An overview on the role of CO2 laser in general dermatology.

Tremendous advances have been made in the medical application of the laser in the past few decades. Many diseases in the dermatological field are now indications for laser treatment that qualify for reimbursement by many national health insurance systems. Among laser types, the carbon dioxide (CO2) laser remains an important system for the dermatologist. The lasers used in photosurgery have wavelengths that differ according to their intended use and are of various types, but the CO2 laser is one of the most widely used lasers in the dermatology field. With its wavelength in the mid-infrared at 10,600 nm, CO2 laser energy is wellabsorbed in water. As skin contains a very high water percentage, this makes the CO2 laser ideal for precise, safe ablation with good hemostasis. In addition to its efficacy in ablating benign raised lesions, the CO2 laser has been reported to be effective in the field of esthetic dermatology in the revision of acne scars as well as in photorejuvenation. With the addition of fractionation of the beam of energy into myriad microbeams, the fractional CO2 laser has offered a bridge between the frankly full ablative indications and the nonablative skin rejuvenation systems of the 2000s in the rejuvenation of photoaged skin on and off the face. The CO2 laser remains an efficient, precise and safe system for the dermatologist. Technological advances in CO2 laser construction have meant smaller spot sizes and greater precision for laser surgery, and more flexibility in tip sizes and protocols for fractional CO2 laser treatment. The range of dermatological applications of the CO2 laser is expected to continue to increase in the future.

The role of CO2 laser in plastic surgery and dermatology is nowadays well established. It has proved to be efficient within different contexts (haemorrhagic-infectious-necrotic ...) or on different tissues as skin, muscles and mucosae. But the role of lasers in oncologic cutaneous surgery is not as precise. The CO2 laser is to be used in a focused mode, to realize the excision of tumour, whatever its size. The advantages lie in minimized blood loss, and in permitting all types of reconstruction (suture, graft or flap). Some clinical cases of photodynamic therapy are reported, but do not appear to be conclusive. Anyhow, PDT is still under investigation and does not seem to be ready yet for routine clinical use. The principle of tissue photo-ablation with excimer of Er-YAG lasers shows some possible interest in the case of tumour treatment. But, here again, this technique has not yet proved to be for any real advantage, as far as technology is concerned. Whatever the type of laser to be used, one basic principle is to completely excise the tumour to meet the classical requirements of oncologic surgery, i.e. to be far enough from the lesion, and to get a microscopic identification of the whole specimen. We therefore think that the use of lasers in case of cutaneous tumour therapy must be considered as follows. The CO2 laser: a useful device (but not a must) which can be used as a normal knife but offering the major advantage of almost bloodless surgery. Until today, spread of metastasis has not been found to be less frequent than with conventional surgery. PDT and photo-ablation: may be of interest in the future, but at the moment:

Lasers in Cutaneous Medicine and Surgery

Chapter 53 - Lasers in Dermatology

The first medical application of laser was reported by Dr Leon Goldman who, in 1962, reported the use of ruby and carbon dioxide (CO2) lasers in dermatology. In cardiovascular disease, early laser use was confined to cadaver vessels, animal models, and arteries located in freshly amputated limbs, until eventually work progressed to the use of laser energy to salvage an ischaemic limb in 1984. The concept of using laser to remove atherosclerotic material in coronary arteries developed as an alternative strategy to simply modifying the shape of an obstructed lumen as occurs with simple balloon angioplasty. Expectations grew that this new biomedical technology may overcome the low success rate and high complication rate of lesions considered non-ideal for balloon angioplasty. However, initial successful reports could not be replicated. Furthermore, underdeveloped catheter technology and limited appreciation of laser/tissue interactions meant that a cure for restenosis was not in fact discovered and laser coronary angioplasty became isolated to only a few centres in the world. However, more recently with advancement in both catheter technology and technique, excimer coronary laser angioplasty (ELCA) has been rediscovered for use in specific subsets of percutaneous coronary interventions (PCIs). This chapter outlines the basic principles of ELCA and important practical aspects for using the device in contemporary PCI. A discussion of the current indications for clinical use follows and these are highlighted by clinical case examples.

Applications for laser in veterinary dermatology

Dear Editor, We read with interest the recently published article by Singh et al. entitled BLaser vaginal rejuvenation: not ready for prime time^ [1]. In this editorial, the role of CO2 laser in gynecology was discussed, focusing on its cosmetic indications. The authors correctly pointed out the almost complete lack of scientific literature on these emerging cosmetic treatments, of which little is known in terms of indications, standardization of the technique, complication rates, functional outcomes, and long-term safety. Despite this, the so-called Blaser vaginal rejuvenation,^ is very popular among women, and is largely marketed, and, in our opinion, improperly offered on the basis of the current evidence. For this reason, we deem this editorial extremely timely, sensible, and appropriate for stimulating good-quality research in this field and to guide clinical practice to an evidence-based and not a business-oriented path. On the other hand, we would like to clarify that CO2 laser is a light energy with recognized therapeutic effects in manymedical fields. Its use in cosmetic gynecology represents just one application, although it is the one most frequently criticized, which should not lead to the misinterpretation that any clinical CO2 laser application is to be blamed. In fact, the CO2 laser is a surgical instrument and, like the cold knife or the electrical scalpel, it can provide different effects, depending on the way we use it and on the energy that we decide to deliver. We have recently reported the regenerative effects of intravaginal fractional CO2 laser on the vaginal epithelium and lamina propria in postmenopausal women with vulvovaginal atrophy (VVA) [2]. A microablative fractional CO2 laser was demonstrated to be feasible, efficacious, and safe in improving VVA-related symptoms in postmenopausal women, at 12-week follow-up [3]. In addition, this technique caused a significant decrease in the severity of the dyspareunia related to vaginal dryness in these patients, and it was consequently associated with a consistent improvement in sexual function and sexual satisfaction of menopausal women with VVA [4, 5]. Therefore, despite the utmost pertinence of the editorial by Singh et al., we decided to write this letter, to avoid the misunderstanding that all gynecological applications of the CO2 laser are lacking scientific evidence and therapeutic effects.

Since the 1960's, thousands of skin and soft tissue malformations have been treated with the Argon and carbon dioxide lasers. The Argon laser, emitting blue‐green light, is very useful for treating port wine hemangiomas and other cutaneous vascular abnormalities; it has also been applied to a variety of nonvascular skin lesions. Its mechanism of action is essentially heat coagulation.Carbon dioxide lasers function as hemostatic scalpels by emitting light that is much less selective in its tissue effect. Its role in the resection of hemangiomas and other lesions is discussed.Histopathologic and tissue culture studies have been undertaken to monitor the effects of laser radiation on tissues. No malignant change has been noted. The Argon and carbon dioxide lasers must be used with great care; safety measures and treatment protocols are outlined.

The carbon dioxide (CO2) laser is currently enjoying a renaissance with the advent of laser skin resurfacing, but from the time it was first introduced in the mid-1960s it was widely used as a cutting and ablative laser and was one of the few lasers genuinely useful to a number of different surgical specialists.

The utilization of lasers in dermatology has greatly expanded in recent decades. Acne scarring is a common indication in which lasers play an important therapeutic role. Available lasers include traditional ablative lasers, such as carbon dioxide and erbium lasers, traditional non-ablative lasers, such as neodymium, diode, alexandrite, pulsed dye lasers and intense pulse light, as well as both ablative, and non-ablative fractional laser systems. We sought to provide a framework for understanding the various types of lasers available to treat acne scars and review the primary literature pertaining to the efficacy, safety, and advantages of each laser discussed.

A range of lasers with acceptably low rates of side effects is now available. Improved laser therapy has been made possible by combining wavelengths that are selectively absorbed by the target and pulses short enough to prevent heat transfer to surrounding tissue. Carbon dioxide (CO2) lasers are useful for treating disorders of skin surface texture and topography (wrinkles, scars, sun damage, benign skin appendages and rhinophyma). Vascular lasers, such as the flashlamp-pumped dye laser, are particularly effective for treating port-wine stains, haemangiomas, telangiectasia, rosacea and spider naevi. Q-switched lasers, which allow ultrashort high intensity pulses, are effective for treating most tattoos and some benign pigmented lesions.

Long aer Einstein proposed the theoretical concept of stimulated photon emission, Maiman built the rst laser in 1960.1 Dr. Leon Goldman then pioneered the use of lasers in dermatology.2,3 Treatment of basal cell carcinoma with ruby and neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers and tattoo removal with Q-switched ruby laser were reported in 1964 and 1965, respectively.4,5 However, surgical applications were limited because the high-power pulses emitted by these pulsed lasers were unable to perform controlled vaporization or coagulation of tissues. Ruby and other pulsed lasers were essentially abandoned when argon-ion and carbon dioxide (CO2) lasers were widely applied for coagulation and cutting during the 1970s. A new era began in dermatology during the early 1980s when Anderson and Parrish proposed a theory for target-selective injury with pulsed lasers, called selective photothermolysis.6 A 450 µs yellow dye laser was initially developed for treating port-wine lesions, the rst laser cavity design intrinsically3.1 Historical Introduction ......................................................................67 3.2 Skin Optics ...........................................................................................68 3.3 Laser-Skin Interactions .....................................................................69

Background: The term sialolithiasis refers to the condition in which a major or minor salivary gland's duct contains one or more calcified structures. Carbon dioxide (CO2) lasers have recently emerged as a minimally invasive option for intraoral therapy of submandibular sialoliths. CO2 lasers minimize postoperative discomfort, scarring, and recovery time by allowing for precision lithotomy with minimum harm to surrounding tissues. Methods: The purpose of this study was to examine the literature and report on two surgical cases of submandibular sialolithiasis treated with carbon dioxide (CO2) lasers. The calculi in both cases were palpable intraorally and were situated in the distal portion of the submandibular duct. Under local anesthesia, surgery was done in an outpatient environment. To uncover and remove the calculi, a CO2 laser was used to make a linear incision in the floor of the mouth at the Wharton's duct opening. Results: In a matter of minutes, the stone was extracted from both patients, resulting in full recovery and no unusual bleeding, nerve damage, or problems with the sublingual glands. Conclusion: We describe the benefits and efficacy of the CO2 laser in two patients who had successful surgical excision of significant salivary stones.

Laser tissue interaction in epidermal pigmented lesions.

Dermatology is one of the oldest medical disciplines where the laser has been used in routine clinical therapy. Tissue cutting and vaporization without bleeding, coagulation of heavily vascularized lesions or skin ablation are the modalities of laser applications. Some typical indications for laser treatment are port wine stain lesions of different colour, hemangioma, condylomata acuminata, tattoos, scars, carcinoma etc.. In the above chapters of this book the clinical potential of lasers in dermatology is extensively discussed. Are there still open questions and is there really a need for new types of lasers?