractional CO2 beam in a uniform fashion. Appropriate hand speed is monitored by an automatic audible monitor. Four passes are always donetwo horizontal and two verti-cal in alternating fashion.

Visual feedback is not as important with Fraxel as it is in flat-beam CO2 laser resurfacing. You have to trust the machine to uniformly deliver the pre- determined energy of your dialled-in settings. Once four passes are completed, you are doneno checking for chamois cloth appearance. I do not wipe debris between passes, as there is little debris to visualize and the attached vacuum removes most debris that is created. Note: be sure to remove the intra-ocular shields after the procedure.

Closure

Once the treatment is completed, apply iced or cold saline soaks to the skin. After the patient feels comfort-able, apply Aquaphor ointment. I have the patient continue saline soaks every 23 hours the first night, gently removing any debris. The patient then applies Aquaphor ointment. Percocet tablets are used for pain management.

Operative steps

Laser safety precautions. Intra-ocular shields. Remove topical only from area to be treated. De-grease skin. Laser settings 2060 millijoules and 2540%

surface area.

Eyelids maximum 20millijoules 40% surface area. Four passes two horizontal, two vertical. Cold saline soaks. Aquaphor ointment. Remove scleral shields.

Four lid CO2 laser blepharoplasty with arcus marginalis release and fat repositioning

In the pre-operative area with the patient sitting up, a surgical marker is used to mark the supratarsal fold and the upper incisional border. Leave at least 1 cm of skin from the upper incisional border to the undersurface of the eyebrow. The medial extent of the supratarsal fold incision is stopped 6 mm from the angular vein. The lateral extent of the supratarsal fold incision is stopped 12 mm lateral to the lateral commissure of the eyelids (Halverson et al 2006).

The depression, or dark circle, beneath the lower eyelid overlying the arcus marginalis is also marked in addition to any protruding fat pocket. Once local or general anesthesia is achieved, stainless steel scleral shields are applied to the globe to protect the cornea.The CO2 Ultrapulse laser with the 0.2 millimeter inci-sional hand piece attached is set at 8 millijoules and 5 watts in Ultrapulse mode. The previously outlined upper blepharoplasty incisions are made using a con-stant rate of hand piece motion at a speed which results in an incision through skin and muscle into the orbital septum (Figure 2.3). Avoid a depth of incision on the supratarsal fold which would injure the levator insertion. The skin and attached muscle is excised with either the laser or cautery. Medial and middle fat resec-tion is done with the laser or cautery (Figure 2.4).

At this point, if a canthoplasty is anticipated, the lateral canthal tendon is identified through the upper blepharoplasty incision. A 5-0 vicryl suture is passed through the canthal tendon and through the perios-teum overlying the medial aspect of the lateral orbital rim 3 mm above Whitnalls tubercle in buried fashion. This suture is left untied until the lower blepharoplasty is completed (Figure 2.5). Next, the lower eyelid is everted and a bone plate is used to compress the globe posteriorly. A laser incision is made in the conjunctiva below the tarsal plate through the middle of the visible vertical vascular plexus (Figure 2.6). Usually two inci-sional passes of the laser are required to expose the fat beneath the orbital septum. Medial, middle and lateral fat resection is done with the laser or cautery and the fat saved.

The undersurface of the septum and orbicularis oculi muscle is treated with the laser to tighten the

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Figure 2.3 Upper blepharoplasty incision with the Ultrapulse 5000 laser set at 8 millijoules and 5 watts. (Redrawn from Seckel BR. Aesthetic Laser Surgery. New York: Little, Brown & Co; 1996)

Figure 2.4 Resection of upper eyelid intraorbital fat. (Redrawn from Seckel BR. Aesthetic Laser Surgery. New York: Little, Brown & Co; 1996)

Figure 2.5 Placement of lateral canthoplasty suture.

Figure 2.6 Location of transconjunctival lower blepharoplasty incision. (Redrawn from Seckel BR. Aesthetic Laser Surgery. New York: Little, Brown & Co; 1996)

Conjuctiva

4mm

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lower eyelid. The lower eyelid is everted and the laser is defocused by holding the hand piece back 23 inches from the septum/muscle complex. The defo-cused beam is passed over the septum muscle complex to tighten and shrink the lower eyelid septum, muscle and attached lower eyelid skin (Figure 2.7). Next, the globe is retracted posteriorly with the bone plate to expose the arcus marginalis. The arcus marginalis is incised with the needle tip cautery and the periosteum elevated off the anterior orbital rim and anterior surface of the maxilla inferiorly for 1 cm. Be careful to avoid injury to the infra-orbital nerve. The resected medial fat is partially cut and unfolded to form a fat

graft of approximately 23 centimeters in length. I prefer the medial fat because it has more vascularity and as a result will take better than middle or lateral intraorbital fat. The fat graft is then placed on the anterior lip of the inferior orbital rim and the lower eyelid is gently re-draped to avoid displacing the fat graft. The fat graft is not fixed with a suture.

Closure

At this point a canthopexy suture has been placed. It is now drawn tightly and tied to complete the cantho-pexy. The upper eyelid incision is now closed with 5-0 nylon simple interrupted sutures. Erythromycin oph-thalmic ointment is applied to the upper eyelid inci-sion, but no dressing is used. The lower eyelid skin is carefully dried, Mastisol is applied to the lower eyelid skin. Steri-Strips are applied to the lower eyelid and pulled laterally and upward, and attached to the skin of the temple to support the lower eyelid in an anti-ectropion fashion. Remove the intra-ocular shields after you have placed the supportive lower eyelid dressing.

Operative steps

Upper eyelid laser incision. Exposure and removal of upper eyelid fat. Place canthoplasty suture. Transconjunctival incision. Exposure and removal of lower eyelid fat. Shrink undersurface of septum and muscle. Arcus release. Fat grafting. Tie canthoplasty suture. Close upper eyelid incision. Support lower eyelid with Steri-Strips. Remove intra-ocular shields.

Figure 2.7 Laser tightening of lower eyelid by laser irradiation of undersurface of orbital septum of lower eyelid.

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Figure 2.9 (A) Before full face Fraxel re:pair laser resurfacing. (B) Three months post full face Fraxel re:pair laser resurfacing.

Figure 2.8 (A) Before flat-beam CO2 full face laser resurfacing. (B) One year post-op post flat-beam CO2 full face laser resurfacing.

Case 1

A B

Case 2

A B

Results

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Case 3

A BFigure 2.10 (A) Immediately post full face Fraxel re:pair laser resurfacing. (B) Six days post full face Fraxel re:pair

laser resurfacing.

Case 4

Figure 2.11 (A) Before four lid CO2 laser blepharoplasty with laser resurfacing of lower eyelids. (B) One year post four lid CO2 laser blepharoplasty with laser resurfacing of lower eyelids.

A B

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Pitfalls and how to correct

Pitfalls of CO2 laser resurfacing

The most common problems following CO2 LSR are prolonged erythema and post-inflammatory hyper-pigmentation (PIH). Prolonged erythema is caused by deeper, higher energy and higher surface area treat-ments. Aggressive treatment of patients with severe wrinkles and skin photo-damage will produce longer lasting post-LSR erythema. Duration of post-LSR ery-thema can be shortened by the use of topical steroids. I routinely begin 1% hydrocortisone two to three times a day for up to 2 weeks after skin re-epithelializa-tion is complete. In patients with severe post-LSR ery-thema lasting more than 34 weeks, I begin 10 day pulses of Temovate cream applied twice a day. If erythema persists after 6 weeks, I begin intense pulsed light treatments with the Palomar LuxGreen IPL to close the superficial vessels and reduce erythema.

Prolonged erythema following CO2 LSR is an indi-cation of profound inflammation. I have found that intense erythema lasting over 6 weeks is often associ-ated with hypo-pigmentation long term. Thus, I aggressively treat erythema and start IPL treatments as soon as I can. PIH is common in individuals with darker Fitzpatrick 3 and 4 skin and particularly common in people of East Indian, Hispanic and Asian descent. Therefore, I treat these individuals with less energy and fewer passes, and today would recommend using fractional CO2 on these individuals.

Case 5

Figure 2.12 (A) Before four lid CO2 laser blepharoplasty with arcus release and no laser resurfacing of the lower eyelid. (B) One year post four lid CO2 laser blepharoplasty with arcus release and no laser resurfacing.

A B

Although there is disagreement in the literature, I do pre-treat patients prone to PIH with a bleaching regimen. I use a combination of 4% hydroquinone, 0.1% Retin-A, and 1% hydrocortisone cream. I have the patient mix the three creams, in equal parts, in the palm of their hand and apply to their face three times a day. Ideally this regimen is started 46 weeks prior to the LSR procedure, although two weeks of therapy will help.

PIH usually begins to appear four to six weeks after LSR. After LSR, I begin treating PIH with a mixture of 4% hydroquinone and 1% hydrocortisone, but do not use Retin-A until about 6 weeks post-op. I also begin IPL treatments at six weeks post-operatively. I use the Palomarly LuxGreen IPL, which works very well. The major serious complications following CO2 LSR are ectropion and hypertrophic scarring. Hypertrophic scarring most commonly follows delayed wound healing caused by post-LSR infections. Management of hypertrophic scarring includes the use of topical ste-roids, steroid injections, compressive silicone sheet-ing, and IPL treatments.

Ectropion is most commonly caused by performing LSR on lax lower eyelids. It is imperative to do the Jelks lid snap test pre-operatively. If the lower eyelid is lax, corrective canthoplasty or other oculoplastic lid reconstruction must be done prior to LSR. Lower ener-gies and fewer passes are done on the lower eyelid as discussed earlier. I anticipate that all of these problems will be seen less frequently with the new fractional CO2 technology.

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Pitfalls of CO2 laser blepharoplasty

The major complications of blepharoplasty can be avoided with proper pre-operative screening and careful technique. Ectropion and eyelid malposition have virtually been eliminated in my practice by adopting the transconjunctival lower blepharoplasty approach and screening patients for lower eyelid laxity with the Jelks lid snap test. Supporting the lower eyelid with Steri-Strips as described above also helps maintain normal eyelid position immediately after surgery as healing begins.

Dry eye syndrome is avoided by pre-operative screen-ing and conservative upper eyelid skin resection. Careful attention to identifying and avoiding the upper lid lacrimal gland during fat resection is also essential. You can avoid corneal injury by using appropriate laser-impermeable scleral shields. The inferior oblique muscle is exposed to risk during transconjunctival lower eyelid blepharoplasty. It is essential that the surgeon is familiar with the anatomy and location of the inferior oblique muscle and identifies and avoids the muscle during medial and middle fat pad resection.

Arcus marginalis release and fat grafting exposes the infraorbital nerve to injury. It is very important to watch for, identify, and avoid this nerve during ante-rior maxillary dissection to create a pocket for the fat graft. Blindness following blepharoplasty is fortu-nately a very rare complication. This dreaded compli-cation, when it does occur, is usually a sequel to retro-bulbar hemorrhage. It is important to post- operatively maintain meticulous hemostasis and normal blood pressure in the patient. Post-operative care includes an awareness of the three Ps of retro-bulbar hemorrhage: pain, proptosis and paralysis of extra-ocular muscles. A lateral orbital canthotomy is an emergency procedure which must be accomplished quickly to avoid permanent visual loss.

Post-operative care

Traditional flat-beam CO2 LSR with the CO2 ultrapulse laser

On the first post-resurfacing day, I switch to an open technique on the facethe Flexan dressing is left on the lower eyelid until it falls off or loosens, usually by day 4 or 5. I treat the remainder of the face with saline soaks every 23 h followed by gentle cleansing to remove debris using saline soaked sponges. This is fol-

lowed by application of Aquaphor ointment. It is very important to keep the surface of the skin moist and protected until re-epithelialization is complete at 1214 days. At this point I start application of 1% hydrocorti-sone cream three times a day for 1014 days to combat erythema. Adequate moisturization of the healing skin is very important. After erythema has resolved, usually by 68 weeks, I start the patient on Retin-A.

Fractional CO2 LSR with the reliant Fraxel re:pair procedure

Depending on the depth of treatment re-epithelializa-tion is complete in 4872 h. Erythema can persist for 57 days or longer with very deep treatments. As soon as re-epithelialization is complete, I start topical steroid therapy until erythema is resolved. After 68 weeks I start the patient on topical Retin-A.

Four lid CO2 laser blepharoplasty with arcus marginalis release and fat repositioning

Ice packs are applied to the eyes for 24 h. Patients are instructed to keep their head and back elevated for at least 2 weeks after surgery. Lacrilube is applied to the eyes at bedtime and twice a day until normal eyelid closure returns. I leave the Flexan dressing on until it falls off after re-epithelialization. However if serous exudate loosens the dressing prior to 5 days, I remove the dressing. External sutures and Steri-Strips are removed at 56 days. After 23 weeks, 1% hydrocor-tisone can be applied to the upper eyelid scars to speed the resolution of redness of the scar.

Conclusion

The CO2 laser is a very useful multi-dimensional tech-nology with wide applications in aesthetic surgery and dermatology. The ability to perform oculoplastic sur-gical procedures, facial skin resurfacing procedures and to spot-treat exophytic skin lesions such as actinic keratoses has made the CO2 laser a valuable, cost effec-tive adjunct to my aesthetic plastic surgery practice. The recent evolution of fractional CO2 technology, I predict, will lessen the occurrence of hypo-pigmenta-tion, PIH, and prolonged erythema post LSR and increase the popularity and application of the CO2 laser in aesthetic practice.

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Further reading

Alster TS, Bellew SG. Improvement of dermatochalasis and periorbital rhytides with a high-energy pulsed CO2 laser: A retrospective study. Dermatol Surg 2004; 30(4): 483487.

Baker SS, Hunnewell JM, Muenzler WS, Hunter GJ. Laser blepharoplasty: Diamond laser scalpel compared to the free beam CO2 laser. Dermatol Surg 2002; 28(2): 127131.

Clementoni MT, Gilardino P, Muti GF, et al. Non-sequential fractional ultrapulsed CO2 resurfacing of photoaged facial skin: Preliminary clinical report. J Cosmetic Laser Ther 2007; 9:218225.

Dijkema SJ, van der Lei B. Long-term results of upper lips treated for rhytids with carbon dioxide laser. Plast Reconstr Surg 2005; 115(6):17311735.

Fitzpatrick RE. Maximizing benefits and minimizing risk with CO2 laser resurfacing. Dermatol Clin 2002; 20:7786.

Halverson E, Husni NR, Pandya SN et al. Optimal parameters for marking upper blepharoplasty incisions: A ten year experience. Ann Plast Surg 2006; 56(5): 569572.

Hatash BM, Vikraditya PB, Kapadia B et al. In vivo histological evaluation of a novel ablative fractional resurfacing device. Lasers Surg Med 2007; 39:96107.

Roy D, Sadick NS. Ablative facial resurfacing. Ophthalmol Clin North Am 2005; 18:259270.

Rahman Z, Tanner H, Tournas J et al. Ablative fractional resurfacing for the treatment of photodamage and laxity. Lasers Surg Med 2007; (suppl 19):15.

Seckel BR. Aesthetic Laser Surgery. New York: Little, Brown and & Co; 1996.

Seckel BR, Younai S, Wang K. Skin tightening effects of the UltraPulse CO2 Laser Plast Reconstr Surg 1998; 102:872877.

Seckel BR, Kovanda CJ, Cetrulo CL et al. Laser blepharoplasty with transconjunctival orbicularis muscle/septum tightening and periocular skin resurfacing: A safe and advantageous technique. Plast Reconstr Surg 2000; 106(5): 11421145.

Chapter 2 CO2 laser applications: new fractional and traditional CO2 laser resurfacing and CO2 laser blepharoplastyCO2 laser skin resurfacingFractional CO2 laser skin resurfacingCO2 laser blepharoplastyPatient selectionIndicationsOperative techniquePre-operative preparationTraditional flat-beam CO2 LSR with the CO2 UltraPulse laserClosureOperative stepsFractional CO2 LSR with the Reliant Fraxel re:pair procedureClosureOperative steps

Four lid CO2 laser blepharoplasty with arcus marginalis release and fat repositioningClosureOperative steps

ResultsPitfalls and how to correctPitfalls of CO2 laser resurfacingPitfalls of CO2 laser blepharoplastyPost-operative careTraditional flat-beam CO2 LSR with the CO2 ultrapulse laserFractional CO2 LSR with the reliant Fraxel re:pair procedureFour lid CO2 laser blepharoplasty with arcus marginalis release and fat repositioning

ConclusionFurther reading