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Therapeutic Guidelines
for Using the
KLS Martin MCO Plus Laser
with Scanner System
Report
Laser- und Medizin-Technologie GmbH
6450667
Berlin, August 2005
Table of Contents
Page:
1
Introduction ............................................................................................4
2
Technical Data of the MCO Plus CO2 Laser System ...........................5
3
Preclinical Evaluation of the MCO Plus CO2 Laser System ...............7
3.1
Using the Scanner with the 127-mm Scanner Handpiece...................7
3.2
Using the Scanner with the 200-mm Scanner Handpiece...................10
3.3
Using the Scanner with the Micro Point Micromanipulator ................10
3.4
Summary .................................................................................................11
4
Principles of Clinical Application of the MCO Plus CO2 Laser
System.....................................................................................................12
4.1
Range of Clinical Indications ................................................................12
4.2
Laser Parameter Selection and Laser Settings ...................................13
4.3
General Information on Preparatory Measures ...................................18
4.4
Required Protective Measures and Auxiliary Devices ........................20
5
Clinical Applications of the MCO Plus System (Examples)................22
5.1
Laser Skin Resurfacing..........................................................................22
5.2
Treating Scars ........................................................................................30
5.2.1
Atrophic Scars........................................................................................30
5.2.2
Hypertrophic Scars / Keloids ................................................................34
5.3
Treating Skin Dyschromias ...................................................................38
5.4
Treating Actinic Keratoses ....................................................................41
5.5
Treating Actinic Cheilitis .......................................................................44
5.6
Treating Seborrhoeic Warts and Hyperkeratoses ...............................47
5.7
Treating Viral Warts (Common and Plantar) ........................................49
5.8
Dermabrasion of Pilose Nevi.................................................................52
5.9
Treating Tongue Tumors .......................................................................55
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5.10
Treating Oral Leukoplakias ...................................................................57
5.11
Treating Benign Skin Tumors ...............................................................59
5.12
Treating Semimalignant and Malignant Skin Tumors .........................62
5.13
Palliative Treatment of Skin Metastases ..............................................64
6
Summary .................................................................................................66
Annex
Laser Therapy Information Sheet & Declaration of Consent
Clinical Use of the MCO Plus System (Illustrations)
3
1
Introduction
With the MCO Plus CO2 laser, users are offered an advanced version of the already
clinically proven MCO laser system. This upgraded system is available in two
models: the MCO 50 Plus with a maximum output power of 50 W, and the
MCO 25 Plus with a maximum output of 25 W.
The MCO 50/25 Plus CO2 lasers can be used for both tissue cutting (using a
focused beam in continuous-wave mode) and superficial, large-scale skin ablation
(in which case a scanner is required). These systems allow you to treat a whole
variety of superficial or deeper lesions encountered in dermatology, plastic surgery,
ENT and gynecology.
Thanks to the wide range of parameter settings available, which allows fine-tuning
the laser to suit specific surgical requirements, the MCO Plus can be considered an
“intelligent system”.
With its three different scanning speeds, the SoftScanPlus scanner represents an
innovative solution. The option to alternate between slow and fast scanning cycles –
a feature implemented in a CO2 system for the first time – goes far beyond the
performance level of conventional ablation. The fast scanning cycle allows users to
reduce the thermal impact on the surrounding tissue to a minimum, thus keeping
the postoperative healing phase as short as possible. A slower scanning cycle, in
turn, increases the thermal impact on the tissue, thus allowing hemostasis as a
result of superficial tissue coagulation.
Another innovative solution is the optional use of the SoftScanPlus scanner in
conjunction with different handpieces and micromanipulators.
4
2
Technical Data of the MCO Plus CO2 Laser System
Manufacturer:
KLS Martin GmbH + Co. KG
Type:
MCO 50 Plus (MCO 25 Plus)
Wavelength:
10,600 nm
Max. output power:
50 W (MCO 50 Plus) or 25 W (MCO 25 Plus)
Scanner:
SoftScanPlus
- This integrated, programmable scanner can be used for controlled superficial
tissue vaporization, using one of two different scanner handpieces (127 mm or
200 mm) or micromanipulators (“Mini Point” or “Micro Point”)
- Scanning patterns available in 6 different shapes, 7 sizes and 4 positions
- Control functions integrated into the laser unit’s display screen
- Scanner can be set to three different scanning speeds:
L = low
M = medium
H = high
Dwell-times range from 0.15 to 1.2 ms, depending on the scanning speed
selected.
127-mm scanner handpiece
- Size (diameter) of the different scanning patterns freely selectable across a range
of 2 to 8 mm
The selectable minimum and maximum energy densities for the 127-mm scanner
handpiece are specified in Table 1 (separately for 50-W and 25-W lasers).
5
Table 1:
Minimum and maximum energy densities for the 127-mm
handpiece
Version
Scanning
Maximum
Maximum
Minimum
Minimum
speed
output power
energy density
output power
energy density
L
50 W
48 J/cm²
10 W
9.6 J/cm²
M
50 W
24 J/cm²
10 W
4.8 J/cm²
H
50 W
12 J/cm²
10 W
2.4 J/cm²
L
25 W
24 J/cm²
10 W
9.6 J/cm²
M
25 W
12 J/cm²
10 W
4.8 J/cm²
H
25 W
6 J/cm²
10 W
2.4 J/cm²
MCO50
Plus
MCO25
Plus
200-mm scanner handpiece
- Size (diameter) of the different scanning patterns freely selectable across a range
of 3 to 13 mm
The selectable minimum and maximum energy densities for the 200-mm scanner
handpiece are specified in Table 2 (separately for 50-W and 25-W lasers).
Table 2:
Minimum and maximum energy densities for the 200-mm
handpiece
Version
MCO50
Scanning
Maximum
Maximum
Minimum
Minimum
speed
output power
energy density
output power
energy density
L
50 W
19 J/cm²
10 W
3.9 J/cm²
M
50 W
9.7 J/cm²
10 W
1.9 J/cm²
H
50 W
4.8 J/cm²
10 W
1 J/cm²
L
25 W
9.7 J/cm²
10 W
3.9 J/cm²
M
25 W
4.8 J/cm²
10 W
1.9 J/cm²
H
25 W
2.4 J/cm²
10 W
1 J/cm²
Plus
MCO25
Plus
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3
Preclinical Evaluation of the MCO Plus CO2 Laser System
The preliminary tests were designed to investigate the scanner’s ablation quality for
different energy densities and different scanning patterns, using the available
scanner handpieces (127 mm and 200 mm) and the Micro Point micromanipulator.
In this process, we also determined the optimal parameters for subsequent clinical
applications of the laser.
3.1
Using the Scanner with the 127-mm Scanner Handpiece
The preliminary tests showed that the beam quality of the MCO Plus is excellent
when using the SoftScanPlus scanner with the 127-mm handpiece (Fig. 1).
Fig. 1:
Macroscopic image of the ablation quality for different scanning patterns
(127-mm handpiece, 25 W, 12 J/cm², scan diameter 6 mm, “medium” (M) scanning speed;
ablation performed on a wooden spatula using a single laser pulse in each case).
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The SoftScanPlus generated highly uniform ablation results for all scanning patterns
and all energy densities, irrespective of whether a wooden spatula or turkey tissue
was used for performing the test. No carbonization was found in any of the tests.
The thermal impact on the tissue depended on the energy density and the scanning
speed selected. In other words, the higher the energy density, the higher was the
thermal impact on the surrounding tissue, even though the zone of damage was
found to be only minimal in any such case. By using the high (“H”) scanning speed,
the thermal impact on the deeper tissue layers could almost be eliminated
(Figs. 2a–2c, 3 and 4a–4c).
2a
2b
2c
Figs. 2a–c: Microscopic image of the ablation quality for different output power settings
and scanning speeds (127-mm handpiece, scan diameter 3 mm,
ablation performed on a wooden spatula): a) 50 W, b) 25 W, c) 10 W;
scanning speed in each case (from left to right): “low” (L), “medium” (M), “high” (H);
one lasing cycle.
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Fig. 3:
Macroscopic image of the ablation quality for different output power settings and scanning
speeds (127-mm handpiece, scan diameter 5 mm, ablation performed on muscle tissue
(turkey): 1st line: 50 W, 2nd line: 25 W, 3rd line: 10 W; scanning speed from left
to right: “low” (L), “medium” (M), “high” (H); three laser pulses used in each case.
4a
4b
4c
Figs. 4a–c: Microscopic image (cross section) of the ablation quality for different output power
settings and scanning speeds (127-mm handpiece, scan diameter 5 mm,
ablation performed on muscle tissue (turkey): a) 50 W, b) 25 W, c) 10 W;
scanning speed from left to right: “low” (L), “medium” (M), “high” (H);
three laser pulses used in each case.
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3.2
Using the Scanner with the 200-mm Scanner Handpiece
The ablation quality was found to be high and uniform also when using the
SoftScanPlus with the 200-mm handpiece. Thus, the preliminary tests confirmed the
excellent beam quality of the MCO Plus in this case as well (Fig. 5).
Fig. 5:
Macroscopic image of the ablation quality for different scanning patterns
(200-mm handpiece, 50 W, 9.7 J/cm², scan diameter 12 mm, “medium” (M) scanning
speed; ablation performed on a wooden spatula, using one laser pulse in each case).
Again, the depth of the ablation and the width of the skin damage zone depended
on the energy density and scanning speed selected. By selecting the high (H)
scanning speed for the scanner, the thermal damage could be kept to a minimum.
3.3
Using the Scanner with the Micro Point Micromanipulator
To examine the SoftScanPlus results achieved with the micromanipulator during the
preliminary tests, we connected the micromanipulator to a surgical microscope with
a focal distance of 200 mm (Opmi/Zeiss product). While beam centering (“center
on” function) proved difficult at first, this task could be mastered with training and
increasing experience. Although the pilot beam image seemed to be less than
satisfactory, the macroscopic examination showed ablation results (performed on a
wooden spatula) that were actually better than could be expected from the pilot
beam image.
10
With the focal distance used, a maximum scan diameter of 3 mm could be used for
all scanning patterns. However, larger scanning pattern sizes would be possible for
greater focal distances.
The minimum output power available was 10 W. With the low (“L”) scanning speed,
this resulted in an energy density of 9.6 J/cm², the medium (“M”) speed
corresponded to 4.8 J/cm² and the high (“H”) speed to 2.4 J/cm². Ablation quality
was good and the ablation rate seemed adequate for clinical use in the ENT area.
The low (“L”) scanning speed led to a slight blackening on the wooden spatula, but
this effect could be prevented by selecting a higher speed.
When using the scanner in repetition (“cycle”) mode, ablation could be performed
fast even when using larger scanning patterns.
3.4
Summary
The preliminary tests showed that the MCO Plus laser with the SoftScanPlus
scanner system provides excellent beam quality. Ablation with the SoftScanPlus
proved highly uniform irrespective of the energy density used. No carbonization was
found in any of the tests. The thermal impact on the tissue was minimal and could
be almost totally prevented by using the high (“H”) scanning speed.
The system allows high-precision and uniform tissue ablation.
Thanks to the wide range of laser parameters available for work, the system can be
used either for fast and deep tissue ablation or for superficial ablation with a
negligible thermal impact, depending on the therapeutic objective.
With its innovative design and the flexible use of the scanner with different
handpieces on the one hand and micromanipulators on the other hand, the
MCO Plus CO2 laser system with its maximum output power of 50 or 25 W
(depending on the model used) represents a truly unique solution. Thanks to its
special features, the MCO Plus outperforms any CO2 laser system currently
available on the market.
In addition, the price-performance ratio of this laser is also significantly more
attractive than that of any other CO2 laser system available on the market.
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4
Principles of Clinical Application of the MCO Plus
CO2 Laser System
4.1
Range of Clinical Indications
Thanks to the wide range of tissue effects that can be achieved with it, the
MCO Plus CO2 laser can be used for tissue cutting as well as for superficial tissue
ablation.
In specific, the laser can be successfully used for the following indications:
• Esthetic-medical indications (laser skin resurfacing):
- superficial and medium-depth peeling
- wrinkle treatment
- acne scar treatment
- treatment of skin dyschromias (discolorations)
• Clinical indications:
- benign skin tumors
- actinic keratoses
- seborrhoeic warts
- viral warts (common and plantar warts, acuminate condylomatas (pointed
warts))
- scars and keloids
- leukoplakias
- semimalignant and malignant skin tumors
- palliative treatment of metastases
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4.2
Laser Parameter Selection and Laser Settings
The clinical result of the laser application depends on the indication, the localization
of the surgical site, the laser parameters selected and the degree of user
experience in handling the system.
Users who wish to take full advantage of the many different ablation options offered
by the MCO Plus CO2 laser and SoftScanPlus scanner system must be fully familiar
with the effects the laser generates on the tissue. The corresponding knowledge
and know-how is available through numerous basic and special training courses on
the medical use of the laser.
The following sections are intended to give users an overview of the laser settings
that play an essential role when using the MCO Plus laser system for different
clinical tasks. The settings are discussed in the sequence of their arrangement on
the laser unit’s display screen.
Operating mode
The MCO Plus CO2 laser can be used for tissue cutting in one of three modes:
continuous-wave (CW), pulsed or superpulse. Due to its excellent quality, the
focused laser beam allows precise tissue resection. With the pulsed and superpulse
modes, the user can eliminate the thermal impact on the edges of the cutting canal
almost completely, although it should be borne in mind that this goes along with a
partial loss of the laser’s coagulation properties. Therefore, the continuous-wave
mode should be used for resections involving highly vascularized tissue because
this mode guarantees sufficient hemostasis. The pulsed and superpulse modes, in
contrast, are recommended for surgical tasks requiring precision cutting of poorly
vascularized tissue.
To use the MCO Plus CO2 laser for superficial tissue ablation, the scanner mode
can be activated simply by selecting the preferred scanning pattern on the laser’s
display screen.
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Scanning pattern
Since the system offers a whole range of different scanning patterns for selection,
the ablation can be optimally matched to the lesion to be treated. Where the lesion
is small and round, either the round or the hexagonal pattern might be most
appropriate. And where large-surface ablation is indicated, confluent square
scanning pulses might yield the best results. The ring-shaped scanning pattern
would be optimal for treating atrophic acne scars because this pattern allows you to
limit ablation to the margin of the scar. However, the usual scanning patterns can be
useful for special indications as well.
Scanning pattern size/diameter
Each of the available scanning patterns can be adjusted in size to optimally suit the
task at hand. When using the 127-mm scanner handpiece, the scanning pattern can
be adjusted in millimeter steps across a range of 2 to 8 mm. With the 200-mm
handpiece, the same variation is possible across a range of 3 to 13 mm. Thus, the
size of the ablation pattern can be fine-tuned to the lesion to be treated. This feature
proved to be especially useful when dealing with extensive (large-surface) lesions
because the use of large scanning patterns shortens operating times significantly.
Output power and energy density
The output power/energy density selected are the determining factors for ablation
depth. The laser calculates the energy density automatically, based on the power
level and scanning speed selected (see below). The lower the output power or
energy density selected, the more superficial will be the ablation effect. Conversely,
ablation depth increases with increasing output power or energy density.
By selecting the most adequate power level, the user can increase ablation
precision as well as optimize the efficiency of the therapy. In other words, the
ablation process can be strictly limited to the affected tissue.
14
It is generally recommended to start the therapy with low energy levels (between 4
and 7 J/cm²) for testing purposes. Depending on tissue response, the power level
can then be increased as appropriate. This careful procedure is especially indicated
for inexperienced users. With increasing experience, the therapy may well be
started with energy densities of 6 to 10 J/cm². Subsequently, the energy density
level can be increased or decreased in accordance with tissue response.
Where thicker lesions (such as plantar warts) need to be treated, it is generally safe
to start the therapy with higher energy densities to increase ablation efficiency and
shorten operating times.
Scanning speed
Thanks to an innovative solution, the MCO Plus CO2 laser gives users the unique
option of controlling the thermal impact on the deeper tissue layers. Conventional
scanner-based CO2 laser systems offer only a single scanning speed. The
MCO Plus laser, in contrast, offers three different scanning speeds: L (low), M
(medium) and H (high).
The high scanning speed allows reducing the thermal impact to a minimum.
Therefore, this speed is recommended for esthetic applications or for facial or
oral/mucosal lesion ablation.
The medium (“M”) speed is most appropriate for clinical indications where the
surgical site is located on the trunk or extremities, as well as for well vascularized
lesions, because the thermal effect of the CO2 laser guarantees efficient hemostasis
when selecting this speed setting.
The low (“L”) speed should be used only for thick and well vascularized lesions. As
a rule, it should be clear that the zone of thermal damage increases with the length
of time the tissue is exposed to the laser radiation. The result can be long-persisting
postoperative reddening, but the risk of scar formation also increases with exposure
time.
Figures 6a–d show in-vivo skin ablation results when using different output power
settings and scanning speeds, together with the condition of the surgical site two
weeks and three months after the operation. As can be easily seen, the use of high
15
power settings leads to a significantly longer persistence of the postoperative
reddening, especially in conjunction with the low scanning speed.
Interval (cycle pause)
The “cycle” option allows you to use the scanning pulses on a repetitive basis. The
interval (cycle pause) between the pulses can be set across a range of 10 ms to
2 s. The treatment speed can be significantly increased by reducing these intervals
to values between 20 and 40 ms. However, such short intervals can be
recommended only for users with sufficient experience in using the laser.
Additional comments
Ablation depth, which has great influence on the length of the healing phase,
depends not only on the energy applied, but on the number of lasing (scanning)
cycles as well. Therefore, similar to energy density selection, the cycle parameter
should always be determined by taking both the region to be treated and the
patient-specific skin properties into account. As a rule, lower energy densities, a
high scanning speed and a maximum of two cycles should be used for sites with a
relatively thin epidermis (such as the orbital region). In other regions, as well as for
patients with a thick epidermis, higher energy densities and several lasing cycles
can be used.
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6a
6b
6c
6d
Figs. 6a–c: Macroscopic images of in-vivo ablation using different power settings and scanning
speeds (127-mm handpiece, scan diameter 5 mm, ablation performed on forearm).
6a) Preoperative condition
6b) Condition immediately after the operation: 1st line: 50 W, 2nd line: 25 W,
3rd line: 10 W; scanning speed (from left to right): “low” (L), “medium” (M),
“high” (H); one pulse used in each case
6c) Condition two weeks after the operation
6d) Condition three weeks after the operation. The reddening is still visible
in areas where higher energy densities were used.
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4.3
General Information on Preparatory Measures
Each laser treatment represents an “operation” both in the medical and the legal
sense of the word. Therefore, the therapy must be carefully prepared and
performed with due diligence.
Indications
As a rule, laser treatment is permitted only for benign skin changes. Therefore, a
biopsy with histological examination of the tissue must be carried out in all cases of
doubt to confirm the diagnosis. Under certain conditions, however, the laser is also
used on semimalignant and malignant skin changes (including palliative indications,
inoperability, multiple tumors, advanced age of the patient and multimorbidity), as
laser treatment can be considered a minimally invasive procedure in most of these
cases.
Esthetic-medical therapies (such as treatment of geroderma or aged skin, wrinkles,
dyschromias or acne scars) constitute a special category. As there are no clinical
indications for such interventions and the therapy takes place only because the
patient wishes to be treated, it is mandatory for the physician to make a careful riskbenefit assessment beforehand.
Preparing the patients
Prior to treatment, it is important to carry out a skin diagnosis along with an
anamnesis. Inasmuch as esthetic indications are concerned, the potential benefits
and limitations of the treatment should be discussed with the patients. Patients with
unrealistic expectations should not even be admitted to treatment.
As a rule, patients must be thoroughly informed about the therapeutic procedure at
least 24 hours prior to the intervention, including any pretreatment and follow-up
treatment involved, any potential immediate or later consequences of the therapy,
as well as all the potential complications and side effects. This instruction must be
documented in writing (see “Laser Therapy Information Sheet” contained in Annex).
18
Especially where esthetic indications are concerned, the law requires the physician
to provide clear and unreserved information. The systemic use of retinoids and the
presence of plastic implants in the facial region constitute contraindications, due to
unacceptably high side-effect and complication rates. The side-effect and
complication rates are also comparatively high for patients with a proneness to
postinflammatory hyperpigmentation or keloid formation.
We recommend photographic documentation before and after treatment.
Preparing the surgical site
Before starting the intervention, the skin must be thoroughly cleaned with water and a
mild soap. In this process, any make-up residues should be carefully removed as
well.
A colorless disinfectant should be used for disinfection. According to our experience,
0.5% chlorhexidine solution can be recommended for this purpose. Alternatively, we
have also used Octenisept solution recently for disinfecting the surgical site and this
has also generated good results.
Our experience shows that the use of low energy densities (2.9 to 4.8 J/cm²) in
combination with the high (H) scanning speed is almost painless for the patients so
no anesthetics are required under these conditions.
For superficial skin ablation with energy densities of up to 12 J/cm² applied in one
lasing cycle, local anesthesia with EMLA cream is usually sufficient. This cream
should be extensively applied to the surgical site in a thick layer for approximately
one hour prior to the operation. Where deeper ablation (with correspondingly higher
power densities and several lasing cycles) is required, local anesthesia should be
used.
For clinical indications, local infiltration anesthesia is sufficient in most cases. Only
in cases where the findings are extensive, treatment is difficult for anatomical
reasons or the patient is a child should the intervention be carried out under general
anesthesia.
For further special preparatory measures for specific indications, please refer to
section 5.
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4.4
Required Protective Measures and Auxiliary Devices
As the MCO Plus CO2 laser is a Class 4 laser unit, it is mandatory to observe all
safety measures required for dealing with laser radiation strictly (see relevant
provisions such as accident prevention regulations (Germany: BGV B2)). It should
be particularly noted that improper handling can pose a fire and explosion hazard.
Before using a Class 4 laser for the first time, it must be registered with the
employers’ liability insurance association (social insurance for occupational
accidents) and the responsible industrial safety authority. Besides, a Laser Safety
representative must be appointed in writing.
The qualification of a Laser Safety representative, together with the requisite special
knowledge, can be acquired through recognized basic and subject-specific training
courses. For Germany, further information may be obtained from Laser- und
Medizin-Technologie GmbH, Fabeck-Str. 60–62, 14195 Berlin, phone: +49 30 84 49
23 0, fax: +49 30 84 49 23 99.
Non-observance of the safety instructions can pose a hazard, as laser radiation may
cause damage to the eyesight. Therefore, both the surgeon and other persons
present in the room must wear appropriate protective goggles during the laser
operation.
The eyes of the patient must also be protected from any radiation impact during
laser application. Commercially available protective metal lenses may be used for
this purpose, but as experience shows, such lenses tend to be badly tolerated by
patients. If they are used nonetheless, care must be exercised not to heat up the
metal when using the laser beam in the orbital area.
According to our experience, it is a good option to cover the patient’s eyes with
moistened gauze pads fixed in place with adhesive tape. When working in the
infraorbital region, the swab over the respective eye is removed and the eye covered
with a metal spatula that can be simultaneously used for pressing the eyelashes
upwards to keep them out of the way. To make sure that eye damage is definitely
prevented, the assistant can pull the skin below the eye a little downwards in
addition.
20
During laser treatment, a smoke evacuator should be switched on to remove any
burn-off products from the surgical site.
It has proved helpful to use a light with integrated magnifying glass during the laser
treatment because this enhances the precision of the ablation procedure due to the
fact that small lesions are better visible, any overlapping of the laser pulses can be
avoided and the color of the skin layer to be removed can be assessed more reliably.
21
5
Clinical Applications of the MCO Plus Laser System
(Examples)
5.1
Laser Skin Resurfacing
One of the most important indications for using the CO2 laser for esthetic medical
purposes is skin rejuvenation by laser skin resurfacing. In this field, the CO2 laser
(used in conjunction with the scanner) provides a good alternative to conventional
methods so far used for esthetic indications, such as dermabrasion by using a
reamer, or chemical peeling (with phenol, trichloroacetic acid or fruit acids). The
procedure can be used either independently or in combination with blepharoplasty
(for skin treatment in the lower eyelid region), or together with endoscopic
metopoplasty (plastic surgery of the forehead). Full face resurfacing following facelifting procedures improves the final esthetic result by producing rejuvenated skin,
based on a preceding surgical correction. Especially the surgical procedure in
conjunction with laser skin resurfacing has set a new standard in the fields of
esthetic medicine and plastic surgery.
In these cases, the laser treatment can cover the whole face (full face resurfacing)
or just specific regions (particular anatomical units such as the frontal, oral or
infraorbital regions). The CO2 laser with scanner allows the targeted ablation of the
epidermal layers down to the papillary layer of the corium. Extremely thin dermal
layers can be removed over a large surface area in a process that is exactly
controllable and hemorrhage-free, thanks to the CO2 laser’s additional coagulative
effect.
Skin rejuvenation is achieved as a result of the following three basic mechanisms:
• wrinkles or “shoulders” (elevated edges) of creases are directly ablated
(mechanical planing);
• the tissue is tightened (smoothened) due to contraction of the collagenous fibers
(so-called “collagen shrinking”) as a result of the slight thermal effect of the laser;
• the wound healing processes lead to a regeneration and restructuring of the
collagen fibers.
Histologic changes resulting from laser skin resurfacing are classified according to
their dermal penetration depth. After the laser wound has healed, it stimulates the
22
formation of fibrous tissue (fibroplasia) and the development of blood vessels
(angiogenesis) in a process working its way up into the upper reticular dermis,
which results in collagen restructuring and the regeneration of dermal elastic fibers.
Whereas the epidermal healing phase is fully completed two weeks after laser skin
resurfacing has taken place, the dermal changes described may take up to six
months. Two weeks after the laser ablation, signs of fibroplasia are already clearly
visible; three months after the laser treatment, the process of recollagenization sets
in, accompanied by a reduction in the dermal glycosaminoglycans (which are
typically found in degenerative elastic dermis). Thus, the histological changes after
laser therapy resemble those associated with the phenol-based peeling technique,
with the important difference that laser skin resurfacing is less detrimental to the
function of melanocytes – which means a lower risk of permanent postoperative
hypopigmentation.
The laser systems commonly used for laser skin resurfacing are based either on a
CO2 laser (pulsed or continuous-wave (cw), with scanner) or a pulsed Er:YAG laser.
However, whereas the CO2 laser also allows efficient deeper ablation (in one or
several scanning cycles, depending on parameter selection), the Er:YAG laser can
only be used efficiently for single-cycle ablation of superficial skin layers. Due to the
high absorption of its radiation in water, the ablation rate of the Er:YAG laser
decreases with each subsequent cycle. Consequently, the CO2 laser covers a
significantly wider range of indications. Moreover, the CO2 laser produces a highly
uniform ablation surface when used with scanner, whereas the Er:YAG laser, due to
its unbalanced beam profile, is less effective in the periphery of the laser spot than it
is in the center of the beam. This is exactly why this laser requires some overlap
between pulses.
Thanks to its special features, the MCO Plus CO2 laser system is highly suitable for
superficial skin ablation, especially where esthetic/cosmetic indications are
concerned. Given appropriate parameter selection, the MCO Plus allows the removal
of very thin skin layers at ablation rates that are comparable to those of an Er:YAG
laser. Besides, the MCO Plus ensures extremely even, uniform ablation. And by
using the high (H) scanning speed, the thermal impact on the deeper tissue layers
can be kept to a minimum while, at the same time, the residual thermal impact is still
23
high enough to induce collagen shrinking. For this reason, the MCO Plus can be
particularly recommended for esthetic indications such as wrinkle treatment.
Indications
Unlike chemical peeling on the one hand or dermabrasion on the other hand, laser
skin resurfacing can be used for a wide range of patients because no allergic or
incompatibility reactions have ever been observed with, or reported for, this
technique. Therefore, laser skin resurfacing can be used for any patient with wrinkles
or geroderma (aged skin). Any type of facial lines – creases as well as wrinkles – can
be successfully treated with the laser to improve the condition. However, this cannot
be said for the throat/neck region, where the laser treatment poses a considerable
risk of scars and leads to postoperative reddening that persists for months, thus
making this therapy inappropriate.
Laser skin resurfacing has been successfully used worldwide for a number of years
for treating sun-damaged as well as aged skin. Results are best for skin types
Fitzpatrick-I and Fitzpatrick-II, although good results have been reported for
Fitzpatrick classes III and IV as well. In contrast, patients with a dark complexion
show a higher risk of postinflammatory hypopigmentation or hyperpigmentation.
Preparing the patients
Adequate preparation of the patient is a factor of utmost importance for successful
treatment. Following skin diagnostics (which should include the general skin status,
symptoms of increased exposure to sunlight, skin care, smoking habits and working
conditions), patients are classified according to Fitzpatrick category and a thorough
anamnesis is carried out. Apart from systemic diseases, this includes existing
allergies, lip herpes occurrences and wound healing problems.
One of the most crucial “counseling issues” is setting a clear objective for the
treatment. This means that both the potential benefits and the limitations of the
chosen method should be thoroughly discussed with the patient. Detailed information
24
on the procedure itself, any follow-up treatment required and potential complications
must be provided at least 24 hours before starting the intervention and must be
documented in writing (see Annex). It is advisable to document the preoperative and
postoperative conditions by photos.
Potential complications include reddening and swelling, but these symptoms are of a
temporary nature. In should be noted, however, that the reddening may persist for up
to six months in extreme cases (depending on the depth of the ablation and the
energy density used), although it usually subsides after two to four weeks. As
sunlight can lead to hyperpigmentation of the treated areas, direct exposure must be
avoided for at least four weeks after the laser intervention. Where appropriate, the
use of a sunblock or cosmetic covering the treated area should be recommended as
a protective measure, to be applied during the convalescence phase following
epithelialization.
For the majority of patients, no antibiotic prophylaxis is required. Patients with a
history of recurrent lip herpes can be treated with three 400-mg daily doses of
Aciclovir for 10 days, starting one day before the operation takes place. This should
usually be enough to prevent the infection from being reactivated.
To ensure uniform pigmentation during the healing phase, the literature recommends
skin pretreatment with an agent that can inhibit the melanogenesis process (e.g. with
2% hydroquinone cream and vitamin A acid). For patients with Type I or Type II skin,
the pretreatment should be started two weeks before the resurfacing operation takes
place; for patients with a darker complexion, it should be started even four to eight
weeks in advance. It must be said, however, that there are no standardized studies
available which could be cited in support of the effectiveness of such pretreatments.
Patients should not be wearing any make-up when they come to the doctor’s practice
to have the operation carried out. Before starting the intervention, the skin must be
thoroughly cleaned with water and a mild soap. During this process, any make-up
residues should be carefully removed as well.
25
For disinfecting the surgical site, a colorless disinfectant should be used (e.g. 0.5%
chlorhexidine or Octenisept solution).
For superficial laser skin ablation in the sense of a peeling – which is carried out at
low energy densities (2–7 J/cm²) in one scanning cycle – local anesthesia with EMLA
cream is usually sufficient. This cream should be applied extensively to the surgical
site in a thick layer approximately one hour before the intervention is started. For
deeper ablation (with higher energy densities and several lasing cycles), injection of a
local anesthetic (e.g. 1–2% Xylocain) may be indicated. If the operation is to take
place in sensitive regions such as the oral cavity, nerve block anesthesia (carried out
via the oral mucosa) has proved useful.
Performing the therapy
Superficial peeling
The laser can be used for superficial skin ablation in the sense of a peeling. In this
case, the entire facial skin surface is lased with the MCO Plus CO2 laser in a single
cycle, selecting an energy density of 2–7 J/cm² (scanning pattern: square or
polygonal, diameter 7–8 mm; cycle mode, pause 0.4 s). The individual laser pulses
should be applied confluently but without overlap. Upon completion of the scanning
cycle, the ablated (vaporized) skin layer is gently wiped away with a gauze pad
saturated with NaCl solution, applying just a little pressure. The 200-mm handpiece
enables you to use scanning patterns with a diameter of up to 13 mm, which
significantly shortens operating times and allows even more uniform ablation of larger
surfaces.
Deep peeling / removal of wrinkles
Where the wrinkles are deep, a two-step procedure is used. The first step consists in
vaporizing the elevated edges or “shoulders” of such folds with the CO2 laser (energy
density 7–14 J/cm²; scanning pattern: square, line-type or polygonal, diameter 3–
4 mm; cycle mode, pause 0.4 s). Again, the individual pulses should be applied
confluently but without overlap. The lased skin layer is then gently removed with a
gauze pad saturated with NaCl solution.
26
In a second cycle, the overall skin surface is laser-treated (vaporized), using the
square or polygonal scanning pattern with a relatively large diameter (6–8 mm for the
127-mm handpiece, or up to 13 mm for the 200-mm handpiece). This can cover
either the entire facial region (full face resurfacing) or just a defined anatomical unit
(for partial resurfacing, e.g. the forehead, oral region or orbital area). Where lines run
deeper, this process is repeated, wiping away the top skin layer with a gauze pad
saturated with physiological salt solution after each lasing cycle.
The energy density to be selected depends on the surgical site as well as on the
patient-specific skin properties. As a rule, regions with a relatively thin epidermis
(such as the orbital region) should be lased with relatively low energy densities (4–
7 J/cm²), limiting the treatment to a maximum of two ablation cycles. Accordingly,
higher energy densities (7–12 J/cm²) and 2 or 3 lasing cycles can be used in all other
regions as well as for patients with a relatively thick epidermis. Using the high (H)
scanning speed allows minimizing the thermal impact on the deeper skin layers, thus
speeding up the healing process. Besides, the postoperative reddening will subside
faster when using the high scanning speed. It is advisable to begin with a trial cycle
(initial laser exposure) in each case to determine the optimal patient-specific
parameters, starting with the lowest energy density recommended for the given
indication and then slowly increasing the energy density to the appropriate level.
To be able to stop the treatment at exactly the right point, it is important to check the
penetration depth visually after each lasing cycle. Once the evaporated skin layer has
been removed with the NaCl-saturated pad, the penetration depth can be roughly
assessed by the color of the respective layer. Whereas the epidermis has a rosy
appearance, the surface assumes a grayish color underneath the basal membrane,
and the papillary layer of the dermis appears a shiny yellow. It should be noted,
however, that the risk of scars increases when ablating down to this skin layer.
Therefore, lasing should be stopped when reaching this layer – even if some wrinkles
should remain. To avoid the risk of causing hypertrophic scars, it is better to perform
a second laser treatment at a later stage.
If the treatment is limited to specific anatomical units, the non-treated skin margins
should be lased at a lower energy density in order to ensure a smooth transition.
27
Follow-up treatment
Immediately after the intervention, the wound should be treated with pure petrolatum,
to be applied to the lased skin region in a thick layer. After returning home, patients
should continue this treatment at regular intervals (every 1–2 hours), gently working
the jelly into the treatment site. This prevents the formation of hard crusts that might
crack, thus causing additional injuries. During the first two days, a serous liquid will
be excreted from the treated skin areas. These excretions should be dabbed off with
a sterile pad.
In some cases, especially in connection with partial resurfacing, the application of
semiocclusive wound dressings (e.g. Spyrosorb®) proved beneficial in the first few
postoperative days. Such dressings close the wound and absorb the exudate.
Closed wound dressings (Flexan® or Second Skin®) are usually used after full-face
laser resurfacing. These dressings have a pain-relieving effect in addition to
preventing exudation and limiting eschar formation. Their disadvantages must be
seen in the fact that they are difficult to apply and must be frequently renewed, since
otherwise a potential infection might be overlooked.
In contrast to this, open wound care is easy to carry out and allows early wound
cleaning as well as easy wound inspection. However, the question of whether to use
occlusive dressings or open wound care is a matter of personal preference and
should have no bearing on the result of the therapy as long as the patient is well
monitored.
Follow-up checks should be carried out on an outpatient basis on the first, third and
seventh postoperative days. This can include wound irrigation with hydrogen
peroxide solution to dissolve any fine, yellowish-brown scab that might have
developed. Thereafter, the wound is additionally treated with petrolatum.
The use of make-up or a similar means for covering the postoperative erythema is
not permitted until the wound has closed up. Otherwise, there would be a risk of
infection and impairment of the wound healing process.
The next check should be carried out 4–6 weeks after the treatment.
28
In the case of very deep, sunken creases, an additional local injection (e.g.
Zyderm®/Zyplast® or Hylaform®) can be taken into consideration.
In certain cases, especially when the patient’s skin has already lost much of its
elasticity, combining the laser therapy with a face-lift can enhance the esthetic
result.
29
5.2
Treating Scars
Scars are either atrophic (involving a loss of substance, such as acne scars),
hypertrophic or keloidal. In contrast to hypertrophic scars, which are characterized
by excessive growth that remains nonetheless limited to the area of the original
defect, keloids typically show highly excessive, tumorous growth reaching beyond
the margins of the original defect area.
5.2.1 Atrophic Scars
Atrophic scars are usually small, circumscribed and recessed. This type of scar is
frequently caused by conglobate acne, varicella infection, necrotizing zoster or
bacterial folliculitis.
Indications
Best suited for ablation with the CO2 laser and scanner are flat and bowl-shaped or
tiny, sharply circumscribed scars with an overall depth of no more than 1 mm. Here,
laser ablation results in a flattening out of the peripheral wall, thereby aligning the
base of the scar to the level of the surrounding tissue – which is why good esthetic
results can be achieved in these cases. Some deeply recessed, fibrous scars can
be improved with this method.
Preparing the patient
It is essential to discuss the objective of the intervention with the patient in sufficient
detail. In some cases, the patient’s wish to have all scars removed may require an
invasive procedure. Patients should be aware, however, that too deep an ablation
(past the papillary dermis) would increase the risk of postoperative scar formation.
Therefore, the ablation depth should be based on a trade-off between an acceptable
cosmetic result and the risk of unwanted side effects of the therapy.
30
The patient must be given detailed information on the procedure itself, any follow-up
treatment required as well as potential complications at least 24 hours before starting
the intervention and this instruction must be documented in writing. Potential
complications include reddening and swelling, both of which are transient in nature. It
should be noted, however, that the reddening may persist for up to six months in
extreme cases (depending on the depth of the ablation or the energy density used),
although it usually subsides after two to four weeks. As exposure to sunlight can lead
to hyperpigmentation in the treated areas, direct exposure must be avoided for at
least four weeks after the laser intervention. If indicated, a sunblock or covering
cosmetic should be used during the convalescence phase following epithelialization.
Prior to the intervention, the skin must be thoroughly cleaned with water and a mild
soap.
A colorless disinfectant (e.g. 0.5% chlorhexidine or Octenisept solution) should be
used for disinfecting the skin surface in the surgical site.
For superficial scar treatment with the CO2 laser, local anesthesia with EMLA cream
is usually sufficient. This cream should be applied to the surgical site extensively in a
thick layer for approximately 30–60 minutes before the operation is started. For
deeper ablation, we recommend injecting a local anesthetic.
In a first step, the peripheral walls of the scars are vaporized with the CO2 laser and
the scanner (energy density 7–14 J/cm²; cycle mode, pause 0.4 s). This is done
either by running the polygonal scanning pattern, diameter 3–4 mm, along the edges
of the scar, or by using the ring-shaped pattern if the scar has the right size, thereby
ablating the peripheral wall with one laser pulse (energy density 7–14 J/cm²). A NaClsaturated pad is then used to wipe the vaporized skin layer gently away.
In a second lasing cycle, the skin surface is ablated on a larger scale (partial or full
face resurfacing), using the same parameters settings. In this process, the individual
31
laser pulses should be applied confluently (spot by spot) but without overlap. Where
scars run deeper, the process is repeated, gently removing the uppermost (ablated)
skin layer with a gauze pad saturated with physiological saline solution after each
lasing cycle.
The energy density to be selected depends on the region to be treated as well as on
the patient-specific skin characteristics. As a rule, regions with a relatively thin
epidermis (such as the orbital region) should be ablated at lower energy densities (4–
7 J/cm²), limiting the treatment to a maximum of two scanning cycles. For all other
regions, as well as for patients with a relatively thick epidermis, higher energy
densities can be applied in two or three lasing cycles, using the 5–6 mm square or
polygonal scanning pattern. It is advisable to begin with a test cycle (initial laser
exposure) in each case to determine the optimal patient-specific parameters, starting
with the lowest energy density recommended for the indication and then slowly
increasing the energy density or output power to the level most appropriate for the
further treatment of the patient.
penetration depth visually after each lasing cycle. Once the vaporized layer has been
carefully removed with a NaCl-saturated pad, the penetration depth can be roughly
assessed by the color of the respective skin layer. It should be borne in mind that
deep ablation (down to the papillary dermis) increases the risk of scars. Therefore,
the laser treatment should be stopped when reaching this layer – even if scar
residues must be left in place. It is better to perform a second laser treatment than
taking the risk of causing new scars.
When limiting the treatment to specific anatomical units, the margins should be lased
at a lower energy density to ensure a smooth transition to non-treated areas.
For facial therapies, the fast (“H”) scanning speed should be used because this
allows you to reduce the thermal impact on the deeper tissue layers significantly, thus
shortening the postoperative healing phase. Besides, the postoperative reddening
subsides faster as well.
32
Follow-up treatment
Immediately after the intervention, the wound is treated with pure petrolatum. This
should be applied to the lased skin region in a thick layer. Back at home, the patients
should continue this treatment at regular intervals (every 1–2 hours), gently working
the jelly into the treated area. This prevents the formation of hard crusts that might
crack, thus causing additional injuries. During the first two days, a serous liquid will
be exudated from the treated skin areas. These excretions should be dabbed off with
a sterile pad.
For treatment areas other than the face, Diprogenta cream (or a similar ointment) in
combination with compresses can be used for wound treatment.
In some cases, the application of semiocclusive wound dressings (e.g. Spyrosorb®)
proved beneficial in the first few postoperative days. Such dressings close the wound
and absorb the exudate.
Follow-up checks should be carried out on an outpatient basis on the first, third and
seventh postoperative days. This can include wound irrigation with hydrogen
peroxide solution to dissolve any fine, yellowish-brown scab/eschar that might have
developed.
The next check should be carried out 4–6 weeks after the operation.
In the case of very deep, sunken scars, an additional local injection (e.g.
Zyderm®/Zyplast® or Hylaform®) can enhance the cosmetic result.
33
5.2.2 Hypertrophic Scars / Keloids
Hypertrophic scars can be the result of skin injuries (such as burns, mechanical
injuries or surgical incisions). Typically, these lesions are elevated on the skin
surface but remain restricted to the original defect area. As regards coloration, this
can range from skin-colored to reddish (due to increased vascularization).
Hypertrophic scars can be strongly itchy, but can also cause pain at rest or on
pressure.
If reddening and itching are the main problems, laser treatment with an argon, KTP
or flash-lamp-pumped, pulsed dye laser can help to remove these symptoms. In
some cases, an ablative procedure may, in principle, also be used, provided that
the treatment is performed with care in order not to cause any new scars. Following
laser ablation, adjuvant measures are required in the form of systematic and
continued compression treatment, use of glucocorticosteroid injections (e.g. “Volon
A” crystal suspension) or silicone film or silicone gel (e.g. Zeraderm gel).
Keloids are true proliferations with excessive collagenation. They tend to occur,
either spontaneously or as a result of skin injury (e.g. pierced ears), especially in
persons with a genetic disposition for keloid formation (keloidosis). As this keloidal
risk is particularly high in adolescents, surgical interventions should preferably be
carried out either before or after puberty.
Like hypertrophic scars, reddened keloids can also be treated with the dye, KTP or
argon laser. Highly exophytic keloids can be ablated with the CO2 laser to remove
any excess tissue and bring them down to skin level. Keloid ablation down to skin
level is recommended because this enhances the effectiveness of any subsequent
therapy (cryotherapy, compression therapy and/or silicone-film or silicone-gel
therapy) and reduces the treatment time in addition.
Our experience shows that good esthetic results can be achieved by laser ablation
of hypertrophic scars or keloids if this is combined with subsequent long-term
treatment with a silicone gel (such as Zeraderm® gel).
34
Indications
Selected cases of hypertrophic scars or keloids, with the objective of reducing the
exophytic tumorous growth.
The objective of the intervention must be thoroughly discussed with the patient. It
should be clear that the ablation procedure can only improve the appearance of the
affected skin region but cannot restore skin health. The subsequent adjuvant therapy
should be performed on a systematic basis, since otherwise there would be a high
risk of a recurrence in the treatment area.
Detailed information on the procedure itself, any follow-up treatment required as well
as potential complications must be provided to the patient at least 24 hours before
starting the intervention and must be documented in writing. Direct exposure to
sunlight must be avoided for at least four weeks after the laser operation. If indicated,
a sunblock or covering cosmetic should be used during the convalescence phase
following epithelialization.
Prior to the intervention, the skin must be thoroughly cleaned with water and a mild
soap. A colorless disinfectant (e.g. 0.5% chlorhexidine or Octenisept solution) should
be used for disinfecting the skin surface of the surgical site.
In most cases, this CO2 laser therapy must be carried out under general anesthesia,
due to patient age and/or invasiveness of the intervention. However, where the skin
changes to be treated are small and flat, injection of a local anesthetic (e.g. 1–2%
Xylocain) may be sufficient.
35
The exophytic tissue is ablated with the CO2 laser in several scanning cycles (energy
density 7–14 J/cm²; polygonal scanning pattern, diameter 4–6 mm; cycle mode,
pause 0.4 s). In this process, the individual laser pulses should be applied confluently
but without overlap. After each scanning cycle, the vaporized layer is gently wiped
away with a gauze pad saturated with saline solution, applying just a little pressure.
As soon as the level of the healthy skin is reached, the final scanning cycle should be
performed at a lower energy density (4–7 J/cm²; high (H) scanning speed; cycle
mode, pause 0.4 s) without any overlap between the individual pulses, in order to
keep the thermal stress as low as possible for the underlying tissue. Using the high
(H) scanning speed also minimizes the thermal impact on the deeper skin layers,
thus speeding up the healing process. Besides, the postoperative reddening will
subside faster when using the high scanning speed.
The optimal energy density and required number of lasing cycles depend on both the
thickness of the exophytic tissue and the patient-specific skin properties. It is best to
determine the optimal parameters for each patient by performing a test lasing cycle.
penetration depth visually after each lasing cycle. When treating only specific
anatomical units, the margins should be treated at a lower energy density to ensure a
smooth transition to non-treated skin areas.
Follow-up treatment
Immediately after the intervention, the wound should be treated with Diprogenta
cream and a dressing. The dressing should be renewed after two days.
Provided no scabs are left, the Zeraderm® gel therapy can be started after approx.
14 days.
The treated skin region should be thoroughly cleaned with a neutral soap solution or
clear water and then carefully dried. Subsequently, a small quantity of Zeraderm® gel
is applied and gently worked into the treatment area in a circular motion to form a
36
very thin protective layer. Once the gel has dried, it works as a semiocclusive, waterrepellent yet air-permeable, permanently elastic film. Excess gel can be removed with
a clean towel. If applied to the face, the usual make-up can be put on once the gel
has dried completely. The gel should be applied twice every day, preferably in the
morning and evening, for at least six months.
37
5.3
Treating Skin Dyschromias
Most superficial pigment disorders can be successfully treated by way of a
superficial CO2 laser peeling. This can be a local form of laser peeling (i.e. limited to
the pigmentation itself) or an extensive one, including the entire face (e.g. in the
case of diffuse dyschromia). A deep resurfacing is seldom required for treating
pigmentation disorders. This technique has the additional advantage that pigments
accumulated on the basal membrane are also dissolved during epidermal
regeneration. In this way, the spotty skin condition caused by photoaging can be
improved.
Indications
Laser treatment of pigmental lesions is permitted only for benign skin changes. If
the nature of the pigmented skin change is in any way doubtful, a biopsy with
subsequent histological examination is indicated to exclude malignancy.
Thus, facial dyschromias caused by photoaging and localized benign pigmental skin
changes (such as senile lentigo or liver spots) represent the main indications for
CO2 laser treatment.
It is of utmost importance to base the treatment on a reliable diagnosis of the skin
change in question.
The patient must be given detailed information on the procedure itself, any follow-up
treatment required and potential complications at least 24 hours before starting the
intervention. Such instruction must be documented in writing. Direct exposure to
sunlight must be avoided for at least four weeks after the laser treatment. If indicated,
a sunblock or covering cosmetic should be used during the convalescence phase
following epithelialization.
38
Patients should not be wearing any make-up when they come for a facial operation.
Prior to the therapy, the skin must be thoroughly cleaned with water and a mild soap.
During this process, any make-up residues should be carefully removed as well. For
disinfecting the surgical site, a colorless disinfectant should be used (e.g. 0.5%
For superficial laser skin ablation in the sense of a peeling – which is performed at
low energy densities (4–7 J/cm²) in one cycle – local anesthesia using EMLA cream
is usually sufficient.
In the case of localized skin changes, a local anesthetic (such as 1–2% Xylocain) can
be injected if required.
Superficial facial peeling
Diffuse facial dyschromias can be treated with the CO2 laser in the form of a “peeling”
(i.e. superficial skin ablation). In this case, the entire facial skin surface is lased with
the MCO Plus CO2 laser in a single cycle and at an energy density of 4–7 J/cm²
(scanning pattern: square or polygonal, diameter 7–8 mm, high (H) scanning speed;
cycle mode, pause 0.4 s). The individual laser pulses should be applied confluently
but without overlap. Upon completion of the scanning cycle, the vaporized skin layer
is gently wiped away with a NaCl-saturated gauze pad, applying just a little pressure.
39
Local treatment of benign pigmental lesions
In this case, only the pigmented lesion as such is scanned with the MCO Plus CO2
laser in one or several lasing cycles, using an energy density of 7–14 J/cm²
(scanning pattern: square or polygonal, diameter 3–8 mm (depending on the skin
change); cycle mode, pause 0.4 s). The individual laser pulses should be applied
confluently but without overlap. After each scanning cycle, the vaporized skin layer
should be gently removed with a NaCl-saturated gauze pad, applying just a little
pressure.
Using the high (H) scanning speed minimizes the thermal impact on the deeper skin
layers, thus speeding up the healing process. Besides, the postoperative reddening
will subside faster when using the high scanning speed.
Follow-up treatment
Immediately after the intervention, the facial wound is treated with pure petrolatum.
This jelly should be applied to the lased skin region in a thick layer. After returning
home, the patients should continue this treatment at regular intervals (every 1–2
hours), gently working the jelly into the treatment site.
For non-facial regions, Diprogenta cream and an adhesive dressing may be used for
wound care.
After large-scale ablation in the facial area, follow-up checks should be carried out
on an outpatient basis on the first, third and seventh postoperative days.
40
5.4
Treating Actinic Keratoses
Actinic keratoses are classified as epithelial dermal precanceroses. Initially a
lentiform spot, they develop into a yellowish, slightly scaly lesion with a slightly
rough surface. Whether and when an actinic keratosis develops into an invasive
squamous carcinoma cannot be determined with certainty. It is estimated that
approximately 20% of the patients with multiple actinic keratoses also suffer from
invasive squamous-cell carcinomas and that, in the long term, actinic keratoses
which are not treated adequately tend to develop into invasive squamous
carcinomas in 15–20% of all cases.
The objective of treating epithelial dermal precanceroses consists in a complete
removal of the epithelial lesion. For small and localized foci, surgical excision is the
method of choice. The histological preparation can subsequently be used to check
whether or not the lesion has been completely removed. Where multiple lesions are
involved, a whole number of other therapeutic methods should be taken into
consideration (e.g. CO2 laser therapy, cryotherapy, curettage, electrodesiccation,
chemical cauterization, local chemotherapy, local application of vitamin-A acid). CO2
laser therapy offers the advantage of a hemorrhage-free intervention in which the
various epithelial skin layers can be ablated one after the other in a highly controlled
manner. Besides, this therapy is easy to perform for extensive lesions and in
anatomically difficult locations. However, it is essential to corroborate the diagnosis
histologically before starting the treatment.
Indications
Multiple
non-carcinous
superficial
lesions
malignancy).
41
(after
histological
exclusion
of
Detailed information on the procedure itself, any follow-up treatment required as well
as potential complications must be provided to the patient at least 24 hours before
starting the intervention and must be documented in writing. Potential complications
include reddening and swelling, both of which are transient in nature. As sunlight
exposure can lead to hyperpigmentation in the treated areas, direct exposure must
be avoided for at least four weeks after the laser intervention. If indicated, a sunblock
or covering cosmetic should be used during the convalescence phase following
epithelialization.
For disinfecting the skin surface of the area to be treated, a colorless disinfectant
should be used (e.g. 0.5% chlorhexidine or Octenisept solution).
For superficial skin ablation with the laser – which is performed at low energy
densities (4–7 J/cm²) in one lasing cycle – local anesthesia using EMLA cream is
usually sufficient.
Where localized skin changes are to be treated, a local anesthetic (such as 1–2%
Xylocain) can be injected.
Where multiple facial lesions are involved, the laser can be used for large-scale
superficial skin ablation. In this case, the entire surface of the face is scanned with
the MCO Plus CO2 laser in one cycle, using an energy density of 4–10 J/cm²
(scanning pattern: square or polygonal, diameter 7–8 mm; cycle mode, pause 0.4 s).
The individual laser pulses should be applied confluently but without overlap. After
completion of the lasing cycle, the vaporized skin layer should be gently wiped away
with a NaCl-saturated gauze pad, applying just a little pressure.
42
If one scanning cycle is not enough to remove all lesions completely, a second,
targeted cycle can be added with the treatment parameters unchanged.
Isolated lesions are locally ablated in one or two lasing cycles (depending on the
depth of the lesion). The individual laser pulses should be applied confluently but
without overlap. After each cycle, the vaporized skin layer is gently wiped away with a
NaCl-saturated gauze pad, applying just a little pressure and verifying complete
removal each time.
Follow-up treatment
Immediately after the intervention, the facial wound should be treated with pure
petrolatum.
Wound care with Diprogenta cream in combination with an adhesive plaster is an
alternative option that can also be used after non-facial local treatment.
In cases of extensive facial skin ablation, follow-up checks should be carried out on
an outpatient basis on the first, third and seventh postoperative days. This may
include irrigation of the skin surface with hydrogen peroxide solution to dissolve any
fine, yellowish-brown eschar that may have developed. Thereafter, the wound is
treated with petrolatum.
The condition should be checked again 4–6 weeks after the therapy. If residues are
found, the laser therapy may be repeated.
43
5.5
Treating Actinic Cheilitis
Actinic cheilitis means actinic damage in the red margin of the lip, whereby the
lower lip is mainly affected. The various forms of actinic cheilitis are distinguished by
their differing appearance, clinical features and treatment options. Both acute and
chronic actinic cheilitis belong to the inflammatory lip diseases. Abrasive cheilitis
with its unclearly circumscribed erosive foci and leukoplakic changes constitutes a
typical precancerosis that mainly occurs in fair-skinned patients after chronic
exposure to sunlight. For both chronic and abrasive cheilitis, the CO2 laser with
scanner system can be therapeutically used to ablate the superficial layers of the
labial lesion. Especially the MCO Plus could be regarded here as a very gentle,
tissue-friendly procedure since it allows ablating very thin layers with a minimum of
thermal damage to the surrounding tissue.
To exclude an invasive carcinoma, it is mandatory to carry out a biopsy with
subsequent histological examination before deciding on laser treatment.
Indications
The cosmetic results are excellent for laser ablation of actinic cheilitis. Recurrences
can be laser-treated again at any time. Due to its minimal invasiveness, along with
the advantage that the intervention can be carried out fast and on an outpatient
basis, the literature classifies laser therapy as the method of choice in cases of
actinic cheilitis.
44
Exact information on the procedure itself, any follow-up treatment required and
potential complications must be given to the patient at least 24 hours before starting
the intervention and must be documented in writing. Postoperative lip swelling is
normal and occasional bleeding and incrustation may occur as well, but these are
transient symptoms. As regards long-term side effects, there is a risk of local scar
formation, depending on the depth of the ablation.
Due to its great painfulness, the therapy is performed under local anesthesia.
To protect the teeth, a moistened pad should be inserted between the teeth and the
lips.
In this application, the surface of the red margin of the lip is lased with the MCO Plus
CO2 laser in one cycle, using an energy density of 4–7 J/cm² (scanning pattern:
polygonal, diameter 3 mm; high (H) scanning speed; cycle mode, pause 0.4 s). The
individual laser pulses should be applied confluently but without overlap. The
treatment should extend beyond the visible margins of the lesion. Upon completion of
the scanning cycle, the vaporized labial layer is gently wiped away with a NaClsaturated gauze pad, applying just a little pressure. After checking the depth of the
lesion visually, another lasing cycle can be added if necessary, using the same
parameters. The high (H) scanning speed allows minimizing the thermal impact on
the underlying tissue, thus speeding up the healing process.
45
Follow-up treatment
Immediately after the intervention, the labial wound is treated with pure petrolatum, to
be applied to the treatment site in a thick layer. Back at home, the patients should
continue this treatment at regular intervals (every 1–2 hours), gently working the jelly
into the treatment area.
Follow-up checks should be carried out on an outpatient basis on the first and third
postoperative days. The condition should be checked again 4–6 weeks after the
therapy. If residues are found, the laser treatment can then be repeated.
46
5.6
Treating Seborrhoeic Warts and Hyperkeratoses
Seborrhoeic warts or keratoses are among the most common skin changes of aged
skin.
Clinically,
the
lesions
appear
as
grayish-brown,
pigmented,
often
hyperkeratotic, flat nodes or plaques. In some cases, they can form large
papillomas of up to several centimeters and can occur scattered over the entire
body. Usually, the surface of seborrhoeic keratoses is irregularly verrucose. Due to
the typical appearance of the skin, diagnosis is easy, although biopsies with
subsequent histological examination are indicated in certain cases to exclude
melanomas or basalomas. Given a reliable clinical diagnosis, seborrhoeic warts can
be ablated with the CO2 laser and scanner. The MCO Plus CO2 laser has proved
especially useful for treating multiple seborrhoeic warts because, due to the gentle
procedure, the treatment can be repeated at regular intervals, in certain cases even
without an anesthetic. And unlike the conventional therapy using curettage, laser
ablation is hemorrhage-free and gives less frequently rise to recurrences.
Indications
Isolated or multiple seborrhoeic keratoses (after histological corroboration of the
diagnosis where indicated).
The patient should be given timely and comprehensive therapeutic information,
which should be documented in writing. Transient complications include swelling
and reddening. Recurrences cannot be ruled out even if the lesion appears to have
been completely removed.
47
Where localized skin changes are to be treated, injection of a local anesthetic (e.g.
1–2% Xylocain) is sufficient. According to our experience, treating multiple superficial
lesions without an anesthetic was well tolerated by the patients in individual cases.
In this case, the individual lesions are ablated with the MCO Plus CO2 laser in one or
two lasing cycles, using an energy density of 7–12 J/cm² (scanning pattern: square or
polygonal, diameter 4–8 mm (depending on the size of the skin change); cycle mode,
pause 0.4 s). Upon completion of each lasing cycle, the vaporized skin layer is wiped
away gently with a gauze pad saturated with NaCl solution, applying just a little
pressure. The high (H) scanning speed allows minimizing the thermal impact on the
underlying tissue, thus speeding up the healing process.
Follow-up treatment
Octenisept solution and adhesive plaster are used for wound care.
Should recurrences occur, the laser treatment can be repeated after 4–6 weeks.
48
5.7
Treating Viral Warts (Common and Plantar)
Warts are frequently occurring, benign, reversible epithelial hyperplasias caused by
human papillomaviruses (HPV). These skin changes can occur both as an isolated
case and in larger numbers, mainly in children and adolescents, but also in adults
with immunodeficiencies. Mostly, these lesions manifest themselves as pinheadsized to pea-sized, hard, skin-colored to grayish-yellow tumors with a roughened
surface, petechial hemorrhages and a central loss of reticulation (mosaic pattern). A
special form are the plantar warts, which tend to occur in pressure-loaded regions of
the sole of the foot. As, however, exophytic growth is not possible in these
locations, plantar warts typically develop inwards, thus causing pain and hindering
walking. A whole range of conservative measures are available for treating viral
warts (e.g. keratolytic measures, chemical cauterization, etc.). Should the
conservative treatment be unsuccessful, or the warts tend to recur, good results can
be achieved by ablating them with the CO2 laser with scanner.
Indications
The treatment of viral warts belongs to the most frequent indications for applying the
CO2 laser with scanner. Apart from common and plantar warts (verrucae vulgares et
plantares), the system can also be used for treating acuminate (pointed) warts.
Intensive keratolysis using occlusive salicylic acid plasters, carried out for
approximately four days prior to the laser treatment, is helpful. Pretreatment with
Acetocaustin (once per week, for four weeks) can also contribute to reducing
extensive lesions before removing them entirely with the CO2 laser in one session.
Prior to the treatment, the patient must be given the usual preoperative information
and this must be documented in writing.
49
If both feet are affected by plantar warts, only one foot should be treated per
session. As the therapy can cause profuse swelling in the treated foot, the patients
should provide for suitable shoes and a possibility for transportation.
A colorless disinfectant should be used for disinfecting the surgical site.
Due to its painfulness, the therapy is usually performed under local anesthesia. For
extensive conditions, however, regional or (occasionally) general anesthesia may
be required.
In this case, a high energy density (approx. 18–24 J/cm²) is required for ablating the
various lesions with the MCO Plus CO2 laser, using the polygonal or round scanning
pattern with a diameter of 3–6 mm (depending on lesion size). Several lasing cycles
are usually necessary to remove the mutated skin completely. Using the cycle mode
with a pause interval of 20–80 ms accelerates the ablation process. Should
hemorrhages occur, these can be treated with the defocused laser beam. The low (L)
scanning speed is also a good option to achieve hemostasis.
If plantar warts show exophytic growth, the hyperkeratosis can first be removed
flatly with a scalpel before ablating the deeper wart sections with the laser.
Follow-up treatment
Braunovidon cream is recommended for wound care, together with a compress
dressing that should be renewed after two days.
To prevent secondary bleeding (postoperative hemorrhages) when treating plantar
warts, the respective leg should be elevated for approximately half an hour after the
50
operation. The treated foot should not be over-exerted during the first few days after
the operation.
A follow-up check should be performed after 4–6 weeks.
Where necessary, the laser therapy can then be repeated.
51
5.8
Dermabrasion of Pilose Nevi
Pilose nevi are large congenital, pigmented, hairy nevi. Given the risk of
degeneration, it is imperative to remove such lesions completely. As this objective
cannot be achieved surgically where the lesions are large or located in anatomically
difficult sites, large-surface dermabrasion under general anesthesia, which can be
carried out with the CO2 laser, represents the method of choice for newborns and in
early infancy. This therapy should be performed as early as possible because the
depth of the nevus cell aggregates increases significantly with time.
Indications
Extensive pilose nevi in infants and lesions in patients with thicker pilose nevi in
exposed locations (e.g. in the facial region) if surgical removal is not possible.
Prior to treatment, a biopsy with histological examination should be performed to
exclude a malignant skin change.
The patient should be given timely and comprehensive therapeutic information and
this should be documented in writing. Transient complications include swelling and
reddening. A recurrence cannot be ruled out even if the lesion appears to have
been completely removed. The risk of scarring increases, the deeper the ablation. It
should also be noted that a potential degeneration of the lesion may be overlooked
when using this method.
The hair of a pilose nevus cannot be removed with the CO2 laser, but an epilation
laser can be used for this additional treatment. Besides, it may be necessary in some
cases to use another laser to remove any residual pigmentation. The benefits and
limitations of the therapy, as well as any necessity for a combination therapy using
different lasers, should be discussed with the patient or his/her parents prior to the
treatment.
52
For disinfecting the skin areas to be treated, a colorless disinfectant should be used
(e.g. 0.5% chlorhexidine or Octenisept solution).
Where localized skin changes are to be treated, a local anesthetic (e.g. 1–2%
Xylocain) may be injected. For extensive lesions and in early infancy, the laser
therapy should be performed under general anesthesia.
In this case, the affected skin area (pigmented lesion) is ablated with the MCO Plus
CO2 laser in one or several lasing cycles, using an energy density of 6–12 J/cm²
(scanning pattern: square or polygonal, diameter 4–8 mm (depending on lesion size)
when using the 127-mm scanner handpiece, or up to 13 mm for the 200-mm
handpiece; cycle mode, pause 0.4 s; medium or high scanning speed). The individual
laser pulses should be applied confluently but without overlap. After each scanning
cycle, the vaporized skin layer should be removed by gently wiping it away with a
NaCl-saturated gauze pad, applying just a little pressure.
It is best to begin with a trial cycle (initial laser exposure) in each case to determine
the optimal patient-specific parameters, starting with the lowest energy density
setting recommended for the indication and then increasing the energy density
(output power) to the appropriate level.
Follow-up treatment
Diprogenta cream and an adhesive dressing are recommended for wound care.
53
Follow-up checks with wound redressing can be carried out on an outpatient basis on
the second and fifth postoperative days.
After 4–6 weeks, the therapy can be repeated (or the next part of the lesion treated)
where required.
54
5.9
Treating Tongue Tumors
Benign, exophytic tongue tumors (papillomas, fibromas) can be successfully treated
with the CO2 laser and the scanner. The objective of the therapy is to ablate the
tumor mass down to tongue surface level. The method can also be used palliatively
for treating exophytic malignant tumors.
Indications
Benign, exophytic tongue tumors with the aim of reducing the tumor mass after
biopsy and histological confirmation of the diagnosis.
Prior to treatment, an anamnesis and diagnosis of the tongue change should be
carried out.
In the same way as for any other surgical intervention, the patient must be given
timely and detailed information on the procedure itself, any follow-up treatment
required and potential complications.
Postoperative mucosal swelling in the treated region is normal, along with occasional
bleeding and incrustation, but these are temporary symptoms. As regards long-term
side effects, there is a risk of local scarring which increases with ablation depth and
size.
Where the condition spreads over a large area, a danger exists of the tongue
swelling profusely after laser treatment. In such cases, the patients should be under
intensive medical observation after the operation; where indicated, intubation should
be employed until the swelling has subsided.
55
Since the therapy is very painful, it is usually performed under general anesthesia.
Dentures should be removed prior to the therapy. During the therapy, the tongue is
held in a stretched position by the assistant with the aid of a moistened compress.
The surface of the lesion is scanned with the MCO Plus CO2 laser in one cycle, using
an energy density of 7–14 J/cm² (scanning pattern: polygonal, diameter 3–4 mm;
cycle mode, pause 0.4 s; medium (M) scanning speed). The individual laser pulses
should be applied confluently but without overlap. Upon completion of the scanning
cycle, the vaporized tongue surface layer is removed with a gauze pad saturated with
NaCl solution, applying just a little pressure. Depending on the depth of the lesion (as
judged visually), another scanning cycle can be added if necessary, leaving the
parameters unchanged. To close the superficial wound, we recommend performing
the final scanning cycle in defocused mode (i.e. with the handpiece at a greater
distance away from the mucosal surface than for ablation); this closes the wound
base by coagulation.
Follow-up treatment
Follow-up checks are carried out on an outpatient basis on the first and third
postoperative days.
Another follow-up check should then be performed after 4–6 weeks to remove any
possibly existing residues.
56
5.10
Treating Oral Leukoplakias
According to the 1978 WHO definition, leukoplakias are white mucosal patches or
plaques that cannot be wiped off and cannot be attributed to any known disease of
the oral mucosa. They are usually caused by chronic mechanical or chemical
irritation, and approx. 10% of them are classified as precanceroses. Ablation using
the CO2 laser with scanner enables a gentle and hemorrhage-free removal of such
superficial lesions. Prior to laser treatment, several biopsies may possibly have to
be taken in order to exclude an invasive growth.
Indications
Oral leukoplakias, based on a histological confirmation of the diagnosis.
In the same way as for any other operation, detailed information about the
therapeutic procedure, any follow-up treatment and potential complications must be
given to the patient at least 24 hours before starting the intervention and this must be
documented in writing.
Postoperative mucosal swelling in the treated area and occasional bleeding and
incrustation occur but are of a temporary nature. As regards long-term side effects,
there is a risk of local scarring that increases with ablation depth and size.
Since the therapy is very painful, it is performed under local anesthesia.
Dentures should be removed prior to the therapy. If necessary, the tongue should be
moved aside with a wooden spatula or a moistened compress in order to ensure free
access of the laser beam to the surgical site.
57
In this case, the mucosal surface is scanned with the MCO Plus CO2 laser in one
cycle, using an energy density of 4–12 J/cm² (scanning pattern: polygonal, diameter
3–4 mm; cycle mode, pause 0.4 s; high scanning speed, or medium speed if there is
a bleeding tendency). The individual laser pulses should be applied confluently but
without overlap. The treatment should extend beyond the visible margins of the
lesion. Upon completion of the scanning cycle, the vaporized mucosal layer is
removed by wiping it gently away with a gauze pad saturated with NaCl solution,
applying just a little pressure. Depending on the depth of the lesion (as judged
visually), another lasing cycle can be added if necessary, using the same
parameters.
Follow-up treatment
Follow-up checks are performed on an outpatient basis on the first and third
postoperative days.
Another check should then be carried out after 4–6 weeks to remove potential
recurrences. Regular follow-up is necessary.
58
5.11
Treating Benign Skin Tumors
A number of benign skin tumors can be removed by dermabrasion using the CO2
laser with scanner. These tumor types include:
Xanthelasmas
Clearly circumscribed, flat xanthomas not caused by any disorder of the lipid
metabolism. Clinically determined as flat nodules and plaques on the eyelids.
Syringomas
Benign sweat gland tumors that often occur on the lower eyelids, in rarer cases also
generalized and disseminated. Clinically determined as skin-colored to yellowishbrown papules.
Trichoepitheliomas
Benign hair follicle tumors that usually manifest themselves at an early adult age.
Clinically determined as skin-colored nodules, mostly located in the nasal region.
Neurofibromas
Benign nerve sheath (perineural) tumors. These neurofibromas are clinically
determined as hemispherical, exophytic, soft, skin-colored to brownish nodules and
nodes. The skin changes occur in multiple fashion in the case of neurofibromatosis
(Recklinghausen’s disease).
Rhinophyma
Bulbous swelling of the nose caused by exophytic tissue growth, mainly in older
patients suffering from rosacea.
59
Indications
Benign skin tumors as specified above, based on a histological corroboration of the
diagnosis where necessary.
As for any other operation, the patient must be given timely and exact information on
the procedure itself, any follow-up treatment and potential complications. This
instruction must be documented in writing.
Postoperative skin swelling in the treated region and occasional bleeding and
incrustation can occur but are of a temporary nature. As regards long-term side
effects, there is a risk of local scar formation that increases with ablation depth and
size.
For disinfection of the skin areas to be treated, a colorless disinfectant should be
used (e.g. 0.5% chlorhexidine or Octenisept solution).
In the case of superficial lesions, local application of EMLA cream may be sufficient.
The cream should be applied in a thick layer one hour before starting the operation.
In most cases, however, local or regional anesthesia is necessary. Extensive lesions
require treatment under general anesthesia.
The affected tissue is ablated with the CO2 laser in several scanning cycles (energy
density 4–14 J/cm²; scanning pattern as appropriate for the lesion to be treated (e.g.
round or polygonal), diameter usually 4–6 mm; cycle mode, pause 0.4 s). The
individual laser pulses should be applied confluently but without overlap. After each
lasing cycle, the vaporized layer is removed by wiping it gently away with a gauze
pad saturated with saline solution, applying just a little pressure.
60
The optimal energy density and required number of lasing cycles mainly depend on
the depth of the diseased tissue and the specific properties of the skin concerned.
penetration depth visually after each lasing cycle. When treating individual
anatomical units, the margins should be lased at a lower energy density to ensure a
smooth transition to the non-treated skin areas.
Follow-up treatment
Immediately after the intervention, Diprogenta cream and a dressing should be
applied to the wound. The dressing should be changed after two days.
A follow-up check should be carried out after 4–6 weeks. If residues are found,
these can then be removed with the laser.
61
5.12
Treating Semimalignant and Malignant Skin Tumors
Under certain conditions (incl. palliative indications, inoperability, multiple tumors,
advanced patient age, multimorbidity, difficult anatomical localization or size of the
lesion), laser therapy can also be used for semimalignant or malignant tumors that
normally have to be excised, followed by a histological examination for ensuring
their complete removal. In such cases, the MCO Plus CO2 laser with scanner allows
successful and high-precision ablation of the affected tissue layer by layer, due to
the fact that the depth and completeness of the removal can be controlled visually
and hemostasis is possible at the same time.
Indications
Among the tumors that can be treated in individual cases under the abovementioned conditions using the CO2 laser with scanner are localized basalomas or
basalomas of the basal-cell nevus (or Gorlin’s) syndrome, basalomas recurring after
previous operations or after cryotherapy, spinocellular carcinomas, Bowen’s
disease (carcinoma in situ, which can occur on any part of the skin including the
genital and perianal regions) and extramammary Paget’s disease.
As for any other operation, the patient must be given timely and detailed information
on the procedure itself, any follow-up treatment involved and potential complications.
This instruction must be documented in writing.
Postoperative swelling of the skin in the treated area and occasional bleeding and
incrustation can occur but are of a temporary nature. As regards long-term side
effects, there is a risk of local scarring that increases with ablation depth and size.
62
Since the treatment is very painful, it is usually performed under local anesthesia, but
general anesthesia may be indicated for extensive conditions.
The affected tissue is ablated with the CO2 laser in several lasing cycles (energy
density 10–18 J/cm²; medium scanning speed, polygonal or round scanning pattern
with diameter according to lesion size; cycle mode, pause 0.4 s). After each scanning
cycle, the vaporized layer is removed by wiping it gently away with a gauze pad
saturated with saline solution, applying just a little pressure. To ensure coagulative
sealing of the surgical site, a lower energy density (10–12 J/cm²; cycle mode, pause
0.4 s) and a defocused beam can be used for the final scanning cycle.
The choice of energy density and number of lasing cycles mainly depend on the
depth of the diseased tissue and the patient-specific skin properties.
penetration depth visually after each lasing cycle.
Follow-up treatment
Immediately after the intervention, Diprogenta cream and a dressing should be
applied to the wound. The dressing should be renewed after two days. Where
necessary, the therapy can be repeated after four weeks.
63
5.13
Palliative Treatment of Skin Metastases
The primary aim of treating regional metastases is the complete surgical removal of
all affected areas, including a safety margin. Where the number of regional
metastases is large, laser-surgical removal may be an option as well. Particularly in
the case of patients with multiple skin metastases of malignant tumors (e.g.
malignant melanomas, mammary carcinomas) that are beyond conventional
therapy, the CO2 laser with scanner can be used for palliative treatment. In this
case, the aim of the treatment is to remove all neoplastic cell nests as completely as
possible in order to restrict further metastatic spread. As this treatment is only
minimally invasive and can thus be administered repeatedly on an outpatient basis
under local anesthesia, it is especially beneficial for patients with a poor general
state of health because it enables the number of resections or courses of radiation
therapy to be reduced.
Indications
Superficial, small metastases are best suited for ablative laser treatment. Thanks to
the visual control, small lesions can possibly be removed completely.
It is mandatory to inform the patient about the procedure as well as alternative
treatment options.
Postoperative skin swelling can occur in the treated region, along with occasional
bleeding and scabbing, all of which are transient in nature. As regards long-term side
effects, there is a risk of local scarring that increases with ablation depth and size.
Despite the complete removal of the lesions (as judged visually), local recurrences
can occur.
64
Since the treatment is painful, it is usually carried out under local anesthesia. If many
metastases need to be treated in one session, or if ablation is difficult due to the
location of the surgical site, the treatment is performed under general anesthesia.
The affected tissue is ablated with the CO2 laser in several lasing cycles (energy
density 10–18 J/cm²; polygonal scanning pattern, diameter 3–4 mm; cycle mode,
pause 0.4 s). After each cycle, the vaporized layer is removed by wiping it gently
away with a swab saturated with saline solution, applying just a little pressure. The
final cycle can be in defocused mode at a lower energy density to ensure coagulative
sealing of the surgical site.
Follow-up treatment
Immediately after the intervention, the wound should be treated with Octenisept
solution and a dressing. The dressing should be changed after two days.
A follow-up check should be carried out after 4–6 weeks. If residues are found,
these can then be removed with the laser. Regular follow-up is necessary.
65
6
Summary
The MCO Plus CO2 laser system with scanner offers special features that enable its
reliable use for treating a variety of skin lesions. This includes thin, superficial lesions
just as much as extensive and deep-reaching ones, all of which can be successfully
removed (ablated) with this laser. A feature of special importance is the thermal
impact control offered by the system. Thanks to the innovative option of alternating
between low and high scanning speed, the user can take advantage of the CO2
laser’s thermal effect in one situation (e.g. for hemostasis), whereas ablation can also
be carried out more or less athermally in other cases. This flexibility ensures that the
system can be used for a wide range of diverse indications. The “athermal” feature is
particularly useful in cases where the cosmetic/esthetic result is of primary
importance. Besides, ablation with the MCO Plus is extremely uniform.
With its innovative solutions, the MCO Plus laser system represents a unique and
complex system that outperforms both conventional CO2 laser systems and Er:YAG
laser systems in terms of precision as well as efficiency. And last but not least, the
MCO Plus laser system impresses with its excellent price-performance ratio.
66
Annex
Laser Therapy Information Sheet
and Declaration of Consent
Name of patient_______________________________________________________
Date of birth____________________________________________________________
Address________________________________________________________________
Type and localization of treatment_________________________________________
________________________________________________________________________
On_______________________________, I was informed personally – and in a manner that
was clear to me – about the type, purpose and course of the operation, including the form of
narcosis (if required). I was also informed about the necessary steps to take before and after
the treatment and about the possible complications and risks.
Laser therapy is a recognized, low-complication and comparatively tissue-friendly treatment
method but nonetheless involves a few risks. Even if the therapy is performed correctly,
certain risks exist which are listed below:
1. Persistence or recurrence
2. Transient reddening and swelling
3. Eschar formation (scabbing)
4. Infections
5. Disturbed healing of the wound
6. Skin structure changes
7. Scarring
8. Pigmentation disorders (hypopigmentation or hyperpigmentation)
9. Other___________________________________________________________________
_______________________________________________________________________
The treated skin area may not be washed during the first three days after treatment. Any
scabbing that may form after the treatment may not be removed mechanically but should be
allowed to fall off on its own accord. Direct sunlight (also including the solarium) should be
avoided for two weeks before and at least six weeks after the treatment.
The costs of the therapy amount to EUR_____________ per session / in total.
I herewith apply for a course of treatment with a private doctor who is to invoice me as a
private patient.
I have had sufficient time and opportunity to consider my decision and now have no further
questions, since the questions I have asked have been fully answered such that I have
understood.
___________________, (date)_________
____________________________________
Signature of patient or parent/guardian
Clinical Use of the MCO Plus System
(Illustrations)
Treatment of dermal dyschromias
Fig. 1
Senile lentigo (liver spots) in the right eyebrow region, preoperative condition.
Fig. 2
Condition 5 weeks after treatment with the MCO Plus CO2 laser with scanner
(energy density 5 J/cm², scan diameter 4 mm, high (H) scanning speed,
two lasing cycles).
Treatment of actinic keratoses (I)
Fig. 3
Actinic keratoses (Type I skin), preoperative condition.
Fig. 4
two lasing cycles).
Treatment of actinic keratoses (II)
Fig. 5
Actinic keratoses on forehead, left upper lid and left cheek, preoperative condition.
Fig. 6
Condition immediately after treatment with the MCO Plus CO2 laser with scanner
(energy density 7.2–9.6 J/cm², scan diameter 4 mm, high (H) scanning speed,
two lasing cycles).
Fig. 7
Condition four weeks after treatment with the MCO Plus CO2 laser
Treatment of actinic keratoses (III)
Fig. 8
Actinic keratoses on forehead and capillitium, preoperative condition.
Fig. 9
two lasing cycles).
Treatment of actinic keratoses (IV)
Fig. 10
Actinic keratoses on upper arm, preoperative condition.
Fig. 11
(energy density 9.6 J/cm², scan diameter 5 mm, medium (M) scanning speed,
two lasing cycles).
Treatment of actinic cheilitis
Fig. 12
Actinic cheilitis, lower lip, preoperative condition.
Fig. 13
(energy density 4.8 J/cm², scan diameter 4 mm, medium (M) scanning speed,
two lasing cycles).
Treatment of benign skin tumors (I)
Fig. 14
Nasal wing fibroma, preoperative condition.
Fig. 15
four lasing cycles).
Treatment of benign skin tumors (II)
Fig. 16
Breast fibroma, preoperative condition.
Fig. 17
(energy density 9.6 J/cm², scan diameters 5 and 3 mm, medium (M) scanning speed,
Treatment of benign skin tumors (III)
Fig. 18
Verrucous nevus, breast region, preoperative condition.
Fig. 19
(energy density 6.9 J/cm², scan diameter 5 mm, high (H) scanning speed,
Treatment of seborrhoeic keratoses
Fig. 20
Multiple seborrhoeic keratoses in back region, preoperative condition.
Fig. 21
(energy density 12 J/cm², scan diameter 5–6 mm, medium (M) scanning speed,
several lasing cycles).
Fig. 22
Condition three weeks after the treatment.
Treatment of viral warts (I)
Fig. 23
Multiple warts in the hand and forearm regions.
Fig. 24
(energy density 12 J/cm², scan diameter 5 mm, medium (M) scanning speed,
Treatment of viral warts (II)
Fig. 25
Multiple warts in the region of the right wrist.
Fig. 26
Fig. 27
Condition two weeks after the treatment of multiple palmar warts.
Treatment of viral warts (III)
Fig. 28
Plantar warts in the left and right foot regions, preoperative condition.
Fig. 29
Fig. 30
Condition six weeks after the treatment. Warts significantly reduced in size.
The small residues can be removed in a second session.
Treatment of viral warts (IV)
Fig. 31
Plantar warts in the left foot region, preoperative condition.
Fig. 32
Treatment of viral warts (V)
Fig. 33
Warts in the right hand region, preoperative condition.
Fig. 34
Treatment of viral warts (VI)
Fig. 35
Infraorbital warts, preoperative condition.
Fig. 36
Gebrüder Martin GmbH & Co. KG
KLS Martin Platz 1 · D-78532 Tuttlingen
Postfach 60 · D-78501 Tuttlingen/Germany
Tel. +49 7461 706-0 · Fax +49 7461 706-193
[email protected] · www.martin-med.com
02.06· 90-287-02-04 · Printed in Germany · Copyright by Gebrüder Martin GmbH & Co. KG · Alle Rechte vorbehalten · Technische Änderungen vorbehalten
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