Department of Ophthalmology
University of Tennessee Health Sciences Center
250 25th Ave North 201
Nashville, TN 37203
Chestnut Hill, Mass
New York, NY
In their editorial "Laser Madness in Facial Plastic Surgery," Anderson and Yen1 offer their personal views of the current role of the carbon dioxide (CO2) laser in facial aesthetic surgery. As we are all aware, the practice of medicine often requires the individual interpretation of scientific data. In some areas, such as the treatment of certain malignancies, management of diabetic retinopathy, and the use of aspirin in reducing the risk of stroke, so many data have been gathered through large multicenter studies that there is little room for personal opinion by any individual practitioner. In other areas, this type of conclusive data does not exist either because long-term studies have not been performed or because the technique in question is heavily dependent on the skill, judgment, and experience of the individual physician. Techniques that work well for some may not for others. Examples of such areas include facial soft tissue augmentation and the use of the CO2 laser in aesthetic surgery. With regard to soft tissue incisional surgery, Anderson and Yen disparage the use of the CO2 laser, stating "the value of the CO2 laser as an incisional instrument has not changed greatly since its introduction in the mid-1970s." In expressing this opinion, the authors do not acknowledge the facts that state-of-the-art CO2 lasers today produce infrared light with a high peak power, short pulse width smaller by a factor of 10, compared with the lasers used a quarter century ago. These developments have reduced the amount of collateral thermal injury by a factor of 5 to 10.2 Laser wounds that are made parallel to relaxed skin tension lines, placed in anatomic regions with a rich blood supply and not closed under tension, heal in such a manner that they usually cannot be distinguished from wounds made with cold steel. That intraoperative hemostasis is improved during laser incisional surgery when performed by an experienced surgeon cannot be disputed. In stating their preference for steel scalpel surgery, the authors state that "zero collateral damage" is produced. They fail to consider the amount of thermal injury produced by the monopolar or bipolar cautery they surely must use, thus overdramatizing the contrast between incisional surgery performed with lasers and with cold steel. They also choose to ignore the fact that other alternatives to cold steel such as monopolar cautery with a micropoint tip and radiofrequency are used to perform soft tissue incisional surgery in aesthetic cases. All of these techniques are associated with a learning curve but there are absolutely no data to suggest that, when performed properly, any one technique is safer or more dangerous than others. We believe that it is the operating surgeon's duty to choose the incisional technique that, in his or her hands, consistently produces the best results safely. Whether that technique involves the use of a knife and cautery, radiofrequency unit, or CO2 laser is irrelevant.
Biesman BS, Dover JS, Arndt KA, Geronemus RG. Lasers in Facial Plastic Surgery. Arch Facial Plast Surg. 2002;4(4):270-271. doi: