The co2 laser
The CO2 laser was invented by Prof. CK Patel at the Bell Laboratories in 1964
Professor C.K. Patel at work on the CO2 laser 1964
It is the laser that has been studied the most and cosmetic and reconstructive surgeons have the most experience with. Indeed, we know it so well, that it is the one laser that we know exactly what it can and cannot do and what the limitations are. A major advance after the laser had been used for several decades was the rather smart observation that “less is more”: to that end, surgeons began to deliver the laser in small spots, leaving adjoining tissue untreated. Contrary to what one might think, this did not give inferior results to full powered total CO2 laser ablation. Healing was noted to be faster as lasered skin heals from cells from appendages in untreated
(and treated skin to a lesser degree) skin.
Results
The results are not only almost as good as full ablation, but some side-effects like loss of pigment are markedly reduced. Of course, with everything delivered in a fractional manner, more than one treatment is needed.
Improve Skin Wrinkles and Texture
The results were not only almost as good as full ablation, but some side-effects like loss of pigment were markedly reduced. Of course, with everything delivered in a fractional manner, more than one treatment is needed.
In the fractional mode, and with the correct duration and power, the fractionated CO2 laser may be used to improve texture, wrinkles, and blotchiness on the neck, chest, arms and legs: however, this is a powerful and effective laser and should only be done by experts because the risk of complications, including scarring, is higher in these areas. Dr. Patel learned all about this laser from Dr. Fitzpatrick in San Diego who took Professor Patel’s invention and came up with the machine we use today in cosmetic and reconstructive surgery. After training with Dr Fitzpatrick, Dr. Patel brought the technology to the Salt Lake City area (together with a couple of other physicians) and lectured and published on it widely.
"Well, the last time I had a picture taken I could hardly see my eyes because of the weight of heavy eyelid. Then I paid attention to how I was actually using my eyes and I really noticed when I was looking at anything especially the computer I was straining my forehead to see better. Since I have had it done I no longer have to lift the forehead and tilt my head to see. It is amazing! I love..." D. Rock 63 Yrs Old with Fat Droopy Eyes - Salt Lake City, UT
What will a co2 laser not do?
The CO2 laser, fully ablative, or fractionated, will not treat vessels and redness on the face and body or the blotchy change one sees on the sides of the neck, called Poikilodema of Cervatte. These changes are treated by using a number of other lasers we have including the 540 nm, 570 nm, 650 nm laser heads, the diolite 532 nm, the 940 nm for deeper and larger veins and the 1064 nm ndYag laser. Horses for courses.
Although the laser will give tightening of tissues, it is not a substitute for proper lifting and repositioning of tissues like a properly performed face lift or a neck lift or a blepharoplasty.
What brand of machine is best for factional co2 laser applications?
FACT: there are more than 30 brands of CO2 laser, although the engine inside these machines is only made by two or three laser manufacturers. So this is an exercise in differentiation by deceipt or camouflage: lipstick, not necessarily on a pig, but there are some pig machines out there which are woefully underpowered.
There are several machines, when used by properly experienced surgeons, that give very good results.
The under-powered machines hurt less but give much less of a result!
The Rolls Royce (and Bentley and Aston Martin and Ferrari) of CO2 lasers is the Lumenis Ultrapulse CO2 fractionated laser, which also allows full ablation and cutting. We use this machine and have used various versions of this laser over the years to great acclaim.
Good equipment in incompetent hands will not help you! So it is wise to look at results and outcomes before undergoing ablative CO2 laser treatments.
What is the difference between the co2 fractional laser & the erbium lasers?
The CO2 laser goes slights deeper and has a different way of shrinking collagen than the Erbium laser. Therefore, it generally gives a better result for deeper wrinkles, acne scars, upper lip lines, and crepiness around the eyes. The CO2 is best for patients who are late 40s to 70s with moderate to deep wrinkles/sun damage or with moderate to severe acne scarring. It also works well on crepy eyelid and neck skin when performed by an expert with the proper settings. But because the CO2 can go deeper, there is more “downtime” than with the Erbium laser. If you cannot take any time off from your normal activities, the CO2 laser on the face is not the right choice for you. Some off-face areas can be kept covered and may be fine.
Erbium lasers are best for the younger patients (approx 30-50ish) who have early wrinkles or mild to mod acne scarring or for those who truly can’t take any time off from work/children to have CO2 treatments.
How does the fractional co2 lasers work?
The fractional CO2 laser takes the CO2 laser beam and fractionates, or pixellates that beam into thousands of tiny little shafts of light. These tiny shafts of light penetrate into the deeper layers of the skin.
The skin then repairs those tiny shafts by pushing out the old sun damaged skin and replacing it with new skin. The “collateral” heat damage also helps to shrink existing collagen.
Can I do the fractional CO2 laser with other cosmetic treatments?
Not the same day generally. The CO2 laser is compatible long term with Botox, Juvederm, Restylane, Sculptra and other laser based technologies like hair removal, Erbium, advanced photofacial rejuvenation lasers, pulsed dye lasers, etc.
Before and after
"I had a excellent eye lift done by Dr. Patel. He knows what he is doing and is very pleasant. Dr.Patel was easy to get an appointment and he works with you. The office staff was very pleasant and made you feel calm." D. Gull Highly recommended for eye lift surgery - Salt Lake City, UT
What do i do prior to my fractionated co2 laser treatment?
Stop use of Accutane 6-12 months before any treatments
1-2 Week Before Treatment:
Buy several bags of ice packs/frozen peas
Buy Cetaphil or another gentle cleanser
Stop use of Asprin, Advil and Aleve if possible. Tylenol is ok.
Stop use of all Retinols/Retin-A
Stop Renova, Tazorac, “anti-aging” products
Stop use of all glycolic acid treatments
Avoid sun exposure 2 weeks prior to your treatment (use sunscreeb)
Stop minocycline, doxycycline and tetracycline
Stop waxing
Stop abrasive scrubs and microdermabrasion treatments
Let us know if you have a history of cold sores- you may need a prescription for Valtrex or Famvir to begin the day before your treatment.
Day of Treatment:
Eat a meal 1-2 hours before your treatment – this prevents feeling jittery with the numbing cream
No caffeine for 4 hours before your treatment
Wear comfortable/ washable sweats or clothes
Arrive with no make-up or eye contacts
Bring a wide brimmed hat to your appointment to wear after your treatment.
Are you pregnant or breast feeding? If so, you are not a candidate at this time
Tendency to hyperpigment? We will start you on a hydroquinone bleaching cream about four weeks prior to your treatment.
Instructions for care after fractionated cos laser treatment?
Ice for ten to fifteen minutes every hour for the next 5 – 6 hours to reduce swelling. Use a bag of frozen peas covered with a thin clean cloth/towel.
USEFUL TIP: mixing a table spoonful of kitchen vinegar in a glass of water and using that to soak the skin four or five times a day helps to remove the peeling skin. It also cleans up the area nicely. Most of my patients find this very useful for the first four to five days. Use a clean face-cloth rather than cotton wool (the wool will stick to the face!).
Avoid scratching or rubbing the treated skin – do not put adhesive dressings over treated areas.
Men may shave 1-2 days post-treatment but be gentle. Best to use an electric razor for the first few days!
Avoid all saunas and hot tubs. Showers can be taken, but avoid hot water and direct shower spray to treatment area for 3 days following treatment. You may, however, shower and get the face and treated areas wet the day after the treatment.
Avoid strenuous exercise for 48-72 hours (this includes all yoga, especially the upside down, inside out Bridge-Lion pose.
Avoid alcoholic beverages for 24-48 hours.
Sleep with 1-2 extra pillows at night to keep head raised for the two nights.
Avoid direct sunlight for a minimum of 4 weeks after your treatment and wear a sun block with 10% zinc or titanium for the next 4 weeks. If actively outdoors, you should reapply your sunscreen every 2-4 hours and wear a wide-brimmed hat
Do not use any retinoid, Retin-A or glycolic products for 1-2 weeks following the procedure. Do not use any non-prescription creams without checking with us first.
Refrain from any chemical peel treatments or microdermabrasion (or deep facials!) for 4 weeks post-procedure.
Take the prescribed pain medication as and if needed and please take the prescribed anti-viral medication to prevent cold sores or a breakout of herpes simples.
How long do the effects of a fractional co2 resurfacing laser treatment last?
That depends on how well you protect your skin from the sun and other factors that cause aging like your general health, smoking, changes in weight, etc. If you apply sunscreen and wear brimmed hats, you can maintain the good effects of your CO2 laser treatment for several years.
With fractionated treatment with the CO2 laser, two treatments are administered, separated by about six months.
When will i see results?
Bear in mind that the fractional CO2 laser can be customized. Treatments can be deeper, with more healing and downtime, or shallower, with less healing time. The deeper the treatment, the better the results generally.
You will see some immediate results but you won’t see the full results for 3-6 months. After your skin heals, which may take up to 3-14 days, there will be a period of 4 to 6 weeks after that when your skin might be slightly pink. During this period, your skin will feel smoother and looks less blotchy. As the color returns to normal, you will see fewer lines, less blotchiness, and more glow.
How are fractional co2 laser treatments performed?
With full-face or neck fractionated CO2 laser treatments, we will prescribe a sedative (like valium or lorazepam) and a prescription pain medication. You will take one of each as you leave home (you cannot drive to and from your treatment).
You will also be prescribed an anti-viral medication like Zovirax or Valtrex which you will start the night before your treatment.
We will also prescribe EMLA topical anesthetic cream for you so you can apply it to the area to be treated before you leave home.
We will cleanse the skin and administer local anesthesia as nerve blocks.
Whilst applying cold with the Zimmer, the CO2 fractionated laser treatment takes about 1 hour. The discomfort level may be a level 1 to level 3/10. Further local anesthetic blocks will be administered if needed. nd feels a little like a “pins and needles” sensation. A strong stream of cold air (a Zimmer cooler) is blown on the area during the treatment to make it comfortable. The discomfort ranges from mild to moderate (2-4/10). Plan on being in the office for 2 ½ hours total.
At the end of the treatment, we will cleanse your face and apply a moisturizer.
You cannot drive to and from your treatment. Please ensure someone patient is picking you up as we do not like to rush our patients! Different human beings need different degrees of care and attention!
Before and after
How does the laser work for acne scars and other scars?
CO2 lasers have always been very effective for acne and other scars and the fractional CO2 is no exception. It remains to be seen if it is as effective as the traditional fully ablative CO2 treatments. However, as the settings for the Lumenic Ultrapulse CO2 laser for both acne, surgical and traumatic scars keep being improved, many of us think that results will be as good without many of the risks with the older forms of this laser. In some instances, we combine treatments: excision of pick and scalloped (divet) scars and repair, followed by sequential fractionated CO2 laser, and sometimes local dermabrasion or peeling. Modalities may be mixed to good effect if one understands
the layers at which acne causes scarring.
Are treatments on the eyelid safe?
Yes, because special laser “contact lenses” are used to protect the eye. Don’t let anyone do treatments directly on the eyelids without these. Numbing eye drops are placed in the eye before insertion of a contact lens-like eye shield. A protective ointment on the side next the eye cushions the special shield. The shield fits comfortably within the eye and is easily removed at the end of the treatment. Even our patients who don’t wear contact lenses have been comfortable.
The eye treatment is then performed on the upper & lower eyelids. It is normal (as with all areas treated with the fractional CO2 laser) to have swelling and redness for 2-4 days after the treatment. You also have to avoid all sun exposure during the healing time. Plan on 2-3 weeks for being “camera ready.”
What will i look like right after treatment and
what is the healing time?
During the first 24 hours after treatment, your skin may feel as though it is sunburned. Ice packs/frozen peas are used 5-10 minutes per hour for the first 5-6 hours after the treatment.
Your skin will peel for 2-7 days and will be pink for 3 to 6 weeks. This healing all depends on how deep your treatment is.
IMPORTANT: the pinkness and oozing from the skin always worsens for the first three days: this is NORMAL. Many patients find the increasing oozing and pinkness disconcerting. Rest assured, it turns the corner on day four!
After a week or so, you can wear make-up to cover the pink. Rarely, bruising may develop, which can take up to two weeks to resolve. Allow 2-4 weeks for weddings, reunions, family pictures, etc just to be safe. Allow longer for
body sites like arms or legs.
Can i go back to work and activities immediately?
No, you will need to take the rest of that day off to ice and care for the treated area. For the lighter fractional CO2 treatments, you will need 3-5 days of downtime. For the deeper treatments, plan on 7-10 days of healing
before you can go out in public.
How many treatments will i need?
The number depends on the extent of your sun damage, scarring or wrinkles, and on how much downtime you can accept. If you can tolerate 7 days of downtime, you would generally need only 1 or 2 fractional CO2 treatment.
Before and after
Are there any reasons not to be treated with these lasers?
Reasons not to do a fractional laser treatment may include use of medications that increase photosensitivity, use of anticoagulants (some are fine), use of Accutane in the last year (vs. 6 months), chemotherapy, history of difficulty healing or scarring, history of bleeding disorders, and pregnancy.
Are there any medical or cosmetic side effects?
Although complications are rare, it is important for you to be properly informed of effects and side-effects that have been reported in the literature and sometimes experienced by our patients:
Pain. Most people feel very little pain during treatment due to the measures discussed above. With fractionated CO2 lase, as the nerves “wake up”, patients sometimes need prescription medication for discomfort for about 24 hours. Thereafter, most patients do well with Ibuprofen or extra-strength Tylenol. There are a few patients who feel no pain for two days and then had discomfort for a day. This may have to do with how deep one goes to treat deeper lines and wrinkles.
Redness. A pink color may persist for two weeks to two months after the laser surgery. In rare instances, it may last three to six months. This is more common in patients who have a history of flushing and blushing easily or who already have dilated vessels on the surface of the skin.
Wound Healing. The CO2 laser causes a superficial wound to the skin that takes approximately 2 to 10 days to heal. The superficial injury of the outer layers of the skin may result in mild to moderate swelling. Crusting is rare but peeling is common. Once the surface is treated, it may be sensitive to the sun for approximately 4-6 weeks. Please see my description of how to use the water-and-vinegar soaks on the face for the first few days.
Pigment Changes. The treated area may heal with increased or decreased pigmentation. This is rare and occurs most often in darker skin and 2-6 weeks after treatment. Hyperpigmentation usually fades in three to six months, though rarely pigment changes can be permanent. We will put you on a hydroquinone and a Retin-A medication if indicated.
Excessive Swelling. Immediately after laser surgery, there will be swelling of the skin. This is a temporary condition and will resolve over three to seven days.
Scarring. There is a very small chance of scarring. This includes hypertrophic scars or, very rarely, keloid scars. Keloid scars are thick, raised scar formations. To minimize chances of scarring, it is important to follow post-operative instructions carefully. It is important that any prior history of unfavorable healing be reported. Please do not pick!
Depression or emotional difficulties even if the procedure is successful.
Since every patient is individual and an individual, you may not respond exactly the way other patients do. You also may not be completely happy with the effects of treatment.
Infection. Occasional infections can occur. If not treated promptly, these could result in scarring.