Offering CO2 Lasers in your Clinic

Since its inception in the mid-1990s, CO2 laser skin resurfacing has long been the gold standard for reducing wrinkles, smoothing uneven skin texture, and improving skin tone due to the consistently high clinical efficacy in treating photodamaged skin.1,2,3 CO2 laser technology has also seen many advancements to keep up with growing patient demand for laser skin resurfacing.4 By 2027 the global skin resurfacing market size is expected to reach a value of US $378.4 million, expanding at a compound annual growth rate of 7.2%.5 In this article, I will look at the types of CO2devices available for purchase in the UK, the benefits of adding this modality to your business, and the considerations you should be aware of. Ablative CO2lasers With its wavelength of 10,600nm in the mid-infrared, CO2laser energy is well absorbed by the high-water percentage in the skin, making it the perfect tool for precise ablation with excellent haemostasis and a high safety profile.6 CO2 lasers have many dermatological applications, from ablating skin lesions to revising acne and surgical scars, as well as advanced capabilities for surgical procedures involving incision, excision, vaporisation, and coagulation. Even with the broad range of dermatological and surgical capabilities for most aesthetic clinics, the major advantage of CO2 lasers lies in its value for rejuvenation of photoaged skin on the face and body. Ablative lasers were the first therapy to effectively improve photodamaged skin and acne scarring. They work by vaporising the entire epidermis and papillary dermis. The first devices created were hindered by bulk heating, unacceptable healing times, and their severe side effects, such as hypopigmentation, scarring and slow wound healing. Although ablative lasers were created to better control the phenomenon of bulk heating, the lengthy recovery

durations after the procedure, with some side effects such as erythema lasting for many weeks, remain unappealing. These days, fully ablative CO2 treatments have now largely been replaced by fractional treatments; nevertheless, fully ablative lasers may still be used for treating wrinkles, acne and atrophic scars alongside surgical procedures. Fractional CO2 lasers The notion of fractional photothermolysis was introduced almost a decade ago to address the main shortcomings of non-fractionated ablative lasers. Fractionating the ablative laser energy into smaller individual spot sizes allows practitioners to maintain resurfacing power while covering only a fraction of the treated area (usually 5-30%) allowing for rapid Offering CO2 Lasers re-epithelialisation from the intact, adjoining epidermis.6 The improved safety profile further reduces the usual recovery time in Your Clinic required for ablative treatments, whilst also minimising post-treatment side effects such as oedema, burning, crusting, and erythema, Mr Ali Ghanem explores the considerations for which can last months.7,8 Clinical side effects are much rarer, with most side effects being adding CO2 lasers to your treatment offering minor and transient following fractional CO2 therapy. 9 Tierney et al. recently published a review specifically comparing non-ablative fractional lasers with ablative fractional lasers and determined that fractional CO2 lasers produced results which were on par with the earlier, fully ablative devices for improvement of skin texture, skin laxity, laxity of lower eyelid skin, periocular and perioral rhytids.10 Considerations for fractional CO2 devices With fractional CO2 laser devices being founded on the same principle of photothermolysis, CO2devices do present similarities. Nevertheless, despite their resemblances these available devices present differences in terms of advancements in output power, dwelltime, distance between dots, varying scanner shapes and the laser beam profile. I find these differences within each device can produce significantly differing clinical results and less flexibility with regards the gentleness and aggressiveness of treatment. When choosing the best option for a laser device, power is clearly a major specification to consider. In my experience, 30W systems are great for typical aesthetic concerns, but heavy-duty surgical procedures will require 50W or 60W options. The second most important feature is pulse shape options or ‘emission modes’. This determines how much ablation and thermal spread is created.11 Practitioners should be cautious of devices with low power and long pulses as they won’t be able to ablate deep enough to treat scars.9 Equally, they should be wary of devices that only provide high power options with short pulses as these will struggle to create significant thermal spread for advanced laxity.12 There are many CO2 laser brands available, and I will always choose one that is supported by numerous of clinical trials for several indications. Due to the broad range of evidence outlined in existing journals, I personally tend to choose fractional laser treatments over ablative due to the ability to replicate results. I will also choose a

device that offers many different pulse shapes and a rolling or spray mode scanning, such as the DEKA SmartXide.

Technical features With today’s devices, practitioners have increased flexibility through being able to control the pulse pattern, size, shape, precise control of depth, and heat produced by the laser. Their treatments are also assisted by computerised pattern generators/automatic scanning tools that allow practitioners to select from a range of shapes, densities, and scanning modes. These patterns can be varied in size to accommodate for small areas, such as those around the mouth, vermilion border, and nasal base. It’s my view that the best tissue effect is achieved by having a device which the practitioner can modify the laser pulse configuration according to the individual’s tissue characteristics. Newer CO2 lasers have complex pulsing and offer varied pulse mode options for optimum tissue effect. Overall, the ability to control these features can allow the practitioner to create customisable operational parameters for all treatable areas and skin types. I have found that having this uncompromised versatility can revolutionise your practise and treatment outcomes, as you have the capability to now tailor the treatment to the individual’s needs.

The results In the hands of a skilled practitioner, the CO2 laser offers a very large range of dermatological indications and treatment capabilities. Due to the increased flexibility in specifications now available for fractional CO2 laser therapy, results can vary depending on the device used and the application. CO2 laser skin resurfacing also has a proven high patient satisfaction rating.13 As with all treatments, a lengthy consultation is needed to understand patient expectations and advise if these can be met. Surgical advances in laser technology have led to the invention of lasers that can accurately employ the transconjunctival approach to remove fat and thin layers of skin with minimal thermal damage to the surrounding tissue, which is particularly useful for treatments such as blepharoplasty. Wound contraction and scarring during the remodelling phase of healing following CO2 laser surgery are reduced compared to scalpel surgery.14 By sealing blood and lymphatic vessels and nerve endings, laser surgery significantly reduces the local inflammatory response and the pain level.15 My personal experience utilising CO2 lasers for blepharoplasty has resulted in reduced erythema, bruising, and skin trauma alongside reduced postoperative pain and downtime following CO2laser surgery with a conventional scalpel, leading to exceptional results for my patients.

Considerations As with all technologies it is possible for things to go wrong. Fractional CO2 can result in infections, scarring, or long-term pigment changes, however complications are rare when the correct protocols are followed.17,18 The recent advancements, already discussed, in device flexibility offer an increased safety profile verses traditional CO2.4 With a range of CO2 devices on the market, I advise practitioners choose a well-established device with tried and tested protocols, experienced users for the full range of indications and, of course, plenty of hands-on training and support. CO2 is a protected revenue stream for medical professionals and is not available to the wider market. Given the efficacy and performance, these treatments remain in high demand and the price point also remains high. Given the versatility of new CO2 devices, clinics will be able to offer the gold-standard of rejuvenating and skin quality improvements with high margins and little competition.

Considering CO2 for your practice There is an ever-growing market for safe, effective, reliable, and well-tolerated technologies capable of reversing cutaneous photodamage, fine lines, wrinkles, and hyperpigmentation. Despite the downtime, the CO2 laser remains a pillar across many specialties in the aesthetic field. Practitioners can achieve predictable and obvious benefits across a wide range of indications, for a wide patient demographic. Gold-standard treatment outcomes result in high patient satisfaction and loyalty.

Disclosure: Mr Ali Ghanem is a key opinion leader for Lynton.

Mr Ali Ghanem is a consultant aesthetic and plastic surgeon. He is the director of the Ghanem Clinic London – Bahrain, Rae Clinic London, and the Cranley Clinic London. He is also a senior clinical lecturer in plastic reconstructive aesthetic surgery at Barts and the London School of Medicine and Dentistry, and programme lead for the MSc in aesthetic medicine and reconstructive microsurgery with an active research, teaching and supervisory role. Qual: MD, PhD, FRCS (Plast)

REFERENCES

1. Pozner, N. J., DiBernardo, E. B., Cook, C. Laser resurfacing of the aging face. Plastic and Aesthetic

Research, 2021 2. Gotkin, R. H., & Sarnoff, D. S., A preliminary study on the safety and efficacy of a novel fractional

CO₂ laser with synchronous radiofrequency delivery. Journal of drugs in dermatology: JDD, 2004 3. Christopher M. Hunzeker, MD, Elliot T. Weiss, MD, Roy G. Geronemus, MD, Fractionated CO2 Laser

Resurfacing: Our Experience with More Than 2000 Treatments, Aesthetic Surgery Journal, Volume 29, Issue 4, July 2009 4. Rossi E, Farnetani, F, Trakatelli M, Ciardo S, Pellacani. G, Clinical and confocal microscopy study of plasma exeresis for non-surgical blepharoplasty of the upper eyelid: a pilot study. Dermatol Surg., 2017 5. Grand View Research, Inc., 2020. Skin Resurfacing Market Size, Share | Industry Report, 20202027.: <https://www.grandviewresearch.com/industry-analysis/skin-resurfacing-market?utm_ source=prnewswire&utm_medium=referral&utm_campaign=hc_08-jun-20&utm_term=skinresurfacing-market&utm_content=rd> 6. Omi T, Numano K. The Role of the CO2 Laser and Fractional CO2 Laser in Dermatology. Laser

Ther. 2014 7. Lederhandler MH, Bloom BS, Pomerantz H, Geronemus RG. Case Series of Fractional Ablative

Laser Resurfacing of Pediatric Facial Traumatic and Surgical Scars. Lasers Surg Med. 2021 8. Chwalek J, Goldberg DJ: Ablative skin resurfacing. Curr Probl Dermatol, 2011 9. Preissig J, Hamilton K, Markus R. Current Laser Resurfacing Technologies: A Review that Delves

Beneath the Surface. Semin Plast Surg. 2012 10. Uebelhoer, N. S., Ross, E. V., & Shumaker, P. R., Ablative fractional resurfacing for the treatment of traumatic scars and contractures. In Seminars in cutaneous medicine and surgery, 2012 11. Alexiades-Armenakas MR, Dover JS, Arndt KA. The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing. J Am Acad Dermatol., 2008 12. Omi T, Numano K. The Role of the CO2 Laser and Fractional CO2 Laser in Dermatology. Laser

Ther., 2014 13. Hantash BM, Bedi VP, Chan KF, et al. Ex vivo histological characterization of a novel ablative fractional resurfacing device. Lasers Surg Med., 2007 14. Sullivan, S, A., Dailey, R, A. Complications of laser resurfacing and their management. Ophthal Plast

Reconstr Surg. 2000 15. Berwald, C, Levy, J, L, Maalon, G. Complications of the resurfacing laser: Retrospective study of 749 patients. Ann Chir Plat Esthet. 2004 16. Fife D J, Fitzpatrick R E, Zachary C B. Complications of fractional CO2 laser resurfacing: four cases.

Lasers Surg Med. 2009 17. Tierney EP, Kouba DJ, Hanke CW. Review of fractional photothermolysis: treatment indications and efficacy, Dermatol Surg. 2009