2

CO2 laser
applications: new
fractional and
traditional CO2 laser
resurfacing and CO2
laser blepharoplasty
Brooke R. Seckel

Key points

What is photothermolysis?
How does the CO laser remove wrinkles and
2

tighten skin?

What are the contraindications to laser skin

What is fractional laser skin resurfacing?

What are the advantages of CO

laser

blepharoplasty?

What are the crucial steps in post laser skin

resurfacing wound care?

resurfacing and blepharoplasty?

CO2 laser skin resurfacing

The technique of CO2 laser skin resurfacing (LSR) for
the removal of photo-aging skin pathology, including
wrinkles and solar lentigines, and skin tightening is
based on the concept of photothermolysis. Utilizing
CO2 laser light (photo) energy which is highly

absorbed by water, the skin is irradiated with the laser

beam, intracellular water is heated (thermo) to a point
where cell rupture (lysis) occurs. With CO2 and 2940
Er:YAG lasers, the lasers most highly absorbed by
water, sufficient cellular injury occurs to actually
ablate or remove photo-damaged epidermal cells and

11

CO2 laser applications

Epidermis

Dermis

Subcutaneous layer
Sun Damaged Skin

Non-Ablative Skin Resurfacing

Ablative Skin Resurfacing

Figure 2.1 Diagrammatic representation of skin changes before, after non-ablative LSR and after ablative LSR.

damaged superficial dermis. In addition, the cellular

injury in the dermis causes residual thermal damage
(RTD) which initiates an intense inflammatory
cascade. This results in the production of new collagen
in the dermis to replace the actinically damaged
dermal collagen.
The new dermal collagen and wound healing
response result in wrinkle removal and skin tightening
(Seckel et al 1998). The ablation of photo-damaged
skin by CO2 LSR provides superior wrinkle removal
and skin tightening compared to non-ablative LSR
which only heats, but does not remove, photodamaged skin (Figure 2.1). However traditional flatbeam ablative LSR is followed by 23 weeks of recovery
time and often months of prolonged erythema, and
long term hypo-pigmentation is common.

Fractional CO2 laser skin

resurfacing
The prolonged recovery and attendant morbidity have
dampened enthusiasm for traditional flat-beam CO2
and erbium laser resurfacing in spite of the ability
to achieve significant results with these techniques.
Recently, new technology called fractional laser skin
resurfacing (LSR) has been developed which has dramatically shortened recovery time and lessened the
occurrence of complications.
With fractional laser resurfacing the laser beam is
broken up or fractionated, into many small microbeams. These micro-beams are separated and thus,
when they strike the skin surface, small areas of the
skin between the beams are not hit by the laser and
are left intact. These small areas of untreated skin

12

promote a much more rapid re-epithelialization,

recovery and healing with less risk of complications.
The small areas treated by the fractional micro-beams,
called micro-treatment zones (MTZs), cause sufficient
laser injury deep in the dermis to promote new collagen production and resultant facial skin rejuvenation.
Early fractional LSR devices were non-ablative. They
heated but did not ablate the tissue in the MTZs.
Although the non-ablative LSR lasers are effective at
plumping the skin and removing pigment, they are
less effective for wrinkle removal than traditional flatbeam ablative LSR lasers. During the past year, fractional ablative CO2 and erbium lasers have been
developed which ablate columns of skin as deep as
1600 microns (Figure 2.2). The Reliant Fraxel re:pair
and the Lumenis UltraPulse Encore DeepFX are two
of the most commonly used ablative fractional CO2
lasers.

CO2 laser blepharoplasty

CO2 laser blepharoplasty using the 0.2mm incisional
hand piece on the Lumenis UltraPulse CO2 laser, is
a very precise, atraumatic technique for incisional
upper and transconjunctival lower blepharoplasty.
The CO2 laser blepharoplasty provides superior hemostasis, accurate control of incisional margins and
reduced operating time in a bloodless field (Box 2.1).
The safety and efficacy of the CO2 laser blepharoplasty
have been well documented (Seckel et al 2000). The
benefits of combined periocular CO2 LSR and transconjunctival orbicularis oculi muscle and septal tightening have dramatically improved cosmetic results in
eyelid and periocular skin rejuvenation.

CO2 laser applications

Ablative Resurfacing
(CO2 & 2.94 Er:YAG)
10200 microns

Superficial Fractional
Ablative Resurfacing
(CO2 & 2.94 Er:YAG)
1070 microns

Non-Ablative
Fractional Resurfacing
6001000 microns

Ablative Fractional
Resurfacing
6001000 microns

Figure 2.2 Diagram comparing depth of skin penetration of traditional flat-beam LSR, non-ablative fractional LSR
and ablative fractional LSR.

Box 2.1 Advantages of laser blepharoplasty

Less bleeding
Less operative time
More precise
Less trauma to tissues
Early recovery of the patient
Less pain
Less swelling

Box 2.2 Contraindications to laser peel

Active herpes simplex infection
Psychoneurosis - active abuse of drugs and alcohol
History of hypertrophic or keloid scar
History of hyperpigmentation or hypo-pigmentation
Use of Accutane in previous 6 months
Unrealistic expectations
The non-compliant patient

Box 2.3 Contraindications to cosmetic

blepharoplasty
Uncontrolled hypertension
Graves disease
Proptosis >3mm
Uncontrolled glaucoma
Serious retinal disease
Dry-eye syndrome
Acute blepharitis or blepharochalasis

CO2 laser blepharoplasty can be done on any

patient who is an appropriate candidate for incisional
upper and transconjunctival lower blepharoplasty.
Contraindications to blepharoplasty include uncontrolled hypertension, Graves disease, proptosis greater
than 3 millimeters, uncontrolled glaucoma, serious
retinal disease, dry eye syndrome, acute blepharitis,
and blepharochalasis (Box 2.3).

Patient selection

Indications

CO2 LSR is best limited to patients with fair skin

because of the risk of post LSR hypo-pigmentation and
demarcation lines between treated and untreated skin.
Therefore I limit CO2 LSR to patients with Fitzpatrick
Type 1, 2, and 3 skin. Although many physicians have
successfully treated darker skin types, I do not because
of the risk of hypo-pigmentation.
Contraindications to CO2 LSR include active
infection, prior use of Accutane within the past 612
months, skin atrophy from previous laser resurfacing
or chemical peel, significant psychopathology, unrealistic expectations, non-compliant patient, active pustular acne or skin infection, deficient wound healing,
and use of anticoagulant medication (Box 2.2).

CO2 LSR is indicated for the treatment of skin photoaging pathology including wrinkles, solar lentigines,
diffuse superficial hyperpigmentation, multiple
widespread actinic keratoses, sebaceous hyperplasia,
rhinophyma, and acne scarring. These are accepted
indications for traditional flat-beam CO2 LSR. Fractional CO2 LSR is indicated primarily for wrinkle and
pigment removal and acne scarring. Efficacy for treatment of actinic keratoses and exophytic skin lesions
has not yet been established for fractional ablative
lasers.
Indications for CO2 laser blepharoplasty include
dermatochalasis, excess upper eyelid skin causing
hooding of the eyes, herniation of the infraorbital fat

13

CO2 laser applications

causing puffiness or bags on the lower eyelids, and

skin excess or photo-aging changes on the lower eyelid
skin. A new indication for lower eyelid blepharoplasty
is the arcus deformity which is also called the dark
circle under the eye. The arcus deformity is caused by
the attachment of the arcus marginalis to the underside of the lower lid combined with skin laxity and
herniation of lower eyelid fat. The arcus deformity can
be corrected with a transconjunctival laser lower
blepharoplasty with arcus release and fat repositioning
or fat grafting onto the orbital rim.

Operative technique
Pre-operative preparation
Pre-operative preparation for all patients includes a
thorough history and physical examination, preferably
performed 10 days to 2 weeks before CO2 laser resurfacing or CO2 laser blepharoplasty. Screening for contraindications to LSR is essential. If CO2 LSR or CO2
blepharoplasty of the lower eyelids is contemplated,
lid laxity must be evaluated using the Jelks lid snap
test. Several predisposing factors, especially laxity of
the lower eyelids, can increase the risk of ectropion
following LSR or blepharoplasty (Box 2.4).
At the pre-operative visit, patients undergoing CO2
LSR are given prescriptions for oral antibiotics such as
Duracef (500 milligrams twice a day) or Eryc (500
milligrams daily) beginning the day of the procedure.
I also prescribe the antiviral Valtrex (500 milligrams
twice a day for 10 days) beginning one day before
the procedure. For patients who are having the CO2
LSR under topical anesthesia I prescribe Percocet (1
tablet) and diazepam (5 milligrams) to be taken 1
hour prior to the procedure. For patients who have, or
are at risk for, hyperpigmentation I also prescribe a
bleaching regimen to begin 36 weeks prior to LSR.

Box 2.4 Conditions associated with an

increased risk of ectropion
Hypotonicity of lid
Malar hypoplasia
Shallow orbit
Graves ophthalmology
Unilateral high myopia (long eyeball)
Large eye
Secondary blepharoplasty

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This consists of a uniform mixture of 4% hydroquinone, 0.1% Retin A, and 1% hydrocortisone cream
which are to be mixed in the hand and applied to the
facial skin one to two times a day and to be discontinued a day before LSR.
Reliant Technologies recommends clobetasol propionate 0.05% cream applied twice daily starting the
day before the Fraxel re:pair fractional CO2 LSR procedure. Benadryl 25 milligrams is also prescribed at
bedtime starting the night before the procedure and
for 23 nights after the procedure. I also have patients
acquire Aquaphor ointment, gauze sponges and
normal saline solution for post-operative wound care.
Patients who are having CO2 blepharoplasty are given
Lacrilube and erythromycin ophthalmic ointment for
use after surgery as well as the prophylactic antibiotics
listed above.

Traditional flat-beam CO2 LSR with

the CO2 UltraPulse laser
Good results and avoidance of complications require
knowledge of laser skin interactions, skin microanatomy, wound healing response and the depth of
laser injury caused by the particular laser in use. These
details cannot be covered here and the reader is
referred to a detailed coverage of these variables
described below for the Coherent Ultrapulse 5000
CO2 laser (Seckel 1996), the most widely available
CO2 laser in use for LSR today. Users of the new
Lumenis Ultrapulse Encore are referred to the users
manual for adjustment of the settings for the new
ActiveFx and DeepFX pattern generator hand piece
in order to achieve the energy and coverage listed
below. It is essential that laser fire precautions be
observed. Eye protection is mandatory for the patient
and all personnel. Smoke evacuation of the laser
plume is crucial throughout the procedure.
Most full face CO2 LSR procedures are done under
general anesthesia. Prior to starting the procedure the
skin is de-greased, rinsed with saline and dried. The
depths of wrinkles, rhytides and acne scars are marked
with a surgical marker so that progression of ablation
can be observed during treatment. The sub-mandibular border is marked symmetrically by observing the
mandible from below so that symmetrical demarcation zones are achieved. Protective stainless steel
scleral shields (Oculo-Plastik, Montreal, Quebec) are
placed over the eyeball.

CO2 laser applications

The CO2 Ultrapulse Laser with the CPG scanning

hand piece is set at 300millijoules, 60 watts, packing
density 5, pattern 3, and size 69. The first pass is
done over the entire face avoiding the eyelids, making
certain the ablation patterns are adjacent or with a 5 %
overlap to avoid skip areas. The gray char is removed
with saline soaked gauze sponges revealing a pink deepithelialized skin surface. A second, and usually, a
third pass are done. If the skin develops a yellowish
chamois cloth appearance it is an indication of injury
into reticular dermis and no further pass should be
done. In patients with very deep rhytids individual
passes with a smaller pattern can be done on the
hillock or shoulder of the wrinkle as long as the
chamois cloth appearance has not developed. More
than three passes does not achieve improvement in
results and can extend the depth of injury to an unsatisfactory level.
The laser is then de-powered to 150 millijoules and
30 watts and a blending pass is done at the demarcation line on the mandible to blend the transition
between treated and untreated skin. The eyelids are
only one-sixth of the thickness of the facial skin and
must not be treated as deeply as the remainder of the
face. I use one to two passes at 300 millijoules 60 watts
with a packing density of 5 on eyelid skin of average
thickness. Thinner skin is treated with 150 millijoules
and 30 watts. A smaller pattern 3 size 23 is used on
the eyelids.

Closure
I apply a mask of Xeroform gauze on the facial skin
and cover this dressing with thick layer of bacitracin
ointment for the first post operative night. I cover the
lower eyelid with a supportive Flexan occlusive dressing and simply apply bacitracin to the upper eyelids.
Some practitioners prefer other occlusive agents such
as Aquaphor or Vaseline due to risk of contact
allergy with topical antibiotic ointment. Percocet
tablets are used for pain management.

Operative steps

Place intra-ocular shields

De-grease skin
Three passes facial skinone to two passes eyelid

skin

Cleanse between passes

Apply Xeroform

dressing with bacitracin or other

occlusive agent

Flexan supportive lower eyelid dressing

Remove intra-ocular shields.

Fractional CO2 LSR with the

Reliant Fraxel re:pair procedure
The Fraxel re:pair LSR procedure is done under topical
or local nerve block anesthesia. Pre-operative preparation has been covered above. I use a topical anesthetic
consisting of benzocaine 12%, tetracaine 8%, and
lidocaine 4%, compounded by University Pharmacy
in Salt Lake City, Utah, which is applied 1 hour prior
to the procedure. This compound should not be used
on large areas like the leg or body because of potential
toxicity; however, use on the face is safe for individuals
who do not have sensitivity to these agents. The topical
anesthetic is removed only from the treatment area
currently being treated leaving the anesthetic on the
areas which will be treated later. Other topical anaesthetics such as Pliaglis (Galderma Labarotories, Ft.
Worth, TX) have been introduced that provide excellent topical anesthesia. The face is prepped with sterile
solution and then the skin cleansed and de-greased.
As in the traditional flat-beam CO2 LSR procedure
above, laser fire precautions, eye protection for patient
and staff, and constant smoke evacuation of the laser
plume are mandatory laser safety procedures.
I use stainless steel intra-ocular shields when doing
ablative CO2 LSR, although if the eyelids are not to
be treated, external shields may be used. The Fraxel
re:pair laser settings below are recommended in
the Reliant user manual and are customized according to skin type and anticipated depth of treatment
required. Depth of penetration is determined by
pulse energy which can be set from 20 millijoules
to 70 millijoules. The second parameter to consider is
the percentage of skin surface area coverage of the
fractional laser beam which, for the face, is usually set
from a low of 25% to a high of 60%. The neck should
not be treated with over 35% coverage. Eyelids are
thinner than facial skin. Thus the eyelid skin
should be treated with lower settings, a maximum of
20 millijoules and no more than 40% surface area
coverage. While higher settings of depth and surface
area coverage will provide more effective wrinkle
removal, higher settings will also increase post LSR
erythema and delay recovery.

15

CO2 laser applications

The Fraxel re:pair is new technology, and you will

experience a definite learning curve. For mild to moderate rhytides and/or pigmentation, I use a 25% surface
area coverage and 40 millijoules and four passes, two
horizontal and two vertical over the same area at 90
degrees to the prior pass. For acne scarring and deeper
rhytids a 40% surface area setting and 50 to 60 millijoules will produce better results, but also prolong
erythema time. The Fraxel re:pair hand piece is a
marvellous technological achievement. The two rollers
glide easily over the skin, delivering the fractional CO2
beam in a uniform fashion. Appropriate hand speed
is monitored by an automatic audible monitor. Four
passes are always donetwo horizontal and two vertical in alternating fashion.
Visual feedback is not as important with Fraxel as
it is in flat-beam CO2 laser resurfacing. You have to
trust the machine to uniformly deliver the predetermined energy of your dialled-in settings. Once
four passes are completed, you are doneno checking
for chamois cloth appearance. I do not wipe debris
between passes, as there is little debris to visualize and
the attached vacuum removes most debris that is
created. Note: be sure to remove the intra-ocular
shields after the procedure.

Closure
Once the treatment is completed, apply iced or cold
saline soaks to the skin. After the patient feels comfortable, apply Aquaphor ointment. I have the patient
continue saline soaks every 23 hours the first night,
gently removing any debris. The patient then applies
Aquaphor ointment. Percocet tablets are used for
pain management.

Operative steps

Laser safety precautions.

Intra-ocular shields.
Remove topical only from area to be treated.
De-grease skin.
Laser settings 2060 millijoules and 2540%
surface area.

Four passes two horizontal, two vertical.

Cold saline soaks.
Aquaphor ointment.
Remove scleral shields.

Eyelids maximum 20millijoules 40% surface area.

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Four lid CO2 laser

blepharoplasty with arcus
marginalis release and fat
repositioning
In the pre-operative area with the patient sitting up, a
surgical marker is used to mark the supratarsal fold and
the upper incisional border. Leave at least 1cm of skin
from the upper incisional border to the undersurface
of the eyebrow. The medial extent of the supratarsal
fold incision is stopped 6mm from the angular vein.
The lateral extent of the supratarsal fold incision is
stopped 12mm lateral to the lateral commissure of the
eyelids (Halverson et al 2006).
The depression, or dark circle, beneath the lower
eyelid overlying the arcus marginalis is also marked in
addition to any protruding fat pocket. Once local or
general anesthesia is achieved, stainless steel scleral
shields are applied to the globe to protect the cornea.
The CO2 Ultrapulse laser with the 0.2 millimeter incisional hand piece attached is set at 8 millijoules and
5 watts in Ultrapulse mode. The previously outlined
upper blepharoplasty incisions are made using a constant rate of hand piece motion at a speed which
results in an incision through skin and muscle into the
orbital septum (Figure 2.3). Avoid a depth of incision
on the supratarsal fold which would injure the levator
insertion. The skin and attached muscle is excised with
either the laser or cautery. Medial and middle fat resection is done with the laser or cautery (Figure 2.4).
At this point, if a canthoplasty is anticipated, the
lateral canthal tendon is identified through the upper
blepharoplasty incision. A 5-0 vicryl suture is passed
through the canthal tendon and through the periosteum overlying the medial aspect of the lateral orbital
rim 3mm above Whitnalls tubercle in buried fashion.
This suture is left untied until the lower blepharoplasty
is completed (Figure 2.5). Next, the lower eyelid is
everted and a bone plate is used to compress the globe
posteriorly. A laser incision is made in the conjunctiva
below the tarsal plate through the middle of the visible
vertical vascular plexus (Figure 2.6). Usually two incisional passes of the laser are required to expose the fat
beneath the orbital septum. Medial, middle and lateral
fat resection is done with the laser or cautery and the
fat saved.
The undersurface of the septum and orbicularis
oculi muscle is treated with the laser to tighten the

CO2 laser applications

Figure 2.3 Upper blepharoplasty incision with the

Ultrapulse 5000 laser set at 8 millijoules
and 5 watts. (Redrawn from Seckel BR.
Aesthetic Laser Surgery. New York: Little,
Brown & Co; 1996)

Figure 2.5 Placement of lateral canthoplasty suture.

Conjuctiva

4mm

Figure 2.4 Resection of upper eyelid intraorbital fat.

(Redrawn from Seckel BR. Aesthetic
Laser Surgery. New York: Little, Brown &
Co; 1996)

Figure 2.6 Location of transconjunctival lower

blepharoplasty incision. (Redrawn from
Seckel BR. Aesthetic Laser Surgery. New
York: Little, Brown & Co; 1996)

17

CO2 laser applications

graft of approximately 23 centimeters in length. I

prefer the medial fat because it has more vascularity
and as a result will take better than middle or lateral
intraorbital fat. The fat graft is then placed on the
anterior lip of the inferior orbital rim and the lower
eyelid is gently re-draped to avoid displacing the fat
graft. The fat graft is not fixed with a suture.

Closure

Figure 2.7 Laser tightening of lower eyelid by laser

irradiation of undersurface of orbital
septum of lower eyelid.

lower eyelid. The lower eyelid is everted and the laser

is defocused by holding the hand piece back 23
inches from the septum/muscle complex. The defocused beam is passed over the septum muscle complex
to tighten and shrink the lower eyelid septum, muscle
and attached lower eyelid skin (Figure 2.7). Next, the
globe is retracted posteriorly with the bone plate to
expose the arcus marginalis. The arcus marginalis is
incised with the needle tip cautery and the periosteum
elevated off the anterior orbital rim and anterior
surface of the maxilla inferiorly for 1cm. Be careful to
avoid injury to the infra-orbital nerve. The resected
medial fat is partially cut and unfolded to form a fat

18

At this point a canthopexy suture has been placed. It

is now drawn tightly and tied to complete the canthopexy. The upper eyelid incision is now closed with 5-0
nylon simple interrupted sutures. Erythromycin ophthalmic ointment is applied to the upper eyelid incision, but no dressing is used. The lower eyelid skin is
carefully dried, Mastisol is applied to the lower eyelid
skin. Steri-Strips are applied to the lower eyelid and
pulled laterally and upward, and attached to the skin
of the temple to support the lower eyelid in an antiectropion fashion. Remove the intra-ocular shields
after you have placed the supportive lower eyelid
dressing.

Operative steps

Upper eyelid laser incision.

Exposure and removal of upper eyelid fat.
Place canthoplasty suture.
Transconjunctival incision.
Exposure and removal of lower eyelid fat.
Shrink undersurface of septum and muscle.
Arcus release.
Fat grafting.
Tie canthoplasty suture.
Close upper eyelid incision.
Support lower eyelid with Steri-Strips .
Remove intra-ocular shields.

CO2 laser applications

Results
Case 1

Figure 2.8 (A) Before flat-beam CO2 full face laser resurfacing. (B) One year post-op post flat-beam CO2 full face
laser resurfacing.

Case 2

Figure 2.9 (A) Before full face Fraxel re:pair laser resurfacing. (B) Three months post full face Fraxel re:pair laser
resurfacing.

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CO2 laser applications

Case 3

Figure 2.10 (A) Immediately post full face Fraxel re:pair laser resurfacing. (B) Six days post full face Fraxel re:pair
laser resurfacing.

Case 4

Figure 2.11 (A) Before four lid CO2 laser blepharoplasty with laser resurfacing of lower eyelids. (B) One year post
four lid CO2 laser blepharoplasty with laser resurfacing of lower eyelids.

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CO2 laser applications

Case 5

Figure 2.12 (A) Before four lid CO2 laser blepharoplasty with arcus release and no laser resurfacing of the lower
eyelid. (B) One year post four lid CO2 laser blepharoplasty with arcus release and no laser resurfacing.

Pitfalls and how to correct

Pitfalls of CO2 laser resurfacing
The most common problems following CO2 LSR are
prolonged erythema and post-inflammatory hyperpigmentation (PIH). Prolonged erythema is caused by
deeper, higher energy and higher surface area treatments. Aggressive treatment of patients with severe
wrinkles and skin photo-damage will produce longer
lasting post-LSR erythema. Duration of post-LSR erythema can be shortened by the use of topical steroids.
I routinely begin 1% hydrocortisone two to three
times a day for up to 2 weeks after skin re-epithelialization is complete. In patients with severe post-LSR erythema lasting more than 34 weeks, I begin 10 day
pulses of Temovate cream applied twice a day. If
erythema persists after 6 weeks, I begin intense pulsed
light treatments with the Palomar LuxGreen IPL to
close the superficial vessels and reduce erythema.
Prolonged erythema following CO2 LSR is an indication of profound inflammation. I have found that
intense erythema lasting over 6 weeks is often associated with hypo-pigmentation long term. Thus, I
aggressively treat erythema and start IPL treatments as
soon as I can. PIH is common in individuals with
darker Fitzpatrick 3 and 4 skin and particularly
common in people of East Indian, Hispanic and Asian
descent. Therefore, I treat these individuals with less
energy and fewer passes, and today would recommend
using fractional CO2 on these individuals.

Although there is disagreement in the literature, I

do pre-treat patients prone to PIH with a bleaching
regimen. I use a combination of 4% hydroquinone,
0.1% Retin-A, and 1% hydrocortisone cream. I have
the patient mix the three creams, in equal parts, in the
palm of their hand and apply to their face three times
a day. Ideally this regimen is started 46 weeks prior
to the LSR procedure, although two weeks of therapy
will help.
PIH usually begins to appear four to six weeks after
LSR. After LSR, I begin treating PIH with a mixture of
4% hydroquinone and 1% hydrocortisone, but do not
use Retin-A until about 6 weeks post-op. I also begin
IPL treatments at six weeks post-operatively. I use the
Palomarly LuxGreen IPL, which works very well. The
major serious complications following CO2 LSR are
ectropion and hypertrophic scarring. Hypertrophic
scarring most commonly follows delayed wound
healing caused by post-LSR infections. Management of
hypertrophic scarring includes the use of topical steroids, steroid injections, compressive silicone sheeting, and IPL treatments.
Ectropion is most commonly caused by performing
LSR on lax lower eyelids. It is imperative to do the
Jelks lid snap test pre-operatively. If the lower eyelid
is lax, corrective canthoplasty or other oculoplastic lid
reconstruction must be done prior to LSR. Lower energies and fewer passes are done on the lower eyelid as
discussed earlier. I anticipate that all of these problems
will be seen less frequently with the new fractional
CO2 technology.

21

CO2 laser applications

Pitfalls of CO2 laser blepharoplasty

The major complications of blepharoplasty can be
avoided with proper pre-operative screening and
careful technique. Ectropion and eyelid malposition
have virtually been eliminated in my practice by
adopting the transconjunctival lower blepharoplasty
approach and screening patients for lower eyelid laxity
with the Jelks lid snap test. Supporting the lower
eyelid with Steri-Strips as described above also helps
maintain normal eyelid position immediately after
surgery as healing begins.
Dry eye syndrome is avoided by pre-operative screening and conservative upper eyelid skin resection. Careful
attention to identifying and avoiding the upper lid
lacrimal gland during fat resection is also essential. You
can avoid corneal injury by using appropriate laserimpermeable scleral shields. The inferior oblique
muscle is exposed to risk during transconjunctival lower
eyelid blepharoplasty. It is essential that the surgeon is
familiar with the anatomy and location of the inferior
oblique muscle and identifies and avoids the muscle
during medial and middle fat pad resection.
Arcus marginalis release and fat grafting exposes
the infraorbital nerve to injury. It is very important to
watch for, identify, and avoid this nerve during anterior maxillary dissection to create a pocket for the fat
graft. Blindness following blepharoplasty is fortunately a very rare complication. This dreaded complication, when it does occur, is usually a sequel to
retro-bulbar hemorrhage. It is important to postoperatively maintain meticulous hemostasis and
normal blood pressure in the patient. Post-operative
care includes an awareness of the three Ps of retrobulbar hemorrhage: pain, proptosis and paralysis of
extra-ocular muscles. A lateral orbital canthotomy is
an emergency procedure which must be accomplished
quickly to avoid permanent visual loss.

Post-operative care
Traditional flat-beam CO2 LSR with the
CO2 ultrapulse laser
On the first post-resurfacing day, I switch to an open
technique on the facethe Flexan dressing is left on
the lower eyelid until it falls off or loosens, usually by
day 4 or 5. I treat the remainder of the face with saline
soaks every 23h followed by gentle cleansing to
remove debris using saline soaked sponges. This is fol-

22

lowed by application of Aquaphor ointment. It is very

important to keep the surface of the skin moist and
protected until re-epithelialization is complete at 1214
days. At this point I start application of 1% hydrocortisone cream three times a day for 1014 days to combat
erythema. Adequate moisturization of the healing skin
is very important. After erythema has resolved, usually
by 68 weeks, I start the patient on Retin-A.

Fractional CO2 LSR with the reliant

Fraxel re:pair procedure
Depending on the depth of treatment re-epithelialization is complete in 4872h. Erythema can persist
for 57 days or longer with very deep treatments. As
soon as re-epithelialization is complete, I start topical
steroid therapy until erythema is resolved. After 68
weeks I start the patient on topical Retin-A.

Four lid CO2 laser blepharoplasty with

arcus marginalis release and fat
repositioning
Ice packs are applied to the eyes for 24h. Patients are
instructed to keep their head and back elevated for at
least 2 weeks after surgery. Lacrilube is applied to the
eyes at bedtime and twice a day until normal eyelid
closure returns. I leave the Flexan dressing on until it
falls off after re-epithelialization. However if serous
exudate loosens the dressing prior to 5 days, I remove
the dressing. External sutures and Steri-Strips are
removed at 56 days. After 23 weeks, 1% hydrocortisone can be applied to the upper eyelid scars to speed
the resolution of redness of the scar.

Conclusion
The CO2 laser is a very useful multi-dimensional technology with wide applications in aesthetic surgery and
dermatology. The ability to perform oculoplastic surgical procedures, facial skin resurfacing procedures
and to spot-treat exophytic skin lesions such as actinic
keratoses has made the CO2 laser a valuable, cost effective adjunct to my aesthetic plastic surgery practice.
The recent evolution of fractional CO2 technology, I
predict, will lessen the occurrence of hypo-pigmentation, PIH, and prolonged erythema post LSR and
increase the popularity and application of the CO2
laser in aesthetic practice.

CO2 laser applications

Further reading
Alster TS, Bellew SG. Improvement of dermatochalasis and
periorbital rhytides with a high-energy pulsed CO2 laser:
A retrospective study. Dermatol Surg 2004; 30(4):
483487.
Baker SS, Hunnewell JM, Muenzler WS, Hunter GJ. Laser
blepharoplasty: Diamond laser scalpel compared to the
free beam CO2 laser. Dermatol Surg 2002; 28(2):
127131.
Clementoni MT, Gilardino P, Muti GF, et al. Non-sequential
fractional ultrapulsed CO2 resurfacing of photoaged
facial skin: Preliminary clinical report. J Cosmetic Laser
Ther 2007; 9:218225.
Dijkema SJ, van der Lei B. Long-term results of upper lips
treated for rhytids with carbon dioxide laser. Plast
Reconstr Surg 2005; 115(6):17311735.
Fitzpatrick RE. Maximizing benefits and minimizing risk
with CO2 laser resurfacing. Dermatol Clin 2002;
20:7786.

Hatash BM, Vikraditya PB, Kapadia B et al. In vivo

histological evaluation of a novel ablative fractional
resurfacing device. Lasers Surg Med 2007; 39:96107.
Roy D, Sadick NS. Ablative facial resurfacing. Ophthalmol
Clin North Am 2005; 18:259270.
Rahman Z, Tanner H, Tournas J et al. Ablative fractional
resurfacing for the treatment of photodamage and laxity.
Lasers Surg Med 2007; (suppl 19):15.
Seckel BR. Aesthetic Laser Surgery. New York: Little, Brown
and & Co; 1996.
Seckel BR, Younai S, Wang K. Skin tightening effects of the
UltraPulse CO2 Laser Plast Reconstr Surg 1998;
102:872877.
Seckel BR, Kovanda CJ, Cetrulo CL et al. Laser
blepharoplasty with transconjunctival orbicularis muscle/
septum tightening and periocular skin resurfacing: A safe
and advantageous technique. Plast Reconstr Surg 2000;
106(5): 11421145.

Halverson E, Husni NR, Pandya SN et al. Optimal

parameters for marking upper blepharoplasty incisions:
A ten year experience. Ann Plast Surg 2006; 56(5):
569572.

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