Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obervation Letter
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Recommendations
2008:74:7;61-67
PMID: 18688106

Standard guidelines of care: CO 2 laser for removal of benign skin lesions and resurfacing

DS Krupashankar
 Member, IADVL Dermatosurgery Task Force* and Department of Dermatology, Manipal hospital, Bangalore, India

Correspondence Address:
D S Krupashankar
Professor and HOD Dermatology, Manipal Hospital, Bangalore
India
How to cite this article:
Krupashankar D S. Standard guidelines of care: CO 2 laser for removal of benign skin lesions and resurfacing. Indian J Dermatol Venereol Leprol 2008;74:61-67
Copyright: (C)2008 Indian Journal of Dermatology, Venereology, and Leprology

Abstract

Resurfacing is a treatment to remove acne and chicken pox scars, and changes in the skin due to ageing. Machines : Both ablative and nonablative lasers are available for use. CO 2 laser is the gold standard in ablative lasers. Detailed knowledge of the machines is essential. Indications for CO 2 laser: Therapeutic indications: Actinic and seborrheic keratosis, warts, moles, skin tags, epidermal and dermal nevi, vitiligo blister and punch grafting, rhinophyma, sebaceous hyperplasia, xanthelasma, syringomas, actinic cheilitis angiofibroma, scar treatment, keloid, skin cancer, neurofibroma and diffuse actinic keratoses. CO 2 laser is not recommended for the removal of tattoos. Aesthetic indications: Resurfacing for acne, chicken pox and surgical scars, periorbital and perioral wrinkles, photo ageing changes, facial resurfacing. Physicians' qualifications: Any qualified dermatologist (DVD or MD) may practice CO 2 laser. The dermatologist should possess postgraduate qualification in dermatology and should have had specific hands-on training in lasers either during postgraduation or later at a facility which routinely performs laser procedures under a competent dermatologist/plastic surgeon, who has experience and training in using lasers. For the use of CO 2 lasers for benign growths, a full day workshop is adequate. As parameters may vary in different machines, specific training with the available machine at either the manufacturer's facility or at another centre using the machine is recommended. Facility: CO 2 lasers can be used in the dermatologist's minor procedure room for the above indications. However, when used for full-face resurfacing, the hospital operation theatre or day care facility with immediate access to emergency medical care is essential. Smoke evacuator is mandatory. Preoperative counseling and Informed consent Detailed counseling with respect to the treatment, desired effects, possible postoperative complications, should be discussed with the patient. The patient should be provided brochures to study and also given adequate opportunity to seek information. Detailed consent forms need to be completed by the patients. Consent forms should include information on the machine used; possible postoperative course expected and postoperative complications. Preoperative photography should be carried out in all cases of resurfacing. Choice of the machine and the parameters depends on the site, type of lesion, result needed, and the physician's experience. Anesthesia: Localized lesions can be treated under eutectic mixture of local anesthesia (EMLA) cream anesthesia or local infiltration anesthesia. Full-face resurfacing can be performed under general anesthesia. Proper postoperative care is important to avoid complications.
Keywords: Ablative laser, Keratoses, Resurfacing, CO 2 laser

Introduction

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. Chemical peeling, dermabrasion, surgical scar revision, electrosurgical planning, and dermal/subdermal filler substances and lasers are some of the modalities used by dermatologists for the correction of scars and wrinkles. Lasers constitute an important modality for both aesthetic and therapeutic indications.

Rationale and Scope

The field of lasers is rapidly evolving and new machines are being introduced every year. Much variation exists in different machines and techniques; therefore, establishing standard guidelines has limitations. The guidelines recommended here indicate minimum standards of care in the use of CO 2 laser.

Background

Principle of ablative resurfacing: Presently, five laser modalities are available for ablative skin resurfacing:

  • Scanned carbon dioxide laser
  • Pulsed carbon dioxide laser
  • Pulsed Er:YAG laser
  • Fractional Er:YAG laser resurfacing
  • Combination carbon dioxide and Er:YAG lasers

Each of these machines relies on the principles of selective photothermolysis in order to selectively target water-containing tissue and cause controlled tissue vaporization. Although devoid of colour, water is the chromophore, CO 2 laser treatment ensures minimal discomfort and rapid recovery, enabling a quick return to daily routine. The carbon dioxide 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. Recent advances in carbon dioxide laser technology have enabled machines to deliver sufficient energy to vaporize the skin in < 1 millisecond. These include:

  1. Use of an ultra-short pulse to deliver the energy to tissue
  2. The use of a scanner minimizes dwell time in a unit volume of tissue; use of a computer-controlled opto-mechanical shutter system helps to scan a continuous wave beam so rapidly that the emitted light is prevented from coming into contact with the skin for > 1 millisecond.

Factors contributing to the absence of uniform laser parameters in clinical practiceUniform criteria for the use of CO 2 lasers are absent. Reasons for this are:

  1. While several clinical and histological studies have been reported in the medical literature, varying styles of laser practice between surgeons could affect the clinical results. In addition to the laser parameters chosen, clinical effect is also influenced by the number of laser passes delivered, the degree of pulse or scan overlap, the complete/incomplete removal of partially desiccated tissue between each laser pass, preoperative preparation, and postoperative wound care.
  2. The use of free hand lasing with a focusing hand piece renders CO 2 lasing operator-dependent and not amenable to precise guidelines on fluence. Hence, descriptions will perforce have to be in terms of spot size, mode, power, focusing, gating, overlap and passes.
  3. The parameters described for scanner-based work and collimated hand pieces do no apply in freehand lasing with a CO 2 laser technique that utilizes a focusing hand piece. The bulk of CO 2 laser surgeries utilize focusing hand pieces with spot sizes of 0.1, 0.2 and 0.4 mm for cutting, coagulation and vaporization.

Physicians′ Qualifications

As with any dermatosurgical modality, the dermatosurgeon must have a complete understanding of the indications and limitations of a given procedure. The dermatosurgeon should possess postgraduate qualification in dermatology and specific hands-on training in lasers either during postgraduation or later at a facility that routinely performs laser procedures under a competent dermatologist/plastic surgeon with experience and training in using lasers. As parameters may vary in different machines, specific training is essential with the available machines at either the manufacturer′s facility or at another centre using the machine. While minimal training is needed for CO 2 lasers for benign growths, which can be given in a day′s workshop, resurfacing for the face needs more advanced training and can only be performed after adequate experience has been gained with the machine.

Facility

A CO 2 laser can be used in the dermatologist′s minor procedure room for removal of benign growths and treating localized lesions. However, when used for full-face resurfacing, a hospital operation theatre or day care facility with immediate access to emergency medical care and standby anesthetist is essential. Smoke evacuator is mandatory.

Indications and Patient Selection

Therapeutic indicationsActinic and seborrheic keratosis (level C), [1],[2],[3],[4],[5] warts (Level B), [6],[7],[8],[9] moles, skin tags, epidermal and dermal nevi (level B), [10],[11],[12],[13],[14],[15] xanthelasma (level C), [16],[17],[18],[19],[20] vitiligo blister and punch grafting. Other conditions that have been shown to respond favorably to carbon dioxide laser resurfacing include rhinophyma (level C), [21],[22],[23],[24],[25] severe cutaneous photodamage (observed in Favre-Racouchot syndrome), sebaceous hyperplasia, syringomas (level B), [26],[27],[28],[29],[30] actinic cheilitis (level C), [31],[32],[33],[34],[35] angiofibroma (level C), [36],[37],[38] scar treatment (level C), [39],[40],[41] keloid (level C), [42],[43],[44] skin cancer (level C), [45],[46],[47],[48] neurofibroma (level C) [49],[50],[51] and diffuse actinic keratoses. Carbon dioxide lasers were used in the past for tattoo removal (in conjunction with dermabrasion and salabrasion); however, their use for this purpose has been largely abandoned because of the availability of more tattoo-specific lasers.

Aesthetic indicationsPeriorbital and perioral wrinkles (level C), [52],[53],[54] facial resurfacing (level B) [55],[56],[57],[58],[59] and acne scars (level C). [60],[61],[62],[63],[64]

Skin resurfacing with a pulsed or scanned carbon dioxide laser is commonly used for improvement of fine or moderate rhytides. While deeper rhytides may also be improved, other procedures such as autologous fat transplantation, contour threadlifting, sculptra ® injections, Gore-Tex/other implantation, or surgical lifting can be used to provide additional benefit. Dyschromias including solar lentigines, [65],[66] are often improved with laser resurfacing, although they are not generally regarded as a primary indication The success of a cutaneous resurfacing procedure relies on the presence of skin appendages ( e.g ., sweat glands, folliculo-infundibular units) to serve as sources of epithelium that can migrate upward to form the new epidermis. Therefore, the greater the number of skin appendages per square centimeter of skin, the more rapid the healing and the lower is the risk for scarring. For this reason, carbon dioxide laser resurfacing is largely limited to the face. Resurfacing of the hands and neck has been successful, although a much greater risk for scarring exists when treating these areas. Improvement of melasma has been reported, although the recurrence rate is high after laser resurfacing.

Carbon dioxide laser resurfacing may greatly improve atrophic scars caused by acne, trauma, or surgery. Deeper pitted acne scars often require ancillary procedures for optimal results, such as excision or punch grafting. These procedures can be performed either prior to or concomitant with carbon dioxide laser resurfacing.

Patient selection, counseling and informed consentAs with any cosmetic procedure, proper patient selection is essential.

  • During the initial consultation, the surgeon should ascertain the patient′s expectations of treatment and the circumstances leading to the decision to have cosmetic surgery.
  • A complete medical and surgical history, including recent use of isotretinoin (its regular use within a year prior to dermabrasion has shown a higher risk of hypertrophic scarring) should be obtained.
  • History of previous laser resurfacing, dermabrasion or deep phenol peel should be noted, because these procedures could potentially delay the wound healing response due to the presence of fibrosis. Patients with a prior history of transcutaneous lower blepharoplasty and limited infraorbital elasticity may have increased risk of ectropion. When applicable, patients should be discouraged from smoking before and after surgery to reduce the risk of delayed or impaired wound healing.
  • Skin to be treated should be thoroughly examined-scarring, dyschromia, rhytid formation, and skin type should be noted carefully. For patients desiring periorbital laser treatment, the eyes should be carefully examined for scleral show, lid lag, and ectropion.
  • Other cutaneous disorders should also be investigated, including seborrheic keratosis, solar lentigines, actinic keratosis, acne vulgaris, and cutaneous carcinomas. The latter should be treated prior to any resurfacing procedures.
  • With this information, the benefits of laser resurfacing must be assessed along with its limitations and risks.

Most importantly, patients should have realistic expectations and sound reasons for deciding to undergo the cosmetic laser surgical procedure. Other cosmetic treatment options should be reviewed too so that the patient may make an informed decision. The patient should understand that there is a postoperative healing phase with erythema and crusting that lasts for 1-2 weeks. The need to avoid sunlight during postoperative healing should be emphasized. It is worthwhile to include explicit instructions to the effect in the consent form (refer Appendix). In dark-skinned patients as seen in south India, pigmentation is a possible complication and this may last for several weeks; this fact should be emphasized in the counseling sessions. While CO 2 laser resurfacing is usually a one-time procedure, many patients may need repeat treatments and if the physician thinks that a second session may be needed, this information should be given to the patient.

ContraindicationsAbsolute contraindications include isotretinoin use within the previous six months, active cutaneous bacterial or viral infection in the area to be treated, and ectropion (for infraorbital resurfacing).

Relative contraindications include patient history of keloid formation or hypertrophic scarring, ongoing ultraviolet exposure, prior radiation therapy to treatment area, and collagen vascular disease.

Caution should be taken with patients who smoke or who have a history of previous laser resurfacing, phenol chemical peel, dermabrasion, and/or transcutaneous lower blepharoplasty. Also, patients planning to undergo neck or extremity laser resurfacing should be forewarned of the increased risk of fibrosis in these areas.

Pretreatment care

The following pretreatment guidelines are only applicable for resurfacing extensive areas:

  • Topical retinoic acid, hydroquinone and broad spectrum sunscreen are required two to four weeks before surgery.
  • Systemic antibiotics: Some surgeons routinely prescribe antibiotics for antibacterial prophylaxis; however, convincing data do not exist to support their use, given the relatively low incidence of postoperative bacterial infection. The choice of the antibiotic is as per patient′s preference; cephalosporin (cephalexin), semisynthetic penicillin (dicloxacillin), macrolide (azithromycin) or quinolone (ciprofloxacin) is begun a day before or on the day of surgery and continued until re-epithelialization is complete. The use of topical antibiotics on the laser-induced wound is not routinely recommended because of the possibility of contact dermatitis.
  • Antivirals: Acyclovir is indicated in patients with history of previous herpes simplex. As laser skin resurfacing can cause reactivation of latent herpes simplex infection or can predispose the patient to a primary infection during the re-epithelialization phase of healing, prophylactic use of an antiviral medication during the postoperative period is recommended, regardless of a patient′s herpes simplex virus history. Acyclovir may be begun either 24 hour prior to surgery, or on the morning of surgery. Commonly used regimens include famciclovir 250 mg PO bid, acyclovir 400 mg PO tid, and valacyclovir 500 mg PO bid for 7-10 days.

Anesthesia

For small lesions, EMLA cream applied under occlusion for 30-60 minutes is adequate. For localized areas, local infiltration with 1% lidocaine and epinephrine is usually sufficient to produce adequate anesthesia. For larger areas, such as full-face resurfacing, nerve blocks ( e.g ., supraorbital, supratrochlear, infraorbital, mental) may be needed along with local infiltration. Some surgeons use tumescent anesthesia with or without nerve blocks to provide local anesthesia, while others prefer to use conscious sedation (or twilight anesthesia) alone or in conjunction with other techniques.

Postoperative care and complicationsCarbon dioxide laser resurfacing imparts a thermal injury to denuded skin. Therefore, side effects are expected and must be differentiated from complications. Nearly all patients encounter minor side effects ranging from postoperative pain and edema to pruritus and tightness.

  • Postoperative edema (swelling) may occur, which usually subsides with cold compresses and nonsteroidal anti inflammatory drugs.
  • A mild serous (watery) discharge is seen, which subsides spontaneously by the 2nd or 3rd postop day.

Postoperative wound care varies considerably depending on the surgeon′s preference. Wounds re-epithelialize more rapidly in a moist environment. Also, crust and eschar impede keratinocyte migration and retard the healing process. Therefore, most surgeons advocate maintaining a moist environment either with topical emollients and/or with semi occlusive dressings.

Postoperative wound care can follow an open or closed method. With the closed method, a semiocclusive dressing (usually involving a hydrogel) is placed on the denuded skin. These wound dressings have been shown to accelerate the rate of re-epithelialization by maintaining a moist environment. In addition, decreased postoperative pain has been reported with their use. However, some authors believe that occlusive dressings also yield a low-oxygen environment that may promote the growth of anaerobic bacteria, thereby causing infection and impeding wound healing. As such, many proponents of the closed technique now combine the use of semiocclusive dressings with topical emollients. Others simply advocate the use of an open postoperative method involving the application of copious amounts of topical emollients to promote rapid re-epithelialization without risking prolonged occlusion and inability to observe the wound surface. Avoidance of undue sun exposure and use of broad spectrum sunscreens is mandatory.

Complications after laser resurfacing Minor complications although frequent, are usually of minimal consequence and include milia formation, perioral dermatitis, acne and/or rosacea exacerbation, contact dermatitis, and post inflammatory hyperpigmentation. Hyperpigmentation (darkening) or erythema (redness) over the treated area is common in coloured 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 candidal 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.

Conclusion

The CO 2 laser is a time-tested machine for treating benign growths, scars and age-related changes in the skin. However, the technique needs proper training, particularly when used for full-face resurfacing. Its use is associated with a significant healing time and postoperative changes such as crusting, pigmentation changes. Patients need to be counseled properly about these aspects of the CO 2 laser; as in all aesthetic treatments, proper counseling and case selection are important.

References
1.
Trimas SJ, Ellis DA, Metz RD. The carbon dioxide laser: An alternative for the treatment of actinically damaged skin. Dermatol Surg 1997;23:885-9.
[Google Scholar]
2.
Phahonthep R, Sindhuphak W, Sriprajittichai P. Lidocaine iontophoresis versus EMLA cream for CO 2 laser treatment in seborrheic keratosis. J Med Assoc Thai 2004;87:S15-8.
[Google Scholar]
3.
Fulton JE, Rahimi AD, Helton P, Dahlberg K, Kelly AG. Disappointing results following resurfacing of facial skin with CO 2 lasers for prophylaxis of keratosis and cancers. Dermatol Surg 1999;25:729-32.
[Google Scholar]
4.
Fitzpatrick RE, Goldman MP, Ruiz-Esparza J. Clinical advantage of the CO 2 laser superpulsed mode. Treatment of verruca vulgaris, seborrheic keratosis, lentigines and actinic cheilitis. J Dermatol Surg Oncol 1994;20:449-56.
[Google Scholar]
5.
Quaedvlieg PJ, Ostertag JU, Krekels GA, Neumann HA. Delayed wound healing after three different treatments for widespread actinic keratosis on the atrophic bald scalp. Dermatol Surg 2003;29:1052-6.
[Google Scholar]
6.
Lauchli S, Kempf W, Dragieva G, Burg G, Hafner J. CO 2 laser treatment of warts in immunosuppressed patients. Dermatology 2003;206:148-52.
[Google Scholar]
7.
Geronemus RG, Kauvar AN, McDaniel DH. Treatment of recalcitrant verrucae with both the ultrapulse CO 2 and PLDL pulsed dye lasers. Plast Reconstr Surg 1998;101:2010.
[Google Scholar]
8.
Landsman MJ, Mancuso JE, Abramow SP. Carbon dioxide laser treatment of pedal verrucae. Clin Podiatr Med Surg 1992;9:659-69.
[Google Scholar]
9.
Lim JT, Goh CL. Carbon dioxide laser treatment of periungual and subungual viral warts. Australas J Dermatol 1992;33:87-91.
[Google Scholar]
10.
Hohenleutner U, Wlotzke U, Konz B, Landthaler M. Carbon dioxide laser therapy of a widespread epidermal nevus. Lasers Surg Med 1995;16:288-91.
[Google Scholar]
11.
Khoo L. Carbon dioxide laser treatment of benign skin lesions. National Skin Centre Exp 2001;12:2.
[Google Scholar]
12.
Verma KK, Ovung EM. Epidermal and Sebaceous nevi treatment with CO 2 laser. Indian J Dermatol Venereol Leprol 2002;68:23-4.
[Google Scholar]
13.
Ratz JL, Bailin PL, Wheeland RG. Carbon dioxide laser treatment of epidermal nevi. J Dermatol Surg Oncol 1986;12:567-70.
[Google Scholar]
14.
Boyce S, Alster TS. CO 2 laser treatment of epidermal nevi: Long-term success. Dermatol Surg 2002;28:611-4.
[Google Scholar]
15.
Hohenleutner U, Landthaler M. Laser therapy of verrucous epidermal naevi. Clin Exp Dermatol 1993;18:124-7.
[Google Scholar]
16.
Raulin C, Schoenermark MP, Werner S, Greve B. Xanthelasma palpebrarum: Treatment with the ultrapulsed CO 2 laser. Lasers Surg Med 1992;24:122-7.
[Google Scholar]
17.
Alster TS, West TB. Ultrapulse CO 2 laser ablation of xanthelasma. J Am Acad Dermatol 1996;34:848-9.
[Google Scholar]
18.
Ullmann Y, Harshai Y, Peled IJ. The use of CO 2 laser for the treatment of xanthelasma palpebrarum. Ann Plast Surg 1993;31:504-7.
[Google Scholar]
19.
Gladstone GJ, Beckman H, Elson LM. CO 2 laser excision of xanthelasma lesion. Arch Ophthalmol 1985;103:440-2.
[Google Scholar]
20.
Gladstone GJ, Beckman H, Elson LM. CO 2 laser excision of xanthelasma lesions. Arch Ophthalmol 1985;103:440-2.
[Google Scholar]
21.
Simo R Sharma VL. The use of the CO 2 laser in rhinophyma surgery: Personal technique and experience, complications and long-term results. Fac Plast Surg 1998;14:287-95.
[Google Scholar]
22.
Goon PK, Dalal M, Peart FC. The gold standard for decortication of rhinophyma: Combined erbium-YAG/CO2 laser. Aesthetic Plast Surg 2004;28:456-60.
[Google Scholar]
23.
Bohigian RK, Sharpshay SM, Hybels RL. Management of rhinophyma with carbon dioxide laser: Lahey Clinic experience. Lasers Surg Med 1988;8:397-401.
[Google Scholar]
24.
Sharpshay SM, Strong MS, Anatasi GW, Vaughan CW. Removal of Rhinophyma with the CO 2 laser: A preliminary report. Arch Otolaryngol 1980;106:257-9.
[Google Scholar]
25.
Greenbauns SS, Krull EA, Watrick K. Comparison of CO 2 laser and electrosurgery in the treatment of rhinophyma. J Am Acad Dermatol 1988;18:363-8.
[Google Scholar]
26.
Wang JI, Roenigk HH Jr. Treatment of multiple facial syringomas with the carbon dioxide laser. Dermatol Surg 1999;25:136-9.
[Google Scholar]
27.
Wheeland RG, Bailin PL, Reynolds OD, Ratz JL. Carbon dioxide laser vaporization of multiple facial syringomas. J Dermatol Surg Oncol 1986;12:225-8.
[Google Scholar]
28.
Nerad JA, Anderson RL. Co2 laser treatment of eyelid syringomas. Ophthal Plast Reconstr Surg 1988;4:91-4.
[Google Scholar]
29.
Kang WH, Kim NS, Kim YB, Shim WC. A new treatment for syringoma: Combination of carbon dioxide laser and trichloroacetic acid. Dermatol Surg 1998;24:1370-4.
[Google Scholar]
30.
Khoo L. Carbon dioxide laser treatment of Benign skin lesions. National Skin Centre Experience 2001;12:2.
[Google Scholar]
31.
Duane C, Whitaker MD. Microscopically proven cure of actinic cheilitis by CO 2 laser. Lasers Surg Med 2005;7:520-3.
[Google Scholar]
32.
Laws RA, Wilde JL, Grabski WJ. Comparison of electrodessication with CO 2 laser for the treatment of actinic cheilitis. Dermatol Surg 2000;26:349-53.
[Google Scholar]
33.
Trimas SJ, Ellis DA, Metz RD. The carbon dioxide laser: An alternative for the treatment of actinically damaged skin. Dermatol Surg 1997;23:885-9.
[Google Scholar]
34.
Alamillos-Granados FJ, Naval-Gias L, Dean-Ferrer A, Alonso del Hoyo JR. Carbon dioxide laser vermilionectomy for actinic cheilitis. J Oral Maxillofac Surg 1993;51:118-21.
[Google Scholar]
35.
Zelickson BD, Roenigk RK. Actinic cheilitis: Treatment with the carbon dioxide laser. Cancer 1990;65:1307-11.
[Google Scholar]
36.
Belmar P, Boixeda P, Baniandres O, Fernandez-Lorente M, Arrazola JM. Long-term follow up of angiofibromas treated with CO 2 laser in 23 patients with tuberous sclerosis. Actas Dermosifiliogr 2005;96:498-503.
[Google Scholar]
37.
Papadavid E, Markey A Bellaney G, Walker NP. Carbon dioxide and pulsed dye laser treatment of angiofibromas in 29 patients with tuberous sclerosis. Br J Dermatol 2002;147:337-42.
[Google Scholar]
38.
Verma KK, Ovung EM, Sirka CS. Extensive facial angiofibromas in tuberous sclerosis treated with carbon dioxide Laserberasion. Dermato Surg 2001;67:326-8.
[Google Scholar]
39.
Lupton JR, Alster TS. Laser scar revision. Dermatol Clin 2002;20:55-65.
[Google Scholar]
40.
Ostertag JU, Theunissen CC, Neumann HA. Hypertrophic scars after therapy with CO 2 laser for treatment of multiple cutaneous neurofibromas. Dermatol Surg 2002;28:296-8.
[Google Scholar]
41.
Kand DH, Park SH, Koo SH. Laser resurfacing of smallpox scars. Plast Reconst Surg 2005;116:259-65.
[Google Scholar]
42.
Nowak KC, McCormack M, Koch RJ. The effect of superpulsed carbon dioxide laser energy on keloid and normal dermal fibroblast secretion of growth factors: A serum-free study. Plast Reconstr Surg 2000;105:2039-48.
[Google Scholar]
43.
Apfelberg DB, Maser MR, Lash H, White D, Weston J. Preliminary results of argon and carbon dioxide laser treatment of keloid scars. Lasers Surg Med 1984;4:283-90.
[Google Scholar]
44.
Cheng ET, Pollard JD, Koch RJ. Effect of blended CO 2 and erbium: YAG laser irradiation on normal and keloid fibroblasts: A serum-free study. J Clin Laser Med Surg 2003;21:337-43.
[Google Scholar]
45.
Kim ES, Kim KJ, Chang SE, Lee MW, Choi JH, Moon KC, et al . Metaplastic ossification in a cutaneous pyogenic granuloma: A case report. J Dermatol 2004;31:326-9.
[Google Scholar]
46.
Vaοsse V, Clerici T, Fusade T. Bowen disease treated with scanned pulsed high energy CO 2 laser. Follow-up of 6 cases.Ann Dermatol Venereol 2001;128:1220-4.
[Google Scholar]
47.
Nouri K, Chang A, Trent JT, Jimιnez GP. Ultrapulse CO 2 used for the successful treatment of basal cell carcinomas found in patients with basal cell nevus syndrome. Dermatol Surg 2002;28:287-90.
[Google Scholar]
48.
Humphreys TR, Malhotra R, Scharf MJ, Marcus SM, Starkus L, Calegari K. Treatment of superficial basal cell carcinoma and squamous cell carcinoma in situ with a high-energy pulsed carbon dioxide laser. Arch Dermatol 1998;134:1247-52.
[Google Scholar]
49.
Lapid-Gortzak R, Lapid O, Monos T, Lifshitz T. CO 2 -laser in the removal of a plexiform neurofibroma from the eyelid. Ophthalmic Surg Lasers 2000;31:432-4.
[Google Scholar]
50.
Becker DW. Use of the carbon dioxide laser in treating multiple cutaneous neurofibromas. Ann Plast Surg 1991;26:582-6.
[Google Scholar]
51.
Roenigk RK, Ratz JL. CO 2 laser treatment of cutaneous neurofibromas. J Dermatol Surg Oncol 1987;13:187-90.
[Google Scholar]
52.
Fitzpatrick RE, Goldman MP, Satur NM, Tope WD. Pulsed carbon dioxide laser resurfacing of photo-aged facial skin. Arch Dermatol 1996;132:395-402.
[Google Scholar]
53.
Pitanguy I, Soares GL, Machado BH, de Amorim NF. CO 2 laser peeling associated with the 'round lifting' technique. J Cosmet laser Ther 1999;1:145-52.
[Google Scholar]
54.
Papadavid, Evangelia MD, Katsambas, Andreas MD. Lasers for facial rejuvenation: A review. Int J Dermatol 2003;42:480-7.
[Google Scholar]
55.
Alster T, Hirsch R. Single-pass CO2 laser skin resurfacing of light and dark skin: Extended experience with 52 patients. J Cosmet laser Ther 2003;5:39-42.
[Google Scholar]
56.
Tanzi EL, Alster TS. Single-pass carbon dioxide versus multiple-pass Er:YAG laser skin resurfacing: A comparison of postoperative wound healing and side-effect rates. Dermatol Surg 2003;29:80-4.
[Google Scholar]
57.
Huilgol SC, Poon E, Calonje E, Seed PT, Huilgol RR, Markey AC, et al . Scanned continuous wave CO 2 laser resurfacing: A closer look at the different scanning modes. Dermatol Surg 2001;27:467-70.
[Google Scholar]
58.
Lent WM, David LM. laser resurfacing: A safe and predictable method of skin resurfacing. J Cutan laser Ther 1999;1:87-94.
[Google Scholar]
59.
Goodman GJ. Carbondioxide laser resurfacing: Preliminary observations on short-term follow up. A subjective study of 100 patients attitudes and outcomes. Dermatol Surg 1998;24:665-72.
[Google Scholar]
60.
Weinstein C. Carbon dioxide laser resurfacing: Long-term follow-up in 2123 patients. Clin Plast Surg 1998;25:109-30.
[Google Scholar]
61.
Sawcer D, Lee HR, Lowe NJ. Lasers and adjunctive treatments for facial scars. J Cutan laser Ther 1999;1:77-85.
[Google Scholar]
62.
Goh CL, Khoo L. Laser skin resurfacing treatment outcome of facial scars and wrinkles in Asians with skin type III-IV with the Unipulse CO 2 laser system. Singapore Med J 2002;43:28-32.
[Google Scholar]
63.
Tanzi EL, Alster TS. Single-pass carbon dioxide versus multiple-pass Er:YAG laser skin resurfacing: A comparison of postoperative wound healing and side-effect rates. Dermatol Surg 2003;29:80-4.
[Google Scholar]
64.
Goodman GJ. Carbon dioxide laser resurfacing: preliminary observations on short-term follow up: A subjective study of 100 patients' attitudes and outcomes. Dermatol Surg 1998;24:665-72.
[Google Scholar]
65.
Stern RS, Dover JS, Levin JA, Arndt KA. Laser therpy versus cryotherapy of lentigines: A comparative trial. J Am Acad Dermatol 1994;30:985-7.
[Google Scholar]
66.
Dover JS, Smoller BR, Stern RS, Rosen S, Arndt KA. Low-fluence carbon dioxide laser irradiation of lentigines. Arch Dermatol 1986;124:8.
[Google Scholar]

Fulltext Views
630

PDF downloads
129
Show Sections