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The carbon dioxide (CO2) 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 CO2 laser and offers guidelines for use in many of the above indications.
The carbon dioxide (CO2) 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. CO2 laser treatment ensures minimal discomfort and rapid recovery, enabling a quick return to daily routine. The CO2 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.
Other conditions that have been shown to respond favorably to CO2 laser resurfacing include dermatofibroma, rhinophyma,[21‐25] severe cutaneous photodamage (observed in Favre-Racouchot syndrome), sebaceous hyperplasia, syringomas,[1,26‐29] actinic cheilitis,[30‐33] angiofibroma,[34‐36] scar treatment,[37‐39] keloid,[40‐43] skin cancer,[44‐47] neurofibroma,[48‐50] diffuse actinic keratoses, granuloma pyogenicum, and pearly penile papules.
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. 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/cm2 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:
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. Figures Figures11‐14 show the results after CO2 laser in different conditions. It is important to know the relation between the power, irradiance and fluence before performing the procedure [Table 3].
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.
1. a, 2. a, 3. b, 4. d, 5. d, 6. c, 7. c, 8. a.
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Conflict of Interest: None declared.