Periorbital resurfacing: Dos and Don’ts

There are several different approaches to treating periorbital wrinkles and other signs of aging. Dr. Joseph Niamtu is a cosmetic maxillofacial specialist based in Midlothian, VA. He discusses several treatment options, including the effective use of the CO₂RE laser. 

Scott: My name is Scott Kober with Dermatology Times, and today we’ll be talking about the do’s and don’ts of laser treatment for periorbital resurfacing.

I’m happy to be joined today by Dr. Joseph Niamtu, a cosmetic maxillofacial specialist at Niamtu Cosmetic Facial Services in Midlothian, VA. Dr. Niamtu is a consultant and speaker for Candela.

Welcome Dr. Niamtu, and thank you for joining me.

Dr. Niamtu: Thanks for having me.

Scott: So what are some of today’s more common approaches for the treatment of periorbital wrinkles and other signs of aging?

Dr. Niamtu: There are a variety of options, including neurotoxins which relax the muscles, fillers that help fill lines and wrinkles, lifting procedures that may help the lateral part of the mouth but really don't do much to the lips, as well as chemical peels and dermabrasions. But in my mind, the most successful, longest-lasting option is laser resurfacing.

Scott: What are the primary pros and cons of these various approaches?

Dr. Niamtu: So with the neurotoxins, you can only use a small amount, or else you will paralyze the lips and create dysfunction. Fillers can be effective, but with patients who have significant lines and wrinkles in the face, there are simply too many areas to address thoroughly. Chemical peels do not offer as predictable results as other options. Dermabrasion is rarely offered in dermatology practices today. That leaves CO₂ or other types of lasers as the most functional and comprehensive treatment.

Scott: What are the specific advantages of using the CO₂RE fractional laser to treat signs of aging?

Dr. Niamtu: The CO₂RE laser is a really good combination of old school CO₂ utility and new school versatility. The CO₂RE laser is designed as a fractional laser, but it offers a variety of settings so that you can treat regions ranging from the most superficial to the deepest layers of the skin. It can also be used a fully ablative laser. What I really appreciate about the CO₂RE laser is that it is adaptable to the skill and experience of the individual practitioner to treat patients with varying severity of facial damage at varying depths.

Scott: How do you determine which sort of approach you’ll use with the CO₂RE laser in a given patient who's seeing you for periorbital resurfacing?

Dr. Niamtu: This is not an issue to be taken lightly because there can be permanent scarring with overtreatment. My advice to anyone starting out with any new technology is to walk before you run. The CO₂RE laser is a wonderful tool, but in some respects, it’s like having a Ferrari or Lamborghini. You can drive it at 30 miles per hour and never have a problem. Or you can drive it at 250 miles per hour and be totally out of control.

You need to understand what the CO₂RE laser is capable of and how to harness those capabilities. You need to understand the physiology of skin wounds and healing. That all takes practice and experience. There is nothing wrong with using the lighter settings of CO₂RE laser that deliver less energy when you are just starting with the laser. Patients may be required to undergo a series of small procedures using a local anesthetic, but that’s better than trying to overreach at the beginning for a larger procedure that causes permanent skin damage. As you get more experienced and seasoned, then you can utilize more of the CO₂RE laser’s potential.

Currently, I perform local or full-face treatments under sedation or general anesthesia. Certainly, that requires a lot of expertise, and patients need to understand that the recovery from more aggressive treatments will require longer healing time. A laser treatment that fully heals in 3 days is likely going to produce a minor result. One that heals in 7 days will produce a more significant result. One that heals in 2 weeks is going to produce the maximum result. Anything longer than that and the patient may have some permanent scarring that won’t heal. The design of the CO₂RE laser is all about science and treatment wavelengths and depth of penetration. But once the laser touches the skin, it's more about experience than science. It takes the combination of the right laser in the hands of the right practitioner to get the right results. One thing that Candela, the manufacturer of the CO₂RE laser, is really good at is putting new users of the platform in touch with more experienced providers so that they can talk to them about safe treatment parameters as they get started and then begin to build up experience.

Scott: How do you ensure that you are setting reasonable expectations in your patients undergoing treatment with the CO₂RE laser?

Dr. Niamtu: My practice is 100% focused on cosmetic surgery, so my patients expect a big bang for their buck when they come to see me. That may not be the case for some of my general dermatology friends down the street who have a broader focus to their practice and don’t perform treatment with their laser that is quite as extensive.

Because a lot of my cases involve more aggressive laser resurfacing with the CO₂RE laser, I tell my patients that they can be back wearing makeup in about 9-10 days. That’s still an improvement over previous lasers where it would take up to 2 weeks for sufficient healing. In cases where I use lighter settings of the laser to treat damage that is less extensive, you are talking maybe 7 days for full healing.

Scott: How long would you say that it took you to become comfortable using the CO₂RE laser for periorbital resurfacing?

Dr. Niamtu: I’ve performed thousands of cases using a variety of lasers over the last 20 years, so for me, when I initially got the CO₂RE laser, it was just like moving from one high-performing car to another. It probably took about 10 cases before I felt extremely confident with the technology, but again, I have a lot of laser and skin healing experience. For a practitioner with either no or little laser experience, I would highly recommend starting with the lowest energy setting of the CO₂RE laser in patients with minimal signs of aging for at least the first 20 or so cases.

As with any treatment modality used for periorbital resurfacing, it’s a fine line between perfect treatment and overtreatment. You need to be able to recognize very early on the possible signs of overtreatment and work to control potential complications.

Scott: So then how do you know when enough is enough?

Dr. Niamtu: There are no cookbook settings for the use of lasers. You certainly can control the laser settings and the amount of energy it will deliver, but it’s the patient that is always going to be different and will require an individualized approach.

There are, of course, published parameters for the CO₂RE laser that are a good starting point for novice providers. Again, start slow and start simply before branching into more complex patients and procedures.

The use of CO₂ lasers has its own subculture – there are a number of providers who have built up a lot of experience with the CO₂RE laser who are willing to offer guidance and assistance to new users. Candela has its own in-house trainers as well who will offer assistance for new users during their first few cases. I can’t emphasize enough how useful that can be.

Scott: Great. I think this has been a valuable discussion regarding the incorporation of the CO₂RE laser into a new practice for the treatment of periorbital wrinkles and other signs of aging.

The opinions expressed in this article are based on the guest’s medical opinion and experience with the product. The content is being provided for informational purposes only. Individual treatment results may vary.

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