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COMPLICATIONS According to Vic Narurkar, M.D., of the Bay Area Laser Institute, San Francisco, ablative fractional lasers were expected to overcome a lot of the risks associated with traditional CO2 laser resurfacing. However, he says, that hasn't necessarily been the case.
"Although fractional CO2 lasers are less risky than traditional CO2 lasers, fractional CO2 lasers still have a higher incidence of complications than nonablative fractional lasers, so we are getting referrals of quite a few adverse effects or complications when fractional CO2 lasers are used on the neck and the chest," he says.
The types of complications associated with fractional CO2 lasers, according to Dr. Narurkar, are hypopigmentation, loss of pigmentation and textural changes, including hypertrophic scars and mottling of the skin. These complications tend to occur when the laser parameters are used more aggressively, and they are often seen on the face, neck and chest, as well as the jawline and the perioral area, he says.
"Once you start getting into fractionated CO2 resurfacing, especially of the face, you really need to respect the neck and the chest," Dr. Narurkar says. "In fact, I personally don't do fractional CO2 resurfacing of the face. I think it's too risky, especially given that we have other alternatives."
The main cause of fractional CO2-related risks is secondary superinfection, he says. "You have to remember that this is ablative technology, so infection with certain bacteria can predispose to higher risks of complications."
Dr. Narurkar also warns of the dangers of overlapping or repeatedly treating the same area of the skin with the laser.
"That creates a phenomenon known as bulk heating of the skin, and bulk heating leads to scarring and pigmentary changes," he says.
According to Dr. Narurkar, it is still unclear whether using these lasers is safe in darker skin types.
"I do not recommend using fractional CO2 lasers in skin types that are higher than skin type III, but if you do go beyond skin type III, use (the lasers) with extreme caution, because we are seeing a higher incidence of pigmentary changes in these darker skin types," he says.
Despite these warnings, Dr. Narurkar says that when the fractional CO2 laser is used carefully, the healing is definitely faster and the incidence of complications is still significantly lower when compared to traditional CO2 laser resurfacing.
COMPLICATION MANAGEMENT Dr. Narurkar recommends very close follow-up of CO2 laser resurfacing patients to ensure that appropriate healing is taking place. He also recommends avoiding aggressive settings, especially in the neck and chest.
Dr. Narurkar says he uses a 1,550 nm nonablative fractional laser or a pulsed dye laser to treat scars resulting from fractional CO2 laser resurfacing. "If you see any signs of infection, start oral antibiotics early," he says.
Other facial complications that Dr. Narurkar sees are those associated with devices that don't use adequate skin cooling.
"You need to protect the epidermis, because if the epidermis isn't adequately protected, you can get a full thickness burn," he says.
Dr. Mittelman stresses he has not seen — either in his experience or in the currently available literature — evidence that one laser brand out-performs another in the anti-aging arena. Ultimately, he says, there are many fractionated CO2 laser systems on the market that are capable of achieving similar clinical results. He says he chose his lasers based on their cost-effectiveness.
In addition to considering the cost of the laser, surgeons need to factor in the cost of associated consumables and the speed with which the procedures can be performed, Dr. Mittelman says. When purchasing a CO2 fractional laser, it's important to know the percentage of skin that is being penetrated by the laser versus how much skin is left intact per pass, he says.
"The footprint designates the size of the scanner or roller tip that is making contact with the skin, and the larger the treatment tip footprint, the quicker the speed of the procedure," Dr. Mittelman says.