BLEPHAROPLASTY

USING FRACTIONAL CO2 FOR NON-SURGICAL BLEPHS IN SKIN OF COLOUR

Dr Sonakshi Khorana and Dr Samantha Hills discuss fractional CO₂ laser for non-surgical blepharoplasty in skin of colour, focusing on safety, ocular protection and strategies to optimise outcomes

The peri-ocular region is one of the first areas where age-related changes become noticeable. Even subtle shifts in eyelid contour or texture can influence how alert, rested or expressive a person appears, and with the skin encircling the eyes being delicate, it demonstrates early signs of collagen depletion, photodamage and lifestyle-related stressors.1

Technologies such as fractional CO2 laser can safely target fine lines and early laxity with a reduced downtime in many skin types, and without requiring surgical intervention but still deliver meaningful rejuvenation. As such, peri-orbital rejuvenation is a highly sought after aesthetic treatment.2

In this article we will examine considerations in doing non-surgical blepharoplasty’s on skin of colour and the safety aspects including intraocular protection.

FRACTIONAL CO2 LASER AS A NON-SURGICAL EYELID REJUVENATION TOOL

Whilst surgical blepharoplasty is an option for peri-orbital rejuvenation it comes with its limitations. A typical surgical blepharoplasty candidate would be a healthy, non-smoking adult over 35 who meets aesthetic criteria.3 Although highly effective, lower blepharoplasty carries a greater risk profile to upper eyelid surgery; including ectropion (when the lower eyelid turns outward), asymmetry, dryness and infection, with a recovery period that usually spans one to two weeks.4 CO2 laser is increasingly being used in surgical blephs as alternative to the scalpel offering enhanced haemostasis and reduced postoperative swelling.5

However, for patients who prefer a more conservative pathway — or whose concerns are primarily textural rather than structural — fractional CO2 laser represents a valuable alternative.

Fractional CO2 technology has become a cornerstone for patients seeking improvement in crepey eyelid skin, early skin laxity or periocular fine lines without undergoing surgery.6 This is particularly beneficial for patients wanting a lesser downtime than traditional CO2 resurfacing whilst still stimulating dermal remodelling and maintaining enough intact skin to support rapid recovery.7

The treatment works by creating microscopic ablative columns within the skin, surrounded by controlled zones of thermal influence. Clinical evidence demonstrates improvements in eyelid texture, fine rhytids and brow position following fractional CO2 resurfacing, with favourable safety profiles when appropriately performed.8,9

While fractional CO2 is a powerful tool for peri-ocular rejuvenation, its use in skin of colour requires modified protocols, stricter prep and enhanced PIH-prevention strategies. Later in this article, it outlines the approach, patch testing methods, aftercare steps and the possible unwanted side-effects clinicians must know.

ESSENTIAL CONSIDERATIONS IN CO2 LASER PRACTICE

Safety is especially important in non-surgical blephs and this means the ocular safety must guide every aspect of treatment planning.

In order to deliver this, the use of metal intraocular shields is mandatory for any periocular CO2 procedure.10 These devices provide effective protection against infrared wavelengths — a level of defence that silicone or plastic shields cannot offer.11 Although the 10,600 nm CO2 wavelength is not absorbed by the retina, unintended exposure can cause substantial corneal injury.12

Intraocular shields are not without risk. There is the chance of corneal abrasion13 and a degree of care must be taken to not fire the laser directly over the shield to avoid head conduction.14 Insertion requires familiarity with ocular anatomy and sterile handling. A typical technique involves placing anaesthetic drops, applying a lubricating ointment and sliding the upper portion of the shield beneath the upper lid as the patient looks down, followed by insertion of the lower edge as they look upwards. Overall, with practice the insertion is relatively fast and comfortable for the patient.

APPROACHING NON-SURGICAL BLEPHS IN SKIN OF COLOUR

In patients with peri-ocular laxity and crepey skin, CO2 laser resurfacing remains one of the most effective modalities for addressing peri-ocular laxity and crepiness. Its ability to deliver controlled thermal injury into the dermis stimulates robust neocollagenesis and dermal remodelling - two key processes that directly improve fine lines, texture irregularities and mild skin laxity around the eyes. Because the CO2 wavelength has a high affinity for water, it enables precise ablation of photodamaged epidermis while simultaneously inducing significant tightening of the underlying tissue. When performed by an experienced practitioner, it offers meaningful, long-lasting improvement in one of the most delicate, treatment-resistant areas of the face.

It is important to remember that the risk of unwanted side effects like hyperpigmentation, keloids and hypertrophic scarring, limits its use in darker skin types. Despite this, there are great devices on the market that can be effective in skin of colour patients if caution is taken. An example of this is the SmartXide CO2 laser.

A thorough consultation is essential to understand the patient’s priorities and to manage expectations, acknowledging that while improvement is typical, individual responses vary.

It is important to have a solid skincare routine with sun protection in place to prevent PIH following CO2 laser treatment. All skin of colour clients should use a tyrosinase inhibitor such as 4% Hydroquinone or tranexamic acid prior to treatment. At Kat and Co we also ask patients to use AlumierMD Retinol Eye Gel every evening as a prophylactic measure to prevent PIH (six weeks prior to treatment), and ask the patient to use these for six weeks post-treatment.We ask the patients to then pause seven days prior to CO2 treatment as it can make the skin more sensitive to the laser and can result in irritation posttreatment or, in extreme cases, burns.

A CO2 laser test patch is always performed on the lateral preauricular skin eight weeks prior to CO2 laser treatment to assess for PIH and adverse reactions. The patch test involves assessing a small area of skin to decide on an appropriate laser setting and to see any potential reactions. These would include burns, infection, poor healing, scarring, contact dermatitis and PIH.7 We would not recommend using CO2 on a large area, such as the face, without a patch test on a small area first.

On the day of the CO2 laser treatment, we confirm strict adherence to pre-treatment skincare, as preventing PIH following treatment is a priority, and the patch test is assessed. We ensure that the patient understands what the treatment entails, the downtime, side effects, risks and complications in order to obtain informed consent.

The patient is provided written instructions for aftercare and a follow-up one week later is conducted to ensure the skin has settled. For after the treatment, the AlumierMD SensiCalm Cleanser is recommended as it is gentle and ideal for redness prone/sensitive/ irritated skin, Vaseline (applied six-eight times per day) and a mineral sunscreen for seven days post-procedure. The patient is also advised to restart Retinol Eye Gel after the first seven days for six weeks post-procedure, to help maximise results. The importance of sun avoidance is emphasised, especially for the first six weeks, as the skin is more sensitive and susceptible to UV light, and the risk of hyperpigmentation is increased.

Eye drops are also advised post-treatment (Hycosan eye drops or Optrex moisturising eye drops) as patients often experience dry eyes after having this treatment.

RECOVERY COURSE

A typical SmartXide blepharoplasty recovery is between six to seven days. Key features of the recovery include:

• Immediate erythema and heat, mimicking sunburn but representing controlled thermal injury rather than UV-induced damage.

• Odema, especially around the eyelids, usually subsiding after three to four days.

• Formation of micro-crusting, which naturally lifts over several days without manual exfoliation.

• Return to social activities by day six to seven, often with tinted SPF or makeup to cover residual pinkness.

• Progressive enhancement over the following months as collagen remodelling continued. The use of the innovative “spray mode” with the SmartXide means that the patient has a reduced “grid” pattern during the recovery creating a smoother, more blended treatment pattern on day one.

Overall, our skin of colour patients who receive this treatment are extremely satisfied with the results, with improved tightness and smoother texture.

CONCLUSION

Many practitioners are reluctant to use a CO2 laser in skin of colour because of the sequelae associated with it, but when used correctly, it is an invaluable tool not only for non-surgical blephs but also for the treatment of acne scarring in Fitzpatrick 4-6.17

This article highlights the importance of sharing experiences and knowledge of treating skin of colour patients among practitioners to increase awareness of the effectiveness and safety of treating various conditions with CO2 lasers within this group. We hope this will encourage more practitioners to consider CO2 lasers as a safe and effective treatment for their skin of colour patients.

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DR SONAKSHI KHORANA

Dr Sonakshi Khorana is an aesthetic doctor and GP with a special interest in dermatology. She is the non-surgical services lead at Kat and Co in Birmingham. She serves as a dermatology expert for renowned skincare brands and holds memberships at the Royal College of GPs, British Medical Laser Association and Aesthetic Complications Expert (ACE) Group World. Qual: MBChB, MRCGP, PGDip Clinical Dermatology (Dist)

DR SAMANTHA HILLS

Clinical Director at Lynton, faculty member of the British Medical Laser Association and Honorary Lecturer at The University of Manchester (Division of Musculoskeletal and Dermatological Sciences).