Fractional Co2 Laser On Darker Skin Types

Fractional CO2 has always been my favourite laser and also my first laser!Although it’s a laser where there is a long learning curve,I am everyday amazed at the versitality of it.Having used it for more than 5 years I have used this laser for various conventional and unconventional uses and still feel there is more to be explored as everyday i learn something new and I am understating the skin better and better.

Non-ablative lasers (ex:Erbium-glass,Erbium-Pixel,ResurFX 1565, Micro-Needle Fractional RF System,etc) will guarantee a minimal downtime yields and good results but in my opinion even though a Fractional CO2 has a longer downtime and chances of PIH is higher,the results are anyday better.If the idea is to treat a burn scar,or extensive scarring we need some ablation as that helps in remodeling of the scar in a more controlled way,along with the growth and healing factors ultimately giving better results.Offcourse if one has the luxury of various lasers to treat certain areas selectively offcourse that would be the best.As a Dermatologist one must try out various combinations as there is never a ready made solution to all the problems we face,especially when it comes to facial rejuevation,pigmentations and scars.

In a CO2 laser, vast majority of treatment is done under the principle that Collagen denaturing leading to remodelling.The heat denatures the proteins,helping in the remodeling,which makes it essential to have a powerfull laser ,which is very precise too and deliveres more than 5j/cms Fluence and has a Thermal relaxation time less than 0.1ms.The more the TRT,more the chances of complications,PIH and Pain. The CO2 fractional laser pokes tiny microscopic holes in the skin down past the epidermis and into the dermis. These holes cause new collagen to be generated which fills in the acne scars and creates rejuvenated smoother skin.(1-3)The intact dermis and epidermis allows the use of high fluencies to be delivered as they provide the structural and nutritional support for recovery.This is the principle which we use to treat acne,chicken pox and traumatic scars,burns,rhytids,facial rejuvenation and skin laxity.

When it comes to pigmented lesions,photothermolysis seems to be the likely cause of the results.Although selective photothermolysis doesn’t occur here,destruction of the tissue and melanin does occur which leads the macrophage actions, healing and removal of the debris.This principle works well when treating Freckles,Lentigines,Melasma ,Lentigo Maligna,Actinic chelitis,etc.

When it comes to cases such as Neurofibroma,Cutaneous horns,Actinic and Seborrheic keratoses,Milia,Syringoma,Trichoepitheliomas,Xanthelasma palpebrarum,Rhinophyma reduction,Corns,Verruca Vulgaris,Epidermal Nevi,Keloid excision including Acne Keloidalis nuchae,even to some extend tattoo removal,ablation,excision,helps a lot and probably play a major role in improvement along with the natural wound healing process of the body.Especially simple things like removing a Verruca Vulgaris becomes more precise,hence faster healing and lesser patient discomfort when done with a Fractional CO2 laser.Bleeding is also less when excised with a CO2 laser.Infact defocusing and firing the laser does cauterize and minimmise the bleeding. (3-22)

When it comes to Dyschromia,Melasma,Riehl’s Melanosis or Post Inflammatory hyperpigmentation due to various causes,its essential to combine the treatment with various combination of lasers and peels too and management of the treatment area post procedure with essential medication and topical application.(13-18)

The limitations of a Fractional CO2 come down to the fact that most Aesthetic or Cosmetic procedures are done to enhance the aesthetic appearance rather than a necessity. This gets us to the point or rule number one that even if we can’t improve, never worsen. One must know the limitations and also have the knowledge to acknowledge the fact that certain conditions never can be improved beyond a certain limit. The conditions I have mentioned above have been tried, tested and delivered to satisfying results of the patients by me with the help of a Fractional CO2 while probably there are more conditions which could be treated with the AcuPulse Fractional CO2 laser that i use from Lumenis Inc.,Santa Clara, which is yet to be explored and learnt by me even after using it for 5 years and speaking about it in various National and International Podiums!I always find something new about it and many a times we all are stuck up upon an idea imprinted in a mind by an article or speaker which mind have been relevant to them but yet to be tested by us.A proper knowledge of the physics of every laser will let us explore and understand the functioning and capability of it although seldom does many of us try to do that. And this should be the case with any surgeon who should be able to acknowledge his limitations. A proper training with an experienced senior would be advisable before one resort to an ablative laser. In case there is difficulty in getting to know the parameters, which we all do face, it’s always better to start with a lower energy and density and take it a step up in the following sittings.The rule is simple and no secret,the more the energy,lesser the density and Vice versa.

It’s not possible to really come to a gold standard protocol when one comes to treating various conditions because as we all know protocols evolve as one learns to master his skills. Never try to copy what’s right for another person as it’s always better to consider every individual as an individual rather than classifying skin types.One should understand what works best for a reputed senior Cosmetic /surgeon in USA or India or wherever may not work for you as given any laser,they would make it work as they have a thorough understanding of the physics and condition they are treating.

The most common treatment that a Fractional CO2 is used is usually for scar reduction.Never buy a Fractional CO2 hoping to treat pigmentation the way a Q-swtiched Nd-YAG would work.Dont go by the world companies write that FDA approved for so many number of conditions! FDA approved means its can be used to treat with satisfactory results ,it need not mean gold standard results as the criteria for FDA approval for lasers and medication is entirely different! Always a good submission few days earlier or on the day of the procedure is beneficial. In real life practice it’s not always possible to prepare the patient few days before the procedure. It’s also very necessary to rule out a history of keloids,connective tissue disorders as this may lead to scarring and also if the patient is on any photosensitive or blood thinning medications or any other ongoing infection or history of Herpes Labialis. It’s probably advisable to do procedures only on patients who haven’t had any procedures done on the area which might have disrupted the epidermis in the near past and it’s better to treat an undisturbed skin for better results and lesser complications.(20-29)

Procedures commonly is done under topical anesthesia.Most patients tolerate it.Many surgeons do nerve blocks,regional blocks and even general anaesthesia for an Ablative procedure as this makes the job of a surgeon more comfortable though not all patients agree to this. Many patients want to feel like an outpatient procedure and not like a big surgery was done on them as most times this is a voluntary procedure as mentioned above out of desire rather than necessity. Local Anaesthesia infiltration into certain areas during the procedure is a good way of treating certain sensitive areas.

During the procedure avoid repeated stamping or overlap as this may lead to bulk heating which may not be visualised immediately, only in few hours time to days post procedure when PIH is the result!Do not leave gaps between the treatment areas as this will effect the long term results.Dont overtreat ,never involve areas which isn’t essential.Be specific of the pit or scar you are treating.Its better if one gives more energy to the main pit and minimal on the sides, Its always better to ‘feather’ the nearby areas as this gives a more even texture once the wound has healed. A cooler or Zimmer helps to reduce the patient discomfort, but maintaining the room temperature at about 24degree centigrade and cold compresses helps, along with not hurrying up the procedure and talking to the patient, which will give the patient more confidence and reassurance that all is fine.

Now when it comes to post procedure care,counselling is the most important fact.Sunscreen has to be applied 3 times a day mimimum,along with the application of moisturisers and if neccesory a topical steroid till the erythema ,edema has subsided,after which the patient can continue on sunscreens alone.As for me I prefer the use of occlusive emollients to start of with.Gentle cleansers are essential to remove the scab and serosanguinous discharge.A course of systemic antibiotics is essential and some surgeons also give systemic steroids for few days or a stat dose.(23)The better the patient handles the post procedure care,the faster is the recovery and downtime.(24-29)

Post operative crusting,edema,erythema,oozing,pin point hemmoraghic spots are quite common.The possibility of scarring and a post inflammatory hyperpigentation lasting longer than expected are the dreaded complications for an Aesthetic Surgeon.On a darker skin type,even experienced surgeons can end up burning ones fingers!(29)

Combination therapy with the help of Er-YAG, chemical peels or the use of good Cosmeceutical products post procedure could be beneficial.

In conclusion a Fractional CO2 has changed the role of a Dermatologists-Cosmetologists ,given opportunities to explore more into Aesthetic Surgery as I truly believe that no one knows the skin better than a Dermatologist and has helped him deliver better results with minimal downtime for various conditions,at times in a single sitting alone unlike many Non-ablative lasers or traditional Ablative CO2 lasers. With the cumulative knowledge of Dermatology and Aesthetic Surgery one can surely deliver satisfying results to the patients.As for Acne scars and rejuvenation which may require multiple sittings clinical improvement is seen right from the 10th day and it might go on to improve till 6 months. When it comes to pigmentary problems usually it’s a single sitting and results are seen by the end of of the first week itself.
While the potential risks are always there like in any other procedure so its essential to understand the laser you have with you before you go aggressive. Offcourse I do agree to the opinion that an Ablative Fractional CO2 is not for novice laser surgeons but rather for a trained Aesthetic surgeon who has preferably had experience with lesser aggressive devices.

1.Alster TS,Lupton JR.An overvew of cutaneous laser resurfacing.Clin Plast Surg 2001;28:37-52

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

3.Manstein D,Herron GS,Sink RK,et al.Fractional photothermolysis:a new concept for cutaneous remodeling using microscopic patterns of thermal injury.Laser Surg Med.2004;34:426.

4.Dover J,Hruza G.Laser skin resurfacing.Semin Cutan Med Surg 1996;15:177-882.Alster TS,Bettencourt MS.Review of cutaneous lasers and their application.South Med J 1998;91:806-14.

5.Flageul G.The use of Ultrapulse CO2 laser in the treatment of skin aging.Orthod Fr 1997;68:83-4.

6.Apfelberg DB.Ultrapulse carbon dioxide laser with CPG scanner for full-face resurfacing for rhytids,photo aging and acne scars.Plast Recinstr Surg 1997;99:1817-25.

7.Biesman B. Carbon dioxide laser skin resurfacing.Semin Opthalmol 1998;13:123-35

8.Fitzpatrick RE,Goldman MP.Advances in Carbon dioxide laser surgery.Clin Dermatol 13:35-47.

9.Ratner D,Tse Y,Marcell N,Goldman Mp,Fitzpatrick RE ,Fader D J,Cutaneous Laser resurfacing.J Am Acad Dermatol 1999;41:365-89

10.Shim E,tse Y,Velazquez E,Kamino H,Levine V,Ashinoff R.Short Pulse carbon dioxide laser resurfacing in the treatment of rhytides and scars:a clinical and histopathological study.Dermatol Surg 1998;24:113-117

11.Hamilton MM.Carbon dioxide laser resurfacing .Facial Plast Surg Clin North Am.2004;12:289-95.

12.Fitzpatrick RE.CO2 laser resurfacing.Dermatol Clin.2001;19:443-51.

13.Chan H 2005 Effective and safe use of lasers,light sources and radio frequency devices in the clinical management of Asian patients with selected dermatoses.Lasers in surgery and Medicine 37:179-185.

14.Tannous ZS,Aster S 2005 Utilizing fractional resurfacing in the treatment of therapy-resistant melanoma.Journal of Cosmetic Laser Therapy 7:39-43

15.Alster TS,Bettencourt MS.Review of cutaneous lasers and their application.South Med J 1998;91:806-14.
16.Alster TS,Lupton JR.An overvew of cutaneous laser resurfacing.Clin Plast Surg 2001;28:37-52

17.Sukal SA,Geronemus RG.Fractional Photothermolysis.J Drugs Dermatol 2008;7:118-22.
18.Hantash BM,Bedi VP,kapadia B,et al.In vivo histological evaluation of a novel ablative fractional resurfacing device.Lasers Surg Med 2007;39:96-107.

19.Rahman Z,MacFalls H,Jiang K et al.Fractional deep dermal ablation induces tissue tightening.Lasers Surg Med 2009;41:78-86.

20.Chapas AM,Brightman L,Sukal S,et al.Successful treatment of acneiform scarring with CO2 ablative fractional resurfacing.Lasers Surg med 2008;40;381-6
21.Alexiades-Armenakas MR,Dover JS,Arndt KA.The spectrum of laser skin resurfacing:nonablative,fractional and ablative laser resurfacing.J Am Acad Dermatol 2008;58:719-37.

22.Sukal SA,Geronemus RG.Fractional Photothermolysis.J Drugs Dermatol 2008;7:118-22.

23.Manuskiatti W,Fitzpatrick RE,Goldman MP,Krejci-Papa N.Prophylactic antibiotics in patients undergoing laser resurfacing of the skin.J Am Acad Dermatol.1999;40:77-84

24.Nanni CA,Alster TS.Complications of carbon dioxide laser resurfacing.Am evaluation of 500 patients.Dermatol Surg 1998;24:315-20.

25.Alster T,Hirsch R.Single-pass CO2 laser skin resurfacing of light and dark skin:extended experience with 52 patients.J Cosmet Laser Ther 2003;5:39-42.

25.Clementoni MT,Gilardino P,Muti GF,Beretta D,Schianchi R.Non -sequential fractional ultrapulsed CO2 resurfacing of photoaged facial skin:preliminary clinical report.J Cosmet Laser There 2007;9:218-25.

26.Tan KL,Kurniawati C,Gold MH.Low risk of post inflammatory hyper pigmentation in skin types 4 and 5 after treatment with fractional co2 laser device.J Drugs Dermatol 2008;7:774-7.

27.Ross RB,Spencer J.Scarring and persistent erythema after fractional ablative CO2 laser resurfacing.J Drugs Dermatol 2008;7:1072-3.

28.David Goldberg,MD;Reduced Down-time Associated with Novel Fractional UltraPulse CO2 Treatment(Active Fx)as compared toTraditional Resurfacing P3115-65th Annual American Academy of Dermatology Meeting.

29.Alster TS,Tanzi EL,Lazarus M.The use of fractional laser photothermolysis for the treatment of atrophic scars.Dermatol Surg.2007;33:295.

29.Weinstein C,Ramirez OM,Pozner JN 1997 Postoperative care following CO2 laser resurfacing:Avoiding Pitfalls.Plastic and Reconstructive Surgery 100:1855-1866