Single-Pass Carbon Dioxide Versus Multiple-Pass Er:YAG Laser Skin Resurfacing: A Comparison of Postoperative Wound Healing and Side-Effect Rates

BACKGROUND: Ablative laser skin resurfacing with carbon dioxide (CO2) and erbium:yttrium-aluminum-garnet (Er:YAG) lasers has been popularized in recent years and their side effects individually reported. No prior study, however, has directly compared the relative healing times and complications rates between the two different systems. OBJECTIVE: To evaluate and compare postoperative wound healing and short- and long-term side effects of single-pass CO2 and multiple-pass, long-pulsed Er:YAG laser skin resurfacing for the treatment of facial photodamage and atrophic scars. METHODS: A retrospective chart review and analysis of sequential clinical photographs were performed in 100 consecutive patients who underwent laser skin resurfacing with single-pass CO2 (Ultrapulse 5000; Coherent, Palo Alto, CA, N=50) or multiple-pass, long-pulsed Er:YAG laser resurfacing (Contour; Sciton, Palo Alto, CA, N=50). All laser procedures were performed by a single operator for the amelioration of facial rhytides or atrophic scars. The rate of re-epithelialization, duration of erythema, and presence of complications were tabulated. RESULTS: The average time to re-epithelialization was 5.5 days with single-pass CO2 and 5.1 days with long-pulsed Er:YAG laser resurfacing. Postoperative erythema was observed in all patients, lasting an average of 4.5 weeks after single-pass CO2 laser treatment and 3.6 weeks after long-pulsed Er:YAG laser treatment. Hyperpigmentation was seen in 46% of the patients treated with single-pass CO2 and 42% of the patients treated with the long-pulsed Er:YAG laser (average duration of 12.7 and 11.4 weeks, respectively). No incidences of hypopigmentation or scarring were observed. CONCLUSION: Skin resurfacing with single-pass CO2 or multiple-pass long-pulsed Er:YAG laser techniques yielded comparable postoperative healing times and complication profiles.     

A Comparative Clinical and Histologic Study of Hair Transplantation Using Er:YAG, Er:YAG/CO2, and Standard Punch Techniques

BACKGROUND: This study compares the effects of Er:YAG laser alone, Er:YAG/CO2 laser at 5 W (low power), Er:YAG/CO2 at 10 W (high power), and standard punch techniques in 10 men with androgenetic alopecia. OBJECTIVE: To study the clinical and histologic features of hair transplantation with recipient graft defects created by a new hybrid Er:YAG and CO2 laser. METHODS: Ten male patients (mean age 34 y) with Norwood IV-VI androgenetic alopecia had hair replacement surgery with the recipient sites divided into four quadrants comparing cold stell, erbium, combined erbium low-power CO2, and combined erbium high-power CO2 technologies. Hair growth, intraoperative procedure, lateral thermal damage, and patient satisfaction were compared, utilizing each of the four stated technologies. RESULTS: The addition of CO2 laser at both low and high power settings resulted in improved hemostasis when compared with standard punch or Er:YAG laser alone. The mean hair counts were similar for the Er:YAG laser, Er:YAG/CO2 (5 W) laser, and standard punch at both 3 and 6 months after treatment. Lateral thermal damage was not significantly increased by the addition of low-power CO2 to Er:YAG. The addition of high-power CO2 (10 W) laser resulted in slightly lower mean hair counts at 3 months, but significantly decreased at 6 months (P =.05). Also, high-power CO2 laser caused significantly increased lateral damage. There were no detectable differences in hsp70 expression among the groups. CONCLUSION: The addition of 5 W CO2 laser to Er:YAG laser results in better hemostasis than Er:YAG laser alone, while not significantly diminishing mean hair counts or inducing increased lateral thermal damage.     

Achieving superior resurfacing results with the erbium:YAG laser

Laser skin resurfacing has become increasingly popular. The carbon dioxide (CO2) laser seemingly remains the most commonly used laser modality for skin resurfacing. Many surgeons still promote the CO2 laser as being superior to the erbium:YAG laser, particularly for individuals with deeper lines. However, further experience with the erbium:YAG laser has shown the converse to be true. The erbium:YAG laser can be used to treat deep rhytids successfully, many times achieving results superior to those seen with the CO2 laser, particularly in the perioral region. The theory behind this relates to the 10-fold greater absorption of the erbium:YAG wavelength by water. The greater absorption produces more efficient vaporization, even at low fluences, with greatly reduced adjacent thermal injury. Ablation can be carried to deeper levels of the dermis than is consistently safe with the CO2 laser. Deliverance of total fluences in the range of 100 to 150 J/cm2, or more, produces a marked reduction or elimination of deeper rhytids. Clinically, experience with more than 300 cases indicates collagen remodeling occurs to a similar degree with the erbium:YAG laser as with the CO2 laser, as improvement in rhytids can be seen for 2 to 3 months after surgery. It would appear that superior results can be obtained without the "heat effect" of the CO2 laser. The erbium:YAG laser is capable of achieving superior resurfacing results, while offering many advantages to the patient, eg, reduced anesthetic requirements, shorter healing time, reduced erythema, less risk of pigmentary change, and more flexibility for resurfacing the skin off of the face.     

Variable pulse erbium:YAG laser skin resurfacing of perioral rhytides and side-by-side comparison with carbon dioxide laser

BACKGROUND AND OBJECTIVE: Laser resurfacing of facial rhytides has become a popular treatment option for many patients with wrinkles, photoaging, and acne scarring. Laser wavelength/pulse duration options and new techniques continue to shorten the healing phase associated with laser skin resurfacing while maintaining clinical efficacy. Variable pulse erbium:YAG (Er:YAG) laser systems are now available that offer the surgeon the ability to vary the Er:YAG pulse duration from a pulse that is primarily ablative to one that is more thermal. The objective of this study was to evaluate the histologic effects created with a variable pulse Er:YAG laser. To study prospectively the clinical effects on upper lip rhytides with a variable pulse Er:YAG laser when compared side by side with pulsed carbon dioxide (CO(2)) laser resurfacing. STUDY DESIGN/MATERIALS AND METHODS: Forty-two treatment sites on 21 patients were randomized and evaluated after treatment of the upper lip region with CO(2) laser resurfacing on one side and a variable pulse Er:YAG laser on the other. Patient diaries were maintained to assess erythema, crusting, pain, and pigmentary changes. Blinded objective grading of improvement was performed. Chromometer measurements were obtained to analyze erythema. RESULTS: The variable pulse Er:YAG laser treatment reduced the duration of crusting on average from 7.7 days with CO(2) to 3.4 days. Chromometer measurements noted decreased postoperative erythema. Grading by physicians in a blinded manner showed 63% improvement for the CO(2) treatment site and 48% improvement in the variable pulse Er:YAG site. No cases of permanent hyperpigmentation, hypopigmentation, or scarring occurred. CONCLUSION: The variable pulse Er:YAG laser resurfacing is a safe and effective resurfacing tool, which combines ablative and thermal modalities. The protocol used in this study approaches but does not equal the results we have traditionally seen with CO(2) laser resurfacing.     

Laser resurfacing with a long pulse erbium:YAG laser compared to the 950 ms pulsed CO(2) laser

BACKGROUND AND OBJECTIVE: Laser resurfacing with the 950 micros pulsed CO(2) laser is an effective treatment for photodamage and acne scarring; however, the potential for prolonged erythema and delayed re-epithelialization dissuade many patients from the procedure. With the use of erbium lasers alone, there is a decrease in the incidence and severity of these adverse sequelae; however, it is difficult to achieve the same degree of improvement as with the CO(2) laser because of the more superficial depth of resurfacing. Thus, new erbium lasers have been developed with longer pulse durations to deliver increased thermal effects to tissue. It is hypothesized that with the use of these lasers, diminished erythema and faster wound healing will be observed as well as enhanced clinical outcomes. STUDY DESIGN/MATERIALS AND METHODS: Sixteen patients were randomized to receive laser resurfacing on one-half of the face with the 950 micros pulsed CO(2) laser (UPCO(2)) followed by short pulse erbium:YAG ablation, and to the other half with a variable pulsed erbium laser (VP Er:YAG) followed by traditional short pulse erbium laser. Patients were evaluated clinically before resurfacing and at 1, 2, 4, 8, and 12 weeks post-operatively. Histologic samples taken at various time periods before and after resurfacing were also evaluated. RESULTS: Overall clinical improvement was equal for both UPCO(2) and VP Er:YAG treated sides with an average improvement in photoaging scores of 57%. Decreased erythema, less edema, and faster healing were observed on the VP Er:YAG treated side. CONCLUSION: The VP Er:YAG laser can achieve a similar degree of improvement as seen with short pulse CO(2) laser resurfacing with decreased thermal tissue effects and decreased risk for adverse sequelae.     

Treatment of Multiple Eruptive Hair Cysts with Erbium:YAG Laser

BACKGROUND: Eruptive vellus hair cysts (EVHC) frequently resist a variety of treatment modalities. While pulsed carbon dioxide (CO2) laser has been used effectively for facial EVHC, this laser presents significant risks for hypertrophic scarring when used on truncal sites. Due to absorption of 2940 nm energy by both tissue water and protein, the erbium:yttrium-aluminum-garnet (Er:YAG) laser ablates more cleanly and creates less residual thermal injury in the wound bed. This laser might prove efficacious and safe in treating nonfacial EVHC. OBJECTIVE: To assess treatment efficacy and wound healing after Er:YAG laser ablation of EVHC. METHODS: Two patients with 32 truncal EVHC were treated with pulsed Er:YAG laser using a drilling technique followed by second intention healing. RESULTS: Laser treatment sites healed without permanent dyspigmentation or hypertrophic scarring. No lesion recurrence was observed. CONCLUSION: Er:YAG laser ablation is an effective method for treating EVHC at anatomic sites prone to hypertrophic scar formation.     

One-Pass CO2 Versus Multiple-Pass Er:YAG Laser Resurfacing in the Treatment of Rhytides: A Comparison Side-by-Side Study of Pulsed CO2 and Er:YAG Lasers

BACKGROUND: The CO2 laser is normally described as an aggressive resurfacing tool, whereas the erbium:YAG laser has enjoyed a reputation as the ideal tool for superficial resurfacing. The implication from many studies is that the CO2 laser is incapable of "minimally invasive" resurfacing. OBJECTIVE: To compare a short-pulsed CO2 laser with an Er:YAG laser over a range of parameters intended to produce equivalent microscopic and clinical injuries. METHODS: A prospective, randomized, comparative interventional trial was conducted in a tertiary care teaching hospital. Thirteen patients with facial wrinkles were enrolled in the study. A side-by-side comparison was performed using periorbital and perioral regions as treatment sites. One side was treated with a pulsed CO2 laser and the other with an Er:YAG laser. Postauricular skin was treated in an identical fashion to the study sites and biopsied for microscopic analysis. The biopsies were obtained before treatment, immediately after treatment, and either 3 or 6 months after treatment to evaluate the acute level of injury and subsequent degree of fibroplasia. Photographs were taken at baseline, immediately after treatment, 1, 2, and 6 weeks, and 3 and 6 months after treatment. Nine physicians evaluated the photographs for erythema, pigmentation, and wrinkle improvement. RESULTS: Investigator assessment showed no statistically significant differences between the lasers with respect to hyperpigmentation and wrinkle reduction. There was less erythema at the CO2 laser-treated sites 2 weeks after treatment; the differences had resolved by 6 weeks after treatment. Histologic examination demonstrated equivalent dermal thermal injury on immediate postoperative biopsies and equivalent fibroplasia on subsequent biopsies. Both CO2 and Er:YAG laser-treated sites showed overall modest wrinkle improvement compared to the pretreatment photographs. CONCLUSION: When CO2 and Er:YAG lasers are used in a manner such that there are equivalent immediate postoperative histologic results, equivalent healing and cosmetic improvement occurs. One can use CO2 laser with one pass to mimic a moderately aggressive Er:YAG laser treatment.     

Combination Surgical Lifting with Ablative Laser Skin Resurfacing of Facial Skin: A Retrospective Analysis

BACKGROUND: Cutaneous aging is manifested by rhytides, dyschromias, and skin laxity. Ablative laser skin resurfacing can effectively improve many signs of skin aging; however, the photoaged patient with facial laxity often requires a surgical lifting procedure in order to obtain optimal results. Concerns with delayed or impaired wound healing has led to reluctance to perform both procedures simultaneously. OBJECTIVE: To report the clinical results and side effect profiles after concomitant surgical facial lifting procedures and ablative carbon dioxide or erbium:YAG laser resurfacing in a series of patients. METHODS: A retrospective analysis and chart review was performed in 34 consecutive patients who underwent combination CO(2) or erbium:YAG laser skin resurfacing and surgical lifting procedures, including S-lift rhytidectomy, blepharoplasty, and brow lift. Side effects and complication rates were tabulated. RESULTS: The side effect profile of the combined surgical-laser procedures was similar to that reported after a laser-only procedure. The most common side effect was transient hyperpigmentation which occurred in 20.6% of treated patients. None of the patients experienced delayed reepithelialization, skin necrosis, or prolonged healing times. CONCLUSIONS: Concurrent laser skin resurfacing and surgical lifting of facial skin maximizes aesthetic results without increased incidence of adverse effects. Patients benefit from the consolidation of anesthesia and convalescent times as well as enhanced global clinical outcomes.     

Clinical and histologic evaluation of six erbium:YAG lasers for cutaneous resurfacing

BACKGROUND: Several erbium:YAG lasers are currently available for cutaneous laser resurfacing. Although different laser systems are purported to produce equivalent laser energies to produce similar laser-tissue interactions, no comparative clinical or histologic studies have been performed to objectively demonstrate their relative efficacies. OBJECTIVE: The purpose of the present study was to examine the in vivo clinical and histopathologic effects of six different erbium:YAG resurfacing lasers. METHODS: A blinded, prospective study using six different erbium lasers (Candela, Continuum Biomedical, HGM, MDLT, SEO, Sharplan/ESC) was performed. The facial halves of 12 patients were randomly resurfaced with one of the six laser systems by using an identical laser technique at 5.0 J/cm2. Intraoperative skin biopsies were obtained after each of three laser passes in two patients for blinded histologic determination of tissue ablation level and presence of residual thermal damage. Clinical assessments of reepithelialization rates, severity and duration of erythema, side effects, and degree of clinical improvement were made at 0.5, 1, 2, 4, 12, 26, and 52 weeks postoperatively. RESULTS: Irrespective of the erbium laser system used, complete reepithelialization typically occurred at 0.5 weeks and resolution of erythema was noted within 1-2 weeks postoperatively. A mean clinical improvement of 50% was observed, with photodamaged skin showing greater improvement than scarred skin. The most common postoperative side effect was hyperpigmentation, with all affected patients having either darker skin tones or preceding dermal inflammation. Three laser passes were needed to effect total epidermal ablation when using any one of the erbium:YAG systems. CONCLUSIONS: Equivalent clinical and histologic results were seen after each of the six erbium:YAG lasers studied. Erbium:YAG laser resurfacing can be used to significantly improve mild cutaneous photodamage and atrophic scars.     

The efficiency of laser for the treatment of Ehlers-Danlos syndrome

BACKGROUND AND OBJECTIVES: A 61-year-old woman presented herself with extensive elastosis of the facial skin caused by Ehlers-Danlos syndrome (EDS). STUDY DESIGN/MATERIALS AND METHODS: Two laser skin resurfacings reduced the wrinkles significantly better than the two preceding conventional facelifts. For the first time, we have been able to compare two treatments with different laser systems on the same patient. The first treatment was performed with a high energy pulsed CO(2) laser, which has been in use for 8 years. The second treatment was performed by us using the latest technology CO(2)/erbium:YAG combination laser. RESULTS/CONCLUSION: Resulting in a similar degree of wrinkle reduction, the treatment with the combination laser markedly reduced the duration of the healing process and erythema phase.     

Use of a novel erbium laser in a Yucatan minipig: a study of residual thermal damage, ablation, and wound healing as a function of pulse duration

BACKGROUND AND OBJECTIVE: Theoretical models show that varying pulse duration influences residual thermal damage in erbium YAG skin resurfacing. Accordingly, our objective was to compare residual thermal damage, ablation, tissue shrinkage, and wound healing between a variable pulsewidth erbium YAG laser and a popular CO2 resurfacing laser. STUDY DESIGN/MATERIALS AND METHODS: The erbium laser delivered a typical ablative pulse (250 microseconds), followed by a heating pulse of variable duration. Pulse durations for specific coagulation depths were selected based on existing heat transfer models. The bilateral flanks of one Yucatan pig were irradiated. Eight sites were treated per group. Biopsies were performed just after treatment and 1, 3, 7, 21, and 60 days postoperatively. RESULTS: Just after irradiation, gross examination of "cold" (without a coagulation pulse) erbium sites showed a reddish papillary dermis consistent with conventional erbium laser ablation. Two and three pass CO2 sites showed uniform surface yellowing. The longer pulsewidth ("hot") erbium groups showed only slight surface yellowing. Biopsies showed immediate thermal damage that increased with erbium pulse duration; however, actual residual thermal damage (RTD) was sometimes less than that predicted by the laser control panel. All wounds healed uneventfully by 14 days. CONCLUSIONS: An erbium laser with a variable macropulse pulsewidth was capable of achieving RTD of up to 80 mum. Even greater RTD depths may be obtainable with future manipulations of fluence and pulse duration.     

Treatment of Atrophic Facial Scars with Combined Use of High-Energy Pulsed CO2 Laser and Er:YAG Laser: A Practical Guide of the Laser Techniques for the Er:YAG Laser

BACKGROUND: Although CO2 laser resurfacing provides substantial clinical improvement for atrophic facial scars, the CO2 laser often results in excessive thermal damage to the skin. It increases complications postoperatively. The Er:YAG laser ablates thinner layers of tissue than the CO2 laser with minimal thermal damage to the surrounding skin. OBJECTIVE: To determine the efficacy of combined treatment of atrophic facial scars with high-energy pulsed CO2 laser and Er:YAG laser. METHODS: One hundred fifty-eight patients were treated with a combination of high-energy pulsed CO2 laser and Er:YAG laser for atrophic facial scars. All patients were evaluated after 3 months of treatment. RESULTS: The scars improved 80-89% in 65 patients, 70-79% in 56 patients, more than 90% in 32 patients, 60-69% in 2 patients, and less than 60% in 3 patients after laser treatment. CONCLUSION: Treatment of atrophic facial scars with combined use of high-energy pulsed CO2 laser and Er:YAG laser is a very effective and useful method.     

Treatment of Facial Skin Using Combinations of CO2, Q-Switched Alexandrite, Flashlamp-Pumped Pulsed Dye, and Er:YAG Lasers in the Same Treatment Session

BACKGROUND: Many patients who seek facial CO2 laser resurfacing for improvement of photodamage are also concerned with "dark circles" under their eyes (periorbital hyperpigmentation) and/or telangiectasia as well as various types of deep scars on their faces. CO2 laser resurfacing alone provides limited improvement for these problems. OBJECTIVE: The purpose of this study was to demonstrate the conjunctive therapeutic effects of the CO2, Q-switched alexandrite, Er:YAG, and/or flashlamp-pumped pulsed dye lasers on facial skin treatments. METHOD: Thirty patients who underwent CO2 laser resurfacing were treated with additional lasers specific for their cosmetic concerns. Twenty patients with facial telangiectasias were treated with the pulsed dye laser immediately prior to CO2 laser resurfacing. Eleven patients with periorbital hyperpigmentation were treated with the Q-switched alexandrite laser immediately following use of the pulsed CO2 laser. Eight patients having sharply defined acne scars were treated with the Er:YAG laser following use of the CO2 laser. All patients had peripheral feathering performed with the Er:YAG laser. Nine patients were treated with all four lasers. RESULTS: In addition to significant improvement of the wrinkle scores from the CO2 laser resurfacing, patients had 75-100% clearing of the periorbital hyperpigmentation. All patients with facial telangiectasia showed virtually 100% improvement. All deep wrinkles and sharply defined scars responded with combined CO2/Er:YAG laser better than with CO2 laser resurfacing alone. All feathering was more uniform, with a more subtle transition to nontreated skin. There were no complications that could be attributed to the simultaneous use of multiple lasers. CONCLUSIONS: For patients who present with multiple cosmetic complaints, combined treatment using appropriate lasers offers excellent therapeutic outcome.     

Combined CO2/erbium:YAG laser resurfacing of peri-oral rhytides and side-by-side comparison with carbon dioxide laser alone.

BACKGROUND: Laser resurfacing of facial rhytids has become a popular treatment option for many patients with wrinkles, photoaging, and acne scarring. Laser wavelength options and optimization of techniques continue to evolve in an attempt to shorten the healing phase associated with laser skin resurfacing. OBJECTIVE: To prospectively study the clinical effects of pulsed carbon dioxide (CO2) laser resurfacing of facial rhytids used alone, compared with a combination of CO2 and the pulsed Erbium:YAG (Er:YAG) laser. METHODS: Forty treatment sites on 20 patients were randomized and evaluated following treatment of the upper lip region with a combination of CO2 laser resurfacing alone or with the same CO2 laser treatment followed by 3 passes with the Er:YAG laser. Patient diaries were maintained to assess erythema, crusting, pain, itching, swelling, pigmentary changes, and the day of first make-up application. Blinded objective grading of improvement was independently assessed by 4 blinded observers at time intervals 3, 6, and 10 days, and 1, 2, and 4 months. Chromometer measurements of erythema were also analyzed and percentage moisture recorded. RESULTS: Subjectively, all patients reported, on average, 10 days of redness and 2.4 days of pain, with no significant difference noted between the two procedures. On average, patients were able to apply make-up 5.5 days postoperatively, regardless of which procedure used. However, the combined CO2/Er:YAG laser treatment patients experienced reduced duration of crusting, compared to the patients treated with CO2 alone. The duration of crusting was reduced on average from 7.4 to 6.5 days, and also the duration of itching was reduced in patients receiving combined treatment from 5.5 to 4.8 days. Chromometer measurements noted no significant difference between techniques in the rate of resolution of erythema. Blinded objective grading revealed that crusting was reduced on average from 7.2 to 6.0 days, and swelling was reduced from 6.3 to 6.0 days in patients receiving the combined procedure. No cases of permanent hyperpigmentation, hypopigmentation, or scarring occurred in any patients. CONCLUSION: The addition of the Er:YAG laser following CO2 laser resurfacing reduces the duration of crusting, swelling, and itching postoperatively. Medium to deep (Grade III) facial rhytids were improved by 70% with both procedures with no significant difference noted between techniques.     

In vivo model of histologic changes after treatment with the superpulsed CO(2) laser, erbium:YAG laser, and blended lasers: a 4- to 6-month prospective histologic and clinical study

BACKGROUND AND OBJECTIVE: To compare the in vivo histologic effects of the pulsed carbon dioxide (CO(2)) and erbium:ytrium aluminum garnet (Er:YAG) lasers and to assess the effects of combining CO(2) and Er:YAG laser modalities during a single treatment session. We previously reported 10 patients treated with four laser regimens: CO(2) alone, CO(2)/Er:YAG, Er:YAG alone, Er:YAG/CO(2) with time points at 1 hour and 7 days between laser treatment and histologic analysis. This study found that the optimal treatment consisted of limited CO(2) laser passes followed by Er:YAG. This treatment produced less collagen injury, less thermal necrosis, and more robust epithelial and dermal fibrous tissue regeneration in the acute phase of healing. The present study examines the histologic changes resulting from the host healing response to laser treatment on long-term follow-up of 4-6 months. STUDY DESIGN/MATERIALS AND METHODS: The Stanford University Committee on Human Subjects in Medical Research approved this study. Nine patients with actinic damage and indications for rhytidectomy volunteered for this interventional study in which each patient served as both experimental and control. The right preauricular area was treated at five sites with the following: (1) CO(2), (2) CO(2) followed by Er:YAG, (3) Er:YAG, (4) blended CO(2)/Er:YAG (Derma-Ktrade mark), (5) phenol. Each was subjected to full-face or sub-unit treatment. Each patient was followed up initially daily then weekly for healing of the full-face laser and for differences in healing of the five treatment areas. Five patients were selected for histologic evaluation. At 4-6 months, these patients underwent rhytidectomy with immediate removal of laser-treated skin, which was evaluated histologically by the study dermatopathologist, who was blinded to the treatment at each site. RESULTS: CO(2) laser treatment produced the greatest thickness of neocollagen (0.27 mm; P < 0.05), the highest neocollagen density (P < 0.05), the greatest decrease in elastosis (27%), but took the longest time for healing and resolution of erythema and inflammation (up to 6 months). Er:YAG used alone produced the least collagen density, with the thinnest band of neocollagen (0.08 mm), but the most rapid resolution of erythema and inflammation (within 10 days). Combined CO(2)/Er:YAG treatments, including Derma-Ktrade mark and CO(2) followed by Er:YAG produced histologic changes that were intermediate, as well as recovery that was intermediate (resolution of erythema within 1 month); the development of neocollagen was greater in CO(2)-containing modalities than Er:YAG used alone by a statistically significant margin (P = 0.001). These histologic findings were corroborated by clinical correlation by examination of the five treatment spots in nine patients and in full-face treatments in 100 patients. CONCLUSION: Collagenesis is greatest with CO(2) and least with Er:YAG. Elastosis decreased to the greatest degree with CO(2), least with erbium, and to an intermediate extent with blended CO(2)/Er:YAG regimens (sequential and Derma-K). These changes from control are statistically significant with all regimens (P < 0.05). Blended CO(2)/Er:YAG treatments provide an optimal combination of the benefits of CO(2) but with lesser erythema and healing delay. Clinical and histologic findings change over time for different treatments. Thus, long-term histology is critical for predicting results of treatment.     

Combined Laser Resurfacing with the 950-μsec Pulsed CO2+ Er:YAG Lasers

INTRODUCTION: Laser resurfacing with the 950 microsec pulsed CO2 laser has been proven to be efficacious in improving photodamaged skin and acne scarring. Unfortunately, prolonged erythema and delayed wound healing are common adverse sequelae, which require intensive patient education and intervention. These adverse effects may be due to the degree of nonspecific thermal damage present after resurfacing with the CO2 laser. Since erbium: YAG (Er:YAG) laser vaporization leaves far less thermal damage, it is hypothesized that its use after CO2 laser resurfacing will decrease the extent of nonspecific damage and result in improved wound healing. METHODS: Ten patients were randomized to receive laser resurfacing of one-half of the face with the 950 Msec pulsed CO2 laser with 3 passes at 300 mJ, utilizing the computer pattern generator (CPG) at settings of 596, 595, 584, and the other half of the face (randomly chosen) resurfaced with the 950 Msec pulsed CO2 laser 2 passes with the CPG at 300 mJ at settings of 596 and 595, followed by 2 passes with the Er:YAG laser (Derma-20 or Derma-K, ESC Medical Systems, Inc., Needham, MA) with a 4 mm diameter spot size at 1.7 J (approximately 14 J/cm2). Patients were evaluated in a "blinded" manner clinically and histologically before resurfacing, immediately after resurfacing, 2 to 3 days postoperatively, 1 week postoperatively, and, 4 to 8 weeks postoperatively. RESULTS: There was slightly less inflammation with the CO2/Er:YAG-treated patients. The epidermis re-formed 1 to 2 days faster with combination (UPCO2)/Er:YAG treatment than with UPCO2 laser treatment alone. In 7 of 10 patients, Er:YAG erythema resolved within 2-3 weeks with CO2 x 3 erythema persisting at the 8-week follow-up period in all patients. Three of 10 patients had no difference in the degree of erythema between the 2 treatment areas. Clinical findings correlated with histologic findings of vascularity. There was no difference in the extent or time of edema between techniques. The usual demarcation line between cheek and neck at the mandibular angle was less apparent when the UPCO2/Er:YAG combination was used. Two of 10 patients noted quicker healing with the combination laser technique. CONCLUSION: Treating a patient with the Er:YAG laser after treatment with the UPCO2 laser results in a decreased incidence of adverse sequelae without a noticeable difference in the degree of wrinkle improvement.     

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.     

Efficacy and Safety of Short-Pulse Erbium:YAG Laser in the Treatment of Acquired Melanocytic Nevi

BACKGROUND: Various laser systems have been used in the treatment of acquired melanocytic nevi. However, CO2 lasers may cause scarring, and some nevi cannot be removed with pigment-specific lasers completely. To date, no study has evaluated the efficacy and safety of an erbium:yttrium-aluminum-garnet (YAG) laser, with its small penetration depth and fewer adverse effects, in the treatment of acquired melanocytic nevi. OBJECTIVE: To investigate the efficacy and safety of the short-pulse erbium:YAG laser in the treatment of acquired melanocytic nevi. METHODS: The study included 28 nevi in 14 patients. The lesions were pigmented, flat, or just palpable nevi. Nevi were irradiated with single-pulse laser energy of 1,000 mJ and a pulse duration of 300 microseconds. Fluences between 5.2 and 14.4 J/cm2 were used. Four months following laser treatment, the entire lesion was excised. Each specimen was histopathologically and immunohistochemically examined for the presence of nevus cells. RESULTS: Clinically, all of the nevi and, histopathologically, 27 of 28 nevi (96%) were completely removed without scarring. Post-inflammatory hyperpigmentation was seen in two patients and hypopigmentation in three patients. CONCLUSIONS: Short-pulse erbium:YAG laser treatment is an effective and safe method for removing acquired melanocytic nevi.     

Effect of Laser Resurfacing on p53 Expression in Photoaged Facial Skin

BACKGROUND: p53 overexpression has been reported in photoaged skin. Meanwhile, p53 gene mutations have been implicated as an important factor in the pathogenesis of ultraviolet (UV) light-induced skin cancer. OBJECTIVE: The objective was to evaluate the effect of laser resurfacing on the epidermal thickness and expression of p53 in photoaged skin. METHODS: Specimens were obtained from the facial skin of 10 patients before and after 3 months and 1 year of treatment using CO(2) (five cases) and erbium (Er):YAG (five cases) lasers. Specimens were also obtained from six age-matched controls. These biopsies were used for routine histopathology, histometry, and p53 immunoperoxidase staining. RESULTS: Both CO(2) and Er:YAG lasers were found to induce a significant decrease in p53 expression in biopsies obtained after 3 months (p=.0004 and .002, respectively) followed by gradual increase (p=.01 in both groups). A significant increase (p<.01) in epidermal thickness was also observed after 1 year of resurfacing. This increase, however, is inversely correlated with the level of p53 expression in such patients. CONCLUSION: The decrease in epidermal p53 expression after CO(2) and Er:YAG lasers may account for some of the benefits of resurfacing on the epidermis, as well as prevention of actinic neoplasia by adjusting any disturbance in the proliferation/apoptosis balance observed in photoaged facial skin.     

Intense pulsed light and Nd:YAG laser non-ablative treatment of facial rhytids

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of the intense pulsed light source (IPL) and the Nd:YAG laser in the treatment of facial rhytids. Both systems can be used in a non-ablative manner and cause a dermal wound. This is thought to stimulate the production of new collagen without epidermal disruption. Non-ablative techniques eliminate the downtime that must be endured by patients treated with ablative methods such as the carbon dioxide and erbium lasers. STUDY DESIGN/MATERIALS AND METHODS: Fifteen subjects with perioral rhytids and Fitzpatrick skin types II and III received three-to-five treatments with the IPL using 590 and 755 nm cut-off filters, and the 1,064-nm Nd:YAG laser. The subjects were evaluated at 2, 4, 8, 12, and 24 weeks after the final treatment for improvement in rhytids and presence of any side effects. RESULTS: At 6 months, the patient satisfaction score (1-10) was comparable in all three groups. Evaluator assessment of improved skin quality was also similar in all three treatment groups. Side effects such as blistering and erythema were most commonly seen in the subjects treated with the IPL. The least discomfort was seen with the Nd:YAG laser. CONCLUSIONS: Although both non-ablative treatment systems improved facial rhytids presumably by causing a non-specific dermal wound, the Nd:YAG laser was better tolerated and produced fewer side effects.