January 2010 16 Volume 9 • Issue 1

Copyright © 2010 Original Articles Journal of Drugs in Dermatology

A Prospective Study of the Improvement in

Periorbital Wrinkles and Eyebrow Elevation With a
Novel Fractional CO2 Laser—The Fractional Eyelift
Dvora Ancona MDa and Bruce E. Katz MDb
a
University of Pavia; Juva Medical Center, Milan, Italy
b
Mount Sinai School of Medicine; Cosmetic Surgery & Laser Clinic; JUVA Skin & Laser Center, New York, NY

Abstract
Background and Objective: The purpose of this study was to assess the efficacy and safety of a new fractional CO2 laser system
for improving periorbital rhytids, tightening skin and elevating the eyebrow.
Materials and Methods: One hundred subjects with periocular wrinkles, tissue laxity, photoaged skin and moderate dermatochala-
sis of the face were prospectively treated one to four times in the periorbital area with a fractional CO2 laser device equipped with a
scanning handpiece. Improvements in eyelid wrinkles, crow’s feet and skin laxity were evaluated photographically by two blinded,
independent observers. Eyebrow elevation was measured by the investigators. Subjects also scored satisfaction and tolerability.
Results: Approximately half of subjects achieved or maintained 26–50% improvement at 12 months. Nearly 40% of subjects main-
tained 1–2 mm elevation of the brow at six and 12 months after treatment. Subject satisfaction was high and the procedure was well
tolerated. Mild-to-moderate erythema and edema persisted for up to three to four days.
Conclusion: Treatment with a fractional CO2 laser device improves periorbital rhytids, tightens skin and elevates the eyebrow with
minimal adverse effects.

Introduction These considerations have led to the development of fractional

T
raditional surgical treatments to improve facial wrinkles photothermolysis (FP), in which delivery of laser energy to skin
and skin laxity include face-lifting and blepharoplasty, produces arrays of microscopic thermal wounds at specified
alone or combined with chemical peels and dermabra- depths without damaging the surrounding tissue. The first FP
sion.1 Chemical peels and dermabrasion are effective, but their device was a 1550 nm erbium-doped laser system.6 Unlike
use around the eyes and mouth is limited1 and the risks of scar- traditional laser devices that produce layers of thermal injury,
ring, pigmentation problems and unpredictability in the depth FP devices produce columns of injury called microscopic
of tissue injury are considerable. Surgical techniques to tighten treatment zones (MTZs). Since these MTZs are surrounded
the lower eyelid may have complications such as overcorrec- by normal tissue, keratinocyte migration distance is shorter,
tion, undercorrection, exposed sutures, suture abscesses, or healing is faster, and the risk of adverse effects is reduced.6,7
temporary point tenderness over the orbital rim where the su-
ture is anchored.2 The success of FP and the time-honored efficacy of the CO2 laser
device led manufacturers to develop fractional CO2 laser devices8–16
CO2 laser devices, though highly effective, are associated with now considered state-of-the-art technology for micro-ablative skin
a three-to-12-month healing time and treatment-induced ery- rejuvenation.15The purpose of this study was to assess the efficacy
thema that occurs in practically all patients.3 In one study4 in and safety of two new fractional CO2 laser systems for improving
which periorbital wrinkles were treated with a CO2 laser de- periorbital rhytids, tightening skin and elevating the eyebrow.
vice, scar formation was apparent in 52% of subjects, resulting
in mild scleral show or a slight thickening of the lower eyelid. Materials and Methods
Another disadvantage of the CO2 laser device is that its opera- One hundred subjects (91 women, 9 men; mean age 45 years)
tion requires considerable technical skill and experience.1 with periocular wrinkles, tissue laxity, photoaged skin and mod-
erate dermatochalasis of the face enrolled in the prospective
The periorbital area is difficult to treat because of its important two-center study. Subjects with recent sun exposure and who
function in vision and the delicate nature of its skin. The had undergone chemical peeling, laser treatment, botulinum
epidermis of eyelid skin, for example, is only 0.04 mm thick.5 toxin injections or isotretinoin therapy during the previous six
Periorbital laser resurfacing carries a risk that lower lid ectropion months were excluded. No subject had extropion or eye dry-
may develop that may require surgical correction.5 ness. All subjects provided informed consent to treatment.
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Journal of Drugs in Dermatology D. Ancona, B. E. Katz
January 2010 • Volume 9 • Issue 1

Subjects were treated in the periorbital area with a SmartXide Eyebrow elevation was assessed by the investigators from stan-
DOT (DEKA, Calenzano, Italy) or Affirm (Cynosure, Westford, dardized photographs obtained with a digital camera (Canon
Mass) fractional CO2 laser device. Both devices are similar and Powershot Pro1 with 8.0 megapixels imaging power or a Nikon
include a fractional CO2 laser and scanning handpiece that Coolpix, Canfield, OH) before treatment and at each follow-up
produces multiple tiny wounds to the epidermis and dermis. visit. To measure elevation, a horizontal line was drawn from
Although manufactured by the same company (DEKA), there are the medial to the lateral canthus, and then a vertical line per-
minor differences which include: 1) the articulated arm on the pendicular to the horizontal line was drawn from the pupil to
Affirm is spring loaded whereas the arm on the SmartXide has the midpoint of the eyebrow. The perpendicular distance (mm)
a bar tension system; 2) the controls for changing pitch, dwell from the center of the pupil to the eyebrow midpoint was con-
and other parameters are situated on the scanner handpiece in sidered the eyebrow elevation. Elevation was scored before
the SmartXide but are placed on the user interface in the Affirm; and after treatment using the following scale: 1=0–1 mm; 2=1–2
and 3) the settings to use the ablative mode in the Affirm are mm; 3=2–3 mm; 4=3 or more mm.
set at 200 µm pitch and in the SmartXide set at 0 µm pitch.
The power (up to 30 W), pulse duration (200–2000 μsec.) and Results
DOT pitch (200–2000 μm, the spacing between tiny wounds) Average improvement grades assigned by independent ob-
are controlled by the user. Penetration depth, which ranges servers are shown in Table 1. Sixty percent of subjects showed
from superficial to deep dermal, depends on skin thickness and 26–50% improvement at three months, and approximately half
treatment parameters.17 achieved or maintained 26–50% improvement at 12 months.
Subject satisfaction was high (Table 2) and the procedure was
Each treatment consisted of a single pass with no pulse well tolerated (Table 3). Brow elevation is shown in Figure 1.
stacking. Treated areas included the upper and lower eyelids, Approximately 45% of subjects achieved 1–2 mm elevation
from the eyebrow to the eyelashes and lower orbital rim; and at three months and 22% had 2–3 mm elevation. Nearly 40%
the lateral periorbital areas (crow’s feet). Subjects wore corneal maintained 1–2 mm elevation at six and 12 months after the fi-
shields during treatment. Tetracaine ophthalmic anesthetic nal treatment. Clinical examples are shown in Figures 2 and 3.
was applied to both eyes 30 minutes before treatment. An
ophthalmic antibiotic ointment was applied to the inner Downtime was one day. Figure 4 shows minimal redness and
concave surfaces of the corneal shield prior to treatment. swelling in a subject 24 hours after treatment. Erythema and
Subjects received an average of two treatments (1–4) at three-
Table 1.
to four-week intervals to allow time for eyelids to recover from
each treatment. Subjects were instructed to apply an antibiotic Percentage of Subjects Showing Improvement in Eyelid
Wrinkles, Crow’s Feet and Skin Laxity
ointment to the target areas for three to four days after each
treatment. Settings at both centers were the following: power, Score Months
10 to 15 watts (W); pitch, 500–700 μm); and pulse duration, 3 6 12
500–900 microseconds. After the initial treatment with a 1 30.5 28 51
low power setting, energies were increased at subsequent 2 60 53 44
sessions as tolerated by the subjects. For example, the first 3 9.5 16 4
treatment settings might be 10 watts, 500 microseconds pulse
4 0 3 1
duration and 700 microns pitch. The second session would
1=0–25%; 2=26–50%; 3=51–75%; 4=76–100%
have energies increased to 11 watts, pulse duration increased
to 600 microseconds, and pitch reduced to 600 microns. Table 2.
Initial settings were determined by thickness of eyelid skin Subject Satisfaction With Results
and amount of downtime the subject was willing to tolerate.
Satisfaction Level*
Photographs were taken before treatment and at one month
(n=100), three months (n=100), six months (n=16), and 12 Excellent Good Fair
months (n=51) after the final treatment. Percentage of Subjects 10 85 5
*No subject rated satisfaction level as “poor.”
Improvements in eyelid wrinkles, crow’s feet and skin laxity
Table 3.
were evaluated by two blinded, independent observers who
compared pre- and posttreatment digital photographs Observ- Pain Score* During Treatment
ers graded improvement on a quartile scale (1=0–25%; 2=26% Score
–50%; 3 51%–75%; 4=76–100%). Subjects rated satisfaction with 0 1 2 3
results as poor, fair, good or excellent and graded pain during Percentage of Subjects 15 45 35 5
treatment on a scale of 0 (no pain) to 4 (very painful). *0=no pain; 4=very painful. No subject rated pain at 4.
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Journal of Drugs in Dermatology D. Ancona, B. E. Katz
January 2010 • Volume 9 • Issue 1

edema persisted for up to three to four days. Two subjects expe- after a single treatment with an RF device. Duration and rates of
rienced hyperpigmentation of the lateral periorbital areas one edema and erythema were less than with ablative procedures and
month after the first treatment; this was attributed to excessive three patients had evidence of scarring at six months.
sun exposure. No other adverse events were observed.
Ruiz-Esparza and colleagues,19 using a nonablative RF device,
Discussion achieved improvement in lower eyelid laxity by treating extra-
Facial wrinkles may arise from age and solar-related changes in orbital areas of nine patients. The authors postulated that the
dermal collagen or by tension in underlying mimetic muscles. temporal and zygomatic skin after treatment would act as an-
Since only the latter can be corrected by botulinum toxin choring points to produce vectors of skin improvement that
injections,18 there is a need for a method to treat age-induced would eventually stretch the lax skin of the lower eyelids. Treat-
wrinkles. The present study shows that the SmartXide DOT ing these areas outside the orbital rim and lateral to the lower
and Affirm fractional CO2 laser devices provide measurable eyelid would also reduce the risk of ectropion. The authors cau-
improvement in periorbital wrinkles, skin laxity and eyebrow tioned that the treatment would not correct muscle hypertrophy
elevation. Subject satisfaction was overwhelmingly high and or fat herniation of the lower eyelid.
the procedure was well tolerated. The advantage of multiple
treatments is that downtime and adverse effects, especially pain
Figure 2. A 38-year-old woman before a) and three months after
during and after treatment, are kept to a minimum. Subjects in
the final of two treatments b) with the Affirm (Cynosure, Westford,
the present study did not receive herpes prophylaxis because Mass) fractional CO2 laser device, showing 3 mm increased eyebrow
none had evidence of this condition. elevation and skin tightening. Settings: 14 watts, 500 microseconds
dwell time, 500 microns dot pitch. Photographs courtesy of Bruce E.
Since the study was completed two herpes cases have emerged Katz, MD.
in the authors’ practices. The authors now routinely treat pa-
A
tients with valacyclovir if they have a clinical history of herpes
infection and are undergoing laser treatment of all facial areas.
Attempts to treat periorbital wrinkles with radiofrequency (RF)3,19,20
and other fractional resurfacing devices13,16 have been reported.

In the six-month, 86-patient study of Fitzpatrick and colleagues,3 the

authors safely achieved skin contraction, reductions in periorbital
wrinkles, and, in 61.5% (40/65) of eyebrows, at least a 0.5-mm lift

Figure 1. Brow elevation scores at three (n=100), six (n=16), and 12

(n=51) months after the final treatment. Scale: 1=0–1 mm; 2=1–2 mm;
3=2–3 mm; 4=3–4 mm.

60 1
2
50 3 B
4
40
Patients (%)

30

20

10

0
3 6 12

Months
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Journal of Drugs in Dermatology D. Ancona, B. E. Katz
January 2010 • Volume 9 • Issue 1

Two years later Biesman and colleagues20 reported the results fold. Wounding, downtime and long-term complications were
of a single treatment of the eyelid itself with the same device, not observed.
this time with a 0.2 cm2 tip. The 0.25 cm2 tip provides maximum
heating at “shallow” depths approximately 1.2 mm beneath the The present study was the first to prospectively evaluate the
skin surface, thus minimizing the risk of injury to vital struc- use of a fractional CO2 laser device for the treatment of eyelid
tures in the eyelid or to the eye itself.20 In their 72-patient study, wrinkles. The strengths of the study are in the large number
the authors achieved lower eyelid tightening in 71–74% of pa- of subjects treated and the 12-month follow-up. It is difficult
tients, upper eyelid tightening in 88%, and hooding reduction to compare our results with those of other studies because of
in 86%. Upper eyelid tightening was greater than lower eyelid different numbers of treatment sessions and methods used
tightening. However, treatment outcomes were variable and to evaluate results. However, our technique is safe enough to
unpredictable for unknown reasons. permit direct treatment of the eyelid. Sixty percent of subjects
showed 26–50% improvement in eyelid wrinkles and skin laxity
An ablative fractional CO2 laser device has also been used to at three months, and approximately half achieved or maintained
treat facial rhytids, including crow’s feet.13 Among eight pa- 26–50% improvement at 12 months. With fractional ablative re-
tients with coarse wrinkles in the crow’s feet area, Clementoni surfacing, these changes are thought to be due to stimulation
and colleagues reported 75–100% improvement in three pa- of new collagen formation.
tients, 50% to 75% improvement in three patients, and 25–50%
improvement in two patients. Healing required eight days and Approximately 45% of subjects achieved a 1–2 mm brow
posttreatment erythema persisted for 17 days. A more recent elevation at three months and 22% had an impressive 2–3
study21 showed that the risk of postinflammatory hyperpigmen- mm elevation. Nearly 40% maintained a 1 to 2 mm eleva-
tation after single-pass treatment with a fractional CO2 laser de-
vice was low in patients with skin types IV and V.
Figure 4. A 38-year-old woman before (upper) and 24 hours after
(lower) a single treatment with the Affirm fractional CO2 laser device,
In a retrospective study 16 of 31 patients treated three to seven showing mild erythema and edema of the eyelids. Photographs cour-
times with a nonablative 1550 nm erbium-doped fractional la- tesy of Bruce E. Katz, MD.
ser resurfacing device, Sukal and colleagues reported eyelid
A
tightening to some degree in all patients; 1–25% tightening was
achieved in 19%, 25–50% in 26%, 50–75% in 26%, and 75–100%
in 29% of patients. Twenty-six percent showed an elevation in
brow position and 44% showed a lifting of the supraorbital

Figure 3. A 42-year-old woman before a) and 3 months after the final

of two treatments b) with the SmartXide DOT (DEKA, Calenzano, Italy)
fractional CO2 laser device, showing 3 to 4 mm increased eyebrow
elevation and skin tightening. Settings: 15 watts, 600 microseconds
dwell time, 700 microns dot pitch. Photographs courtesy of Dvora
Ancona, MD.
A

B
 20
Journal of Drugs in Dermatology D. Ancona, B. E. Katz
January 2010 • Volume 9 • Issue 1

tion at six and 12 months after the final treatment. These re- Reconstr Surg. 1997;13(3):199-203.
sults show that overall improvement and brow elevation are 3. Fitzpatrick R, Geronemus R, Goldberg D, et al. Multicenter study of
achieved quickly and persist for at least 12 months. Erythema noninvasive radiofrequency for periorbital tissue tightening. Lasers
and edema cleared in four days or less. Of particular interest Surg Med. 2003;33(4):232-242.
is the brow elevation, which our society regards as a means 4. Reed JT, Joseph AK, Bridenstine JB. Treatment of periorbital wrin-
of brow and upper-eyelid rejuvenation.22 It is not completely kles. A comparison of the SilkTouch carbon dioxide laser with a
clear what was responsible for the eyebrow elevation in our medium-depth chemical peel. Dermatol Surg. 1997;23(8):643-648.
study. However, Sukal and colleagues16 noted similar eye- 5. Manaloto RM, Alster TS. Periorbital rejuvenation: A review of der-
brow lifting effect in 26% of subjects who had full-face treat- matologic treatments. Dermatol Surg. 1999;25(1):1-9.
ments. Treatment of the lateral periorbital areas (and skin of 6. Manstein D, Herron GS, Sink RK, et al. Fractional photothermoly-
the superior and lateral orbital rim) in our study may have sis: A new concept for cutaneous remodeling using microscopic
created skin-tightening vectors that were responsible for the patterns of thermal injury. Lasers Surg Med. 2004;34(5):426-438.
elevation in the eyebrows. Further investigation in which 7. Geronemus RG. Fractional photothermolysis: Current and future
treatment is localized only to this area may shed more light applications. Lasers Surg Med. 2006;(3):169-176.
on this question. 8. Rahman Z, Tanner H, Tournas J, et al. Ablative fractional resurfac-
ing for the treatment of photodamage and laxity. Laser Surg Med.
The minimal downtime experienced by subjects in this study 2007;39(Suppl 19):S15.
contrasts with other studies utilizing fractional CO2 technologies 9. Weiss RA, Weiss MA, Beasley KL. Prospective clinical trial of a
where the downtime was often three to five days. The reason fixed spacing array computer scanned fractional CO2 laser for
for this difference is likely due to the low wattages used in the rhytids. Laser Surg Med. 2007;39(Suppl 19):16.
initial treatments and the very gradual increases in energies 10. Levy JL, Journier N, Mordon S. CO2 fractional resurfacing com-
utilized in subsequent sessions. Also, the ability to vary the bined with air cooling: Histologic investigation and optimal param-
lasers’ parameters such as pulse duration and pitch attenuated eters determination. Laser Surg Med. 2007;39(Suppl 19):17.
the amount of erythema and edema. Most subjects had 11. Hantash BM, Bedi VP, Kapadia B, et al. In vivo histological evalua-
significant downtime for only one day with only mild erythema tion of a novel ablative fractional resurfacing device. Lasers Surg
and edema for several days after the treatments. Med. 2007;39(2):96-107.
12. Hantash BM, Bedi VP, Chan KF, et al. Ex vivo histological character-
The authors agree with Biesman and colleagues,20 who state ization of a novel ablative fractional resurfacing device. Lasers Surg
that setting appropriate expectations is the key to patient sat- Med. 2007;39(2):87-95.
isfaction. The procedure in the present study, although not an 13. Clementoni MT, Gilardino P, Muti GF, et al. Non-sequential fraction-
alternative to blepharoplastic surgery, is a viable non-surgical al ultrapulsed CO2 resurfacing of photoaged facial skin: Preliminary
option for rejuvenating the periorbital areas of facial skin. clinical report. J Cosmet Laser Ther. 2007;9(4):218-225.
14. Chapas AM, Brightman L, Sukal S, et al. Successful treatment of
The authors will continue to follow subjects in this study to fur- acneiform scarring with CO2 ablative fractional resurfacing. Lasers
ther evaluate the longevity of clinical benefits. Surg Med. 2008;40(6):381-386.
15. Christiansen K, Bjerring P. Low density, non-ablative fractional CO2
Conclusions laser rejuvenation. Lasers Surg Med. 2008;40(7):454-460.
Treatment with a fractional CO2 laser device produces long-last- 16. Sukal SA, Chapas AM, Bernstein LJ, et al. Eyelid tightening and im-
ing improvement in periorbital rhytids, skin laxity and eyebrow proved eyelid aperture through nonablative fractional resurfacing.
elevation after an average of two treatments spaced three to Dermatol Surg. 2008;34(11):1454-1458. Epub 2008 Sep 15.
four weeks apart. Adverse events are minimal. 17. Gotkin RH, Sarnoff DS, Cannarozzo G, et al. Ablative skin resur-
facing with a novel microablative CO2 laser. J Drugs Dermatol.
Disclosures 2009;8(2):138-144.
Dr. Katz is a consultant to El-En Engineering, the parent com- 18. Keen M, Blitzer A, Aviv J, et al. Botulinum toxin A for hyperkinetic
pany of Deka. facial lines: results of a double-blind, placebo-controlled study.
Plast Reconstr Surg. 1994;94(1):94-99.
Dr. Ancona has no relevant conflicts of interest to disclose. 19. Ruiz-Esparza J. Noninvasive lower eyelid blepharoplasty: a new
technique using nonablative radiofrequency on periorbital skin.
References Dermatol Surg. 2004;30(2 Pt 1):125-129.
1. Alster TS, Garg S. Treatment of facial rhytides with a high-energy 20. Biesman BS, Baker SS, Carruthers J, et al. Monopolar radiofre-
pulsed carbon dioxide laser. Plast Reconstr Surg. 1996;98(5):791- quency treatment of human eyelids: a prospective, multicenter,
794. efficacy trial. Lasers Surg Med. 2006;38(10):890-898.
2. Liu D. Lower eyelid tightening: A comparative study. Ophthal Plast 21. Tan KL, Kurniawati C, Gold MH. Low risk of postinflammatory hy-