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Seminars in Ophthalmology

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Periorbital Carbon Dioxide Laser Resurfacing

David S. Felder & Nathan Mayl

To cite this article: David S. Felder & Nathan Mayl (1996) Periorbital Carbon Dioxide LaserResurfacing, Seminars in Ophthalmology, 11:2, 201-210, DOI: 10.3109/08820539609063812

To link to this article: http://dx.doi.org/10.3109/08820539609063812

Published online: 02 Jul 2009.

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Periorbital Carbon Dioxide Laser Resurfacing David S. Felder and Nathan May1

Recent advances in carbon dioxide laser technology have been brought into the forefront of cosmetic surgery. Carbon dioxide lasers are used for resurfacing photoaged skin, reducing rhytids, and improving acne scarring. These resurfacing lasers vaporize intracellu- lar water in an explosive fashion at the site of impact, minimizing heat conduction and thermal damage in the surrounding tissue. Selection of the appropriate patient for laser resurfacing will avoid undesirable results. One of the most important factors in patient selection is the degree of skin pigmentation and its response to sun exposure, known as Fitzpatrick Classi- fication. The higher the Fitzpatrick class, the greater the risk that the patient will develop postlaser hyper- pigmentation. Pretreatment of patients with Retin-A and hydroquinone may decrease the incidence of hyperpigmentation. Checking for eyelid laxity is para- mount and, if noted, it must be treated before or concomitant with the laser resurfacing to avoid postla- ser ectropion. Safe parameters for laser resurfacing

HE TECHNIQUE of cosmetic eyelid sur- T gery has evolved over the past several years from transcutaneous to transconjunctival blepharoplasty. Recently, we have been able to add adjunctive procedures to the treatment of eyelid wrinkles, sun-damaged skin, and Crow’s feet. In the past, patients would have undergone a standard transcutaneous subciliary incision lower lid blepharoplasty for steatoblepharon and the periorbital wrinkling would remain. In addition, those individuals would have an exter- nal incision, with an increased risk of ectropion and lower lid retraction. Periorbital laser resur- facing combined with transconjunctival lower eyelid blepharoplasty is a solution for perior- bital rhytids and lower lid fat herniation. This combination of procedures addresses lower eye- lid fat herniation, Crow’s feet, and lower lid wrinkling, allowing for complete rejuvenation of the periorbital region.

The carbon dioxide (C02) laser has been used in medicine since the 1960’s and remains one of the most widely used of all surgical lasers. Its uses have included ablation of skin lesions, as a bloodless scalpel, and as a destruc- tive device for malignancies. Conventional C 0 2 lasers when used in either continuous wave, chopped or super pulsed modes, had caused char and lateral thermal damage limiting their usefulness for skin resurfacing. Recently, two

are reported for treatment of the periorbital region, using the Sharplan SilkTouch laser system (Sharplan Laser Corp, Allendale, NJ). The investigators have divided the periorbital region into specific cosmetic units to treat the area in a consistent fashion and to avoid complications. Depth of treatment is gauged by color of the remaining tissue in the various zones. The resurfaced areas are covered with Flexzan dressing, which increases the rapidity of re-epithelialization and decreases discomfort. The majority of patients are re-epthelialized in 7 to 10 days, at which time make-up is applied along with moisturizers and sunscreen. The most common postlaser sequelae are temporary ery- thema and postlaser hyperpigmentation. Periorbital laser resurfacing is an effective treatment for efface- ment of rhytids and mild skin tightening. It is the perfect compliment used with a transconjunctival blepharoplasty in an effort to achieve periorbital reju- venation. Copyright o 1996 by W.B. Saunders Company

technologies have solved these problems. These recent advances have brought the C 0 2 laser into a new domain, that of resurfacing the skin or vaporization of surface irregularities in a con- trolled, precise manner. Oculoplastic surgeons or ophthalmologists who perform cosmetic eye- lid surgery and wish to provide a superior result, will find that laser resurfacing is a viable method for eradication or improvement of crow’s feet and lower eyelid wrinkles. Most ophthalmolo- gists do not perform chemical peels, and have not had an alternative modality to remove periorbital rhytids. We believe that C02 resur- facing’s introduction into this new sector will be met with a positive response. This report is not a commentary on the benefits of laser resurfacing versus chemical peels, but only a study in the pre, peri, and postoperative techniques of peri- orbital laser resurfacing using the Sharplan SilkTouch laser system (Sharplan Laser Corp, Allendale, NJ). The majority of our patients underwent periorbital laser resurfacing concomi- tant with a transconjunctival blepharoplasty

From the Departments of Ophthalmology and Plastic Sur-

Address reprint requests to David S. Felder, MD, 6405 N.

Copyright 0 1996 by W.B. Saunders Company

gery, Imperial Point Medical Center, Fort Lauderdale, FL.

Federal Highway, Suite 200, Fort Lauderdale, FL 33308.

0882-0538/96/1102-0008$5.00/0

Seminarsin Ophthalmology, Vol 11, No 2 (June), 1996: pp 201-210 201

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and/or a standard upper eyelid transcutaneous blepharoplasty.

CO2 LASER TECHNOLOGY

The C 0 2 laser emits a continuous beam having a wavelength of 10,600 nm in the midin- frared portion of the electromagnetic spectrum. The laser is absorbed by biologic tissues regard- less of pigmentation or vascularity due to the fact that its target is water, which is the main component of skin. The C 0 2 laser destroys tissue by rapidly heating and vaporizing intracel- Mar water. Because the C02 laser beam is not visible, a low power visible laser beam (usually helium-neon) must be coaxially aligned with it to provide an aiming dot for the surgeon to guide its beam to the target tissue. The conven- tional C 0 2 laser causes a large build-up of heat in the surrounding tissue while heat is con- ducted away from the impact site, thus damage is not confined to the target area. The resurfac- ing C 0 2 lasers solve this problem by delivering energy in such a short period of time that thermal conduction away from the site of im- pact is minimal. Resurfacing is accomplished by removal of a specific amount of tissue as prede- termined by C02 wavelength properties and those properties that are modified by the deliv- ery mode of the particular laser and handpiece. The resurfacing lasers modify the delivery of energy so that heat is not allowed to accumulate in or conduct through adjacent tissue, decreas- ing lateral thermal damage.’ The water in cellu- lar tissues is rapidly vaporized by energy from the C 0 2 laser, thereby creating a wound in an explosive fashion. The COz wavelength ablates approximately 50 to 100 pm of tissue each pass. Clean ablation of tissue requires sufficient en- ergy to vaporize the water contained in the tissue. If vaporized quickly enough, there is insufficient time for an appreciable amount of heat conduction into surrounding tissue to cause thermal damage. Enough power density is deliv- ered so that the rate of vaporization is faster than the rate of heat conduction. The ablation front travels faster than the thermal conduction front with resultant minimal thermal injury.

Current laser technology, both Coherent’s Ultrapulse (Coherent Lasers, Inc, Palo Alto, CA) and Sharplan’s SilkTouch, enable us to resurface skin more precisely than past resurfac-

ing techniques (ie, chemical peels and dermabra- sion). The C 0 2 laser allows for vaporization of tissue without accumulation of heat in the adjacent tissue, resulting in extremely precise vaporization, minimal thermal damage and ulti- mately will furnish us with a more predictable and an improved resurfacing result. Thermal relaxation time is defined as the time required for the heated tissue to lose 50% of its heat through diffusion. Minimal thermal diffusion will occur if the pulse duration is shorter than the time it takes the heated layer to cool. The thermal relaxation time for human skin has been determined to be approximately 695 micro- seconds.

Currently, the two leaders in C 0 2 resurfacing laser technology (Coherent and Sharplan) use a different technique to accomplish selective tis- sue ablation with eradication of rhytids and a restoration of a youthful skin architecture. Co- herent’s Ultrapulse technology uses high energy short duration pulses, while the Sharplan Silk- Touch system uses a computer controlled scan- ner that focuses a laser beam in a continually moving spiral pattern. The goal of both of these devices is to cause vaporization without char. Both systems seem to accomplish this goal in an equal fashion. Other manufacturers are rapidly making competitive products available.

The Sharplan SilkTouch flashscanner takes a 200 pm spot size and through microprocessor controlled mirror deflections, moves this spot in a uniform spiral pattern over the predetermined scan area. The end result is a superficial vapor- ization of tissue with negligible thermal damage to the area. The 2 0 0 - ~ m spot spends less than 1 microsecond on any given point in order to prevent thermal damage and char.2 The Silk- Touch uses a highly focused beam to provide this small 200-~rn spot size, resulting in a very high power density. Thus, vaporization of tissue is easily performed even with low power lasers. The SilkTouch currently offers scan sizes from 2 to 16 mm.

The Coherent Ultrapulse resurfacing laser provides high energy (up to 500 mj) and a short duration pulse wave, less than the thermal relaxation time of the skin estimated to be approximately 695 microsecond^.^ The Ultra- pulse laser was designed so that the power density delivered during a single laser pulse is

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PERIORBITAL C02 LASER RESURFACING 203

above the level needed for clean tissue vaporiza- tion. Enough power density is delivered so that the rate of vaporization is faster than the rate of heat conduction.

Although the technologies of both lasers differ, the end result is a very selective tissue ablation with minimal residual thermal tissue damage.

Indications Indications for C 0 2 laser resurfacing include

sun-damaged facial skin, reduction of rhytids (periorbital, perioral, and glabellar region), crow's feet, hair transplantation, rhinophyma, actinic cheilitis, and acne scarring (mildly re- cessed scars, not ice pick scarring). Due to the fact that the depth of laser resurfacing is con- trolled, the results should be more reproducible and predictable than those of standard chemical peels (phenol, trichloroacetic acid [TCA], etc) or dermabrasion. Furthermore, dermabrasion is not usually performed in the periorbital region, and chemical peels are more likely to be sur- geon dependent. Laser resurfacing can be used as a stand alone procedure or in conjunction with blepharoplasties, rhytidectomies, and chemical peels.

PATIENT SELECTION

The recognition of the suitable candidate for this procedure is essential to prevent undesired outcomes. The same rules apply for laser resur- facing as they do for chemical peels. In general, female patients who are middle aged (40 to 65) with fine static rhytids and are fair skinned, tend to do the best.4 It must be made very clear to the patient that while some of the static rhytids may be eradicated completely, others may be only softened and may return. This does not apply to dynamic rhytids, which that are not significantly altered. Just as for chemical peels and dermabra- sion, laser resurfacing can produce the compli- cations of scarring, hypopigmentation, and postinflammatory hyper~igmentation.~ The re- surfaced area may remain red or pink for up to several months and on average will take longer to heal than an incisional surgical procedure such as a blepharoplasty. Patients must have realistic expectations, as laser resurfacing is not a universal remedy. It will not have a significant effect on cutis laxa, and in general, is not a

replacement for blepharoplasty or rhytidec- tomy, but rather an adjunct. We have had good success on crow's feet and lower lid wrinkles, either alone or in combination with transcon- junctival blepharoplasty. Although our results are approaching 1 year status postresurfacing, we are confident that we will not find a rapid return of periorbital rhytids.

Selection of patients for laser resurfacing of the periorbital region uses the same rules as a chemical peel and goes one step further. Before evaluation of the periorbital region, the degree of skin photoaging and pigmentation status needs to be addressed. Surgery improves the laxity and excess of the skin, but periorbital laser resurfacing improves the texture of the skin, targeting the epidermal and dermal aging.4 One needs to determine if the main problem is skin photoaging versus excess skin, herniated fat, or all of the above. To create complete rejuvenation, each problem needs to be specifi- cally analyzed. Glogau's Photoaging Classifica- tion scheme (Table 1) divides patients into different categories of photoaging and provides a simplified approach for chemical peeling treat- ment.6 By using this classification, physicians may obtain a greater consistency and predictabil- ity with regard to chemical peeling and laser resurfacing.

Table 1. Glogau's Classification of Photoaging

Type 1 "No wrinkles" Early photoaging Mild pigmentary changes Minimal wrinkles Younger patient, twenties orthirties

"Wrinkles in motion" Early to moderate photoaging Early lentigines Parallel smile lines begin to appear Patient age, late thirties or forties

"Wrinkles at rest" Advanced photoaging Dyschromia, telangiectasia Wrinkles even when not moving Patient age, fifties or older

"Only wrinkles" Severe photoaging Yellow-gray skin color Wrinkled throughout, no normal skin Patient age, sixth or seventh decade

Type 2

Type 3

Type 4

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Type 1 patients do not need deep peeling or laser resurfacing and do best with a contempo- rary skin care program. Type 4 would not benefit from superficial peeling, but may do well with multiple laser resurfacings. Managing middle of the road patients (Type 2 and 3), who will benefit from either medium to deep peels or laser resurfacing, represents those who are likely to get the best result^.^

One of the most important preoperative fac- tors, if not the single most influencing one, is the patient’s type of pigmentation. Fitzpatrick’s Scale (Table 2) is routinely used and is the foundation for making the determination of a patients skin pigmentation and its suitability for chemical peels. The scale extends from Type 1 to 6 and denotes a patient’s response to sun exposure>.’ Fitzpatrick’s classification under- scores the patients’ responses not only to sun- light, but to chemical peels, dermabrasion, and laser resurfacing.

Types 1 and 2, usually fair-skinned individu- als, can normally withstand medium or deep resurfacing without the fear of postinff amma- tory hyperpigmentation or permanent hypopig- mentation. Type 4 or olive-skinned individuals with dark hair and dark eyes are at an increased risk for postinflammatory hyperpigmentation with most types of peels or laser re~urfacing.~ The Fitzpatrick scale is a guide to predict the response of the skin to chemical peels and thus laser resurfacing. While very superficial chemi- cal peeling may eliminate dyschromia, only with medium depth treatment will you truly reduce the fine wrinkles and Crow’s feet.s

Transient or permanent skin color changes are significant risk factors with regard to laser resurfacing, and the reason why we stress the importance of the preoperative evaluation. By determining the patients skin pigmentation sta- tus and photoaging grading, one can predict with reasonable accuracy the outcome of perior-

Table 2. Fitzpatrick’s Sun-Reactive Skin Types

Skin Type Skin Color Tanning Response

Type 1 White Always burn, never tan Type 2 White Usually burn, difficult to tan Type 3 White Sometimes mild burn, average tan Type4 Brown Rarely burn, tan with ease Type 5 Dark brown Very rarely burn, tan very easily Type6 Black No burn, tan very easily

bital laser resurfacing. Rebound postinflamma- tory hyperpigmentation may occur with the use of C02 lasers, and many times fades spontane- ously with time. Patients with diminished der- mal appendages (s/p radiation therapy or accu- tane therapy) are poor candidates for laser resurfacing or chemical peels, as epithelial regenera- tion is slowed, thus increasing the chance of de- layed healing and scarring! Thin-skinned individu- als need to be treated very superficially as they are at an increased risk for post-laser scarring. Fortunately, scarring in the periorbital region is rare and more commonly seen in the perioral locale or in areas of increased mobility. Patients who have had prior phenol peels need special consideration, although they may be treated.

In addition to skin type evaluation, the perior- bital structures also need assessment. Eyelid laxity is one of the most crucial concerns. The examination of the patient should always include visual acuity, followed by a snapback test of the lower eyelid. If there is poor eyelid tone as deter- mined by a snapback test, then there exists the possibility of a post-laser resurfacing ectropion. Also, the patients present makeup routine is ques- tioned, and those who are in the habit of wearing heavier makeup will more easily adapt to the post-laser routine. Patients who refuse to consider makeup may need to be excluded.

To evaluate patients on a rigid basis and target specific areas for laser treatment, we devised a zonal mapping system to isolate com- ponents of the periorbital region. We developed three areas or zones to treat specific cosmetic units of the periorbital region (Fig 1). Zone 1 is the area immediately below the lower eyelid margin extending inferiorly to the orbital rim and medially beneath the punctum, extending to the lateral one quarter of the eyelid. This is the zone where one has to be extremely cautious with regard to eyelid laxity. If you are consider- ing laser resurfacing of the lower eyelid (zone l), in a patient with lower eyelid laxity, we would recommend a tarsal strip procedure ei- ther before or concomitant with the periorbital laser resurfacing. There is a definite shortening of tissue with the C02 laser, and if significant eyelid laxity is present, one must be extremely cautious. Zone 2 is the region extending later- ally from the lateral canthus to the temporal area, encompassing the Crow’s feet. Further-

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PERIORBITAL CO, LASER RESURFACING 205

Fig 1. Preoperative periorbital zonal mapping of Zones 1,2 and 3. Also noted is the upper eyelid blepharoplasty marking.

more, this area extends from the lateral portion of the upper eyelid to the lateralmost portion of the lower eyelid. This region can withstand heavy laser resurfacing without difficulty. How- ever, even using these guidelines, we have seen transient lateral ectropion, treating only zone 2. The final region, zone 3, is defined as the area over the malar eminence, which also bridges the inferior portion of zone 2 to zone 1. If the periorbital rhytids or malar bags extend infero- laterally, this zone should be included in treat- ment. Zone 3, which is facial skin, will tolerate higher energy density. However, if eyelid laxity is present, caution in warranted. Table 3 summa- rizes our evaluation of the periorbital area for laser resurfacing.

Male patients have been treated, but our experience is limited. The evaluation is identi- cal except the male patient needs to understand there may be the need to wear makeup post- laser resurfacing. If they are not motivated to do so, they need to comprehend that post-laser erythema may last at least 4 to 6 weeks.

Table 3. Preoperative Evaluation for Periorbital Laser Resurfacing

TECHNIQUE

All patients chosen for laser resurfacing were women with Fitzpatrick classification 1 to 3. Each patient was checked for eyelid laxity. If significant lid laxity was present, zone 1 was not treated. We now place most of our patients on pretreatment with Retin-A and hydroquinone or pHaze 13 Pigment Gel (Physicians Choice, Scottsdale, AZ) for a minimum of 2 weeks, if lightening of skin pigmentation is needed. All patients are placed on prophylactic oral Acyclo- vir(Zovirax) to prevent herpetic outbreaks. The dose used is 400 mg 3 times a day, beginning 1 day before the laser resurfacing and continuing 7 to 10 days postresurfacing or until the crusting has completely healed.

The majority of our patients underwent stan- dard upper lid blepharoplasty and lower lid transconjunctival blepharoplasty at the time of laser resurfacing (Figs 2 through 9).Before local anesthesia, the patients were marked with a methylene blue pen to outline the areas or zones for laser resurfacing. The local anesthesia was comprised of 2% xylocaine with 1:100,000 epinephrine mixed equally with 0.5% Marcaine

Fig 2. Preoperative frontal view of patient before undergo- ing bilateral upper eyelid blepharoplasty, lower eyelid transcon- junctival blepharoplasty, and periorbital laser resurfacing.

0 Fitzpatrick skin type 0 Glogau level of photoaging 0 Visual acuity 0 Evaluation of eyelid laxity 0 Patients level of sun exposure 0 Previous medication or therapy (Accutane, birth control

0 History of keloids or hypertrophic scarring 0 Willingness to wear make-up

pills, radition) Fig 3. Postoperative frontal view of same patient in Fig 2

after bilateral upper eyelid blepharoplasty, transconjunctival . . lower eyelid blepharoplasty, and periorbital laser resurfacing.

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and Wydase. The injections were given preop- eratively for the lower lid transconjunctival blepharoplasty through the inferior fornix. Be- fore the laser procedure, the upper lid incisions were closed and the transconjunctival blepharo- plasty was completed. The upper lid incision was closed medially and centrally with a 6-0 Novafil (Davis and Geck) running suture and laterally with 6-0 Novafil interrupted sutures. Thus, if the laser resurfacing inadvertently cut a suture in the lateral aspect of the incision, the entire wound would not have to be resutured. Supplemental transcutaneous injections were given immediately before the laser through the skin in the previously marked zones. Topical Tetracaine drops were placed into both eyes, followed by placement into the fornices of Trelles Metal Scleral Shields (Byron Medical, Tucson, AZ, catalog #P7923S-M) covered with Lacrilube ophthalmic ointment. The Sharplan SilkTouch laser was used. Settings were as follows: the 125-mm handpiece was used, with a 0.2 second scan time and 200 p.m beam. The laser repeat mode was used with the laser set to 0.2 sec “on time,” and 0.4 sec “off time.” A spot size of 3 mm, and 7 W of power were used for the first pass settings covering zones 1, 2 and 3. Zone 2 (Crow’s feet) is treated first, usually proceeding perpendicular to the rhytids and covering the entire area. The treatment area is extended to within 1 to 2 mm of the lateral cantha1 angle. Zone 1 ( h W eyelid) is treated next, staying parallel to the lid margin and extending from 1 to 2 mm below the eyelash line superiorly, to the level of the orbital rim, inferi- orly. Zone 3 (malar region) is usually a fill-in region between the lower portion of zone 2 and

Fig 4. lntraoperative lateral view after first pass with laser before wiping of desiccated tissue.

Fig 5. Postoperative lateral view with Flexzan applied over laser resurfaced area.

Fig 6. Preoperative laterdl view of same patient. Fig 7. Postoperative lateral view of same patient.

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PERIORBITAL C 0 2 LASER RESURFACING 207

Fig 8. Preoperative lateral view of patient before undergo- ing bilateral upper eyelid blepharoplasty, lower eyelid transcon- junctival blepharoplasty, and periorbital laser resurfacing.

the inferior portion of zone 1. After one side is finished with the first pass, the desiccated layer of tissue is not removed. The other side is then treated and compared with the first with regard to symmetry. If both sides appear symmetrical, a saline-soaked gauze is used to gently scrub off the layer of desiccated tissue. Evaluation of treatment depth is made by observation of color. If the skin appears pink, there is epider- mis still present. If the zone 1 or lower eyelid rhytids are deep, treatment is usually continued to the papillary dermis, which is a gray color. When the skin tone is yellow or chamois, this is approximately at the level of the upper reticular dermis. Any treatment below this level in- creases the chance of scarring. As a general rule, zone 1 is treated twice if there is good lid tone. However, this varies with the degree of eyelid laxity and depth of lower lid rhytids. The second pass parameters are as follows using the same handpiece: the spot size is 4 mm and the power varies from 5 to 6 W. The end point on zone 2 is the chamois or yellow color. In areas that receive more than one pass, the second pass is placed just outside the area of the first pass, in order to blend or feather the edge. Feathering a zone blends or softens the line of demarcation and can be done to improve the result. For the SilkTouch system, one pass usually ablates the epidermis, creating a 20 to 30

p,m zone of thermal damage in the dermis, approximating the injury depth of a medium depth Jessner’s solution and 35% TCA peel. Two to three passes approximate dermabrasion depth.3 Male and thick-skinned female patients may need limited third or fourth passes. After both sides are wiped clean, they are dried with 4 x 4’s. Flexzan (PolyMedica Industries, Inc; distributed by Dow B. HicKam, Inc, Sugar Land, TX), which is a semipermeable stick-on dressing, is applied over the treated areas and will remain for 4 to 6 days. We have found that patient’s note less discomfort and crusting while the area is covered. It is also thought that reepithelialization of the treated area is en- hanced if the area is covered.s Any exposed edge is kept moist with gentamicin ophthalmic ointment. The patient returns the following day and then in 4 to 5 days. If the Flexzan is loose and ready to come off, it is removed at this visit. Most patients have kept the Flexzan on and intact for 5 to 7 days without difficulty. When the Flexzan is removed at 1 week, the resur- faced area is 75% to 90% reepithelialized, avoiding much of the crusting, scabbing and drying normally seen. At this point, they can be placed on moisturizers, sunscreen, and make-up to conceal the resurfaced area. If complete

Fig 9. Postoperative lateral view of same patient in Fig 8 after bilateral upper eyelid blepharoplasty, transconjunctival lower eyelid blepharoplasty, and periorbital laser resurfacing. Note extensive reduction of periorbital rhytids.

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reepithelialization has not taken place, we use either Pramosone, Aquaphor, or gentamicin ointment. The majority of patients remain pink for 4 to 6 weeks, at which time, this begins to fade. Sun avoidance is a strict rule post-laser resurfacing. Patients must place a sunblock on the treated area every morning once they are reepithelialized, as the resurfaced area will tan rapidly and will become dark. Once hyperpig- mentation is identified, its resolution will be hastened with the use of hydroquinones or kojic acid (Figs 10 and ll).9 We have been using pHaze 13 Pigment Gel with hydroquinone for post-laser resurfacing hyperpigmentation. This is manufactured by Physician’s Choice of Ari- zona, Inc and its major components include 2% hydroquinone, kojic, lactic, and citric acid along with aloe cellulose. Most treatment would begin at least 3 to 4 weeks after resurfacing and continue for 4 to 6 weeks, applying this to the entire periorbital area twice daily. Both hydro- quinone and kojic acid have been shown to prevent the formation of melanin by blocking crucial steps in its synthesis.1° Risk factors for postinflammatory hyperpigmentation include birth control pills, supplemental estrogen, preg- nancy, excessive sun exposure, and photosensi- tizing pharmaceutical agents. It has been shown, that pretreatment with Retin-A and hydroqui- none will improve postoperative healing, as well as decrease the development of postinflamma- tory hyperpigmentati~n.~ Persistent erythema may also be encountered, and is defined as redness of the treated area remaining 3 months

following laser or chemical peel. This can be treated with a mild topical steroid cream or oral steroids until it resolves.

RESULTS

At 10 months follow up, all of the patients treated with the laser resurfacing in zones 1, 2, and 3 have had a decrease in the number and depth of the rhytids. We have had best success with zone 2 (crow’s feet), as we feel this area is amenable to deeper treatment without postop- erative complications. One must be cautious in treating zone 1 (lower eyelid) with heavy treat- ment, as the risk of ectropion is real. One patient had persistent erythema for 2 months, which was treated with a topical steroid cream. This resolved within 2 to 3 weeks of treatment. Though none of the patients developed hypopig- mentation, we have noted that a significant number have developed a temporary hyperpig- mentation at 3 to 4 weeks post-laser resurfacing. Although this may be due to the lack of pretreat- ment with Retin-A and hydroquinone or mini- mal sun exposure, we have also have seen this in pretreated individuals. These hyperpigmented areas are treated with pHaze 13 Pigment Gel with hydroquinone or hydroquinone alone with resolution in 3 to 5 weeks. The application of the pHaze 13 pigment gel must be applied to the entire periorbital area twice daily. There is a pHaze 13 Pigment Gel, which lacks hydroqui- none, and can be used for those patients who develop a sensitivity to hydroquinones. An occlu-

Fig 10. Postinflammatory hyperpigmentation occurring 4 Fig 11. Three weeks after topical hydroquinone therapy. weeks after periorbital laser resurfacing. Note reduction of hyperpigmentation.

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PERIORBITAL CO, LASER RESURFACING 209

sive dressing, such as Flexzan, has been shown to improve reepithelialization by as much as 40% versus an open wound covered by oint- m e n t ~ . ~ Patients have very little discomfort and are usually reepithelialized by 7 to 12 days. Although we have not seen hypertrophic scar- ring or keloid formation in the patients we have treated, we have been referred one patient with significant hypertrophic scarring and cicatricial ectropion formation (Figs 12 through 15). She is currently being treated with high potency topi- cal steroids (Aristocort HP or Temovate-E) along with periorbital steroid injections, Cor- dran tape, and ocular lubricants. Previous re- ports indicate that the incidence of hypertro- phic scarring and keloid formation from COz laser resurfacing is exceedingly low, however, the cosmetic laser surgeon should be aware of this potential complication."

CONCLUSION

Carbon dioxide laser resurfacing of the peri- orbital region is a safe and effective treatment

Fig 12. Frontal view of patient referred t o our practice 6 weeks after undergoing periorbital laser resurfacing. Note persistent erythema, right lower eyelid medial cicatricial ectro- pion, and hypertrophic scarring in both upper eyelids.

Fig 14. Magnified frontal view of right eye. Note hypertro- phic scarring of the medial aspect of the upper eyelid and medial cicatricial ectropion with punctal eversion.

for Crow's feet and lower eyelid wrinkles. It may allow the surgeon to have more control than chemical peels, as the depth of treatment is judged by direct visualization. The technique is dry and bloodless, and with magnification, it allows us to assess each pass. Periorbital laser resurfacing used concomitantly with transcon- junctival blepharoplasty provides a superior re- sult, and is now our standard treatment for lower eyelid steatoblepharon and periorbital

Fig 15. Magnified lateral view of right eye. Note hypertro- phic scarring of lateral canthal region along with cicatricial ectropion. Also note that the laser treatment of the upper eyelids appears to extend on to the pretarsal skin encroaching

Fig 13. Frontal view of same patient with voluntary do- sure. Note bilateral lagophthalmos and right lower eyelid cicatricial ectropion. on the lashline.

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210 FELDER AND MAYL

rhytids. When evaluating patients for perior- bital laser resurfacing, check for eyelid laxity to prevent a post-laser ectropion. Although this is not a cure all for Crow’s feet and lower eyelid wrinkles, as dynamic wrinkling will remain, it is

a major step forward in periorbital rejuvena- tion. We are currently evaluating the use of botulinum toxin as an adjunct to laser resurfac- ing and blepharoplasty in an effort to diminish the dynamic wrinkling of the periorbital region.

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New Technology for Skin Resurfacing in Aesthetic Surgery. J Clin Laser Med Sue. 1995;13:97-100.

3. Hruza GJ. Skin resurfacing with lasers. Fitzpatrick’s J Clin Dem. 1995;3:30-41.

4. Glogau RG, Matarasso SL. Chemical face peeling: Patient and peeling selection. Facial Plast S q . 1995;ll:l-8.

5. Perkins SW, Gibson FB. Medium-depth peels. Facial Plast SUT. 1995;11:22-29. 6. Glogau RG. Chemical peeling and aging skin. JGeriatr

Dermatol. 1994;2:30-35. 7. Fitzpatrick T. The validity and practicality of sun-

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8. Rubenstein R, Roenigk HJ, Stegman SJ, et al. Atypi- cal keloids after dermabrasion of patients taking isotreti- noin. JAm Acad Dermatol. 1986;15:280-285.

9. Dyer WK. Postoperative regimen for chemical peel- ing: A clinical approach. FacialPlast Sue. 1995;11:47-52.

10. Chen JS, Wei C-I, Marshall MR. Inhibition mecha- nism of kojic acid on polyphenol oxidase. J Agric Food Chem. 1991;39:1897-1901.

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