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Treatment of Perioral RhytidesA Comparison of Dermabrasion and Superpulsed Carbon Dioxide Laser

Abstract

Objective  To directly compare the cosmetic outcome and adverse effects of dermabrasion and superpulsed carbon dioxide laser for the treatment of perioral rhytides.

Design  Subjects were randomly assigned to receive treatment with carbon dioxide laser resurfacing to one side of the perioral area and dermabrasion to the other side in a prospective, comparative clinical study. The duration of follow-up by blinded observers was 4 months.

Setting  University hospital-based dermatologic surgery clinic.

Patients  Fifteen healthy fair-skinned volunteers with moderate to severe perioral rhytides and no history of prior cosmetic surgical procedures to the same anatomic area.

Interventions  One half of the perioral area was treated with the LX-20SP Novapulse carbon dioxide laser (Luxar Corp, Bothell, Wash), and the other half was treated with dermabrasion using either a hand engine–driven diamond fraise or a medium-grade drywall sanding screen (3M Corp, St Paul, Minn).

Main Outcome Measures  Improvement in rhytides, patients' subjective reports of postoperative pain, time to reepithelialization, degree of postoperative crusting, and duration of postoperative erythema were observed for both methods. Standardized scoring systems were used to quantify outcome measures. Paired t tests were used for statistical comparisons of the 2 resurfacing methods.

Results  The difference in rhytide scores for the 2 methods was not statistically significant (P=.35) at 4 months. Less postoperative crusting and more rapid reepithelialization were noted with the dermabrasion-treated skin. Postoperative erythema was of longer duration on laser-treated skin. Patients reported less pain with dermabrasion treatment. Subtle differences that were difficult to quantify were also noted between the methods.

Conclusions  Both dermabrasion and carbon dioxide laser resurfacing are effective in the treatment of perioral rhytides. Both methods have unique advantages and disadvantages.

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PERIORAL RHYTIDES can be successfully treated with various resurfacing methods, including dermabrasion and carbon dioxide laser. Specific advantages and disadvantages of the 2 methods are well known.

Dermabrasion has a long history of success in the treatment of wrinkles and scars. It has recently fallen out of favor because many surgeons have found carbon dioxide lasers to be more predictable as to the depth of tissue injury, and lasers are easier to master. Advantages of dermabrasion include the relatively low cost of equipment. Disadvantages include potential exposure of health care personnel to blood-borne pathogens aerosolized by the dermabrading fraise.

Pulsed and scanned carbon dioxide laser methods also have potential risks. As with dermabrasion, scarring, infection, prolonged erythema, transient hyperpigmentation, and prolonged hypopigmentation are potential complications. Laser equipment is more costly to purchase and maintain. Risks to the operator include potential exposure to infectious agents in the laser plume and ocular injury when adequate safety precautions are neglected. However, there is less potential for blood exposure.

The dermabrasion and carbon dioxide laser methods have been compared in only a few published studies. Fitzpatrick et al1 found dermabrasion-treated skin and carbon dioxide laser–treated skin to have similar courses of healing both clinically and histologically in a porcine model.

The goal of our study was to directly compare the cosmetic outcome and complications of the 2 methods in human subjects. To control for intersubject variation, the 2 techniques were applied to opposite sides of the same anatomic area (the perioral area) in each subject.
 

PATIENTS AND METHODS
PATIENTS

Fifteen patients with rhytides around the mouth area were enrolled in the study to receive treatment with dermabrasion to one half of the perioral area and carbon dioxide laser resurfacing to the other half. Patients were recruited from the community via advertisements in local newspapers and from our dermatologic surgery practice at the Boston University Medical Center, Boston, Mass. Inclusion criteria were ages from 25 to 75 years, ability to provide informed consent in English, fair skin (Fitzpatrick skin phototypes I-III3), and symmetric rhytides in the perioral area. Exclusion criteria included a history of cosmetic surgery to the anatomic area, including resurfacing procedures (ie, laser, dermabrasion, and chemical peel), cosmetic tattoos, implantation of synthetic materials, and implantation of collagen or autologous fat within the past year. Additional exclusion criteria were active skin disease in the perioral area (ie, acne), immunosupression, human immunodeficiency virus (HIV) or hepatitis infection, diabetes mellitus, active psychiatric illness, tobacco use, bleeding disorder, history of poor wound healing or abnormal scarring, pregnancy, isotretinoin (Accutane; Hoffman-LaRoche, Nutley, NJ) use within the past 2 years, active herpes simplex infection at the time of surgery, and concurrent participation in other research studies. The Institutional Review Board for Human Research at Boston Medical Center approved our research project.dental laser handpiece

Potential enrollees were interviewed briefly over the telephone. If they met the inclusion and exclusion criteria and were interested in hearing more about the study, they were invited for a face-to-face interview and evaluation. Risks and benefits of the procedure were reviewed in detail at this time, and patients were given copies of consent forms. Rhytide scores and Fitzpatrick phototypes were determined. The rhytide score was determined based on comparison with a series of 5 standardized photographs showing wrinkles of increasing depths, grade 1 being the mildest and grade 5 the deepest. All patients returned for a final preoperative visit 2 to 3 weeks before the date of surgery. Consent forms were signed during this visit. Two weeks prior to surgery, each subject began a twice daily topical pretreatment regimen of 0.025% tretinoin cream (Retin-A; Ortho Pharmaceutical Corp, Raritan, NJ) at bedtime and 4% hydroquinone cream with sunscreens (Solaquin Forte; ICN Pharmaceuticals Inc, Costa Mesa, Calif). Subjects received oral doses of antiviral prophylaxis that consisted of famciclovir, 125 mg, or acyclovir, 400 mg, 2 times a day for 5 days beginning the day before surgery and oral doses of antibiotic prophylaxis that consisted of cephalexin, 250 mg, 4 times a day for 5 days beginning the morning of the surgical procedures.

CARBON DIOXIDE LASER AND DERMABRASION PROCEDURES

Both procedures were completed during the same treatment session. All patients received treatment on 1 of 2 consecutive days. A team of 2 physicians using uniform technique performed all procedures (K.A.H. and G.S.R.). Preoperative and immediate postoperative photographs of the perioral area were taken on the day of surgery using uniform photographic technique. The perioral area was anesthetized with a combination of infraorbital and mental nerve blocks and local infiltration with 0.5% lidocaine hydrochloride with epinephrine, 1:100,000. The skin was prepared with chlorhexidine gluconate. Damp gauze and sterile surgical towels were placed around the surgical field and over the patients' eyes.

The right and left halves of the perioral area were randomly assigned to receive 1 of the 2 procedures on the day of surgery. An envelope containing a specific assignment was opened for each patient. It was then sealed and placed in the patient's chart for the remainder of the study.

The carbon dioxide laser system used in the study was the LX-20SP Novapulse (Luxar Corp, Bothell, Wash). The Novascan E8 exposure program with a power setting of 5 W or 6 W was used for each pass. This program produces rapid superpulses of extremely short duration that are clustered together into bursts. The dwell time (pulse width) is approximately 500 microseconds. The fluence (energy density) is 4.24 J/cm2. A spinning pie-shaped 0.7-mm spot creates 3-mm circular scans. Each scan is completed in 60 milliseconds. The operator keeps the handpiece in continuous motion so that minimal overlap occurs between adjacent scans. The scans were delivered at frequency of 8 per second. With the power settings used, 300 to 360 mJ was delivered with each scan. Two passes were completed to the entire treatment area. A third pass was completed to the shoulders of any residual rhytides. Devitalized tissue was removed using saline-soaked gauze between passes. No subject received more than 3 passes.

Dermabrasion was performed on 8 patients using an engine-driven 17 × 8-mm cylinder-shaped coarse diamond fraise (Robbins Instruments Inc, Chatham, NJ). On the remaining 7 patients, dermabrasion was performed using a medium-grade drywall sanding screen (3M Corp, St Paul, Minn). Assignment to method was randomized. Cryogen spray was not used with either technique. All patients receiving treatment on a given day received the same method of dermabrasion. The method of manual dermabrasion using drywall sanding screen has been described in detail by Zisser et al.4 The dermabrasion was continued until uniform pinpoint bleeding was noted throughout the treatment area and smaller rhytides were effaced. Hemostasis was obtained with pressure. The same team of physicians completed all of the procedures.

Both halves of the perioral area were cleansed with sterile saline solution and dressed with Aquaphor healing ointment (Beiersdorf Inc, Wilton, Conn). All patients followed the same postoperative care regimen, which consisted of frequent (at least 5 times daily) cleansing with tap water and reapplication of the Aquaphor ointment. After reepithelialization, patients were instructed to daily apply to the treatment area a sunscreen with a sun protection factor of at least 15. They were encouraged to avoid unnecessary sun exposure.


RESULTS

Patients ranged in age from 46 to 73 years (mean, 59 years). All participants were women. The mean preoperative rhytide score was 3.73 (SD, 0.88). All patients were judged to have the same score on the 2 halves of the perioral area.

The wounds created by dermabrasion showed more bleeding during the immediate postoperative period (Figure 1). Subjective reports of pain were on average slightly greater for the carbon dioxide laser–treated side, although the difference was not statistically significant (P=.13) (Table 1). Patients were asked to rate their pain at each follow-up visit during the first 2 weeks, and the highest score for each treatment area was used for the analysis. Individual reports of pain for each method were highly variable, ranging from 1 (no pain) to 4 (severe pain). Patients reported the greatest amount of pain during the first 48 hours. No patients required pain medication other than acetaminophen.

Crusting was more extensive on carbon dioxide laser–treated skin, and the difference between the 2 methods was statistically significant (P=.002) (Table 1). The mean crusting scores were highest at the 2-day follow-up visit. An example of the difference in postoperative crusting is shown in Figure 2. Again, there was significant individual variation, with crusting scores ranging from 1 (none) to 4 (severe). Patients with heavier crusting were encouraged to cleanse their wounds more aggressively and subsequently improved. A difference in reepithelialization is illustrated in Figure 3. Differences in reepithelialization for the 2 methods are represented in Figure 4. Statistical analysis was not possible for this outcome measure since the exact day of reepithelialization was not known for each patient. For both methods, reepithelialization was complete in some individuals by the 1-week follow-up visit. All of the dermabrasion-treated areas and all but one of the laser-treated areas were fully reepithelialized by the 2-week follow-up visit.

Erythema was more pronounced at all points in time on laser-treated skin. The difference in erythema score was statistically significant at 1 week (P=.003), 2 weeks (P=.001), and 1 month (P=.003) but not at 2 or 4 months (P=.19 and P=.15, respectively) (Table 1). A typical case at 1 month is shown in Figure 5. Differences in the duration of postoperative erythema are represented in Figure 6. Scarring, infection, and postoperative hyperpigmentation did not occur in any of the research subjects.

One patient, for reasons unrelated to the study, was unable to return for the 2- and 4-month evaluations. By telephone, she denied experiencing any complications and was pleased with the outcome. Another patient missed her 1- and 2-month follow-up visits because of unanticipated travel. Data analysis was restricted to results gathered by the blinded observers during actual patient visits.

Both treatment methods resulted in statistically significant improvement in the rhytide score (P=.001 for dermabrasion and P=.002 for carbon dioxide laser). The mean rhytide score at 4 months was slightly lower for laser-treated skin; however, the difference in scores between the 2 methods was not statistically different (P=.35) (Table 1). The mean postoperative rhytide score was 2.64 for laser-treated skin and 2.79 for dermabrasion-treated skin. The mean decrease in rhytide score was 1.09 for laser-treated skin and 0.94 for dermabrasion-treated skin. Figure 7 shows a patient with more improvement on the laser-treated side. Figure 8 shows a patient with equal improvement on both sides. When comparing the 2 treatment areas side-by-side, subtle differences were noted that could not be quantified using any of our outcome parameters. Fine rhytides were more responsive to the treatments than deeper rhytides. The texture of laser-treated skin appeared smoother in some patients. Dermabrasion-treated skin retained more of the preoperative "lumpy" or "elastotic" appearance in a few subjects who showed similar improvement in rhytides with the 2 methods. The subset of subjects with the most severe wrinkles (preoperative wrinkle scores >3) was analyzed separately. The difference in rhytide scores for the 2 methods was not statistically significant (P=.35) in this subset of 9 individuals at 4 months.

Subjective opinions regarding superior cosmetic outcome were similar for patients and blinded observers. Seven of the 14 patients selected the laser-treated side as more improved at the 4-month follow-up visit. One patient believed the dermabrasion-treated side looked better. The remaining 6 patients did not see a difference between the sides. Blinded observers preferred the laser-treated side in 6 cases, preferred the dermabrasion-treated side in 1 case, and stated no preference in the remaining 7 cases.
COMMENT

With our study design we were able to directly compare dermabrasion and carbon dioxide laser resurfacing of the upper and lower lips in a side-by-side fashion. Our study demonstrated wide variation among subjects with respect to wound healing and complications, such as postoperative erythema and cosmetic outcome. These individual differences challenge the usefulness of comparative studies in which subjects receive only 1 of 2 treatments.

Some of the differences between the 2 methods we noted were anticipated based on previously published literature and our own experience. For example, prolonged postoperative erythema was observed only with carbon dioxide laser treatment in our study. This has been demonstrated in many other studies5- 9 and is believed to correlate with the depth of tissue ablation. We did not make any effort to histologically grade the injuries created by the resurfacing methods used in our study.

The immediate postoperative appearance of the 2 wounds was quite different. The wound created by the carbon dioxide laser showed greater hemostasis. Again, this was expected. Since the wavelength of the carbon dioxide laser (10,600 nm) is strongly absorbed by water, tissue heating and destruction result, effectively sealing off capillaries. The intraoperative shrinkage of tissue that is observed most commonly during the second pass of laser resurfacing is also attributable to the physical properties of the carbon dioxide laser. The tissue is instantly desiccated and the uppermost layer of residual collagen is denatured. Kirsch et al10 demonstrated increased collagen fiber diameter and loss of normal collagen fiber banding periodicity after pulsed carbon dioxide laser irradiation in the zone of residual thermal collagen damage. It is unclear if these altered fibers are responsible for any of the long-term changes that are seen with laser resurfacing. Wounds produced by dermabrasion show uniform hemorrhage during the immediate postoperative period, and no shrinkage of tissues is seen intraoperatively. Presumably, the uppermost layer of the dermabrasion wound is more viable.