Alternatives to the Use of Carbon Dioxide Laser

James J. Romano, MD

There has been an explosion in the usage of CO2 lasers for skin resurfacing over the last five years. This has been due mostly to the distinct advantages of this technology over other methods in removing skin wrinkles and pigmentation. Its heavy usage has also been increased by massive marketing by CO2 laser manufacturers to doctors in all specialties, higher overhead due to the CO2 laser purchase or lease, media publicity, and the need to be "on the cutting edge". Many patients, physicians, and skin care specialists have become less and less enthusiastic about laser resurfacing because of the pain, prolonged redness, potential complications, down-time, and intense care required. There is growing concern that CO2 lasers are being overutilized for treatment of conditions that can be successfully handled by other less invasive modalities and the question arises “What did we do before CO2 lasers, and what are the alternatives”?

CO2 Lasers provide a controllable and predictable technology for treatment of skin textural wrinkles and irregular pigmentation. When clients with these conditions are interested in other options or other modalities is when we should be aware of the treatment alternatives. What did we offer clients and patients before laser?

I present the available spectrum of treatment alternatives to every patient interested in removal of skin wrinkles and pigmentation. This depends mostly on how complete a result they want, but to a lesser extent on how much down time they can tolerate, their compliance, clinical skin condition, patience, pain thresholds, and how long they can stand to be treated. I emphasize that this spectrum starts out with treatments in your hands in your salon as their skin care specialist. If they require more, then the increasingly aggressive treatments are given in my office. Treatments can nicely graduate from one setting to the next but overlap enough that clients really like the opportunity to take the best advantage of both. I do not provide routine skin care services in my office.

I begin by having every patient in my office fill out an extensive skin history form that includes the information necessary for my referring estheticians to provide the best care. On examination I am sure to determine exactly which wrinkles and spots my patients focus on and the degree to which each bothers them. I ask if they are satisfied with “softening” the spots or wrinkles, or want the most complete improvement possible. I am careful to evaluate and classify their wrinkles in terms of textural, dynamic, or furrows. The fine, medium or deep textural wrinkles in the dermis of the skin respond well to surface treatments. Dynamic wrinkles still in the dermis of the skin are more byproducts of muscle activity and can be softened but less completely removed. Hanging loose excess skin like in the jowls, or furrows like in the nasolabial area are more related to the underlying anatomy and are better treated surgically by facelift, for example. Pigmentation changes can be spotty or diffuse, deep or superficial. Some are genetically programmed such as freckles. Most pigmentation can be improved, some completely. An electric UVB black light examination in your salon can help assess the depth and predictability of surface treatments on skin pigment improvement. I am careful to evaluate the patient’s expectations, motivations, and degree of compliance.

So what are the alternatives then?

First, I always start with and emphasize the importance of skin care and esthetician services including glycolic peels. Your role in the care and education of these patients should not be underestimated. Skin care specialists are already very familiar with and play a huge and growing role in the treatment of plastic surgical and laser patients. Every physician treating wrinkles should remember that this practice was introduced and gained momentum and popularity in the 1880's through the efforts of lay peelers ("beautifiers") and these early estheticians actually taught it to the dermatologists some years later. As peeling became more aggressive and deeper, the physicians gradually took over most of this practice as complications related to these deeper procedures began to arise. Nowadays estheticians treat so many clients undergoing plastic surgery and laser resurfacing that you have become extremely aware of complications and the potential for complications. Even though you don't provide these services, you are play a vitally important role in educating and preparing clients. Often physicians depend on you for this care and counseling of their patients. Therefore from its most basic start, excellent and aggressive skin care plays a role. Cleansing, exfoliants, hydration, masks, products, and various modalities (such as microcurrent) all play a role. Often it is slight or "soft" and involves some improvement of the very finest of wrinkles, but don't forget that this might be enough to satisfy some clients, and this should not be underestimated, and at least they should be offered this option. I also emphasize that regardless of the degree of results, skin treatments represent an excellent preparation for the next aggressive stage of any skin resurfacing intervention.

Sun avoidance should not be forgotten. The wrinkle lines and pigmentation we treat are mostly the result of photodamage. Studies have shown that complete avoidance of sun over the course of years can reverse some of the damaged skin. Since this is not practical many times, we should at least suggest sunblocks.

Through your supervision glycolic products and Retin-A can be used as the main ingredients of an excellent home program. It has been shown that using both of these is better than either one alone. Coordinating this type of home program with a physician to systematically and aggressively increase the glycolic and Retin-A over time can produce a dramatic improvement of both fine wrinkles and pigmentation if the client is patient and cooperative.

The next step up in the spectrum of alternatives you can offer is the light (superficial) epidermal peeling that can be provided by glycolic peels or a slightly deeper peel in the form of Jessner's solution. Glycolic peels need to be presented as a program with frequent intervals in the beginning, increasing the duration and concentration of glycolic as tolerated with each visit until a stable endpoint of improvement is obtained at which time maintenance is begun. I have seen nice improvement in fine wrinkle lines and softening of medium depth wrinkle lines with this program.

The next step up alternative is offered in my office and is one of my favorites. It consists of a physician supervised very aggressive skin-bleaching program using Retin-A, glycolics, and hydroquinone known as the Obagi system. It is totally customizable and individualized to each patient. I reassure patients that have used Retin-A alone, and don't like the side effects, that it is very different and well worth the effort. There is essentially no down time, it is easy to use, and provides very predictable results. It works best for patients concerned with pigmentation, but also works well to soften wrinkles and improve skin texture. I use it as a preparation on virtually all my laser and facial cosmetic surgery patients with an overwhelming high degree of satisfaction. Very importantly, it is used as a supplement to the products and the services offered by my referring estheticians and does not present any conflict in this situation at all. In fact, I request the referring esthetician to follow these patients with me.

The next alternative up offered in my office is the medium depth peel. The most popular product is low concentrations (15-30%) TCA. There are many great indications for its usage. It is an excellent "refresher" minimal downtime peel that can be frequently safely repeated for cumulative benefits. I also like to offer it for use in the nonfacial areas such as the chest, hands, and arms. I also use this to feather the edges of demarcation along and into the neck when I use deeper (laser or phenol peel) treatments to the face. I suggest this as a "jump-start" to the patients on the bleaching program in which cases it works extremely well. It is an excellent stand-alone treatment for such things as the fine wrinkles of lower eyelids. A popular product I use is the Obagi Blue Peel that compliments nicely their bleaching program. A methylene blue dye added to the TCA solution makes the application and endpoint of the peel much easier to identify and control. I offer this as the "weekend peel", performed on a Thursday, back to work on Friday, peel on Saturday and Sunday and mostly done by Monday or Tuesday. It looks like a deep brown sunburn that comes off like a "snake-skin". It further increases the amount of improvement in pigmentation and softening wrinkle lines. I offer this also as part of a program and caution patients that a one-time isolated treatment is simply not enough.

Dermabrasion is still a very viable alternative that I continue to offer to my patients. It heals faster than laser and I still use it in small or localized areas where wrinkles are not too deep. It seems to work better with acne because in these patients with a lot of facial skin and dermal scarring there is less post-op redness and swelling, and they see their results quicker.

Many doctors continue to prefer and offer phenol peels over laser. It seems to be more effective for coarse deep wrinkles. Hypopigmentation is still an unavoidable byproduct of phenol peels.

Non-resurfacing treatments are in some cases preferred, depending on the anatomy of the problem. Here collagen, fat grafting, synthetic filler materials (Gore-Tex®, Softform®), botulinum toxin, or surgery may be indicated.

In summary, the message here is several fold. First, don't underestimate the very important role you as a skin care specialist play in client education especially about the CO2 laser resurfacing procedure. Your awareness and client education may be the first line of identifying and preventing complications. There are numerous excellent modalities available for treatment of wrinkle lines and pigmentation that can be employed prior to or even instead of laser resurfacing. Your client may depend on you to be aware of these alternatives.