Combined Fractionated CO 2and Low-Power Erbium:YAG Laser Treatments




This article addresses the use of fractionated CO 2 laser and erbium:YAG laser for facial rejuvenation. Outcomes and limitations of these techniques are discussed, along with a stepwise summary of techniques as they are used in clinical practice. An evaluation of patient satisfaction is presented for a group of patients who underwent combined fractional CO 2 and erbium:YAG facial resurfacing.








  • Even in the hands of the most experienced surgeon, a laser of any type requires proper laser-specific training from the manufacturer and strict adherence to safety guidelines.



  • Appropriate patient selection is very important. One must be thorough during the interview.



  • While Fractionated CO 2 Laser alone can produce excellent and predictable results, concurrent Er:YAG Laser resurfacing can be included to maximize results without significant impact on safety or recovery time.



Key Points
The fractionated CO 2 laser is overwhelmingly the most popular laser skin rejuvenation technology currently in use. Produced in the 10,600-nm spectrum, the CO 2 laser has become an essential tool in the facial plastic surgeon’s nonsurgical armamentarium when treating light-to-medium rhytides. Its popularity has steadily increased since its first application in cosmetic facial rejuvenation in the 1980s, particularly so since the advent of fractionated and pulsed technologies. These technologies allow the face to be treated essentially in its entirety but with less healing time; however, there is always room for improvement.


Compared with some technologies, the CO 2 laser has some limits with respect to unwanted thermal spread and a less than impressive ability to be a superficial ablative tool. The effectiveness of the CO 2 laser as a resurfacing tool is not in question. However, the residual coagulative thermal damage produced by the CO 2 laser is not easily controlled, and is imprecise when treating rhytides and superficial dyschromias. The erbium:YAG laser emits a 2940-nm light that can be delivered with precise depth control at a spot size of 1 to 10 mm, making treatment of large areas of fine rhytides and dyschromias practical. The control of depth and collateral thermal damage with the erbium:YAG laser is made possible by its very high affinity for H 2 O (10–12 times greater than CO 2 ). The resultant energy delivery to the tissue is 1.5 J/cm 2 versus the 5.5 J/cm 2 with the CO 2 laser. This controlled energy delivery and decrease in coagulative damage limits ablation to the epidermis and papillary dermis, resulting in very shallow ablation craters and, thus, augmentation of the fractionated CO 2 laser therapy by removing some superficial dyschromias and thermal debris without any increase in healing time.


The combination of fractionated CO 2 laser and erbium has been a popular treatment in the authors’ office, perhaps the most popular. Originally the senior author’s practice offered fractionated CO 2 laser alone, with very acceptable results and minimal downtime for the patients. However, the use of fractional CO 2 resurfacing alone resulted in suboptimal improvement of dyschromias. The addition of the minimally ablative erbium laser to the fractional CO 2 has made it possible to further improve fine rhytides and superficial dyschromias in a very controlled fashion with regard to the depth of tissue ablation. The downtime associated with combination treatment with these 2 lasers is not significantly increased compared with fractional CO 2 resurfacing alone, and posttreatment discomfort seems to be comparable. Furthermore, no increase in the rate of complications has been noted, particularly regarding postinflammatory hyperpigmentation (PIH).


To investigate patient satisfaction with the combined fractionated CO 2 and erbium:YAG laser treatment, the senior author conducted a prospective study of 23 consecutive patients undergoing this treatment in his practice. The results of this study are summarized here, and illustrate the level of patient satisfaction with this new combined technique.


General considerations in combined laser treatment


Patient Healing Time


Compared with the many nonablative laser and intense pulsed light options currently on the market, fractional CO 2 resurfacing is moderately invasive. Patients typically experience around 1 week of social downtime. Pain is variable and depends on the specific laser used and the fluence level. Similarly, postlaser swelling can also vary.


Varieties of Lasers


Many varieties of fractionated CO 2 devices are available today. The senior author has tested most available devices and has found that, with the appropriate settings, each available device is capable of effective and safe treatment. The model currently used in the authors’ practice is the Matrix Fractional CO 2 device (Sandstone Medical Technologies, Homewood, AL, USA).


Patient Selection


Appropriate patient selection is an important topic, and merits special mention here. Fractional CO 2 resurfacing is indicated in the treatment of the following conditions:




  • Sun-damaged skin



  • Sallow color of aging skin



  • Texture irregularities



  • Pigmented dyschromias and scars



  • Skin striations and early rhytides



  • Wrinkles



  • Ablation and resurfacing of soft tissue.



In the authors’ experience, performing a fractionated CO 2 laser resurfacing procedure on a patient of Asian or Mediterranean descent can be safe. With the proper patient selection and a clear explanation of the risks and benefits for the patient, these patients can be treated effectively and safely. When beginning to offer this treatment for patients, it is best to choose patients carefully and be more conservative. A Fitzpatrick 1 to 2 would be in the clinician’s and the patient’s best interest. One should be thorough with patients during the interview. What are their recreational habits? Do they plan significant sun exposure of the next month? Is their hair dark but their skin relatively fair? One should ask if they are of Mediterranean lineage and if so, consider more conservative settings with a shorter duty time and decreased energy. In addition, whenever treating a patient suspected to be at risk for PIH, the senior author insists he or she start on tretinoin and hydroquinone 10 days before and again for a period of time 2 weeks after treatment. It is truly unsettling to be unpleasantly surprised by PIH in a patient who was apparently quite fair at the time of interview.


Potential Complications of Laser Use


In the authors’ experience, the combination of CO 2 and erbium:YAG lasers is safe and very effective, with only 5 to 7 days of downtime practically speaking. However, in the laser-naïve hands of even some of the most experienced surgeons, a laser of any type can be not only ineffective but also dangerous. The depth of penetration of a CO 2 laser and the untoward effects of beam scatter can be harmful. Preventable complications such as corneal injury, perforation of the globe, unintended injury to adjacent structures, and material fires cannot be ignored. Standard safety measures when performing CO 2 or erbium laser resurfacing are as follows:




  • Proper ventilation for the room and a vacuum to collect laser plume created during resurfacing. (Detailed explanations of Occupational Safety and Health Administration requirements can be found at www.osha.gov/SLTC/laserhazards/ . )



  • Use of properly snug-fitting surgical mask, specific for laser plume.



  • If draping is used then wet towels should drape the areas adjacent to that being treated.



  • Metal CO 2 corneal protectors or external eye shields. Though slightly more troublesome, when treating the eyelids the senior author prefers to place corneal protectors as opposed to external eye shields.



  • Eye protection for the operator and assistants. These protectors should be specific to the wavelengths of the lasers used.



  • Absence of any oxygen source, open or closed.



  • Proper signage on the door of the procedure room notifying of current laser use, with laser-protective eyewear available outside the room in case entry is necessary during the procedure.





Combination fractionated CO 2 and erbium:YAG laser resurfacing technique


Patient Preparation


When convenient, 10 days before their procedure, patients are started on a daily skin-conditioning regimen:




  • Retinoic acid 0.05% to 0.1% cream each evening



  • Hydroquinone 2% to 4% cream twice daily (not necessary in Fitzpatrick I patients)



  • α-Hydroxy acid 2% to 4% cream each morning



  • Sun protection factor–containing moisturizer daily.



Patients are instructed to withhold aspirin-containing products or nonsteroidal anti-inflammatories for 2 weeks before the procedure. Patients with a history of herpes simplex outbreaks are provided with a prescription for valacyclovir (500 mg twice a day) with instructions to begin on the day before the procedure. This regimen is continued for 7 days. Patients are instructed to wash their face with a mild soap the evening before and on the morning of the procedure. Patients must not wear makeup on the day of the procedure.


Premedication is provided to the patient 1 hour before the start of the procedure. The regimen in use in the authors’ practice includes 10 mg loratadine and 1–2 mg lorazepam administered by mouth. Occasionally patients are administered 5 mg hydrocodone for discomfort if they report difficulty tolerating mild discomfort. Twenty to 30 minutes before the procedure, topical anesthesia containing lidocaine, prilocaine, and phenylephrine (Custom Scripts Pharmacy, Tampa, FL) is applied in a thin film to the entire surface to be treated and is allowed 20–30 minutes to take effect, then is removed with clean gauze. The patient’s hair is pulled back with an elastic band, and a bouffant surgical cap may be placed. If it is used and the material is flammable, it must be covered with a wet drape before starting the procedure.


The upper body may be covered with a surgical drape, and a moist towel placed around the area to be treated.


Room and Patient Setup


The patient is placed in a semirecumbent position, and the eyes covered with moist gauze pads or metal eye shields (corneal shields are necessary if the upper or lower lids are to be resurfaced). For patient comfort there should be a cooling machine (such as Cryo 6, Zimmer MedizinSystems, Irvine, CA, USA; or ThermaCool, Thermage, Hayward, CA, USA), with cool air aimed at the area treated. Also, a smoke evacuator is positioned so that the laser plume is captured easily and near the skin surface. The authors have found that the addition of soft lighting and relaxing music is valuable in creating a calming atmosphere for the patient.


Laser Settings and Protocol


It is important to acknowledge that the description of this laser protocol applies specifically to the laser hardware in use in the authors’ practice. It is an absolute requirement to obtain proper training from each laser manufacturer in the use and settings of these devices before use. ANSI Z136.3 is recognized as the definitive document on laser safety in health care environments, and each facility should have a Laser Safety Officer to implement the necessary safety measures.


For the lasers discussed herein, the settings shown in Table 1 are in use. Table 2 shows the number of passes typically used for each facial subunit. These recommendations are not absolutes, but are guidelines that have been developed over years of practice by the senior author.



Table 1

Typical laser settings for the lasers used in the authors’ office

























Power Density Pulse Duration (ms) Pulse Frequency (Hz) Size (mm)
Fractionated CO 2 22–26 W 35% (0.8 mm spot spacing) 2–3 15–18
Erbium:YAG 600 mJ 5–10 9

Laser protocol described applies specifically to the laser hardware in use in the authors’ practice. Before use it is an absolute requirement to obtain proper training from each laser manufacturer in the use and settings of this equipment.

Feb 8, 2017 | Posted by in General Surgery | Comments Off on Combined Fractionated CO 2and Low-Power Erbium:YAG Laser Treatments
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