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• W74212777 abstract "Aging of the skin of the face consists of an intrinsic aging process that is genotypically inherent and inevitable, which accounts for the thinness of tissue that is lax and redundant. It can include benign and premalignant neoplasms [1, 2]. While photoaging or extrinsic aging is environmentally mediated and is characterized by fine and deep facial skin wrinkling; it can be characterized by thickened, coarse, yellow, sallow skin, that is studded with telangiectasia, macules of hyper-and hypopigmentation, benign, premalignant and malignant neoplastic lesions [1, 3—6]. There are many ways to rejuvenate aged skin, which include topical treatments with vitamin A acid [7,8], alpha and beta hydroxy acids [9, 11] and various types of skin resurfacing either by chemical peelings of glycolic, trichloracetric or phenolic acids for superficial, medium to deep depth resurfacing respectively [12, 13], or by performing a mechanical dermabrasion [14, 17]. This presentation will highlight rejuvenating the photodamaged and aged skin of the face by the currently most popular modality of resurfacing, which is using a high energy carbon dioxide laser that is either pulsed or flashscanned [18—23]. There are presently two systems being utilized for high energy CO2 laser skin resurfacing. One laser system produces a high energy, super (ultra) pulsed, collimated CO2 laser light beam, called the UltraPulse® laser which is manufactured by Coherent, Inc., Palo Alto, CA. The other laser system, manufactured by Sharplan Lasers, Inc., Allendale, NJ, known as Silk Touch™ technology, utilizes a high energy continuous wave, non-collimated CO2 laser beam that is processed by an optico-mechanical flash scanner that emits a light beam that is rapidly rotated or flashscanned over the surface of the skin, lasting less than one msec. The effects of the Silk Touch™ laser are similar to and the results are comparable to those of the UltraPulse® laser [24-26]. The word laser is the acronym for Light Amplification by the Stimulated Emission of Radiation. When an atom of either a solid, liquid or gas is excited by an external power source, it causes an electron of an atom of that element to jump its usual orbital into a suborbital, causing it to be in a higher energy or excited state. This energized, excited electron, as it returns to its usual orbital, emits its surplus energy in the form of a photon or light energy. As this light energy is emitted, it then collides with other nearby atoms stimulating them into an excited state. This results in the additional release of photons that continue to stimulate the additional release of photons. In an actual laser, this stimulation of energy occurs in a holding container or resonator cavity, in which the emitted photons resonate or bounce back and forth within this cavity, deflected internally by mirrors at either end of the container. At one particular end there are partially reflective mirrors. At this end, the laser light is allowed to escape out of the resonator cavity and into an angulated tube which contains additional reflective mirrors at various points along its sides. As the laser light travels through and down this articulated tube or arm, these mirrors then direct the laser light through a terminal focusing lens finally to exit through an aperture and onto a target [27]. When laser light is emitted out of the external hand piece, it can be reflected either off the surface of the target that is being irradiated, or it can be scattered within or transmitted through the surface of a target, or it can be absorbed by that target. Characteristically, laser light has the features of being coherent, monochromatic and collimated. The wavelength of a photon is characterized by a sine wave consisting of peaks and troughs. When the peaks and troughs of the sine waves are parallel, and exactly in the same phase, both in time and space, they are said to be coherent. When laser light is emitted, it is non-convergent or divergent and therefore has no focal point. This means that the sine waves of the light are parallel and continuous, or collimated. Since laser light is produced from a individual gas, liquid or solid, the wavelength of the light that it produces is particular to that individual element. Consequently, this light is characterized by only one color and not by a spectrum of colors, and therefore it is monochromatic. In the case of CO2 gas, the wavelength of the emitted laser light is invisible and found in the infrared region of the electromagnetic radiation spectrum at 10,600 nanometers [27]. Another important characteristic of CO2 laser light is its extinction length in water, which is relatively shallow when compared to the light emitted by other lasers, such as the argon, holmium, ruby or KTP lasers. Since dermal tissue is made up mostly of water, this also means that the depth of penetration of CO2 laser light through skin is very shallow, i.e., within a few millimeters from the skin surface, and it is not dependent on whether the skin is pigmented or non-pigmented. When laser light penetrates the skin, the energy that is absorbed in the tissue is converted into heat. If this heat is hot enough, e.g., 100°, it will vaporize the tissue. However, if its not hot enough, it will conduct the heat peripherally and thermally damage the surrounding tissue. This thermal damage to the adjacent surrounding tissue also is dependent on the length of time the laser light is in contact with the skin. A very short exposure time of high energy laser light pulses will cause instantaneous vaporization of tissue with minimal peripheral thermal damage [27,28]. In the past, CO2 laser light was produced as a continuous wave (CW). Since CW laser light was in contact with the skin for a relatively longer period of time, there was peripheral conduction of heat of lower temperature than that of the vaporization threshold longer than 1 msec, which is longer than the thermal relaxation time of skin [29]. The thermal relaxation time is that time necessary for any tissue to recover from thermal injury before irreparable charring and protein coagulation occurs because of heat diffusion to the tissue adjacent to and surrounding the targeted tissue. This resulted in extensive burning and frequent scarring. Now that CO2 lasers have a higher energy output, and their light emission time can be instantaneous, i.e., less than one msec, there is more efficient tissue ablation with much less peripheral conduction of heat, and much less charring and ultimately much less scarring. These improvements make the recently developed high energy CO2 lasers ideal for tissue resurfacing [29]. Coherent’s UltraPulse® CO2 laser now is fitted with a computerized pattern generator (CPG)™ that is attached to the distal aperture of the articulated arm of the laser [30]. The CPG creates various geometric shapes of varying sizes of the emitted laser light, enabling larger spot sizes to contact the skin with each burst of ultra short pulses. This results in an automated delivery of collimated laser light, which facilitates the precise treatment of larger areas of tissue in a shorter amount of time. Sharplan’s Silk Touch™ technology utilizes a CW beam that is not collimated and therefore needs to be focused. The emitted CW laser light passes through a microprocessor located at the terminal end of the articulated arm. This computerized optical microprocessor mechanically spins or flash scans the high energy laser beam away from each contact point so quickly that the laser beam at any given spot will contact the target tissue less than one msec, thereby not exceeding the thermal relaxation threshold for skin. Like the collimated patterned laser beam of the UltraPulse® CO2 laser, Silk Touch™ lasers emit a high energy CW non-collimated, focused CO2 laser beam that is mechanically rotated and flash scanned away from each contact point over a period of time that is less than one msec, minimizing peripheral spread of conducted heat to adjacent tissue [31]. One of the advantages of the Silk Touch™ or Feather Touch™ laser technology is that the laser light can be used either in a focused or defocused mode. When the laser beam is focused and perpendicular to the skin surface, one gets homogenous, instantaneous vaporization. However, when the laser light is defocused and kept perpendicular to the surface of the skin, one can vaporize tissue more superficially so that the laser operator can tailor the depth of his treatment according to the area and location of the surface of the skin being treated. Then, when the laser beam is tangentially angled and defocused, one can nicely feather the peripheral edges of the surgical field. Also, the hand piece containing the flash scanner is more compact and smaller than Coherent’s CPG™. Its ergonomic design makes it more comfortable and less fatiguing to use, especially during larger cases and longer procedures. Moreover, clinical trials by others indicate that the postoperative course and the final results were comparable when patients had one side of their face treated by the UltraPulse® laser and the other side by the Silk Touch™ laser [24, 26]. A brief word about laser safety. When using any laser, there must be a sign posted on the door outside the treatment area. Proper protection apparel for the physician laser operator, surgical assistants and the patient should be utilized at all times. This includes a cap and gown and eye protection for the patient and the surgical team. In addition, the surgical team must wear special micropore face masks to prevent the particulate matter in the laser plume from being inhaled into the upper respiratory tract. Also, wet gauze should be placed over the patient’s teeth to protect them from accidental pitting from aberrant laser light. There should not be any flammable material in and around the environment of the laser while it is being used. If the laser is to be used as a surgical cutting instrument, then the other surgical instruments need to be coated so as not to reflect the laser light, which can cause accidental injury to the surgical personnel and patient. Finally, a plume evacuator must be operating at all times while the laser is in use. The following is a brief discussion on my personal technique of facial rejuvenation, using CO2 laser resurfacing. After the usual preoperative consultation and assessment of the patient’s eligibility for the procedure, a series of preoperative blood tests are taken, which include a complete blood count, clotting profile, kidney and liver function assessment, hepatitis screen and HIV testing. On the day of the procedure, and about one to two hours prior to initiating the procedure, the patient is given an intramuscular injection of Toradol®. A benzodiazipine (Valium®) is then either dispensed to the patient sublingually or injected intramuscularly. Next, the area to be treated is cleansed with an antiseptic wash. At about one hour after the premedication, injections of modified Klein’s tumescent fluid anesthesia is begun as nerve and regional blocks. The modified Klein’s tumescent fluid is administered from four 10 ml syringes each with 1/2 inch 30 gauge needle and containing 10ml of a mixture of fluid consisting of 4 ml of 2% lidocaine with epinephrine (1:100,000), 4 ml of 1/2 % marcaine with epinephrine (1:100,000); and 2 ml of normal saline. These are used for the nerve blocks in the center of the face. Then for the regional blocks to the lateral edges of the face, four to six 10 ml of a more diluted mixture of fluid are used, consisting of 2 ml of 2% lidocaine with epinephrine (1:100,000); 2 ml of 1/2 % marcaine with epinephrine (1:100,000); and 6 ml of normal saline. After waiting 15–20 minutes, laser resurfacing commences. Depending on the extent of the photodamage of each individual patient, one, two or additional passes of laser irradiation will be made [32, 33]. At the conclusion of the procedure and after all the necrotic, charred tissue has been wiped away, the patient’s face is covered with bandages and the patient is sent home with written postoperative home care instructions and medications. These medications include oral antivirals, antibiotics, analgesics and somnifacients. The patient is instructed to return for postoperative visits in 24 hours, at which time the facial dressings are removed and may or may not be replaced, depending on the condition of the patient. The patient is then re-seen for wound evaluation on day 3, 5, 8, 12 postoperatively, and whenever necessary thereafter [34–37]. In conclusion, CO2 laser resurfacing is the newest technique for those who want to have their photodamaged facial skin rejuvenated. Although there has been intense enthusiasm for this technique, long term follow up has uncovered many adverse affects and residual changes that initially were not anticipated [38–41]." @default.
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• W74212777 modified "2023-09-23" @default.
• W74212777 title "Carbon Dioxide Laser Resurfacing of the Aged Face" @default.
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