Plasma versus CO2: decision rests with patients
Toronto -- While plasma and CO2 laser resurfacing technologies each offer distinct advantages for perioral treatments, meeting patients' goals and preferences is the key to success, an expert says.
"CO2 laser skin resurfacing remains the gold standard for the treatment of deep lines and wrinkles in the perioral region," says Ross A. Clevens, M.D., F.A.C.S, a facial plastic surgeon in private practice at the Center for Facial Cosmetic Surgery in Melbourne and Merritt Island, Fla., and president of the Florida Society of Facial Plastic Surgery. However, he says, "Plasma skin resurfacing (Portrait PSR 3 , Rhytec) offers an excellent opportunity for substantial reduction in lines and wrinkles with a dramatically shorter healing period and downtime as compared with CO2 laser skin resurfacing "
In approaching the patient with perioral rhytids, Dr. Clevens says an important element of the consultation is learning what the patient seeks to achieve and what will make them happy.
If a patient wants his or her wrinkles gone or treated as thoroughly as possible with maximal results, he says, "CO2 laser skin resurfacing remains the treatment of choice. However, laser skin resurfacing carries certain drawbacks."
Typically, he notes, it takes seven to 10 days for re-epithelialization; 10 to 14 days until the patient can apply makeup; and up to three months for pinkness in treated areas to resolve. "A long-term and perhaps long-lasting risk of laser skin resurfacing is hypopigmentation," he adds.
If any of those risks prove unacceptable to the patient, says Dr. Clevens, "Then laser skin resurfacing is not a viable option; indeed, the patient's desired outcome of eradicating lines and wrinkles is not achievable" within the patient's parameters. By the same token, he adds that if a patient tends not to wear makeup, "Oftentimes laser skin resurfacing is an unacceptable option" due to the long-term potential for hypopigmentation.
Conversely, Dr. Clevens says that plasma skin resurfacing offers two modes, each with less downtime than is associated with CO2 lasers. The first is a low-energy treatment consisting of three sessions spaced about a month apart. "Each of those sessions is associated with a day or two of healing, and very transient redness, on the order of a few days," he states.
Plasma skin resurfacing also can deliver a single high-energy treatment, says Dr. Clevens. At the higher energy level, he says patients usually experience three to six days' healing time. "The patient can apply makeup within five to seven days," Dr. Clevens adds, "and the patient is mildly pink for two to three weeks."
Alternately, he reveals that he sometimes follows up high-energy treatments with a second pass at either the high or low energy level, delivered during the same session to address individual wrinkles. "If one treats the deeper wrinkles with a second high-energy pass," he says, "one gets better improvement than one would with a single pass."
To date, Dr. Clevens says he has treated approximately 100 patients with plasma skin resurfacing and has been very pleased with its results. With this modality, he states, "We can get a very good -- perhaps not excellent or great -- reduction in lines and wrinkles, with a procedure that offers a substantially shorter recovery period and does not carry a risk of pigmentary change."
In contrast, he says that when done properly, laser skin resurfacing remains "a home run with respect to lines and wrinkles." To extend the baseball metaphor, says Dr. Clevens, "Plasma skin resurfacing is a double or triple, with a lot less work." Accordingly, he frequently tells patients that choosing between the two is "not a question of what's better -- it's a question of which treatment modality offers a portfolio of healing times, risks and downsides relative to the patient's desired outcome."
Which modality patients choose also depends somewhat on factors including geography and demographics, Dr. Clevens says. "In Central Florida's Sunbelt ," he explains, "my patients often are extensively sun-damaged." Such patients tend to split 50-50 between CO2 lasers and plasma resurfacing treatments, he adds.
"But as one looks to the older patients with more sun damage and wrinkles," Dr. Clevens says, "more patients select laser skin resurfacing." In younger patients with less extensive damage (and perhaps less use of makeup) who may desire some skin tightening effect, though, he says plasma resurfacing dominates.
By the same token, he says male patients, who represent 10 to 20 percent of his resurfacing cases, typically choose plasma skin resurfacing. "In a male patient," Dr. Clevens explains, "one does not want to create hypopigmentation" or the need to wear makeup.
Other resurfacing treatments range from at-home glycolic peels and treatments delivered by aestheticians to photofacials, microdermabrasion and deeper chemical peels. "This really represents a continuum of expected outcomes that we can offer patients relative to expected recoveries, downtimes and risk profiles," he says. As with laser or plasma skin resurfacing, Dr. Clevens adds, "It's a matter of figuring out where the patient stands relative to their desired outcome," balanced against the risks and downtime they're willing to tolerate.
"My approach to the perioral region in general is that numerous aging changes affect the area around the mouth. It's not only lines and wrinkles" that one must address, he notes. As the perioral region ages, in addition to the formation of lines and wrinkles, the pink lips become thinner, the white upper lip lengthens, the corners of the lip become downturned and the nasolabial folds deepen. Rather, he says, " To rejuvenate the perioral region successfully, the surgeon should consider a variety of procedures in addition to resurfacing such as fillers or grafts to soften the nasolabial folds or to plump the lips, surgical lip lift or corner of the lip lift."
"There are a number of anatomical elements in the perioral region. Often, these are neglected. Many physicians think that if one uses lasers or another resurfacing modality around the mouth, one makes patients look younger, which is not true," he says. For such reasons, Dr. Clevens says he often performs plasma skin resurfacing in conjunction with other rejuvenative procedures for the perioral region.