Laser Surgery

Surgical Lasers and Soft-Tissue Laser Surgery

This page highlights the practical aspects of learning and using LightScalpel flexible fiber CO2 lasers in every-day soft tissue laser surgeries

LightScalpel laser surgery products are FDA cleared for incision, excision, vaporization, ablation, and coagulation of soft tissue in medical specialties such as oral surgery, dentistry, plastic & reconstructive surgery, dermatology, ophthalmology, otorhinolaryngology, podiatry, gynecology, neurosurgery, urology, and general surgery.

Our American-made surgical CO2 lasers come with durable flexible fibers and ergonomic scalpel-like handpieces.  Over 12,000 surgeons world-wide enjoy their many praised clinical benefits and ease of use (see bloodless laser blepharoplasty in Figure 1 and bloodless laser frenectomy in Figure 2) of flexible fiber CO2 lasers since 1991.

CO2 laser surgery in progressFigure 1. CO2 laser surgery (blepharoplasty) in progress, photo courtesy of Edward M. Zimmerman, MD, Pres. ABLS, Las Vegas, NV.
Figure 2. CO2 laser frenectomy, (laser surgery) in progress, photo courtesy of Leonard Kundel, DMD, Stamford, CT.Figure 2. CO2 laser surgery (frenectomy) in progress, photo courtesy of Leonard Kundel, DMD, Stamford, CT.
Figure 3. Water absorption spectrum. Figure 3. Absorption Coefficient Spectra , 1/cm, for histologically relevant concentrations of water, hemoglobin (Hb), oxyhemoglobin (HbO2) in sub-epithelial oral soft tissue. Logarithmic scales are in use.
Why a CO2 Laser?

The wavelength of the laser and how it interacts with water (the dominant component of soft tissue) is the key to understanding how the laser light cuts soft tissue – see Figure 3:

LightScalpel CO2 Laser Wavelength

The absorption/penetration depth in water for the LightScalpel CO2 laser wavelength (10,600 nm) is approximately 0.015 mm, which explains the very thin (less than 0.1 mm) thermal damage zone on the margins of the incision in soft tissue [1]. Such short penetration depth enables high precision in removing the tissue, while simultaneously providing sufficient hemostasis.

Diode Laser Wavelengths

In contrast, the absorption/penetration depth in water for diode laser wavelengths in the 800-1,000 nm range is a thousand times greater than for the CO2 laser wavelength. Although hemoglobin and melanin strongly absorb light in the 800-1,100 nm range, their relatively low concentrations in soft tissue result in a widely spread thermal damage zone of several mm.[2, 3] Such deep penetration of diode laser light enables many useful non-surgical applications such as hair removal, spider vein reduction, biostimulation, etc.

Erbium Laser Wavelengths

Erbium laser wavelengths in the 2,780-2,940 nm range are shown to be energy efficient and spatially accurate for photo-thermal ablation; however, their coagulation ability is poor. Compared to the CO2 10,600 nm wavelength, erbium lasers are 5-15 times less efficient at coagulation. The optical absorption and coagulation depths of the erbium’s wavelengths are much smaller than blood vessel diameters; this accounts for the inability of erbiums to prevent bleeding from the blood vessels severed during tissue ablation.[4]

The ability of the CO2 laser’s 10,600 nm wavelength to vaporize water-rich soft tissue makes it a true “What You See Is What You Get” soft tissue-laser with maximum precision; its minimal collateral thermal effects are sufficient for hemostasis. The CO2 laser is THE ONLY practical soft-tissue surgical laser that uses the laser beam directly to cut, ablate and photo-thermally coagulate the soft tissue.

testimonial author
Did a quad bleph and vaporized elevated lesions on face. Machine and variable spot size handpiece performed perfectly and air purge dialed down exactly as you showed me. Very cool machine. Definitely an upgrade! It’s the difference between a Chevy Malibu and a Bentley Continental GT…both good, reliable cars, but the Bentley gets you there quicker, more precisely, more comfortably and in Style, Babe!!
Edward Zimmerman, MD
President, American Board of Laser Surgery Fellow, American Society of Laser Medicine and Surgery; American Academy of Cosmetic Surgery...
testimonial author
When I first got this 20 Watt LightScalpel machine I was hoping to have a good replacement for the old Luxar LX 20. However what I am really finding out is that this is not a replacement for that machine but truly a second-generation machine. This is a whole new level of CO2 laser. I am not easily impressed – congratulations!
Robert A. Strauss, DDS, MD
President, American College of Oral and Maxillofacial Surgeons; Professor of Surgery...
The Learning Curve in Laser Surgery

The LightScalpel flexible fiber CO2 laser is a soft-tissue laser scalpel that is easy and fun to use due to:

  1. The clinical benefits it brings, such as the ability to accurately cut and coagulate soft tissue simultaneously, minimal bleeding, less trauma to the tissue, reduced postoperative pain, and increased visibility of the surgical field[5]
  2. The ease and comfort of the scalpel-like handpiece with easily interchangeable modalities for cutting, ablation and/or photo-coagulation
  3. The abundance of training and educational resources available

Laser power density

Consider a steel blade: regardless of how sharp the blade is, there will be no interaction between the blade and tissue unless mechanical pressure is applied to the blade, forcing it through the tissue surface. For a laser scalpel, the power density of the focused laser beam is equivalent to the mechanical pressure that is applied to a cold steel blade:  the greater the laser power density, the greater the rate of soft tissue interaction.

Laser handpiece

Disposable-free “tipless” laser handpieces from LightScalpel are designed to closely simulate the scalpel-like experience without making any contact with the tissue. Maintaining a 1-3 mm distance between the distal end of the handpiece and the tissue (see Figure 5) is required to achieve the designated spot size.

Beam spot size for cutting

A quality cut made by a sharp steel blade can likewise be achieved by adjusting the focal spot size of the laser beam. The smaller (or sharper) the focal spot of the beam, the narrower and the deeper the incision. Just like a dull blade, an oversized laser beam spot cannot produce a good quality incision. For laser tips, the 0.4 mm spot size is the most popular for cutting applications. For newer tipless handpieces, the best spot size for cutting is 0.25 mm.

For a rapid switch from cutting to just photo-coagulation, the laser beam can be defocused by either (1) selecting a larger spot size, or (2) simply moving the handpiece away from the tissue by 10-15 mm, and “painting” the “bleeder” for enhanced hemostasis.

Beam spot size for superficial ablation

Not all types of laser surgery involve incising the tissue. Superficial surface ablation is best achieved through using large beam spot size settings, such as 0.8 mm or 1.4 mm diameter.

Hand-speed and incision/ablation depth control

For the most comfortable hand-speed control, while achieving the desirable incision depth or superficial ablation rate, the clinician can vary the average laser power. A thin skin incision made by a gently applied sharp blade can also be accomplished by the finest spot size of 0.25 mm and low power settings. For thicker skin incisions, a higher power setting is recommended while the 0.25 mm spot size is still appropriate. However, when debulking a large tumor, the larger 1.4 mm spot size and higher power settings are recommended for comfortable hand-speed and the most efficient completion of the laser surgery.

Controlling thermal effects during laser surgery

The SuperPulse mode (see Figure 6) is made of bursts of very high peak power laser pulses that are spaced far enough apart to allow for efficient tissue cooling between the pulses. SuperPulse minimizes the amount of heat escaping from the cutting/ablation zone to surrounding tissue; it results in less char on the margins of the cut, facilitating greater healing and reduced post-operative scarring of the surgical wounds. For a stronger hemostasis effect through photocoagulation by laser light, turning SuperPulse mode off is recommended, e.g., for procedures such as debulking of highly vascular tumor masses.

Figure 4. Surgical and Dental laser handpiece for laser surgery. Figure 4. Medical laser / surgical laser, and dental laser handpieces.
soft tissue laser surgery Figure 5. "Tip-to-tissue" distance explained: 1-3 mm is required to achieve designated focused beam spot size.
Figure 6. SuperPulse explained: high power, short laser pulses maximize soft tissue removal rate and keep adjacent tissue cool. Figure 6. SuperPulse explained: high power, short laser-pulse duration maximizes soft-tissue removal rate and keeps adjacent tissue cool.
Summary

Flexible fiber soft tissue CO2 laser surgery can be easily learned by any skilled dentist or physician. Advances in handpiece technology and fast ROI make CO2 laser surgery enjoyable and affordable as never before.

Learn more about LightScalpel surgical lasers being used in specific medical specialties:
oral and maxillofacial, dentistry, pediatrics, dermatology and plastic surgery, ophthalmology, ENT, podiatry, gynecology, and neurosurgery.

References
  1. P. Wilder-Smith et al. “Incision properties and thermal effects …”, Oral Surgery Oral Medicine Oral Pathology, 1995, p.685.
  2. P.W.A. Willems et al. “Contact laser-assisted neuroendoscopy …”, Lasers in Surgery and Medicine, 2001, p. 324.
  3. L. B. Rizzo et al. “Histologic comparison of skin biopsy …”, JAVMA, 2004, p. 1562.
  4. Vitruk P. “Oral soft tissue laser ablative and coagulative efficiencies spectra“, Implant Practice US, 2014;7(6):22-27.
  5. Kaplan M, Vitruk P. “Soft tissue 10.6 micrometers CO2 laser…“, Orthodontic Practice US, 2015;6(6):53-57.

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