Sorry, there is no online preview for this file type. Laser skin resurfacing with the fractional carbon dioxide co2 laser is one of the Fractional co2 laser our most advanced skin laser treatment. Mechanisms of action, treatment parameters, as well as pre and postoperative care will be discussed. A sunscreen is mandatory, and emollients may be prescribed for the dryness and peeling that could occur. Two passes of Active FX at 90 mJ, density 4.
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The carbon dioxide CO 2 laser is a versatile tool that has applications in ablative lasing and caters to the needs of routine dermatological practice as well as the aesthetic, cosmetic and rejuvenation segments. This article details the basics of the laser physics as applicable to the CO 2 laser and offers guidelines for use in many of the above indications. The carbon dioxide CO 2 laser is the gold standard in ablative lasers. Detailed knowledge of the machines is essential.
Over the past decade, advances in laser technology have allowed dermatologists to improve the appearance of scars and wrinkles and to remove benign skin growths using both ablative and nonablative lasers. CO 2 laser treatment ensures minimal discomfort and rapid recovery, enabling a quick return to daily routine.
The CO 2 laser emits an invisible infrared beam at 10, nm, targeting both intracellular and extracellular water. When light energy is absorbed by water-containing tissue, skin vaporization occurs. Isotretinoin use within the previous six months, active cutaneous bacterial or viral infection in the area to be treated, history of keloid formation or hypertrophic scarring, ongoing ultraviolet exposure, prior radiation therapy to treatment area, collagen vascular disease, chemical peel and dermabrasion.
Informed consent should be obtained before the procedure according to guidelines. Position the patient according to the area of lesion such that the area to be treated is close to the laser [ Table 1 ]. Gloves, mask and cap should be used by surgeons and assistants. Depending upon the site and type of lesions, one of the following types of anesthesia can be given:. The occlusion should be removed just before the procedure.
Lignocaine with adrenaline should be avoided at areas with end arteries like fingers, toes, earlobes, nose, and penis. Local anesthesia LA is injected as follows:. Using 30G needle with bevel pointing upward LA is injected immediately below the planned area of laser. Pinching the lesion before injection will reduce the pain. Insert the needle at a distance from the lesion such that the tip of the needle is below the lesion after it is pushed in to its full length, failing which anesthesia will be deposited distal to the lesion.
Ring block is employed to anesthetize fingers, toes and penis. The needle is inserted at the base of the fingers and toes on either side or a ring of anesthesia is deposited around the digit. The LA is injected while withdrawing. A distal digital nerve block on either sides of lateral nail folds can supplement a ring block for nail surgeries.
In case of penile region, LA is given at the base of the shaft. LA is infiltrated circumferentially around the site blocking the nerve impulse from leaving the area. The actual surgical site is not injected. They are particularly useful when a large area needs to be anesthetized. Patient's eye should be protected with the eye shield or with wet gauze.
Dermatologist and assistants should use wavelength-rated spectacles. Hold the hand piece perpendicular to the lesion and press the foot pedal to fire the laser. Vaporize the lesion in coiled, whorled, centrifugal, vertical or horizontal fashion.
Vaporize the flat lesions from the top. Pedunculated lesions can be excised by lasing from the base of the lesion. Hold the lesion with toothed forceps on the top, pull it to the side on the top of the wet gauze to prevent charring of the normal skin. Always use wet gauze as dry gauze can catch fire. Wipe the vaporized lesions with wet gauze. Always make sure to dry the area or wipe the water with dry gauze. Look for the raw areas. Coagulate the bleeding spots if any by defocusing the laser beam.
In additions to the above general measures that have to be adopted for lasing various cutaneous lesions, there are special considerations for some. The same and the laser settings are summarized in Table 2. It is important to know the relation between the power, irradiance and fluence before performing the procedure [ Table 3 ].
Verrucous epidermal nevus on cheek cleared with mild post-inflammatory hypopigmentation and scarring. Always apply hydrocolloid dressings on facial procedures, never undertake a facial procedure, if hydrocolloid dressings are unavailable.
Emphasize on sunscreen application three times a day from day one for the lesions on the face and neck. Avoid contact with dust. Use handyplast if needed for a couple of days for protection. Hyperpigmentation or erythema over the treated area is common in colored skin and causes anxiety to patients.
However, this is temporary, lasting for only about six weeks and gradually improves. More serious complications include localized viral, bacterial, and candidial infection, delayed hypopigmentation, persistent erythema, and prolonged healing.
The most severe complications are hypertrophic scarring, disseminated infection, and ectropion. Early detection of complications and rapid institution of appropriate therapy are extremely important. Delay in treatment can have severe deleterious consequences including permanent scarring and dyspigmentation. Moving hand piece away [defocusing] leads to logarithmic fall in irradiance; use this to coagulate. Use continuous wave in highly vascular lesions and areas, debulking and where esthetics is not an issue e.
Laser settings in texts are often for collimated hand pieces, read carefully before applying. One-third to one-fourth the irradiance suggested in the texts seems to deliver the results.
The newer CO 2 lasers with advanced output control software when used in the super-pulsed mode for carrying out free hand procedures are versatile devices with numerous therapeutic options. Apply topical anesthesia liberally.
Occlude the anesthetic cream with provided plastic sheets and 3M transpore and leave it for min. After min, remove the occlusion and wipe the anesthesia completely with dry gauze.
Avoid overlapping but give two passes if scars are deep. The following must not be used to sterilize the treatment area in CO 2 laser therapy:. Source of Support: Nil. Conflict of Interest: None declared. National Center for Biotechnology Information , U. J Cutan Aesthet Surg. Author information Copyright and License information Disclaimer.
Address for correspondence: Dr. E-mail: moc. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Abstract The carbon dioxide CO 2 laser is a versatile tool that has applications in ablative lasing and caters to the needs of routine dermatological practice as well as the aesthetic, cosmetic and rejuvenation segments.
Keywords: CO 2 laser, CO 2 pixel, dermatological surgery. Position Position the patient according to the area of lesion such that the area to be treated is close to the laser [ Table 1 ]. Table 1 Appropriate positioning of the area to be treated. Area to be treated Position Face, chest and abdomen Supine position Sides of face, neck and body Lateral position Nape of neck and back Prone position Palms Supine position with palms above his head Soles Prone position with extended ankle.
Open in a separate window. Aseptic measures Gloves, mask and cap should be used by surgeons and assistants. Anesthesia Depending upon the site and type of lesions, one of the following types of anesthesia can be given: Topical anesthesia Eutectic Mixture of Local Anesthesia EMLA cream is used.
Local anesthesia LA is injected as follows: Using 30G needle with bevel pointing upward LA is injected immediately below the planned area of laser. Inject the anesthesia while withdrawing and slowly to minimize the pain. Insert the needle at a distance from the lesion such that the tip of the needle is below the lesion after it is pushed in to its full length, failing which anesthesia will be deposited distal to the lesion Anesthesia must be infiltrated slowly and not pushed in briskly to avoid pain.
Ring block Ring block is employed to anesthetize fingers, toes and penis. Field block LA is infiltrated circumferentially around the site blocking the nerve impulse from leaving the area. Eye protection Patient's eye should be protected with the eye shield or with wet gauze. Figure 1. Figure Table 2 Laser specifications and special considerations for various cutaneous lesions. Dermatological conditions Laser settings Comments Actinic and seborrhoeic keratoses 4 to 7 watts super pulse mode Topical local anesthesia applied under occlusion at lesions for 45 to 60 min prior to procedure.
Dermatosis papulosa nigra 3. Warts 9 to 15 watts continuous mode, continuous wave for common warts, use 4 to 6 watts superpulse for flat warts Precede the vaporization of all types of warts with superficial vaporization of a 1-mm margin of normal skin at half the fluence, before treating the actual lesion, to reduce lesional recurrence. Filiform warts can be excised by vaporizing the base Palmoplantar warts 8 to 15 watts continuous mode, continuous wave Precede the vaporization of all types of warts with superficial vaporization of a 1-mm margin of normal skin at half the fluence, before treating the actual lesion, to reduce lesional recurrence Skin tags 4.
Do not go too deep to prevent scar formation Intradermal and melanocytic nevi on face 4. Review the patient on Days 30, , If any pigment is noted at treated area, vaporize and repeat follow-up as above Syringomas, angiofibroma, sebaceous hyperplasia, senile comedones 4. The marks must be made with a thin-tipped surgical pen and must circumambulate each lesion Scars 2. Vaporize the nail in vertical fashion running from the proximal to distal end over the marked line.
Separate the nail fold from the nail bed with nail elevator, separate proximal and lateral nail folds from nail plate with curved nail elevator.
Carbon Dioxide Laser Guidelines