The carbon dioxide laser surgical unit as an instrument for surgery of brain tumours — its advantages and disadvantages

Summary The author started in 1969 his studies on developing the practical models of the carbon dioxide laser surgical units and produced Medilaser-S, Model MEL-442 and MEL-444.By the end of 1982 the author had operated on 143 cases of brain tumour with the laser. Most of those cases were brain tumours which were difficult or impossible to remove by conventional means. The major points of this paper are as follows: The principle of the laser, the mechanism of the CO₂ laser, the biomedical features of the CO₂ laser, the advantages and disadvantages of the CO₂ laser, indications and contraindications for the use of the CO₂ laser, development of the CO₂ laser surgical units, surgical procedures and techniques of brain tumour laser surgery, adjuvant methods of laser surgery and comparison between the CO₂ laser and the Nd-YAG laser.     

LED phototherapy in full-thickness burns induced by CO<Subscript>2</Subscript> laser in rats skin

Many studies have been conducted on the treatment of burns because they are important in morbidity and mortality. These studies are mainly focused on improving care and quality of life of patients. The aim of this study was evaluate the LED phototherapy effects in rats skin full-thickness burns induced by CO₂ laser. The animals were divided in NT group that did not received any treatment and LED group that received LED irradiation at 685 nm, 220 mW, and 4.5 J/cm² during 40 s by burned area. Biopsies were obtained after 7, 14, and 21 days of treatment and submitted to histological and immunohistochemical analysis. The LED phototherapy shows anti-inflammatory effects, improves angiogenesis, and stimulates the migration and proliferation of fibroblasts. The T CD8+ lymphocytes were more common in burned areas compared to T CD4+ lymphocytes since statistically significant differences were observed in the LED group compared to the NT group after 7 days of treatment. These results showed that LED phototherapy performs positive influence in full-thickness burns repair from the healing process modulated by cellular immune response. The obtained results allowed inferring that burns exhibit a characteristic cell immune response and this cannot be extrapolated to other wounds such as incision and wounds induced by punch, among others.     

Pulsed carbon dioxide laser ablation of burned skin: In vitro and in vivo analysis

Pulsed lasers produce efficient and precise tissue ablation with limited residual thermal damage. In this study, the efficiency of pulsed CO₂ laser ablation of burned and normal swine skin was studied in vitro with a mass loss technique. The heats of ablation for normal and burned skin were 2,706 and 2,416 J/cm³ of tissue ablated, respectively. The mean threshold radiant exposures for ablating normal skin and eschar were 2.6 J/cm² and 3.0 J/cm², respectively. Radiant exposures greater than 19 J/cm² produced a plasma, which decreased the efficiency of laser ablation. Thus the radiant exposures for efficient ablation range from 4 to 19 J/cm², and within this radiant exposure range 20–40 μm of tissue are ablated per pulse. We also examined, on a gross and histo-pathologic basis, in vivo burn eschar excision with a pulsed CO₂ laser. The laser allowed bloodless excisions of full thickness burns on the backs of male hairless rats. The zone of thermal damage was approximately 85 μm over the subjacent fascia. The pulsed CO₂ laser can ablate burn eschar efficiently, precisely, and bloodlessly and may prove valuable for the excision of burned and necrotic tissue.     

Biophysical basis and technical requisites for the use of Nd-YAG laser in neurosurgery

Summary The different interactions between laser light and biological tissue are demonstrated for the CO₂- and the Nd-YAG-laser by histological examinations.For Neurosurgery the following results became significant: The CO₂ laser has become an important tool in contactless cutting and vaporization. The Nd-YAG-laser is suitable as a coagulator whenever the site and vascularity make the removal of a tumour difficult. For the various surgical techniques in Neurosurgery using the Nd-YAG laser, special laser attachments have been developed including micro-surgical and endoscopic instruments.     

Refractory Postinflammatory Hyperpigmentation Treated Fractional CO2 Laser

Objective: Postinflammatory hyperpigmentation is a reactive hypermelanosis of the skin that occurs as a consequence of an inflammatory process, such as acne, eczema, drug reactions, burns, chemical peelings, and laser applications. Although topical agents remain to be the first-line treatment of postinflammatory hyperpigmentation, treatment of recalcitrant cases is challenging. The Q-switched ruby laser, the low-dose Q-switched neodymium-doped yttrium aluminum garnet laser, and the fractional 1550nm erbium-doped fiber laser have been reported to improve postinflammatory hyperpigmentation. Design/setting/participants: The authors present a case of refractory postinflammatory hyperpigmentation successfully treated with two sessions of fractional CO₂ laser in a 24-year-old woman with Fitzpatrick skin type III. Results: After two treatment sessions with a one-month interval, the lesion totally cleared without any complications. Conclusion: Although many laser systems, including fractional CO₂ lasers, can cause postinflammatory hyperpigmentation, they also can be very efficacious tools by using conservative laser settings and by providing appropriate post-treatment care in recalcitrant postinflammatory hyperpigmentation treatment.Postinflammatory hyperpigmentation (PIH) is a reactive hypermelanosis of the skin. It appears as asymptomatic macules or patches that may be different in size and distribution depending on the causative pathology. Characteristically, it occurs as a consequence of an inflammatory process, such as acne, eczema, drug reactions, burns, chemical peelings, and laser applications. Increased amounts of arachidonic acid metabolites, cytokines, inflammatory mediators, and histamine in the inflammatory process may stimulate the melanocytes causing an increase in the melanin synthesis and transfer of pigment to the surrounding keratinocytes. In PIH, there is either excess melanin production or an abnormal distribution of melanin pigment deposited in the epidermis and/or dermis.1Treatment of PIH consists of a variety of medications and procedures. These include topical bleaching agents, such as hydroquinone, azelaic acid, kojic acid, retinoids, vitamin C, chemical peels, laser therapy, and sunscreens.1,2 The Q-switched ruby laser, the low-dose Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, and the fractional 1550nm erbium-doped fiber laser have been reported to improve PIH.1-4 Here, the authors present a case of refractory PIH treated with fractional CO₂ laser.     

Evaluation and application of CO2 laser fiber delivery for single port transoral robotic surgery

Background

Transoral robotic surgery (TORS) using the Single-Port system (SPS) relies on electrocautery, limiting its applications in the upper aerodigestive tract. We evaluated the feasibility of a CO₂ delivery system for the SPS.

Methods

Otolaryngology residents performed a cutting exercise using a handheld CO₂ laser and participated in a cadaveric oropharyngeal dissection using the SPS with monopolar cautery (SP + EC) and CO₂ laser (SP + CO₂). Residents completed the System Usability Scale (SUS) questionnaire to evaluate these techniques.

Results

The same laser fiber was used for all combined dissections. The handheld CO₂ laser, SP + EC, and SP + CO₂ demonstrated similar SUS scores. On individual domain scores, SP + CO₂ received less favorable ratings compared to the handheld CO₂ laser for complexity, integration, and cumbersome experience (p < 0.05). On subgroup stratification, less TORS experience was associated with worse SUS scores.

Conclusion

SP-guided CO₂ laser delivery is a viable alternative to electrocautery in robotic surgery, and should be considered when performing TORS.     

Experimental study of partial liver resection with a combined CO2 and Nd:YAG laser

The use of the CO₂ laser in liver surgery is mainly limited by the lack of coagulation of the larger vessels. In an experimental study, partial liver resections were performed on pigs with a Nd:YAG as well as with a combined CO₂ and Nd: YAG laser. The best cutting efficiency was obtained with the CO₂ laser. On the other hand, the Nd:YAG laser and the combined laser sources showed excellent hemostasis at the cutting edge corresponding with a width of necrosis at about 5 mm in histomorphometric examination and zones with histologically different characteristics. Rebleedings from the resection lines were avoided in all cases using the combined CO₂ and Nd:YAG laser.     

The Gold Standard for Decortication of Rhinophyma: Combined Erbium-YAG/CO<Subscript>2</Subscript> Laser

Rhinophyma is a benign condition of the nose that often is severely disfiguring and occasionally causes functional problems. A considerable proportion of the patients, with rhinophyma are elderly with chronic medical problems. Electrocautery, heated scalpel, carbon dioxide (CO₂) laser, argon laser, Weck blade, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel have been used either alone or in combination. All these techniques have disadvantages that are resolved by using the combined erbium:yttrium-aluminum-garnet (YAG)/CO₂ laser. The authors present their technique and the results from decortication of rhinophyma using a combined erbium:YAG/CO₂ laser. The technique requires only local anesthesia with a vasoconstrictor. The combination of an efficient vaporization tool consisting of the erbium:YAG laser and the CO₂ coagulation laser provides a nearly bloodless field for accurate sculpting of the nose and produces cosmetically pleasing results.     

Fractional CO<Subscript>2</Subscript> laser contributes to the treatment of non-segmental vitiligo as an adjunct therapy: a systemic review and meta-analysis

The treatment of stable non-segmental vitiligo is often challenging, which new therapies are being searched. Multiple clinical trials have proposed the benefits and safety of using fractional carbon dioxide (CO₂) laser as an adjunct therapy to conventional treatments. This study aimed to evaluate the safety and efficacy of fractional carbon dioxide laser as a combination therapy to conventional treatments in patients with stable non-segmental vitiligo. A literature search using PubMed, EMBASE, and the Cochrane Library was performed for comparative studies among vitiligo patients treated with additional fractional CO₂ laser. Clinical outcomes in the selected studies were compared, and a meta-analysis was performed via Review Manager version 5.3, according to the PRISMA guidelines. Six studies with a total of 184 patches/patients were included in the present meta-analysis. The combination therapy group had significantly superior results than that of the control group (≥?75% re-pigmentation, risk ratio [RR] 2.80, 95% confidence interval [CI] 1.29–6.07; ≥?50% re-pigmentation, RR 2.26, 95% CI 1.23–5.9; <?25% re-pigmentation, RR 0.57, 95% CI 0.43–0.75). Limitations of the study included the small number of studies and sample size, inadequate blinding of participants, and variation between therapy protocols. Meta-analysis revealed that using fractional CO₂ laser in combination with conventional treatments is efficient and safe, and may be considered as an adjunct therapeutic option for patients with refractive non-segmental vitiligo.     

Experimental study of laparoscopic selective proximal vagotomy using a carbon dioxide laser

This study investigated the effectiveness of laparoscopic selective proximal vagotomy using a CO₂ laser. Irradiation of the stomach was performed from the serosal aspect using a defocused CO₂ laser beam. In the first experiment, the inhibitory effect on cysteamine ulcers in rats was compared between surgical vagotomy and CO₂ laser vagotomy using three different irradiation fields. The results suggested that irradiation near the lesser curvature provided sufficient denervation. In the second experiment, CO₂ laser vagotomy was performed laparoscopically in dogs. The procedure lasted less than 1 h and a postoperative endoscopic Congo red test confirmed its effectiveness. Subserosal tissues including the vagus nerve branches showed degeneration and were replaced by fibrosis 3 months postoperatively, but the deeper tissues were spared. In conclusion, laparoscopic CO₂ laser vagotomy may be as effective for reducing acid secretion as standard surgical vagotomy. Its simplicity and safety suggest that a clinical trial in humans may be warranted.     

Tissue changes following application of lasers to the rabbit brain

Summary The effect of CO₂ and Nd-YAG lasers on rabbit brain tissue was investigated using various energy levels. With a defocussed CO₂ laser beam the depth of damage increases with application time; the superficial extension remains nearly equal. In focussed setting the CO₂ laser produced deep, fissured incisions; surrounding reactions remain relatively low. With the Nd-YAG laser the depth of the lesion is clearly dependent on the energy applied. In contrast to the absorption of the defocussed CO₂ laser beam at the surface, the Nd-YAG laser beam penetrates rather deeply into the brain tissue and produces necroses at even greater depths. The depth effects of laser radiation are limited. The focussed CO₂ laser beam appears suitable for cutting and vaporizing brain tissue. With the defocussed Nd-YAG laser beam selected areas may be destroyed by heat with sufficiently accurate prediction of depth.

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Zusammenfassung Bei variierter Energie wurde die Einwirkung des CO₂- und des Nd-YAG-Laser auf das Hirngewebe des Kaninchens systematisch untersucht. Bei defokussiertem CO₂-Laser-Strahl nimmt bei weitgehend gleichbleibender Oberflächenausdehnung die Schädigungstiefe entsprechend der Einwirkungsdauer zu. In fokussierter Stellung führt der CO₂-Laser zu tiefen spaltförmigen Inzisionen. Die Umgebungsreaktion bleibt hierbei relativ gering. Beim Nd-YAG-Laser besteht eine klare Abhängigkeit der Läsionstiefe von der verwendeten Energie. Der Nd-YAG-Laser-Strahl dringt im Gegensatz zum defokussierten CO₂-Laser-Strahl, der oberflächlich absorbiert wird, relativ weit in das Hirngewebe ein und verursacht auch noch in größeren Tiefen Nekrosen. Die Tiefenwirkung der verwendeten Laser-Strahlung ist jedoch begrenzt. Insgesamt halten wir den fokussierten CO₂-Laser-Strahl zum Schneiden und Verdampfen von Hirngewebe für geeignet. Mit dem defokussierten Nd-YAG-Laser-Strahl hingegen lassen sich umgrenzte Areale gezielt und mit genügend genau voraussagbarer Tiefenwirkung thermisch zerstören.

     

The Efficacy and Safety of Epidermal Growth Factor Combined with Fractional Carbon Dioxide Laser for Acne Scar Treatment: A Split-Face Trial

BackgroundEpidermal growth factor (EGF) stimulates collagen production and supports the wound healing process. However, there are no studies on fractional carbon dioxide (CO₂) laser combined with EGF for acne scar treatment.ObjectiveWe sought to evaluate the efficacy and safety of fractional CO₂ laser combined with topical EGF versus fractional CO₂ laser alone in the treatment of acne scars.MethodsTwenty-three patients with atrophic acne scars underwent three monthly sessions of randomized split-face application of fractional CO₂ laser combined with topical EGF or placebo twice daily for seven days following each laser session. Scar improvement was evaluated at one month and three months posttreatment by two blinded dermatologists and the Antera 3D^® skin analysis system. Wound healing response and adverse events were also evaluated.ResultsTwenty-one patients completed the trial. According to dermatologist grading and skin analysis system, EGF showed significant superiority at three months posttreatment compared to placebo. The wound healing response did not differ between the groups. Surprisingly, the melanin index on the EGF side showed a significant decrease at three months posttreatment, compared to placebo. There was no allergic reaction to the topical EGF.ConclusionTreatment with topical EGF after ablative fractional CO₂ laser improves the clinical appearance of atrophic acne scars, and EGF may help decrease skin pigmentation after laser treatment. The use of topical EGF is safe when applied to post-laser ablation.     

Routine use of the CO2 laser technique for resection of cerebral tumours

Summary The CO₂ laser technique has been routinely used from 1988 through 1992 for the resection of 93 cerebral tumours (meningiomas 58%, gliomas 15%, neurinomas 9%, miscellaneous 18%).The CO₂ laser technique was found the more effective 1) in tumours of hard consistency, 2) in large or giant tumours, 3) in tumours with scarce vascularization. Meningiomas were the indication of choice (54 cases that is 58% of all tumours treated with CO₂ laser, and 64% of all meningiomas operated on during the same period). Among the meningiomas treated with the CO₂ laser, 54% were located on the skull base. The CO₂ laser beam provides good haemostasis of small vessels during the vaporization process. When attached to the operative microscope, the other advantages of the CO₂ laser technique are: the absence of a handle-piece, the absence of manual manipulation of the tumour, the coaxiality of the laser beam with the visual beam. The disadvantages are: the rigidity of the coupled microscope-Laser arm, the smoke produced by the vaporization of hard tumours, the noise of the device.     

Comparison of stationary and dynamic fractional CO2 laser modalities of large burns treatment: Experimental laboratory model

ObjectivesTo experimentally compare two fractional ablative CO₂ laser handpieces intended for the treatment of large area burn scars. Each handpiece coverage rate, depth of penetration and application time were measured and compared in a simulation model of large area burns scars using a dynamic/roller handpiece (small footprint) and a stationary/stamping handpiece (large footprint).MethodsA 30 W fractional ablative CO₂ laser was applied using 2 different handpieces and footprints on a A4 size paper stack. The handpieces were a stationary (stamping) handpiece with 7 × 7 (49 pixels/square shape) and dynamic (roller) handpiece with 7 × 1 (7 pixels/single row shape). For both handpieces the laser settings were fixed at "High" power (30 W), providing an energy level of 100 mJ/pixel. Both handpieces were applied perpendicular to the surface, with the process repeated for the dynamic handpiece with an angled operation. The depth of laser penetration was assessed by the number of pages of paper having visible holes and burn area coverage time measured under each handpiece/condition.ResultsThe application time was faster and the penetration deeper for the dynamic handpiece compared to the stationary handpiece in both the perpendicular and angled conditions. This study has practical implications for lasers operators to improve time efficacy in large area scars with improved clinical endpoints.ConclusionThe fractional ablative dynamic handpiece demonstrated superior application efficiency compared to the stationary handpiece in the simulated treatment of large surface area burn scars, reducing treatment time with improved depth of penetration.     

Efficacy and safety of fractional CO<Subscript>2</Subscript> laser versus fractional Er:YAG laser in the treatment of facial skin wrinkles

Ablative fractional lasers were introduced for treating facial rhytides. Few studies have compared fractional CO₂ and Er:YAG lasers on cutaneous photodamages by a split trial. The aim of the present study was to compare these modalities in a randomized controlled double-blind split-face design with multiple sessions and larger sample size compared to previous studies done before. Forty patients with facial wrinkles were enrolled. Patients were randomly assigned to receive three monthly treatments on each side of the face, one with a fractional CO₂ and one with a fractional Er:YAG laser. The evaluations included investigating clinical outcome determined by two independent dermatologists not enrolled in the treatment along with measuring skin biomechanical property of cheeks using a sensitive biometrologic device with the assessment of cutaneous resonance running time (CRRT). Moreover, possible side effects and patients’ satisfaction have been recorded at baseline, 1 month after each treatment, and 3 months after the last treatment session. Clinical assessment showed both modalities significantly reduce facial wrinkles (p value?<?0.05), with no appreciable difference between two lasers. Mean CRRT values also decreased significantly after the laser treatment compared to the baseline in both laser groups. There was no serious long-standing adverse effect after both laser treatments, but the discomfort was more pronounced by the participants after CO₂ laser treatment. According to the present study, both fractional CO₂ and fractional Er:YAG lasers show considerable clinical improvement of facial skin wrinkles with no serious adverse effects, but post-treatment discomfort seems to be lower with Er:YAG laser.     

A randomized controlled clinical and histopathological trial comparing excisional biopsies of oral fibrous hyperplasias using CO<Subscript>2</Subscript> and Er:YAG laser

This study was conducted in order to compare clinical and histopathological outcomes for excisional biopsies when using pulsed CO₂ laser versus Er:YAG laser. Patients (n?=?32) with a fibrous hyperplasia in the buccal mucosa were randomly allocated to the CO₂ (140 Hz, 400 μs, 33 mJ) or the Er:YAG laser (35 Hz, 297 μs, 200 mJ) group. The duration of excision, intraoperative bleeding and methods to stop the bleeding, postoperative pain (VAS; ranging 0–100), the use of analgesics, and the width of the thermal damage zone (μm) were recorded and compared between the two groups. The median duration of the intervention was 209 s, and there was no significant difference between the two methods. Intraoperative bleeding occurred in 100% of the excisions with Er:YAG and 56% with CO₂ laser (p?=?0.007). The median thermal damage zone was 74.9 μm for CO₂ and 34.0 μm for Er:YAG laser (p?<?0.0001). The median VAS score on the evening after surgery was 5 for the CO₂ laser and 3 for the Er:YAG group. To excise oral soft tissue lesions, CO₂ and Er:YAG lasers are both valuable tools with a short time of intervention and postoperative low pain. More bleeding occurs with the Er:YAG than CO₂ laser, but the lower thermal effect of Er:YAG laser seems advantageous for histopathological evaluation.     

The efficacy and safety of fractional CO2 laser therapy in the treatment of burn scars: A meta-analysis

Although we have numerous publications about the effect of fractional CO₂ laser therapy for burn scars, quantitative data about its efficacy and safety are sparse. The purpose of this meta-analysis was to assess the efficacy and safety of fractional CO₂ laser therapy for the treatment of burn scars. Pertinent studies were identified by a search of PubMed, Embase and Web of Science up to 20 September 2020. Weighted mean difference (WMD) was conducted to combine the results, and a random-effect model was used to pool the results. Publication bias was estimated using Begg and Egger’s regression asymmetry test. Twenty articles were included. Our pooled results suggested that fractional CO₂ laser therapy significantly improved the Vancouver Scar Scale (VSS) score (WMD = −3.24, 95%CI: −4.30, −2.18; P < 0.001). Moreover, the Patient and Observer Scar Assessment Scale (POSAS)-patient (WMD = −14.05, 95%CI: −22.44, −5.65; P = 0.001) and Observer (WMD = −6.31, 95%CI: −8.48, −4.15; P < 0.001) also showed significant improvements with the treatment of fractional CO₂ laser therapy. Fractional CO₂ laser significantly reduced scar thickness measured with ultrasonography (WMD = −0.54, 95%CI: −0.97, −0.10; P < 0.001). For other outcomes, including pigmentation, vascularity, pliability, and height of scar, vascularity and relief, laser therapy was associated with significant improvements. However, only the cutometer measure R2 (scar elasticity) (WMD = −0.06, 95%CI: −0.10, −0.01; P = 0.023) was significantly improved with the laser therapy, but cutometer measures R0 (scar firmness) (WMD = 0.03, 95%CI: −0.04, 0.09; P = 0.482) was not. Side effects and complications induced by fractional CO₂ laser were mild and tolerable. Fractional CO₂ laser therapy significantly improved both the signs and symptoms of burn scars. Considering potential limitations, more large-scale, well-designed RCTs are needed to verify our findings.     

carbon dioxide surgical laser in neurological surgery,decubitus ulcers,and burns

Laser surgery has become an established part of general and specialty surgical techniques. Of all the lasers available today, the carbon dioxide laser possesses the physical and biological-surgical properties of most value to the surgeon. The CO₂ laser puts out a spatially and temporally coherent beam of high intensity, infrared radiation at 10.6 μm, a wavelength nearly 100% absorbed by tissue. Its action is dependent on heat, and it has the ability to vaporize, cut, and excise all tissue hemostatically, sterilizing as it proceeds. Experimental work in animal patients and man has laid the groundwork for clinical application. The CO₂ laser's value as a surgical tool has been clearly shown in the treatment of cancers and other neoplasms in brain, thoracic, and abdominal viscera; larynx; pharynx; nasal and sinus cavities; rectum; vulva, vagina; and uterus, for palliation and, at times, cure. It has been found of undoubted value in the debridement of decubitus ulcers and burns and has great potential for orthopedic surgery and breast surgery. The surgical laser is safe for patient and operating personnel, relatively simple to use, rapid in its action and without untoward impact on tissue locally or at a distance.     

Endoscopic submucosal dissection using a carbon dioxide laser with submucosally injected laser absorber solution (porcine model)

Background

Recently, endoscopic submucosal dissection (ESD) has been performed to treat early gastric cancer. The en bloc resection rate of ESD has been reported to be higher than that of conventional endoscopic mucosal resection (EMR), and ESD can resect larger lesions than EMR. However, ESD displays a higher complication rate than conventional EMR. Therefore, the development of devices that would increase the safety of ESD is desired. Lasers have been extensively studied as a possible alternative to electrosurgical tools. However, laser by itself easily resulted in perforation upon irradiation of the gastrointestinal tract. We hypothesized that performing ESD using a CO₂ laser with a submucosal laser absorber could be a safe and simple treatment for early gastric cancer. To provide proof of concept regarding the feasibility of ESD using a CO₂ laser with submucosally injected laser absorber solution, an experimental study in ex vivo and in vivo porcine models was performed.

Methods

Five endoscopic experimental procedures using a carbon dioxide (CO₂) laser were performed in a resected porcine stomach. In addition, three endoscopic experimental procedures using a CO₂ laser were performed in living pigs.

Results

In the ex vivo study, en bloc resections were all achieved without perforation and muscular damage. In addition, histological evaluations could be performed in all of the resected specimens. In the in vivo study, en bloc resections were achieved without perforation and muscular damage, and uncontrollable hemorrhage did not occur during the procedures.

Conclusions

Endoscopic submucosal dissection using a CO₂ laser with a submucosal laser absorber is a feasible and safe method for the treatment of early gastric cancer.     

Periocular skin reshaping by CO2 laser coagulation

When blepharoplasty is performed by transconjunctival route, sometimes the excess of skin created by overlaxness of the lower lid does not retract to achieve the desired cosmetic result. We propose a method for controlled retraction of the eyelid by coagulating the skin using the CO₂ laser. Thanks to this approach, the lower eyelid's tone recovers and the desired cosmetic appearance is achieved. Results of 37 patients that were treated by 10 W CO₂ laser, 5-mm defocused beam diameter, and pulses of 100 ms, are presented. Follow-up shows that periocular skin reshaping by CO₂ laser for laxened eyelid is a safe method and it can be considered a good alternative of treatment for blepharochalasis without skin excision.