A common procedure in our practice is combination therapy with CO2 laser and platelet-rich plasma (PRP) for optimal skin resurfacing results. Although a variety of laser systems and PRP kits exist out there, my goal is to break down our techniques, which can be applied across all platforms.
Of utmost importance is patient selection. An ideal candidate would have light skin, many fine wrinkles, not needing or expecting facelift-like results, be able to endure down-time, has reasonable pain tolerance, and is committed to the entire process.
Once a patient is deemed an appropriate candidate for CO2 laser skin resurfacing, our aesthetician is vital in preparing the skin four weeks pre-procedure to facilitate enhanced healing and results.
A hydro facial is ideally performed first in order to clean, exfoliate and hydrate the skin. We start Retin-A and glycolic acid for three weeks, stopping one week before the laser treatment. Hydroquinone is used at least 10-14 days prior to the procedure and stopped 24 hours before the procedure. We make sure that a patient has not taken Accutane within 12 months as this medication hinders wound healing by suppressing the pilosebaceous units and by inhibiting collagenase. We start herpes prophylaxis on everyone, usually Valtrex 500 mg twice daily for seven days beginning one day before the procedure.
On the day of the procedure, we have our patients topically numb with BLT cream (Benzocaine 27%/Lidocaine 12%/Tetracaine 12%) for one hour before the procedure. This is all thoroughly removed, and the face is cleansed prior to the laser application. All laser precautions are taken including damp towels, laser safe eye shields, smoke evacuator and appropriate laser safe goggles for all people in the room.
We usually harvest the patient’s PRP before we begin the laser treatment, typically as the patient is numbing. A 60 mL syringe is filled first with 10 mL of sodium citrate anticoagulant. Then 50 mL of whole blood from the patient is drawn into this syringe for a total of 60 mL. This is then transferred to the centrifuge vial and centrifuged for two minutes as the initial spin. Once complete, the plasma and platelets are then aspirated and placed in a second vial for a double spin for six minutes to ideally achieve a con-centration of platelets 5-7 times the native concentration.
For a “no burn” technique, the platelet-poor plasma is aspirated leaving approximately 1 mL of buffy coat and 8 mL of bacteriostatic normal saline is then injected. This is then swirled to resuspend the platelet buffy coat into the normal saline. The “no burn” pure PRP is then drawn up into a syringe of choice, ready for use.
We use a fractionated CO2 resurfacing system with a 9x9 ipixel handpiece to treat fine lines, wrinkles, acne scars and for skin resurfacing. Energy (mJ/pixel) can range depending on the skin type and application to be treated.
I typically use high power with multiple passes for the perioral and cheek regions, but adjust more conservatively around the periorbital regions, neck and bony prominences. I find that most laser setting parameters suggested by the laser company are a good and safe starting point, but are often too conservative. I find that I am either at or higher than the suggested range to achieve the results we desire. Again, this has to be carefully weighed against the patient’s skin type and skin health.
Furthermore, carefully evaluating the skin’s response to the treatment is essential. A reddish-pink color indicates removal of the epidermis; pin-point bleeding usually indicates entrance into the papillary dermis. A chamois yellow appearance means that we have entered the reticular dermis. The superficial to the mid-reticular dermis is the depth I like to be for treatment. Frayed white strands are seen in the deep reticular dermis, and entrance here has a higher risk of scarring.
After CO2 laser resurfacing is complete, we immediately place the PRP topically over the treated areas. We allow this to set in for 5-10 minutes. As with any controlled injury to the tissues, mechanically with dermabrasion or with heat energy via lasers, as in this case, the wound healing process is initiated. Many studies have shown that PRP enhances wound healing by decreasing downtime and scarring and improving aesthetic results. We have certainly seen this in our practice.
Within the first 24 hours after treatment, care typically consists of dilute vinegar soaks (one cup water mixed with two tsp vinegar) 2-3 times per hour, icing the face for 20 minutes at least every two hours, and applying Aquaphor ointment. After 24 hours, a gentle facial cleanser is applied twice a day in addition to continuous dilute vinegar soaks and Aquaphor. Peeling occurs 72 hours after treatment, and Vanicream moisturizer is applied to help with this. Patients are instructed not to pick at the scabs to avoid scarring. After 10-14 days, patients can continue Vanicream as a moisturizer and are reminded to use sunblock.
In conclusion, it makes sense to combine CO2 laser and PRP together. The CO2 laser alone works great at introducing controlled tissue injury to stimulate wound healing. The addition of PRP to this injured site, either topically or injected, significantly enhances the end result. We continue to use this combination as our standard for skin resurfacing in our practice, and we are excited about applying future applications and developments as we continue to expand our understanding and growth in the field of regenerative medicine.
About the Author
|Vincent McGinniss, DO, FAOCO
Dr. McGinniss is a board-certified cosmetic and reconstructive facial plastic surgeon in Ohio. He currently serves as clinical faculty for the Osler Institute, where he helps prepare physicians studying for their upcoming written and oral board examinations. He is fellowship-trained in facial plastic surgery through the mentorship of Dr.Ross Clevens in Melbourne, Fla. He was honored with the title of Fellow in his academy by the board of governors of the American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery. Dr. McGinniss graduated from medical school and residency through Michigan State University College of Osteopathic Medicine. He served active duty with the rank of captain as a Flight Surgeon for the 354th Fighter Squadron based in Ariz., and received an Air Medal award for flying in combat and medivac missions.