Complications

Similar to other resurfacing modalities, the incidence of complications after CO2 laser resurfacing is primarily linked to the depth attained during treatment12. One of the most commonly expected complications is post‑resurfacing swelling, which generally peaks at 2–3 days and subsides after 1 week. Intravenous betamethasone intraoperatively and a course of oral prednisone postoperatively for 5 days can help to decrease any swelling.

Erythema, to some degree, is observed in all patients. It is related to increased blood flow, collagen remodelling, inflammation, and increased metabolic activity. Pruritus is also common after laser resurfacing, but may signal infection, contact dermatitis, or early scarring. In the absence of these conditions, pruritus responds to an oral antihistamine. Milia and acne can also be seen 2–3 days postoperatively and are partially related to the use of occlusive ointments. Many of these patients are acne prone prior to treatment, and their condition can be improved significantly by introducing topical retinoic acid and topical antibiotics to their post-resurfacing regimen.

Figure 1a. Before blepharoplasty treatment

Figure 1a. Before blepharoplasty treatment

 

Figure 1b. Hyperpigmentation of blepharoplasty incisions after treatment

Figure 1b. Hyperpigmentation of blepharoplasty incisions after treatment

Post-inflammatory hyperpigmentation (Figure 1) tends to occur 2–3 weeks after therapy, especially in patients who have darker skin tones. Any patient may develop transient hyperpigmentation, but this side‑effect is more common in darker skin types. Approximately 40% of patients with Fitzpatrick skin types I–III will experience transient hyperpigmentation. In contrast, 66–100% of patients with Fitzpatrick skin types IV–VI will develop some degree of hyperpigmentation. While the aetiology of this side‑effect is not definitively known, it is presumed that the greater concentration of melanosomes in darker skin absorbs more laser energy — even at a lower fluence. Pre‑conditioning the skin with retinoic acid and hydroquinone prior to CO2 resurfacing may decrease incidence, severity, and duration of this phenomenon, and aggressive post-resurfacing skin reconditioning using hydroquinone 2–4% twice per day, retinoic acid (0.05–0.1%) at bedtime, and daily broad-spectrum sun protection can quickly resolve the problem.

Unexpected complications associated with CO2 laser resurfacing include infection (bacterial, viral, yeast, fungal). A typical presentation is a papulopustular eruption with itching or pain and delayed healing. Irritant or allergic contact dermatitis can also be seen secondary to topical antibiotics (e.g. neomycin, bacitracin). Hypopigmentation in darker-skinned individuals can be a risk, which increases with increased depth of laser penetration and can be disguised with total facial treatment as opposed to regional therapy. Additional unexpected complications include sharp demarcation lines, which can be avoided by creating a transitional zone of resurfaced skin.

The development of hypertrophic and keloid scars can occur and are related to the depth of resurfacing achieved, development of infection, postoperative wound care, genetic predisposition, and the treatment of non‑facial areas. Ectropion of the lower eyelid has also been reported and is usually the result of an over‑aggressive treatment, a pre‑existing laxity, activation of a previous blepharoplasty scar, or development of an infection. It can be avoided by testing the lid for laxity before resurfacing, by limiting the depth of resurfacing to the papillary dermis, and by decreasing the power settings. Tooth enamel and corneal damage can occur, but are easily avoided if the correct protection is used.

Discussion

Before periorbital rejuvenation

Before periorbital rejuvenation

 

Facial skin resurfacing has undergone many changes over the past 15 years. In summary, treatments went from aggressive high-fluence, high-density, multipass resurfacing to more gentle fractional treatments, both of which have their pros and cons. The newer fractional treatments are superb for minor rejuvenation with minimal downtime. Traditional high‑power, high‑density, ablative CO2 treatments produce a burn of the entire skin surface. Fractional laser treatment, on the other hand, is a subtotal treatment and leaves untreated regions of normal skin next to micro-columns of burned skin. As the entire skin surface is not treated, the recovery process is easier and re-epithelialisation faster.

After periorbital rejuvenation

After periorbital rejuvenation

Newer 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-based skin resurfacing has shown promise for a more user-friendly procedure, but to this point it cannot rival the results of traditional, aggressive CO2 laser skin resurfacing quality and results.  Ultimately, the CO2 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 the degree of improvement is less than with traditional CO2 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 (regardless of company, wavelength, etc.) 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 really significant results, the patient may have to undergo up to five treatments. In the author’s 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 patient’s 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.

Figure 2a. Before treatment

Figure 2a. Before treatment

 

In the author’s clinic the use of the CO2 laser is not limited to skin resurfacing, but is also used in laser-assisted blepharoplasty procedures (Figure 2) 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.

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.

Figure 2b. After laser blepharoplasty of the upper eyelids and skin resurfacing of the lower lids

Figure 2b. After laser blepharoplasty of the upper eyelids and skin resurfacing of the lower lids

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 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 (Figure 2). 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.