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Re: improvement of dermatochalasis and periorbital rhytids with a high-energy pulsed CO laser: a retrospective study.

To the Editor: In a recent study, Alster and Bellew presented retrospective data of 67 patients treated with periocular CO2 laser for dermatochalasis and rhytids. Through photographic analysis they demonstrated that dermatochalasis was improved by an average of 1.9mm. I laude the authors for making these observations, but would caution on the validity of the findings. When studying any eyelid skin changes, one must control for many factors including eyelid and eyebrow position. This is quite apparent in Figure 2. In the preoperative photograph the eyelid margin to light reflex distance is approximately 1mm in the right eye and 2mm in the left eye. In the postoperative photo, the margin to light reflex distance has increased to 4mm in the left eye and almost 5mm in the right. This discrepancy would explain for much of the improvement the authors have seen with upper eyelid show. The question in this example is whether the eyelid position is improved due to patient opening the eyes more or induced upper eyelid retraction from the CO2 surgery. If the cause were the latter, that would be a bad consequence of the surgery. Furthermore, eyelid position should always be evaluated before offering surgery for dermatochalasis; often the eyelid has underlying ptosis that should be addressed surgically through an incisional approach. Eyebrow position should also be evaluated in the setting of dermatochalasis because eyebrow ptosis can amplify the appearance of involutional dermatochalasis. In these cases, a brow lift often reduces the dermatochalasis significantly. Conversely, addressing the dermatochalasis without addressing the brow ptosis can exacerbate the descending brow position. Finally, to properly determine the effect of CO2 laser on dermatochalasis, a prospective study controlling for eyelid and eyebrow position is necessary.