| 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. 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.
Keywords: CO 2 laser, CO 2 pixel, dermatological surgery
|How to cite this article:|
Krupa Shankar D S, Chakravarthi M, Shilpakar R. Carbon dioxide laser guidelines. J Cutan Aesthet Surg 2009;2:72-80
| Introduction|| |
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 10,600 nm, targeting both intracellular and extracellular water. When light energy is absorbed by water-containing tissue, skin vaporization occurs.
| Indications|| |
Actinic and seborrheic keratosis, ,,,, warts, ,,, moles, skin tags, epidermal and dermal nevi, ,,,,, xanthelasma. ,,,
Other conditions that have been shown to respond favorably to CO 2 laser resurfacing include dermatofibroma,  rhinophyma, ,,,, severe cutaneous photodamage (observed in Favre-Racouchot syndrome), sebaceous hyperplasia, syringomas, ,,,, actinic cheilitis, ,,, angiofibroma, ,, scar treatment, ,, keloid, ,,, skin cancer, ,,, neurofibroma, ,, diffuse actinic keratoses, granuloma pyogenicum,  and pearly penile papules. 
Periorbital and perioral wrinkles, ,, facial resurfacing ,,,, and acne scars, ,,,, dyschromias including solar lentigines. ,
| Contraindications|| |
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.
| Preoperative Preparation|| |
Informed consent should be obtained before the procedure according to guidelines.  The consent form should specifically state the possible postoperative appearance of the treated area, possible pigmentation changes and need for post-treatment care.
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. Clean the area with povidone iodine 5% solution (spirit should not be used because it is inflammable).
Depending upon the site and type of lesions, one of the following types of anesthesia can be given:
Eutectic Mixture of Local Anesthesia (EMLA) cream is used. Apply 2mg/cm 2 topically under occlusion for 60 min. The occlusion should be removed just before the procedure.
Lignocaine 2% with or without adrenaline 1:100000 is used. Dosage of lignocaine plain is 3 mg/kg and lignocaine with adrenaline is 7 mg/kg. 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.
- In case of palms and soles, insert the needle with 45Ί angulation to the skin surface.
- 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 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.
| General Instructions for the Operation of Laser|| |
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.
| Laser Specifications for Various Dermatological Conditions and Special Concerns|| |
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]. [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12],[Figure 13],[Figure 14] show the results after CO 2 laser in different conditions. It is important to know the relation between the power, irradiance and fluence before performing the procedure [Table 3].
| Postoperative Care|| |
- Always apply hydrocolloid dressings on facial procedures, never undertake a facial procedure, if hydrocolloid dressings are unavailable. [See Appendix for instructions on use of hydrocolloid dressings].
- Apply topical antibiotics for the superficial lesions for one week.
- Allow the scabs to fall on own. Avoid picking.
- Emphasize on sunscreen application three times a day from day one for the lesions on the face and neck.
- Treat for post-inflammatory hyperpigmentation if any with Kligman's formula.
- Allow occlusive pressure dressing to remain in place for three to seven days.
- Look for healthy granulation tissue after removal of the occlusive dressing.
- Avoid contact with dust. Use handyplast if needed for a couple of days for protection.
| Complications|| |
Minor complications although frequent, are usually of minimal consequence and include post-inflammatory hyperpigmentation, milia formation, perioral dermatitis, acne and/or rosacea exacerbation and contact dermatitis. 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.
| Practical Tips on use of Co 2 Laser|| |
- Always use hand piece pointer on skin to cut.
- Remember, lens focuses beam and renders it collimated.
- Moving hand piece away [defocusing] leads to logarithmic fall in irradiance; use this to coagulate.
- Super-pulse CO 2 laser reduces dwell time, maximizes power.
- Use continuous wave in highly vascular lesions and areas, debulking and where esthetics is not an issue e.g., foot.
- Under-treat, eschew therapeutic greed.
- 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.
| Guidelines for Co 2Pixel Laser|| |
- Apply topical anesthesia liberally. Occlude the anesthetic cream with provided plastic sheets and 3M transpore and leave it for 30-45 min.
- After 30-45 min, remove the occlusion and wipe the anesthesia completely with dry gauze.
- Set the pixel laser at 21 watts.
- Give single pass using 7*7 tip, that is, 49 pixel dots. Avoid overlapping but give two passes if scars are deep.
- Apply hydrocolloid dressing for 12 h.
- Procedure has to be repeated every month for four months.
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Department of Dermatology, Manipal Hospital, 98 Rustom Bagh, HAL Airport Road, Bangalore - 560 017, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
[Table 1], [Table 2], [Table 3]