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Laboratory and mathematical skin examination has played an important role in defining the clinical usefulness and limitations of laser, developing concepts and techniques that have further improved the effectiveness of laser treatment. In addition to this, new technological developments over the years, have helped define the specificity of laser-tissue interaction. Instantaneous conversion by thermal energy of water in a liquid state to a gaseous state when irradiation of skin is done by high power density carbon dioxide laser in short pulses, occurs so quickly that there is minimal thermal conduction to the adjacent tissues structures. The zone of thermal injury could be minimized to the order of only 50 micron thick. In spite of the limited effects of heat conduction, coagulation in vessels can be obtained as well, since small blood vessels are immediately sealed by the laser. Modern carbon dioxide systems can be programmed and make it possible to reproduce shots precisely to vaporize identically thin layers of soft tissue, since absorption by intracellular water limits the depth of penetration. Moreover, collimated handpieces make it possible to deliver a fixed beam diameter and a constant power density as the handpiece is steadily moved over lesions situated on uneven facial contours. The use of large spot sizes gives a more uniform vaporization thus damaging adjacent tissues to a lesser degree, but enlarging of the spot size requires higher energy levels per pulse so that the whole surface can reach a sufficiently high fluence for clean vaporization to take place. For this to be achieved, the fluence required is about 4 - 5 J/cm2 and so UltraPulseR carbon dioxide laser with a 3 mm spot size may be operated with optimal parameters for clean ablation. The resulting surface, covered by dry debris, can be removed by gently scrubbing to avoid thermal build-up, otherwise this remaining tissue can act as a refracting surface as the practical absence of water content means that the carbon dioxide laser light is not efficiently absorbed. This process is repeated layer-by-layer using the same laser parameters until all remaining abnormal tissue has been grossly removed. Utilized as a chain of rapid, short (approx. 1 ms) pulses, with high peak power, tissue can be effectively eliminated, taking advantage of the concept of the known thermal relaxation time of soft tissue. The current laser systems which are built according to the new concept of high technology based upon the knowledge of laser tissue interaction, known as UltraPulsedR Carbon Dioxide Laser, are capable of precise ablation and also of being used in cosmetically sensitive areas with minimal thermal damage. Although the precise clinical role for this laser has yet to be accurately defined, the potential benefits offered by its use appear to be substantial.
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