Plasma ablation versus super pulse CO2 laser ablation for treatment of benign eyelid margin lesions

Abstract

Purpose:

To compare the outcomes of plasma ablation and super pulse CO2 laser ablation for treatment of benign eyelid margin lesions.

Design:

Retrospective nonrandomized comparative study.

Methods:

Setting: institutional.

Study Population:

Thirty-eight adults with unilateral clinically benign eyelid margin lesions were nonrandomly divided into two groups based on the treatment method. Lesions <10 mm and stable for at least 6 months were included. Lesions >10 mm, suspected premalignant or malignant lesions, and patients with active systemic disease were excluded.

Intervention Procedures:

Group 1: plasma ablation, Group 2: super pulse CO2 laser ablation.

Main Outcome Measures:

postoperative pain, time to wound epithelialization, postoperative complications and recurrence, and patient satisfaction.

Results:

Group 1 included 20 lesions, and Group 2 included 18 lesions. The mean size of the lesions was 5.7 ± 1.7 mm and 6.2 ± 1.8 mm, respectively (P = 0.336). There was a highly significant difference between the two groups as regards mean time to wound epithelialization (9.1 ± 2.4 days in group 1 versus 21.1 ± 4.3 days in group 2, P < 0.001). Longer epithelialization time was associated with significantly greater pain (P = 0.002). In group 2, transient hypopigmentation occurred in 2 (11.1%) patients and maldirection of eyelashes in 1 (5.6%). No recurrence was observed in either group. All (100%) patients of group 1 and 88.9% of group 2 were completely satisfied.

Conclusion:

Both plasma ablation and super pulse CO2 laser ablation are effective in the treatment of benign eyelid margin lesions with good cosmetic outcomes. The choice of the procedure should be individualized according to the patient’s general condition, needs, and lesion characteristics.

The eyelid skin is delicate; it is the thinnest skin of the body and the most exposed to sunlight. It is therefore vulnerable to various types of tumors, most of which are benign in nature. Though the principles of tumor removal are similar to skin elsewhere, tumors in specific areas of the eyelid can be challenging.[1] The eyelid margin, in particular, is complex with vital structures as the exocrine glands, lashes, and tarsus. Traditional surgical removal is the standard treatment, but it is not without complications. Eyelid scarring and malposition may limit the success of the procedure and patient satisfaction.[2] As the indication for removal of benign tumors is mainly cosmetic, there has been an increased demand for less invasive and similarly effective procedures.[3]

Periocular laser surgery combines the innovations in dermatology and esthetic surgery and has gained popularity in the recent years. CO2 laser is commonly used in ablative eyelid surgeries. The laser is absorbed by water naturally present in the tissues, causing a rapid increase in temperature and ultimate evaporation. This offers noncontact, hemorrhage-free incisions.[4] However, the main drawback is that thermal injury extends to the surrounding tissue, and the incidence of complications is related to the extent of collateral damage. To obtain more localized ablation, the laser pulse duration should be less than the interpulse duration. These settings are the basis of the super pulse CO2 laser which is preferred over the continuous mode.[5]

Lately, plasma ablation technology has been introduced as a versatile tool for facial skin esthetic treatments. It has also been successfully used in the treatment of several benign skin lesions.[6] Most devices used in esthetic procedures create plasma by ionization of the air between the device tip and the skin. Plasma is an ionized gas that allows energy transfer to the skin epidermis without direct contact.[7] The target tissue undergoes a process of sublimation, which is direct conversion into gas without an intermediate liquid state. This avoids thermal damage to the adjacent tissue and gives high precision ablation.[8]

Despite the functional and cosmetic importance of the eyelid margin, there are insufficient reports on the best method of removal of lesions in this area. Therefore, the aim of this study was to compare the outcomes of plasma ablation and super pulse CO2 laser ablation in the treatment of benign eyelid margin tumors.

Methods

This retrospective nonrandomized comparative study was conducted in accordance with the principles of the Declaration of Helsinki and received ethical approval from the institutional review board (IRB) (ZU-IRB#10343-20-8-2023). All patients were asked to sign a written consent form after full explanation of the intervention procedure, potential risks, and alternative treatments. Records of patients with clinically benign eyelid margin lesions attending the outpatient clinics during the period from July 2021 to August 2023 were retrieved. Inclusion criteria were adults (>18 years) with lesions located at the eyelid margin, equal to or less than 10 mm, and stable for at least 6 months. Exclusion criteria were lesions greater than 10 mm, history of rapid growth, ulceration, cystic lesions, suspected premalignant lesions such as keratoacanthoma or actinic keratosis, patients with active systemic disease, for example, collagen vascular disorders, malignancy, pregnancy, history of previous eyelid surgery or keloid formation, and patients lost to follow-up.

Before intervention, thorough history taking and complete ophthalmic examination were performed to determine the size and nature of the lesion and eligibility for the procedure. This included visual acuity assessment, refraction, intraocular pressure (IOP) measurement, slit-lamp examination of the eyelids and the anterior segment, and biomicroscopic inspection of the fundus examination. All lesions were photographed before and after removal for documentation. According to the ablation technology used for lesion removal, patients were divided into two groups. Group 1: patients who received plasma ablation and Group 2: patients who received super pulse CO2 laser ablation. All lesions were removed in a single session.

All procedures were performed outpatient using a magnifying loupe (2.5 ×) under local anesthesia. 0.1–0.4 ml of 2% lidocaine was injected close to the lesion, and topical anesthetic eye drops (0.4% benoxinate) were instilled. A nonreflective corneal shield was placed to protect the anterior segment of the eye. If the mass involved the lash line, the related lashes were cut to facilitate ablation. In lesions close to the punctum, the punctum was dilated before starting treatment to be easily identifiable and avoid inadvertent damage. The duration of each procedure was timed from the start of ablation till complete removal of the lesion.

In group 1, Maglev plasma pen (Guangzhou Allfond Electronics Co., Ltd, China) was used. The device was set on the high-power mode (a power of 1 W and a frequency of 1.1 MHz ± 0.3MHz). The tip of the needle was held close to, but not touching, the lesion during the procedure. Several passes were applied according to the thickness of the lesion, until healthy tissue was reached. Any formed debris was removed with a cotton tip applicator to increase visibility.

In group 2, the CO2 laser machine (FONS SVR, RUIKD Medical Co., Ltd, Korea) was used. Using the surgical hand piece, the device was set to the super pulse laser mode (spot size: 150 μm, pulse energy: 1–300 mJ, pulse width 0.1–10 ms, adjusted according to the size and depth of the lesion). First, the lesion was held with microforceps and the laser was used as a blade to excise the main bulk of the lesion along its base at the level of the eyelid margin. Then, direct ablation was applied to the resultant raw area to remove any remnants of the lesion.

After treatment, patients were instructed to apply combined topical tobramycin and dexamethasone eye ointment once daily for 2 weeks and to avoid direct sun exposure for 1 month. Follow-up visits were scheduled daily till complete wound epithelialization and then monthly for 6 months after treatment. At each visit, patients were examined for epithelialization of the wound, cosmetic outcomes, any complications such as infection, eyelid malposition, and recurrence. Pain was assessed on the first postoperative day using the verbal rating scale (VRS): 0 = No pain, 1 = Mild pain, 2 = Moderate pain, and 3 = Severe pain. The time till complete epithelialization of the wound was recorded. Subjective symptoms, for example, irritation and epiphora, were evaluated by direct questioning. At the last follow-up visit, patients were asked to rate their satisfaction using the validated Global Aesthetic Improvement Scale (GAIS). Grade 3: Excellent (patient completely satisfied with the result), Grade 2: Very good (patient very satisfied with the result), Grade 1: Satisfactory (although the patient sees slight improvement, additional correction is required), Grade 0: Indifferent (patient sees no changes), and Grade -1: Unsatisfied (patient’s condition is worse than before the procedure).

Statistical analysis

The collected data were statistically analyzed using Statistical Package for Social Science (SPSS) software (version 20, SPSS Inc., Chicago, IL). Continuous variables with a normal distribution were reported as mean ± SD and range. Categorical variables were summarized as frequencies and percentages. An independent sample t-test was used to compare normally distributed data of two groups. The ANOVA test was used to compare between normally distributed data of more than two groups. Qualitative data were evaluated by Chi square (χ2) and Fisher-exact test. P-values <0.05 and <0.001 were considered statistically significant and highly statistically significant, respectively.

Results

This study included 38 patients with a single benign eyelid margin lesion. Twenty lesions were treated by plasma ablation (Group 1), and 18 lesions were treated using super pulse CO2 laser (Group 2). Group 1 included 11 (55%) males and 9 (45%) females with a mean age of 44.1 ± 7.2 years. Group 2 included 10 (55.6%) males and 8 (44.4%) females with a mean age of 45.4 ± 5.8 years. In group 1, the site of the lesion was the lower lid in 12 (60%) patients, the upper lid in 4 (20%), and peripunctal in 4 (20%). The mean size of the lesion was 5.7 ± 1.7 mm. In group 2, the lesion was located in the lower lid in 10 (55.6%) patients, the upper lid in 5 (27.8%) [Fig. 1a], and peripunctal in 3 (16.7%). The mean size of the lesion was 6.2 ± 1.8 mm. There was no statistically significant difference between the groups as regards to baseline characteristics [Table 1].

Figure 1.

A case treated with super pulse CO2 laser: (a) Preoperative photo; (b) 18 days after treatment, the wound is still not completely epithelialized (arrow); (c) At the last follow-up, the patient showed maldirection of the eyelashes

Table 1.

Baseline characteristics of the studied groups

Variable		Group 1		Group 2		P
Number of patients		20		18
Age
Mean±SD     Range		44.1±7.2 33 – 55		45.4±5.8 34 – 54		0.549*
Sex
Male     Female		11 (55%) 9 (45%)		10 (55.6%) 8 (44.4%)		0.973⸷
Lesion site
Lower lid     Upper lid     Peripunctal		12 (60%) 4 (20%) 4 (20%)		10 (55.6%) 5 (27.8%) 3 (16.7%)		0.847⸷
Lesion size (mm)
Mean±SD     Range		5.7±1.7 3 - 9		6.2±1.8 3 - 10		0.336*

*Independent t-test, ^⸷Chi-square test, P>0.05=not significant

The mean duration of the procedure was 239.3 ± 40.3 seconds (range 181–315 s) in group 1 and 261.4 ± 43.3 seconds (range 185–384 s) in group 2. The difference between the two groups was not statistically significant (P = 0.112). Postoperative pain was rated as 0, 1, or 2 by 13 (65%), 6 (30%), and 1 (5%) patients of group 1, respectively, and by 10 (55.6%), 5 (27.8%), and 3 (16.7%) patients of group 2, respectively. None of the patients in either group reported severe (grade 3) pain. The resultant wound showed complete epithelialization after 9.1 ± 2.4 days in group 1 versus 21.1 ± 4.3 days in group 2 [Fig. 1b]. This difference was highly statistically significant (P < 0.001) [Table 2].

Table 2.

Intraoperative and postoperative outcomes of the two procedures

Variable		Group 1		Group 2		P
Duration of the procedure (s)
Mean±SD     Range		239.3±40.3 181 - 315		261.4±43.3 185 - 384		0.112*
Postoperative pain
0 (no pain)     1 (mild)     2 (moderate)     3 (severe)		13 (65%) 6 (30%) 1 (5%) 0 (0%)		10 (55.6%) 5 (27.8%) 3 (16.7%) 0 (0%)		0.501⸷
Wound epithelialization time (days)
Mean±SD     Range		9.1±2.4 6 - 14		21.1±4.3 14 - 29		<0.001*
Complications
Hypopigmentation     Maldirected lashes     None		0 (0%) 0 (0%) 20 (100%)		2 (11.1%) 1 (5.6%) 16 (88.9%)		0.164⸷
Patient satisfaction
Grade 3 (completely satisfied)     Grade 2 (very satisfied)     Grade 1 (satisfied)     Grade 0 (indifferent)     Grade -1 (unsatisfied)		20 (100%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)		16 (88.9%) 2 (11.1%) 0 (0%) 0 (0%) 0 (0%)		0.126⸷

*Independent t-test, ^⸷Chi-square test, P>0.05=not significant, P<0.001=highly significant

There was a significant relation between the mean epithelialization time and degree of postoperative pain in both groups. The longer the time to achieve complete wound epithelization, the greater the pain perceived by the patient. The mean time to epithelialization was significantly longer among patients with moderate pain (24 ± 6.8 days) as compared to those with mild pain (17 ± 6.2 days) and no pain (5.7 ± 1.2 days) (P = 0.002).

In group 2, 2 (11.1%) patients experienced transient hypopigmentation, and 1 (5.6%) patient showed maldirection of the lashes at the site of ablation [Fig. 1c]. The lashes did not rub into the cornea, and thus, no side effects occurred. No other complications were recorded in either group. The lid margin maintained a good anatomical position with no scars, notching, or lash loss [Fig. 2]. None of the patients complained of symptoms of lacrimal dysfunction such as epiphora or dryness even in those who had peripunctal lesions. None of the patients showed recurrence of their lesion throughout the study period. In group 1, 20 (100%) patients were completely satisfied with the final esthetic outcome, while in group 2, 16 (88.9%) patients were completely satisfied, and 2 (11.1%) patients were very satisfied [Table 2].

Figure 2.

A case treated with plasma ablation: (a) Preoperative photo; (b) At the end of the procedure, after complete removal of the lesion; (c) At the last follow-up, the wound is completely epithelialized with an excellent cosmetic result

Discussion

Removal of benign eyelid margin tumors can be challenging even in the hands of the experienced surgeon. The structural and functional aspects of the lid margin must be preserved without compromising the cosmetic results.[9] The continuous evolution in the field of esthetic surgery has raised patients’ expectations. Minimally invasive procedures with high comfort, rapid recovery, and satisfactory outcomes have become an increasing request.[10] Only a limited number of these procedures can be safely applied to the eyelid margin. Also, any treatment protocol should be tailored to adapt to the specific features of this area. Limited studies have been published on the feasibility and results of minimally invasive techniques in eyelid margin lesions.

Laser therapy is a widely accepted procedure for the treatment of benign eyelid masses. Nowadays, it is preferred by many surgeons over traditional surgery. It is rapid and easy, and no sutures are needed, so it is performed as an outpatient procedure.[2] It causes less pain and edema; thus, there is faster recovery. There is less postoperative reaction, good healing, and minimal scar formation. CO2 laser is favored in eyelid lesions because its absorption spectrum allows simultaneous cutting and hemostasis regardless of the melanin content.[11] The CO2 laser in its super pulse mode has proved superiority due to its shorter exposure time and less thermal damage.[12]

In our study, we reported good cosmetic and functional outcomes with super pulse CO2 laser ablation. Our results are consistent with previous studies in the literature. Zhang et al.[12] studied the use of super pulse CO2 laser in the treatment of 99 benign eyelid lesions, 18 of which involved the lid margin. The wounds were dry, not infected, and completely epithelialized within 2–4 weeks (14–29 days, approximately 2–4.1 weeks in our study). None of the lesions showed notching, lash loss, or recurrence. All patients were satisfied with the results. Song et al.[1] focused on peripunctal benign tumors. The procedure was safe and effective even without lacrimal tube insertion. No side effects such as epiphora or punctal obstruction occurred, and none of the lesions showed recurrence. Zhao et al.[13] investigated meibomian gland function after super pulse CO2 laser therapy at the palpebral margin. They concluded that the laser had no effect on meibomian gland structure or function. This explains why none of the patients in our study experienced symptoms of dry eye after the procedure.

Plasma exeresis is a relatively new technology that was proposed to have an intermediate action between ablative and nonablative techniques. It aims to provide the same effectiveness of ablative lasers while maintaining the safety and rapid recovery of nonablative techniques.[3] Plasma energy causes instant, precise, and uniform heating of the target tissue. Cooling occurs by evaporation of the injurious fluids without transmitting excess heat to the surroundings.[14] The result is a layer of intact and dried epidermis that promotes better healing. It is thus believed to achieve optimal esthetic results with minimal collateral effects.[15]

In our study, we observed satisfactory clinical outcomes with plasma therapy. All patients had good cosmetic results and were satisfied with the procedure. This comes in agreement with the findings of Ucar and Unluzeybek.[16] Their study included 77 eyelid lesions, 44 of them (61.9%) were located at the eyelid margin and 6 (8.4%) were close to the punctum. The mean duration of the procedure was 4.0 ± 0.7 minutes (similar to our study; 239.3 ± 40.3 s, approximately 3.99 ± 0.67 min). Three (4.2%) cases complained of postoperative irritation after removal of conjunctival extending lesions. None of the patients in our study experienced irritation as the lesions did not show conjunctival extension. Wounds showed complete epithelialization within 1–2 weeks (range = 6–14 days, approximately 0.9–2 weeks in our study). The final cosmetic appearance was satisfactory with no discoloration, scar formation, notching, or malposition. The punctum remained intact in peripunctal lesions.

On comparison of the two techniques, plasma ablation did not cause any pigmentary changes or lash affection in contrast to 2 (11.1%) cases which showed transient hypopigmentation and 1 (5.6%) patient who had maldirected eyelashes after super pulse CO2 laser. These results can be attributed to the different mode of tissue interaction with each technique. Plasma energy causes ablation of the skin in layers, avoiding unwanted damage to the underlying healthy structures.[17] Laser ablation is more diffuse as it depends on the water content of the tissue. The use of CO2 laser as a blade to excise the lesion first instead of traditional ablation makes laser penetration more controlled, minimizing damage to hair follicles and lasting pigmentary changes. It also helps preserve tissue for histopathological examination.[18]

In addition, plasma ablation showed faster wound epithelialization than super pulse CO2 laser, and this difference was highly statistically significant (9.1 ± 2.4 days versus 21.1 ± 4.3 days, P < 0.001). Plasma energy has been shown to stimulate the production of collagen and growth factors that facilitate rapid wound healing.[16] On the contrary, CO2 laser wounds show delayed inflammation, collagen production, and re-epithelialization in the early stages of repair.[19] Clinically, this may be reflected as a longer downtime or higher risk of infection in the early postoperative period. In our study, the longer re-epithelialization time was directly related to greater perception of immediate postoperative pain. However, it did not affect the ultimate patient satisfaction, probably due to the small size of the lesions.

There are several limitations to our study, namely, its retrospective nature and small sample size. This is mainly because we limited our study population to eyelid margin lesions only, due to the unique nature of this region. Although all lesions were clinically benign, we did not confirm the nature of the lesions by histopathology.

Conclusion

Plasma ablation and super pulse CO2 laser ablation are equally safe and effective in the treatment of benign eyelid margin lesion with good esthetic outcomes. The choice of the procedure should be tailored according to the patient’s general condition, needs, and the characteristics of the lesion. Patients with impaired wound healing or increased risk of infection could benefit from the rapid rehabilitation of the plasma ablation technique. On the other hand, patients with lesions in which histopathology is recommended yet refusing or unfit for traditional surgery are good candidates for super pulse CO2 laser ablation.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.