Combination Treatment of Melasma with Pulsed CO2 Laser Followed by Q-Switched Alexandrite Laser: A Pilot Study

BACKGROUND: Melasma is very difficult to treat and often refractory to treatment with topical creams and pigmented-lesion lasers. OBJECTIVE: Pulsed CO2 laser alone is compared with the combination of pulsed CO2 laser followed by Q-switched alexandrite laser in the treatment of dermal-type melasma. This combination is proposed to be effective by first destroying the abnormal melanocytes with the pulsed CO2 laser and then selectively eliminating the dermal melanin with the alexandrite laser. METHODS: Four patients were randomly chosen for each treatment arm. There were multiple follow-up visits for examination by an objective blinded investigator. RESULTS: All patients in the combination laser group showed complete resolution, and two patients in the CO2 laser only group had peripheral hyperpigmentation in the long-term follow-up evaluation. CONCLUSION: These laser therapies are safe, as there was no scarring and no infection. The combination laser therapy was highly effective in removing the hyperpigmentation and all patients in this group showed complete resolution without any peripheral hyperpigmentation.     

Laser Blepharoplasty: Diamond Laser Scalpel Compared to the Free Beam CO2 Laser

BACKGROUND: Blepharoplasty has long been employed for functional and cosmetic purposes. Different modalities have been utilized to incise and remove excess eyelid tissue in an attempt to improve surgical technique. OBJECTIVE: This study compares a free beam CO2 laser to a diamond surgical scalpel combined with a CO2 laser for performance of blepharoplasty. METHODS: Ten patients underwent bilateral upper lid blepharoplasty. One side was randomly assigned to the free beam CO2 laser technique, while the other side was performed with the diamond laser scalpel. Intraoperative surgical times and hemostasis were measured. Masked observers assessed postoperative parameters at day 1, week 1, week 2, week 4, and month 4. These assessments were analyzed clinically and statistically. RESULTS: The two modalities produced similar results for the intraoperative and postoperative parameters studied. CONCLUSION: The diamond laser scalpel has the advantage of tactile feedback and the option of use without coagulation.     

Laser Resurfacing of the Neck with the Combined CO2/Er:YAG Laser

BACKGROUND: Several clinical studies on laser resurfacing on the neck have yielded variable results with adverse sequelae of hypopigmentation and scarring using the CO2 laser. The Er:YAG laser on the neck resulted in an improved appearance with no adverse sequelae. The combined CO2/Er:YAG laser is a laser that combines a low fluence CO2 laser with the Er:YAG laser in a near simultaneous beam. OBJECTIVE: To study the effects of the CO2/Er:YAG laser on the neck. The decreased nonspecific thermal damage of the CO2/Er:YAG laser should result in decreased postoperative erythema and improved wound healing. METHODS: Eleven patients were treated with the CO2/Er:YAG laser on the neck as well as the face at identical settings. The face was treated with four passes while the neck was treated with two passes. The patients were evaluated for the first 2 weeks then 3-6 months postoperatively. Patients were asked about treatment satisfaction and improvement in skin texture and color using a 25% scale. Skin texture and color, as well as improvement in wrinkling and adverse results were judged by a dermatologist using a 0-4 scale. RESULTS: Moderate improvement was seen in skin color while a higher degree of improvement was seen in skin texture and wrinkling in all 11 patients. No adverse sequelae, including hypopigmentation or scarring, were observed. The majority of patients had a 75-100% improvement in skin texture and color in addition to a 75-100% overall satisfaction rating. CONCLUSIONS: There is a higher degree of overall patient satisfaction, as well as improvement in skin texture and skin color, compared to patients treated with the Er:YAG laser alone. The CO2/Er:YAG laser is a highly effective laser for neck resurfacing with no adverse sequelae to date.     

Laser Skin Resurfacing of the Face with a Combined CO2/Er:YAG Laser

BACKGROUND: A combined, dual-wavelength CO2/Er:YAG laser system having the ability to deliver both clean ablation of skin with the erbium wavelength and a simultaneous deeper penetrating subablative thermal pulse of CO2 was developed for full-face resurfacing. The CO2 component can be pulsed from 1 to 100 msec at a power of 1-10 W with the Er:YAG component pulsed at 350 microsec at 1.7 J/cm2 through either a computer pattern generator with 3 mm diameter spot size or through a noncollimated spot ranging from 0.2 to 8 mm in diameter. Our previous study using this laser on the neck using a 4-8 mm diameter spot with Er:YAG fluence at 1.7 J and the CO2 at 5 W with a 50 msec pulse at a frequency of 10 Hz showed a higher degree of overall patient satisfaction, as well as improvement in skin texture and skin color, compared to patients treated with an Er:YAG laser alone. OBJECTIVE: This study evaluated the CO2/Er:YAG laser treatment modality in facial resurfacing. METHODS: Ten patients were treated with four passes at 1.7 J with a 4 mm diameter spot and the CO2 at 5 W with a 50-msec pulse at a frequency of 10 Hz. Photoaging scores as well as thermal damage and new collagen formation were compared immediately before and after treatment as well as at 2 weeks and 3 months postoperatively. RESULTS: The average pretreatment periorbital score was 6.2 The average posttreatment periorbital scores were 4.2 (P =.0239) at 2 weeks postoperatively (32% improvement) and 3.8 (P =.0028) at 3 months postoperatively (38% improvement). The average pretreatment perioral score was 5.9. The average posttreatment perioral scores were 3.0 (P =.0001) at 2 weeks postoperatively (49% improvement) and 3.3 (P =.0009) at 3 months postoperatively (44% improvement). The average pretreatment cheek score was 4.7. The average posttreatment cheek scores were 2.7 (P =.0066) at 2 weeks postoperatively (43% improvement) and 3.8 (P =. 0152) at 3 months postoperatively (36% improvement). The average pretreatment forehead score was 4.7. The average posttreatment forehead scores were 3.8 (P =.0340) at 2 weeks postoperatively (33% improvement) and 3.6 (P =.0147) at 3 months postoperatively (37% improvement). The average depth of collagen measured in the dermis pretreatment was 29 microm. The average depth of collagen 3 months posttreatment was 54 microm. This is an average increase of 25 microm or an 86% increase in collagen (P =.006). The average thermal damage immediately after treatment was 20 microm. CONCLUSION: The CO2/Er:YAG laser utilized with four passes at the above-mentioned parameters results in a similar degree of improvement as other forms of laser resurfacing with high-energy, short-pulsed CO2 lasers.     

Treatment of Pearly Penile Papules with CO2 Laser

BACKGROUND: Pearly penile papules are angiofibromas found on the corona and sulcus of the glans penis. While these represent a benign condition, psychological and cosmetic concerns often prompt patients to seek therapeutic removal of these lesions. Multiple therapeutic modalities have been reported; however, use of CO2 laser has proven to be the most effective to date. OBJECTIVE: To demonstrate the efficacy of CO2 laser in treating pearly penile papules. METHODS: Case report. RESULTS: We report the successful treatment of pearly penile papules in an African American man with CO2 laser. CONCLUSION: The use of CO2 laser is an effective treatment for pearly penile papules. J. E. Lane, MD, C. M. Peterson, MD, and J. L. Ratz, MD have indicated no significant interest with commercial supporters.     

Minimally Invasive Surgery for Axillary Osmidrosis: Combined Operation with CO2 Laser and Subcutaneous Tissue Remover

BACKGROUND: Axillary osmidrosis is a distressing problem characterized by unpleasant odor, profuse sweating, and occasionally staining of clothes that may handicap those affected both socially and psychologically. Various types of surgical procedures have been developed for the treatment of axillary hyperhidrosis and osmidrosis. OBJECTIVE: To introduce a new odor measurement method and minimally invasive surgery technique for axillary osmidrosis. METHODS: Eighty-eight patients with axillary osmidrosis were treated by combined operation using a carbon dioxide (CO2) laser and subcutaneous tissue remover. Measurement of axillary odor was done with the cotton-roll method. RESULTS: Eighty-seven of the 88 patients (98.8%) had good to fair results; only one patient (1.2%) had poor results. Complications such as ecchymosis and partial skin necrosis with delayed wound healing occurred in four patients (4.6%). CONCLUSION: A combined technique using a CO2 laser and subcutaneous tissue remover has the advantages of a high success rate, low complication rate, no admission treatment, less scarring, and rapid recovery. This combined approach should become the preferred technique for the treatment of axillary osmidrosis.     

Principles of CO2/Erbium Laser Safety

BACKGROUND: There are a variety of potential hazards with laser technology. METHODS: A review of the literature. OBJECTIVE: To summarize the potential hazards of CO2 and erbium laser technologies and the safety guidelines and equipment developed to minimize them. RESULTS: Laser hazards can be divided into the following categories: mechanical, environmental, macrobiologic, microbiologic, and iatrogenic. CONCLUSION: At the conclusion of this learning activity, the reader should be able to discuss the mechanical, environmental, macrobiologic, microbiologic, and iatrogenic hazards of resurfacing laser technology, the literature cited to support current safety guidelines, and the equipment developed to promote laser safety.     

Treatment of Fordyce Spots With CO2 Laser

BACKGROUND: Fordyce spots are heterotopic sebaceous glands that can be located at the lips' vermilion or the oral mucosa. Although this is considered a rather common disorder, a treatment for this condition that sometimes affects patients from only a cosmetic viewpoint has not yet been described. OBJECTIVE: To evaluate CO2 superpulsed laser treatment in two subjects with Fordyce spots. METHODS: Two patients with papules and yellowish plaques at the upper lip corresponding to Fordyce spots were treated with coherent Ambulase CO2 superpulsed laser (Coherent Medical, Palo Alto, CA); after informed consent was obtained, two to three passes were performed in one session using 2 and 4 W and a spot size of 2 mm. RESULTS: Complete re-epithelization was observed 2 weeks later with no residual Fordyce papules in the treated area and no side effects. CONCLUSION: Our findings suggest that CO2 superpulsed laser can be considered a safe and effective treatment for patients with Fordyce spots, offering excellent cosmetic results.     

Treatment of Vitiligo with Suction Epidermal Grafting by the Use of an Ultrapulse CO2 Laser with a Computerized Pattern Generator

BACKGROUND: Laser ablation is used to remove the recipient epidermis in the suction epidermal grafting in vitiligo surgery. OBJECTIVE: To evaluate the effectiveness and safety of a suction epidermal grafting method after the removal of the epidermis by the use of the Ultrapulse CO2 laser with a computerized pattern generator. METHODS: Eleven patients with 34 lesions of refractory stable vitiligo were studied. RESULTS: Of the 34 lesion sites, excellent repigmentation was seen in 30 and the other 4 had good repigmentation. No complications occurred. CONCLUSION: The Ultrapulse CO2 laser is particularly well suited for deepithelialization in vitiligo surgery.     

Treatment of Multiple Cutaneous Leiomyomas with CO2 Laser Ablation

BACKGROUND: Cutaneous leiomyomas are benign tumors that can be exquisitely painful. Symptomatic lesions often necessitate treatment, but many options are inadequate or create substantial morbidity. Without a definitive therapy of first choice, the search continues for alternative methods to alleviate discomfort in affected patients. OBJECTIVE: To describe the use of CO2 laser ablation for the symptomatic treatment of a 73-year-old woman with multiple cutaneous leiomyomas in whom pharmacologic therapy was contraindicated and surgical excision was impractical. METHODS: CO2 laser ablation of six symptomatic cutaneous leiomyomas was performed under local anesthesia. After initial success, all remaining symptomatic lesions were treated. RESULTS: There was complete pain relief in the originally treated lesions 9 months postoperatively, and in all remaining treated lesions 3 months postoperatively. CONCLUSION: CO2 laser ablation may be an effective alternative treatment for symptomatic cutaneous leiomyomas.     

CO2 Laser Treatment of Epidermal Nevi: Long-Term Success

BACKGROUND: Epidermal nevi have been notoriously difficult to treat due to their large size and often conspicuous location. Variable results have been obtained with different laser treatments, and scarring and/or incomplete removal is typical after excisional or other destructive modalities. OBJECTIVE: To outline the successful use of a short-pulsed CO2 laser in the long-term eradication of epidermal nevi in three patients. METHODS: Three females (ages 15-19) presented with extensive grouped verrucous papules and plaques on the face, trunk, and extremities. A pulsed CO2 laser was used to vaporize the lesions using a 500 mJ pulse energy, 3 mm spotsize, and 7 watts of power. RESULTS: All lesions healed without incident. No lesional recurrence was observed 10 to 13 months after treatment except in one small area on the ankle in one patient. CONCLUSIONS: Carbon dioxide laser vaporization of epidermal nevi provides good clinical effect and offers unique advantages for the treatment of these lesions, including effective intraoperative hemostasis with excellent lesional visualization. It is also possible to treat widespread areas in one laser treatment session. While the results of this series clearly show the benefit of CO2 laser treatment, epidermal nevi may not always respond so favorably, due in part to the variability in their depths of involvement.     

Brooke–Spiegler Syndrome: Treatment of Cylindromas with CO2 Laser

Brooke–Spiegler syndrome is an autosomal dominant inherited disease characterized by the development of multiple trichoepitheliomas and cylindromas. We report two patients with Brooke–Spiegler syndrome whose scalp cylindromas were treated with a high-energy continous wave CO₂ laser after debulking with bipolar scissors in one of the patients. The special feature in our report is the coexistence of three adnexal skin neoplasms in one case, and the close association of cylindroma and eccrine spiradenoma in the same lesion. We also support that debulking with bipolar scissors prior to laser therapy can be a technique of great benefit in large tumors.     

End-tidal CO2 monitoring

Two cases of malignant hyperthermia are described where the earliest sign was a rise in the end-tidal CO2 concentration. This led to nearly immediate detection and adequate treatment with sodium dantrolene. These cases demonstrate the efficacy of monitoring end-expired CO2 concentrations in patients at risk from malignant hyperthermia, as well as a means for following the adequacy of treatment.     

Development of Multiple Warts After Skin Resurfacing with CO2 Laser

BACKGROUND: Skin resurfacing with CO2 laser is a common surgical procedure to improve photodamaged skin. Many complications may occur after this procedure, however, common warts is relatively rare. OBJECTIVE: To report a case of multiple warts after CO2 laser resurfacing and discuss the complete involution of these lesions. METHODS: A 78-year-old woman with multiple warts after CO2 laser resurfacing is described. RESULTS: The patient developed multiple common warts on the face after resurfacing with CO2 laser. Retinoic acid was introduced and complete involution of the lesions was observed after 5 days with no scars. CONCLUSION: Although emphasis is placed on the hazards of the laser plume to the medical staff, one should be aware of this complication. We believe that the regression of the lesions was spontaneous rather than induced by the retinoic acid.     

Comparison of Electrodessication with CO2 Laser for the Treatment of Actinic Cheilitis

BACKGROUND: Actinic cheilitis is a common premalignant condition that is most often treated with destructive therapy. The most effective technique is usually considered to be CO2 laser resurfacing. Little has been written on the use of electrodessication for this condition. OBJECTIVE: We designed a study to compare these two treatment modalities for the treatment of biopsy-confirmed actinic cheilitis. METHODS: A random half of the lower lip was treated with electrodessication. The contralateral half was then treated with CO2 laser. Healing time, subjective pain during healing, and clinical outcome at 3 months was compared. RESULTS: The side treated with electrodessication took significantly longer to heal than the side treated with the CO2 laser (23 versus 14 days, P <.001). There was no difference in subjective pain or clinical appearance at 3 months. CONCLUSION: Although the healing time is longer with electrodessication, this modality represents an inexpensive practical ablative treatment method for actinic cheilitis.