Improvement of Dermatochalasis and Periorbital Rhytides With a High-Energy Pulsed CO 2 Laser: A Retrospective Study

Transcription

1 Improvement of Dermatochalasis and Periorbital Rhytides With a High-Energy Pulsed CO 2 Laser: A Retrospective Study TINA S. ALSTER, MD, n AND SUPRIYA G. BELLEW, MD w n Washington Institute of Dermatologic Laser Surgery, Washington, DC, and w New Jersey Medical School, Newark, New Jersey BACKGROUND. Upper eyelid dermatochalasis is typically treated with excisional blepharoplasty. The role of the CO 2 laser previously had been confined to that of a vaporizing, incisional, or hemostatic tool. Over the past several years, however, ablative CO 2 laser skin resurfacing has been popularized as an adjunctive treatment to blepharoplasty to minimize periorbital rhytides through its vaporizing as well as skin-tightening action. OBJECTIVE. To evaluate the safety and efficacy of a high-energy pulsed CO 2 laser as a stand-alone treatment for dermatochalasis and periorbital rhytides. METHODS. Sixty-seven patients (skin phototypes I IV) with mild-to-severe upper eyelid dermatochalasis and periorbital rhytides received periocular CO 2 laser skin treatment. Global assessment scores of dermatochalasis and rhytides were determined by a side-by-side comparison of periocular photographs preoperatively and 1, 3, and 6 months postoperatively. In addition, caliper measurements of upper eyelids before and 1, 3, and 6 months after treatment were obtained. RESULTS. Both dermatochalasis and periorbital rhytides were significantly improved after periocular CO 2 laser skin resurfacing. Patients with more severe dermatochalasis and rhytides showed greater improvement after CO 2 laser treatment than did those with mild or moderate involvement. Side effects were limited to erythema and transient hyperpigmentation. No scarring, hypopigmentation, or ectropion were observed. CONCLUSIONS. Periocular skin resurfacing with a CO 2 laser can safely and effectively improve upper eyelid dermatochalasis and periorbital rhytides. T. S. ALSTER, MD, AND S. G. BELLEW, MD HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS. BLEPHAROPLASTY HAS been the gold standard of treatment for upper eyelid dermatochalasis. 1 Early use of the CO 2 laser for eyelid rejuvenation was limited to its function as an incisional and/or hemostatic tool. 2 Over the past decade, concomitant with the popularization of laser skin resurfacing, the role of the CO 2 laser has expanded to one of selective skin vaporization and rejuvenation. 3 7 In addition to its ability to vaporize water-containing tissue (and thereby minimize fine lines), pulsed CO 2 laser skin vaporization also effects tissue tightening and collagen shrinkage Although it has been maintained that preferable results in eyelid rejuvenation are obtained by combining CO 2 laser resurfacing with blepharoplasty, this study was conducted to determine whether excessive and redundant upper eyelid skin could be substantially improved by laser skin resurfacing alone. The effect of CO 2 laser resurfacing on periorbital rhytides was also Address correspondence and reprint requests to: Tina S. Alster, MD, Washington Institute of Dermatologic Laser Surgery, 2311 M Street, N.W. Suite 200, Washington, DC 20037, or talster@skinlaser. com. analyzed. Included in this discussion is an evaluation of whether the degree of improvement is affected by patient age, prior history of blepharoplasty, or severity of dermatochalasis and rhytides. Methods A retrospective photographic analysis of all patients who received periorbital CO 2 laser skin resurfacing at the Washington Institute of Dermatologic Laser Surgery over a 6-month period was conducted. Only patients with matching presurgical and postsurgical photographs (in terms of patient positioning, lighting, and camera angle) were included. Patients were excluded if they had blinked or slightly closed the lids in any one of the series of photographs. Patients were also excluded if any treatments (including botulinum toxin or filler injections) other than topical skin care were received in the periocular regions within 6 months of study entry or during the 6-month postoperative study period. Sixty-seven female patients (ages 31 to 70 years, mean age of 49 years, skin phototypes I IV) with mild-to-severe upper eyelid r 2004 by the American Society for Dermatologic Surgery, Inc. ISSN: /04/$15.00/0 Dermatol Surg 2004;30: Published by Blackwell Publishing, Inc.

2 484 ALSTER AND BELLEW: CO 2 LASER FOR DERMATOCHALASIS AND PERIORBITAL RHYTIDES Dermatol Surg 30:4:April 2004 dermatochalasis and periorbital rhytides met the criteria for study inclusion. CO 2 Laser Protocol Local cutaneous anesthesia was delivered with intralesional and trigeminal nerve blocks using 1% lidocaine without epinephrine. Sand-blasted metal eyeshields were inserted with Lacrilube and topical proparacaine for corneal protection during laser treatment. The periorbital region was treated with one to four passes of confluent nonoverlapping pulses with a high-energy pulsed CO 2 laser (Ultrapulse; Coherent Corporation, Palo Alto, CA). All treatments were delivered by a single operator (T.S.A.) using a collimated 3-mm handpiece at a fluence of 500 mj/cm 2 and 7 mw of power. The upper eyelid was treated from the lower margin of the eyebrow to the upper eyelid crease, whereas the infraorbital region was treated from the malar arch to within 1 to 2 mm of the lower eyelashes. Treatment extended medially to the nasal root and laterally to the hairline. Saline-soaked gauze was used to remove partially desiccated tissue after each laser pass. Ice packs and Aquaphor ointment (Beiersdorf, Inc., Wilton, CT) were applied immediately after treatment and reapplied every 2 hours for 72 hours. Postoperative wound care continued, with in-office evaluations and physician follow-up as described previously. 13,14 Photographs were obtained preoperatively and 1, 3, and 6 months postoperatively with a 35-mm singlelens reflex camera equipped with a lens-mounted ring flash (Nikon Corp., Tokyo, Japan) and ASA 100 film (Kodachrome; Eastman Kodak Company, Rochester, NY) using identical patient positioning and ambient room lighting. All film was processed by a single laboratory. The amount of upper eyelid show from the upper eyelid margin to the upper palpebral fold was measured (in millimeters) at baseline and at 1, 3, and 6 months after treatment. An average of four caliper measurements was made from comparative photographs in each patient. Two physician assessors masked to the treatment protocol independently assigned numerical global assessment scores (GASs) based on severity (mild 5 1 to 3, moderate 5 4 to 6, severe 5 7 to 9) of dermatochalasis (DGAS) and rhytides (RGAS) preoperatively and at each postoperative visit. Mean DGAS and RGAS scores were calculated at each evaluation point and compared using the two-tailed paired student s t- test. Repeated-measures analysis of variance (Fisher s protected least significant difference) was used to determine the effect of patient age or history of prior blepharoplasty on treatment. Results Dermatochalasis and periorbital rhytides were significantly improved after periocular CO 2 laser skin treatment (Figures 1A,B and 2A,B). Upper eyelid show was increased by a mean of 1.9 mm (range of 1 to 4 mm) after treatment. Mean DGAS decreased from 4.6 at baseline to 3.0 at 6 months (po0.001), and mean RGAS was reduced from 4.1 to 2.2 (po0.001) during the same time period. For both conditions, improvement was dependent on baseline severity. Patients with severe dermatochalasis or rhytides (score of 7 to 9) had a significantly greater response than patients with minimal (score of 1 to 3) or moderate (score of 4 to 6) involvement (Figs 3 and 4). Neither age nor prior blepharoplasty affected the DGAS. Patients older than age 50 (n 5 30) did not have better outcomes than younger patients (n 5 32). Unlike DGAS, the RGAS was significantly affected by both age and history of blepharoplasty. Older patients responded more favorably than younger patients (mean difference of 0.56, po0.05). Patients who had undergone prior Figure 1. (A) Mild dermatochalasis and periorbital rhytides (DGAS 5 3, RGAS 5 3). (B) Same patient 6 months after periocular CO 2 laser skin resurfacing (DGAS 5 2, RGAS 5 2).

3 Dermatol Surg 30:4:April 2004 ALSTER AND BELLEW: CO 2 LASER FOR DERMATOCHALASIS AND PERIORBITAL RHYTIDES Minimal Moderate Severe 6 DGAS Baseline GAS: 1-3 mild, 4-6 moderate, 6-9 severe 6 Months Postop Figure 3. Dermatochalasis global assessment scores (DGAS) at baseline and 6 months postoperatively. Patients with severe dermatochalasis showed the greatest improvement Minimal Moderate Severe 6 RGAS 5 4 Figure 2. (A) Moderately severe dermatochalasis and periocular rhytides before treatment (DGAS 5 7, RGAS 5 6). (B) Same patient six months postoperatively (DGAS 5 3, RGAS 5 4). blepharoplasty did not demonstrate as much improvement in their rhytides as did patients without a history of blepharoplasty (mean difference 0.92, po0.01). The treatment was generally well tolerated, with edema and erythema universally evident for 2 to 4 weeks postoperatively. Transient hyperpigmentation was experienced by 25% of patients, with an average duration of 1.5 months. No scarring or hypopigmentation was observed. Discussion Our study demonstrated that the high-energy pulsed CO 2 laser is a safe and effective tool to induce significant improvement in both upper eyelid dermatochalasis and periorbital rhytides. This is the first study demonstrating the effective use of the CO 2 laser as the sole treatment modality for dermatochalasis and is consistent with results obtained previously for rhytides Baseline GAS: 1-3 mild, 4-6 moderate, 7-9 severe 6 Months Postop Figure 4. Rhytides global assessment scores (RGAS) at baseline and 6 months after CO 2 laser skin resurfacing. Patients with severe rhytides demonstrated the most change. Dermatochalasis and periocular rhytides are a common manifestation of aging. Over time, collagen and elastin in the thin tissue of the eyelids and periorbital skin undergo both ultraviolet-induced and age-related degeneration. 15 In addition, the damaged epidermis releases collagenases, which further contribute to collagen degeneration. Resurfacing of photodamaged skin with a CO 2 laser leads to vaporization of the damaged epidermis and partial upper dermal ablation with a variable degree of reversible thermal damage to deeper tissues Reepithelialization of the epidermis occurs by cell

4 486 ALSTER AND BELLEW: CO 2 LASER FOR DERMATOCHALASIS AND PERIORBITAL RHYTIDES Dermatol Surg 30:4:April 2004 migration from adjacent follicular adnexae. Dermal remodeling results in replacement of damaged collagen and elastin with new compact collagen and organized normal elastin. Histologic studies have documented neocollagenesis and neoelastogenesis with increased horizontal orientation occurring in the papillary and reticular dermis for at least 18 months after CO 2 laser resurfacing. 20 New collagen synthesis results from an increase in dermal stromal cells after laser treatment. After CO 2 laser impact on skin, immediate visible collagen shrinkage occurs. This is to be expected as heat-induced collagen contraction is observed at temperatures exceeding 601C. The use of higher fluences and additional application of laser passes effects as much as 38% tissue shrinkage. 21 Although the intraoperative collagen contraction was initially thought to be temporary, subsequent histologic observation of partially denatured, shortened collagen fibers and quantitative clinical measures of skin tightening after CO 2 laser treatment has demonstrated persistent improvement several months later. Seckel et al. 22 observed significant shortening of collagen fibers in pig skin after CO 2 laser irradiation and decreased dermal area (38.5% length reduction, 17% width reduction) 3 months after treatment. The partially denatured, shortened collagen fibers resulting from CO 2 laser irradiation are postulated to provide a matrix for new collagen formation that is 20% to 30% smaller than the original. 18,23 Wound contracture also contributes to skin tightening via the influx of new fibroblasts and their contractile proteins, most notably actin. 10 Clinical skin tightening has been observed after a single pass with a high-energy pulsed CO 2 laser on facial skin. 24 In this scenario, where the depth of injury is limited to the epidermis and perhaps the uppermost dermis at best, skin tightening is probably due entirely to normal wound contracture that occurs as a consequence of secondary intention healing, with little or no contribution from collagen shortening and/or neocollagenesis. 25 Thus, the long-term tissue tightening observed after CO 2 laser skin resurfacing likely results from the combination of thermally induced collagen shrinkage, new collagen deposition that is more compact and well-organized than in the pretreatment skin, and normal wound contracture. The tissue-tightening properties of the CO 2 laser thus effects contraction of the redundant upper eyelid skin in patients with dermatochalasis, leading to a favorable outcome. Although other ablative laser systems, such as the erbium:yag laser, can also result in clinical skin tightening, 26 the underlying mechanism of action likely depends more on wound contracture than on heat-induced collagen shrinkage. Thus, in order to achieve a degree of tissue injury comparable to that of the CO 2 laser, more aggressive erbium:yag laser treatment would be required, which carries a greater risk of scarring or other adverse sequelae. A limitation of this retrospective study is the lack of long-term (1 year or more) objective follow-up. Unfortunately, only a handful of patients had photographs that could be used for direct comparison (because of a change in camera system and room lighting conditions incorporated in the practice). Of note, however, was a lack of hypopigmentation in any of the patients studied a complication often delayed in presentation several months after laser skin resurfacing. Conclusion High-energy pulsed CO 2 laser irradiation of periocular skin can safely and effectively improve dermatochalasis, thereby offering a less invasive alternative to surgical blepharoplasty. In addition, the skin-tightening effect of the CO 2 laser can be used to the surgeon s advantage, making it unnecessary to pull skin as tightly during concomitant blepharoplasty or facelifting procedures. Because periorbital rhytides also can be treated simultaneously, periocular rejuvenation can be further optimized. References 1. DeAngelis DD, Carter SR, Seiff SR. Dermatochalasis. Int Ophthal Clin 2002;42: Baker SS, Hunnewell JM, Muenzler S, et al. Laser blepharoplasty: diamond laser scalpel compared to the free beam CO 2 laser. Dermatol Surg 2002;28: Munker R. Laser blepharoplasty and periorbital laser skin resurfacing. Facial Plast Surg 2001;17: Koch RJ. Laser resurfacing of the periorbital region. Facial Plast Surg 1999;15: Alster TS. Cutaneous resurfacing with CO 2 and erbium:yag lasers: preoperative, intraoperative, and postoperative considerations. Plast Reconstr Surg 1999;103: Alster TS, Garg S. Treatment of facial rhytides with a high-energy pulsed carbon dioxide laser. Plast Reconstr Surg 1996;100: Fitzpatrick RE, Goldman MP, Satur NM, et al. Pulsed carbon dioxide laser resurfacing of photoaged facial skin. Arch Dermatol 1996;132: Fulton JE, Barnes T. Collagen shrinkage (selective dermoplasty) with the high-energy pulsed carbon dioxide laser. Dermatol Surg 1998;24: Fitzpatrick RE, Rostan EF, Marchell N. Collagen tightening induced by carbon dioxide laser versus erbium:yag lasers. Lasers Surg Med 2000;27: Smith KJ, Skelton HG, Graham JS, et al. Increased smooth muscle actin, factor XIIIa, and vimentin-positive cells in the papillary dermis of carbon dioxide laser debrided porcine skin. Dermatol Surg 1997;23: Ross EV, Yashar SS, Naseef GS, et al. A pilot study of in vivo immediate tissue contraction with CO 2 skin laser resurfacing in a live farm pig. Dermatol Surg 1999;25: Kirsch KM, Zelickson BD, Zachary CB, et al. Ultrastructure of collagen thermally denatured by microsecond domain pulsed carbon dioxide laser. Arch Dermatol 1998;134: Horton S, Alster TS. Preoperative and postoperative considerations for carbon dioxide laser resurfacing. Cutis 1999;64:

5 Dermatol Surg 30:4:April 2004 ALSTER AND BELLEW: CO 2 LASER FOR DERMATOCHALASIS AND PERIORBITAL RHYTIDES Alster TS, Lupton JR. Prevention and treatment of side effects and complications of cutaneous laser resurfacing. Plast Reconstr Surg 2002;109: Kurban RS, Bhawan J. Histologic changes in skin associated with aging. J Dermatol Surg Oncol 1990;16: Mannor GE, Phelps RG, Friedman AH, et al. Eyelid healing after carbon dioxide laser skin resurfacing: histological analysis. Arch Ophthalmol 1999;117: Rosenberg GJ, Brito MA, Aportella R, et al. Long-term histologic effects of the CO 2 laser. Plast Reconstr Surg 1999;104: Ross VE, McKinlay JR, Anderson RR. Why does carbon dioxide resurfacing work? A review. Arch Dermatol 1999;135: Alster TS, Kauvar ANB, Geronemus RG. Histology of high-energy pulsed CO 2 laser resurfacing. Semin Cutan Med Surg 1996;15: Walia S, Alster TS. Prolonged clinical and histologic effects from CO 2 laser resurfacing of atrophic acne scars. Dermatol Surg 1999; 25: Koch RJ, Cheng ET. Quantification of skin elasticity changes associated with pulsed carbon dioxide laser skin resurfacing. Arch Facial Plast Surg 1999;1: Seckel BR, Younai S, Wang K. Skin tightening effects of the ultrapulse CO 2 laser. Plast Reconstr Surg 1998;102: Alster TS. Increased smooth muscle actin, factor XIIIa, and vimentin-positive cells in the papillary dermis of carbon dioxide laser-debrided porcine skin [commentary]. Dermatol Surg 1998; 24: Ruiz-Esparza J, Gomez JMB. Long term effects of one general pass laser resurfacing: a look at dermal tightening and skin quality. Dermatol Surg 1999;25: Ross EV, Naseef GS, McKinlay JR, et al. Comparison of carbon dioxide laser, erbium:yag laser: implications for skin resurfacing. J Am Acad Dermatol 2000;42: Tanzi EL, Alster TS. Treatment of atrophic facial acne scars with a dual-mode Er:YAG laser. Dermatol Surg 2002;28: Commentary Although many blepharoplasty surgeons have used both the incisional and resurfacing modes of their CO 2 lasers, to my knowledge, this is the first article to analyze the resurfacing result from a blepharoplasty point of view. 1 The authors have documented that there is indeed more than one way to skin the blepharoplasty cat. By retexturing the upper eyelid skin instead of partially removing and redraping it as in a traditional surgical or laser blepharoplasty, an aesthetic result is achieved, particularly in subjects with more dermatochalasis. All subjects who had had concurrent BOTOX or filler were excluded. No claim is made that orbital fat prolapse can be treated, and the authors find that the best results are not obtained in individuals with less dermatochalasis. The results are relatively short term, and it will be interesting to review the 5-year appearance of this cohort in contrast to a group of age-, gender-, and severitymatched surgical blepharoplasty patients. References JEAN CARRUTHERS, MD British Columbia, Canada 1. Glassberg E, Babapour R, Lask G. Current trends in laser blepharoplasty: results of a survey. Dermatol Surg 1995;21: