fraction at ed co2 laser skin rejuvenation
TRANSCRIPT
Fractionated CO2 laserskin rejuvenationdth_1377 41..53
Emily P. Tierney*†‡, Richard F. Eisen† & C. William Hanke‡*Boston University School of Medicine, Boston, Massachusetts; †South ShoreSkin Center, Plymouth, Massachusetts and ‡Laser and Skin Surgery Center ofIndiana, Carmel, Indiana
ABSTRACT: Fractional photothermolysis has been reported in the literature to improve both the pig-mentary and textural changes associated with photoaging. The objective of the study was to review theliterature of non-ablative fractional laser (NAFL) and ablative fractional laser (AFL) resurfacing for thetreatment of photoaging. This is a review of the Medline literature evaluating NAFL and AFL for pho-toaging. Review of the literature supports the use of NAFL and AFL as safe and effective treatments forphotoaging. It is likely that the controlled, limited dermal heating of fractional resurfacing initiates acascade of events in which normalization of the collagenesis/collagenolysis cycle occurs. The advent offractionated resurfacing for the treatment of photoaging is a significant advance over ablative laserresurfacing treatments, which were complicated by prolonged erythema, delayed onset hypopigmen-tation, and scarring.
KEYWORDS: fractional photothermolysis, laser surgery, photoaging
Background
For nearly 15 years, ablative resurfacing of the skinusing the carbon dioxide (CO2) laser was the goldstandard for treatment of photoaging. Despite itssuperiority in the treatment of rhytides (1–3), pho-todamage (4,5), and acne scars (6,7), the CO2 laserhas fallen out of favor in recent years because of thelengthy recovery period after treatment and therisk of serious side effects, including scarring anddelayed onset hypopigmentation.
The goals of decreasing recovery time, minimiz-ing side effects, and avoiding complications toincrease patient acceptance and satisfaction withtreatment were the impetus for the development ofnon-ablative laser treatments (8–16). Non-ablative
lasers heat the dermis, without injury to the epi-dermis, to stimulate dermal remodeling (8–16).Although very safe, these devices are unable to gen-erate significant dermal coagulation and are not aseffective as ablative laser resurfacing (12).
The concept of fractional photothermolysis (FP)(17) revolutionized laser surgery by enabling thedelivery of dermal coagulative injury without con-fluent epidermal damage, thus decreasing the risksof scarring as well as decreasing the downtimeassociated with traditional ablative resurfacing. FPis based upon the scientific concept of creatingmicroscopic thermal wounds deep to the surface ofthe skin, which allow for tissue contraction, stimu-lation of collagen, and rapid wound healing (17,18).Fractionated lasers drill microscopic holes intothe dermis in a grid pattern (17–19). FP has beenlikened to aerating a lawn (19). The “lawn plugs,”termed microscopic epidermal necrotic debris, areexpelled via a transepidermal elimination processover 7–10 days (19). The consequences are twofold:(i) dermal conditions that have been approached
Address correspondence and reprint requests to: EmilyTierney, MD, South Shore Skin Center, 1 Scobee Circle, Unit 3,Plymouth, MA 02360, or email: [email protected].
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Dermatologic Therapy, Vol. 24, 2011, 41–53Printed in the United States · All rights reserved
© 2011 Wiley Periodicals, Inc.
DERMATOLOGIC THERAPYISSN 1396-0296
indirectly in the past via epidermal wounding arenow directly wounded as portions of the normaldermis are removed; and (ii) the remaining adja-cent intact dermis and epidermis allow for rapidhealing without relying on the presence of adnexalstructures to regenerate the epidermis (19).
The original prototype device was a 1550-nmerbium-doped laser, which created noncontiguousmicroscopic columns of thermal injury in thedermis (termed microscopic thermal zones orMTZs) surrounded by columns of normal tissue(7). As the tissue surrounding each MTZ is intact,uninjured epidermal and dermal cells at the borderof each column of injury contribute to rapidhealing (7). Histologic studies evaluating thepattern of injury with FP demonstrated homogeni-zation of the dermal matrix and the presence ofmicroscopic epidermal necrotic debris. Micro-scopic epidermal necrotic debris represents theextrusion of damaged epidermal keratinocytes byviable keratinocytes at the lateral margin of theMTZ.
FP has known effects on tissue shrinkage andtissue texture, likely through stimulation of nor-malization of the collagenesis/collagenolysis cycle.Manstein et al. (17) reported significant improve-ments in periorbital rhytids and skin texture afterinitial treatments with their prototype FP device.Interestingly, Manstein et al. found a linear patternof shrinkage along the triangular-shaped sides oftattoos of treated skin relative to control site, sug-gesting that thermal injury induced by FP resultedin wound contraction and tissue shrinkage (7). Ini-tially, at 1 week, there was statistically significantshrinkage, followed by an apparent relaxation after1 month with retightening at 3 months (17). Tissuetightening and clinical improvement of periorbitalrhytides was observed; however, results werelimited to 2.9% linear shrinkage correlating with a19% clinical improvement in periorbital rhytides(17).
In 2007, Hantash et al. (20) first described theuse of an “ablative” CO2 fractional resurfacingdevice (AFP), which produces an array of micro-thermal zones of a customizable density anddepth, with a confluent pattern of ablation andcoagulation extending from the stratum corneumthrough the dermis (20). In the initial in vivostudies demonstrating the histologic and clinicaleffects of this device, Hantash et al. confirmed withimmunohistochemistry that collagen remodelingoccurred for at least 3 months posttreatment (20).
AFP, creating confluent columns of thermalinjury in a random array extending from thestratum corneum to the reticular dermis, has dem-
onstrated significant effects on skin tightening andtexture beyond that seen with the original genera-tion of non-ablative fractional photothermolysis(NAFP) devices (20–29).
The safety profile seen with AFP marks a sig-nificant advantage over the traditional ablativeresurfacing devices associated with prolongedpostoperative erythema and risk of post-inflammatory pigmentary change and scarring(20–29). Following full-face resurfacing with AFP,complete re-epithelialization is generally seen in3–6 days (20–28). This is in contrast to the 2–3weeks of recovery following full-face resurfacingwith traditional CO2 laser systems (1–16). Rapidre-epithelialization after AFP treatment results invery few infections, which are further reduced withthe use of prophylactic antiviral and antibiotictherapy. Faster re-epithelialization also results inpatients requiring fewer days of occlusive ointmentapplication. This greatly reduces the rate of acnei-form eruptions, which are seen in up to 83% ofpatients treated with traditional CO2 lasers (16).Erythema, an expected side effect after treatment,also resolves much more quickly after ablative frac-tional resurfacing (AFR) (20–29) compared withtraditional ablative CO2 laser treatments, wherepostoperative erythema persists for up to 3–4months posttreatment (1–16).
The present authors present herein a review ofthe literature of AFP for the treatment of photoag-ing as well as a practical guide to the treatment ofphotoaging with some of the currently availableAFP devices.
Review of the literature on AFP treatmentfor photoaging
Review of the recent literature demonstrates sig-nificant advantages of FP in terms of decreasedrecovery times and benign side effect profiles rela-tive to traditional ablative laser resurfacing devices(CO2 and Er : Yag) (17–30). Although traditionalablative laser resurfacing was able to achieveresults for skin tightening, which rivaled surgicalcorrection, the side effects of several months oferythema and swelling, and long-term risks of pro-longed dyspigmentation and potential scarringsignificantly limited the application of this tech-nology (11–16). Additionally, it has been speculatedthat fractionated resurfacing may have greater effi-cacy in skin tightening than traditional ablativeresurfacing because of the pattern of thermal abla-tion, which provides for deeper dermal penetration(19,20,26,27). One possible explanation for thegreater degree of tightening observed with FP is the
Tierney et al.
42
greater depth of dermal penetration, which couldnot be achieved safely with traditional ablativedevices (19,20,26,27).
The rapid recovery times seen with fractionatedCO2 laser marks a significant improvement overtraditional CO2 and Er : Yag laser resurfacing. It ispostulated that the differences in healing timebetween traditional ablative resurfacing and frac-tional resurfacing result from differences inmechanisms of wound healing (31). Traditionalablative laser wounds heal by migration of stemcells from hair follicles (31). In contrast, with frac-tional ablative resurfacing, it is hypothesized thatre-epithelialization occurs more rapidly as recov-ery occurs because of migration of neighboringcutaneous stem cells (31). Additional histologicand molecular studies need to be performed tobetter characterize and understand the healingmechanisms involved.
The mechanism of improvement in skin textureand tightening with AFP is not precisely known. Ithas been observed that as tissue is ablated, there isa bimodal immediate collagen contraction and asecond effect at 3–6 months afterward from persis-tent collagen remodeling (31).
There are a number of fractionated CO2 devicescurrently on the market characterized by adjust-able fluences and pulse durations, which allowtargeting of the amount and depth of dermalheating delivered (Table 1). A number of recentstudies have evaluated changes in photoagingwith these devices, and both clinical and histo-logic data have confirmed the exciting promise ofthese devices in achieving improvements in skintexture and laxity, which are significantly greaterthan the previous generation of non-ablative FPdevices (24–31).
In 2009, Rahman et al. (24) reported a highdegree of safety and efficacy in photoaging with anAFP device in the Food and Drug Administrationstudies, leading to approval of the device (FraxelRe:pair, Reliant Technologies, Mountain View, CA,USA). Patients were treated on both the face andneck with settings of fluence/MTZ of 10–40 mJ/MTZ and densities of 400–1000 MTZ/cm2. Averageimprovement in indices of skin texture and tight-ening (on a quartile scale) was 2.30 (rhytides), 2.42(texture), and 1.65 (laxity) (24). A follow-up to thepresent study was reported by Ortiz et al. on thelong-term outcomes of 10 subjects previouslytreated with fractional CO2 resurfacing (25).Patients returned for long-term follow-up visits at 1and 2 years, respectively. Subjects maintained 74%of their overall improvement at their long-termvisits compared with 3-month follow-up visits.
Although clinical improvement was maintainedlong term, the results were not as remarkable asthose seen at 3-month visits. The authors specu-lated that results seen at 3 months may beenhanced by persistent inflammatory changes, asevidenced by heat shock protein 47 activity andongoing collagen remodeling seen in previoushistologic studies. Although fractional CO2 laserresurfacing does have long-term efficacy and per-sistence of improvement of acne scarring and pho-todamage compared with baseline, additionaltreatments may be necessary to maintain and/orenhance long-term results.
Berlin et al. (26) performed a study in 10 sub-jects who received one treatment with an AFPdevice (UltraPulse Encore, Lumenis, Inc., SantaClara, CA, USA). The authors evaluated clinicalchange in photoaging as well as histologic andultrastructural change in collagen deposition onboth light and electron microscopy (26). Blindedinvestigator assessment of skin textural alterationsand rhytid reduction revealed a mean improve-ment of 1.8 (on a five-point scale) at 4 weeks and1.6 at 24 weeks posttreatment. Posttreatment biop-sies documented greater fibrosis in the papillarydermis (26). Additionally, electron microscopyrevealed a decrease in the average diameter of thecollagen fibrils, consistent with greater depositionof collagen type III, suggesting new collagen depo-sition induced by fractionated laser resurfacing(26).
A recent study by Tierney and Hanke (27) dem-onstrated significant improvement in neck skintightening with the Smartxide DOT (DEKA, Calen-zano, Italy), where after a series of one to two treat-ments with AFP, a 63% improvement in skintexture, a 57% mean improvement in skin tighten-ing, and a 51.4% improvement in skin rhytideswere observed. This degree of improvement in skintightening of the neck has only previously beenreported with ablative CO2 laser resurfacing (27).
Karsai et al. (28) performed a randomized con-trolled double-blind split-face study to comparethe effects of a single treatment with ablative frac-tional CO2 and Er : Yag lasers for rhytides inthe periorbital region. The evaluation included theprofilometric measurement of wrinkle depth, theFitzpatrick wrinkle score, as well as the assessmentof side effects and patient satisfaction. Interest-ingly, both modalities showed a roughly equivalenteffect on wrinkle depth and Fitzpatrick score ofperiorbital rhytides, where both were reduced byapproximately 20% and 10%, with no appreciabledifference between lasers. Side effects and discom-fort were slightly more pronounced after Er : Yag
Fractionated CO2 laser skin rejuvenation
43
Tab
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Tierney et al.
44
treatment in the first few days, but in the latercourse, there were more complaints following CO2
laser treatment. Patient satisfaction was fair, andthe majority of patients would have undergone thetreatment again without a clear preference foreither method. In the present study, a single abla-tive fractional treatment session has an appre-ciable yet limited effect on periorbital rhytides,where multiple sessions are likely required formore extensive improvement.
A recent report by Goldberg et al. (29) evaluatedthe treatment of perioral rhytides with a fraction-ated ablative Er : YSGG laser (2790 nm). Thisdevice, associated with a 2790-nm wavelength, hasa water absorption coefficient between that of CO2
and Er : Yag lasers. All subjects underwent a two-pass full-face treatment for rhytides at 160 mJ andan 8% density. For perioral rhytides, subjects weretreated with a 160-mJ first pass, and a second andthird pass of 200 mJ with a 12% density. Based onthe Fitzpatrick Scoring System for wrinkles at base-line and at final follow-up, a statistically significantmean reduction of 1.25 (standard deviation 0.71)was observed in overall wrinkle score (reductionfrom 5.88 to 4.63, p-value 0.002) and perioralwrinkle score (reduction from 5.63 to 4.38, p-value0.002). There was no incidence of scarring, post-inflammatory pigmentary changes, or infectionsobserved. The authors reported that the Er:YSGGlaser is safe and effective for photodamage andperioral rhytides.
A recent study by Abbasi et al. (31) reported acomparison of four AFP devices in the treatment ofthe pigmentary and textural components of photo-aging, the Fraxel Re:pair (Solta Medical, Inc.,Hayward, CA, USA), Active and Deep FX (Lumenis,Inc.), Quadralase (Candela Corporation, Wayland,MA, USA), and Pearl Fractional (Cutera, Brisbane,CA, USA). Twelve patients with moderate to severesun damage between the ages of 30 and 65, and ofFitzpatrick skin types I–IV were treated to fourquadrants of the face. Blinded evaluators assessedpatients at 1 month, 3 months, and 6 months post-treatment to evaluate changes in skin texture, len-tigenes, pore size, and rhytides. One- and 3-monthfollow-up data showed improvement in photo-aging in all patients studied across all quadrants.In the present study, no differences were beenobserved to date among the four devices studied.However, one of the significant challenges with thepresent study was in setting equivalent parametersacross the four devices studied. In future studies,extensive preoperative trials will be likely neededto establish comparative settings in studies com-paring two or more devices.
Tierney and Hanke (32) reported the results of aseries of 45 patients with moderate to severe pho-toaging treated with the Smartxide DOT (DEKA).A total of 39 women (86.7% of total) and 6 men(13.3% of total) were enrolled in this trial. Patientsranged in age from 45 to 75 years with a mean ageof 58.5 years. The patients were Fitzpatrick skintypes I–III, with 26.7% Fitzpatrick skin type I, 60.0%Fitzpatrick skin type II, and 13.3% Fitzpatrick skintype III. Patients received between two and threetreatment sessions, with a mean of 2.4 treatmentsessions per patient. The results of a total of 108treatment sessions were included in the results ofthe study. For skin texture, mean improvement was48.5% (95% confidence interval (CI): 44.6%, 52.4%)(p < 0.05). For skin laxity, mean improvement was50.3% (95% CI: 46.1%, 54.5%) (p < 0.05); for dys-chromia, mean improvement was 53.9% (95% CI:49.5%, 58.5%) (p < 0.05); and for overall cosmeticoutcome, mean improvement was 52.4% (95% CI:47.9%, 56.9%) (p < 0.05).
Tierney et al. (33) reported the results of a seriesof 25 patients with moderate to severe laxity andrhytids of the periorbital region treated with theSmartxide DOT (DEKA). The number of treatmentsessions required for significant improvement ofeyelid laxity ranged from two to three, with anaverage of 2.44 sessions. For skin texture, the meanscore decreased from 3.6 to a mean of 1.2 at 6months posttreatment (p < 0.05) for a 62.6% meanimprovement. For skin laxity, the mean scoredecreased from 3.3 to 1.3 at 6 months posttreat-ment (p < 0.05), 65.3% mean improvement. Forrhytids, the mean score decreased from 3.5 to 1.3at 6 months posttreatment (p < 0.05), 62.1% meanimprovement. For overall cosmetic outcome, meanscore decreased from 3.6 to 1.2 at 6 months post-treatment (p < 0.05), 65.7% mean improvement.Moderate postoperative erythema and edema werenoted by patients, which resolved by the 1-weekposttreatment visit. Patients reported minor crust-ing and oozing, which resolved within 48–72 hours.
It has been reported in the literature with FP inclinical–histologic correlation experiments that agreater depth of injury maximizes texture improve-ment, whereas a higher density of more superficialinjuries maximizes improvement in pigmentation(17,18,26,32–36). Part of the rationale for the sig-nificant degree of improvement in skin textureand laxity obtained in this series is the long pulseduration applied (1000–1500 microseconds) (36).Clinical and histologic correlation studies by ourgroup have identified greater improvement intissue tightening associated with the greater depthof penetration of this AFP device at longer dwell
Fractionated CO2 laser skin rejuvenation
45
times (36). Specifically, at a dwell time of 1000–1500 microseconds, the microthermal zone ofablation extends to the depth of the deep reticulardermis (Tierney and Hanke, unpublished data).Thus, the pattern of deep ablation into the reticulardermis and resultant stimulation of collagen con-traction and synthesis likely accounts for its greaterefficacy in tissue tightening and skin texture.
Complications of fractionatedCO2 resurfacing
Recently, three reports of complications of frac-tionated CO2 resurfacing have been reported in theliterature, highlighting the importance of utilizingconservative treatment parameters, particularlyfor anatomic sites with decreased dermal thick-ness, such as the neck and eyelid skin.
Avram et al. (36) reported on five cases of post-AFP hypertrophic scarring, which likely resultedfrom high pulse durations and high levels of treat-ment coverage. These reports highlight the impor-tance of treating with conservative fluences andpulse duration with AFP, particularly for theneck, where decreased density of pilosebaceousunits can lead to prolonged times for re-epithelialization and increased risk of scarringwith all forms of ablative laser resurfacing. Addi-tionally, Fife et al. (37) described four cases ofpost-AFP scarring, including one case where thepatient developed erosions and swelling of theright lower eyelid 2 days postoperatively, whichdeveloped into scarring and an ectropion. In asubsequent commentary to this report, Biesman(38) raised the important question of whether it isreally necessary to extend treatment depths to800–1500 um for areas of thin dermis, such as theneck and eyelids, where hypertrophic scarring hasbeen reported with AFP. Although additional studywith AFP devices are highly needed, preliminarydata suggest that deeper wounds increase the riskof complications and that there may be amaximum depth that should be respected whentreating thinner skin.
Practical tips for treatment of fractionated CO2
laser resurfacing
Basic principles. Prior to treating patients with anyof the available fractional ablative CO2 lasersystems, it is important for the practitioner to havean understanding of the extent of tissue injuryproduced by the device at various settings and
consider the thickness of the skin and the depthrequired to ablate the skin abnormality, in order tochoose safe and effective treatment settings.
Published histologic studies on the thickness ofthe skin, and the depth and number of adnexalstructures at various anatomic sites, and histologicstudies showing the depth and width of tissueinjury with varying laser parameters are helpful inguiding the clinician in the choice of appropriatelaser settings (20,39,40).
Additional guidance on appropriate protocolsfor treatment of various clinical conditions may beobtained from clinical trials with a specific device.There are many publications in the literature usingthe Fraxel Re:pair and the Active and Deep FXlasers for treatment of photoaging and scars. In onestudy of five ablative fractional devices, the DeepFX and Fraxel Re:pair lasers showed the deepesttissue penetration (40). Recent studies using theDEKA Smartxide are also available for guidance inthe use of this device. There is a lack of publishedstudies for many of the other AFP devices currentlyon the market. These devices are continuous CO2
lasers, equipped with fractionated scanners andstamping devices. However, with a basic under-standing of the pattern of tissue injury producedat various settings (i.e., spot size, pulse duration,energy, and density), the practitioner should beable to achieve effective treatment and avoidcomplications.
All of the currently available fractional CO2 abla-tive laser systems allow the operator to adjust theenergy and density. Some of the laser systems alsoallow adjustment of the pulse duration, whereasothers have a fixed or automatically adjusting pulseduration. The Lumenis system (Active and DeepFx), Fraxel Re:pair, Lutronic eCO2, and the CandelaQuadralase/Mixto have two spot sizes, allowing theoperator to achieve superficial or deep ablation.
It is important to note that it is currently notknown if extending tissue injury to the reticulardermis results in additional clinical benefit. Addi-tional studies are needed to establish optimal treat-ment parameters for a desired clinical outcome(40).
Below is a brief discussion of the various lasersettings and how changes to these parametersimpact the laser tissue interaction.
Energy. When using AFP devices with small spotsizes, increasing energy results in deeper tissueinjury. Studies using the Deep FX, spot size 120 um,and Fraxel Re:pair, spot size 135 um, show a corre-lation between energy and depth of penetration.Energy settings of 5–20 mJ with the Deep FX result
Tierney et al.
46
in tissue injury to depths of 500–2000 microns,whereas energy setting of 5–70 mJ with the FraxelRe:pair resulted in tissue injury to depths of 300–1600 microns (20). Increasing energy with both ofthese devices also increased the width of the zonesof ablation and coagulation of tissue. Treatmentsutilizing higher energies increase the time requiredfor resolution of edema and erythema followingtreatment. In addition, deeper treatments result inmore pinpoint bleeding during and following treat-ment. It is important to use lower energies whentreating areas with thinner skin, such as the eyelidsand neck.
Spot size. Spot size is another important param-eter. In general, spot sizes <200 Um allow fordeeper penetration into tissue, whereas spot sizesgreater than 300 Um result in a shallower depth ofpenetration at the same energies. The Active FX,spot size 1.3 mm, only penetrates to the papillarydermis regardless of treatment fluence (40).
When superficial treatment is the goal, as intreatment of dyschromia, the practitioner maychoose a larger spot size, whereas for treatment ofskin conditions, such as scars and rhytids, a smallspot size will result in deeper tissue injury requiredto achieve a clinical result.
Density. Density determines the distance betweenMTZs. Increasing the density decreases the dis-tance between MTZs, resulting in treatment of alarger percentage of the skin surface. Treatments athigher densities increase the duration of edemaand erythema following treatment. It is prudent touse lower densities in areas with lower density ofhair follicles, such as the neck and lower eyelid.Higher densities are necessary and can be usedsafely to treat deep rhytids in the perioral region.
Pulse duration. In general, shorter pulse durationsare desirable. Longer pulse durations result inmore collateral heating of the tissue. This results inincrease of the width of the MTZ, potential forcharring of the epidermis, and the persistence of avisible pattern of laser impacts on the skin for aprolonged period following treatment. When usinglasers that have pulse durations greater than 2 mil-liseconds, the authors recommend compensatingfor the increase in collateral tissue heating by usinglower densities.
Pre-treatment preparation and anesthesia. At thetime of the consultation, patients are given pre-scriptions for an oral antibiotic, oral antiviralpreparation.
Prior to the procedure, the skin is cleansed witha mild cleanser to remove any makeup, sunscreen,creams, or lotions. Topical anesthetic is applied tothe skin 60 minutes prior to treatment. A variety oftopical anesthetics are available. In the authors’experience, the two most effective topical anes-thetics are a mixture of 23% lidocaine and 7%tetracaine ointment and bupivicaine, lidocaine,tetracaine ointment. Topical anesthetic is adequatefor superficial AFP treatments. However, withdeeper and higher density treatments, topicalanesthetic alone is not adequate to keep thepatient comfortable during the treatment. Optionsinclude oral sedation, intravenous sedation, coldair, regional blocks (41), and tumescent anesthesia.
During the procedure, it is important to wear ahigh filtration mask and use a smoke evacuatorto capture plume produced by the laser. Useof a smoke evacuator is especially importantwhen using cold air anesthesia during the lasertreatment.
Posttreatment care. Following AFP, patients areinstructed to compress the areas and apply a blandtopical ointment. The present authors use a dilutesolution of acetic acid and Aquaphor ointment(Eucerin, Beiersdorf AG, Hamburg, Germany).Benadryl (Pfizer, New York, NY, USA) and coldcompresses are recommended for control ofitching, which commonly develops after treatment.Cold compresses are also helpful in reducing swell-ing. Although the importance of avoiding rubbing,scratching, and picking the treated area may seemobvious to the practitioner, it is important toinstruct patients to avoid rubbing to alleviateitching and avoid removal of coagulum and cruststhat develop following treatment. Patients shouldalso be instructed to avoid clothing that may rub theskin after treatment of the neck. Manipulation ofthe skin by the patient after treatment will delaywound healing and increase the risk of scarring.Immediately following treatment, Kenalog solution(Bristol-Myers, Squibb Co., New York, NY, USA)10 mg/cc may be gently rubbed onto the skin to aidin decreasing posttreatment edema.
Smartxide DOT laser
The Smartxide DOT fractionated CO2 laser(10,600 nm) has a variable pulse duration(200 microseconds–2.0 milliseconds), with a350-um beam spot size, a scanner area of 15 mm ¥15 mm, and a penetration depth of 200 um–1500 um. For facial resurfacing of mild photoaging(dyschromia, and minimal rhytids and skin laxity),
Fractionated CO2 laser skin rejuvenation
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settings utilized are fluence: 30 W, pitch: 500 um,and pulse duration: 500 microseconds. For facialresurfacing of moderate photoaging (dyschromia,and moderate rhytids and skin laxity), settings uti-lized are fluence: 30 W, pitch: 500 um, and pulseduration: 800–1000 microseconds. For facial resur-facing of severe photoaging (dyschromia, andsevere rhytids and skin laxity), settings utilized arefluence: 30 W, pitch: 300–400 um, and pulse dura-tion: 1500–1800 microseconds. For areas of deeprhytids (i.e., deep perioral rhytids) settings offluence: 30 W, pitch: 200–300 um, and pulse dura-tion: 1500 microseconds are utilized. For perior-bital rejuvenation, more conservative parametersare applied, given the thin density of the skin in thisarea. For mild periorbital rhytids, settings utilizedare fluence: 25 W, pitch: 500 um, and pulse dura-tion: 500 microseconds; for moderate periorbitalrhytids, setting utilized are fluence: 30 W, pitch:500 um, and pulse duration: 1000 microseconds;and for severe periorbital rhytids, settings utilizedare fluence: 30 W, pitch: 500 um, and pulse dura-tion: 1200–1500 microseconds.
For resurfacing of the neck and chest, more con-servative parameters are applied, given the reduceddensity of adnexal structures in this area. For neckand chest resurfacing, settings utilized are fluence:20 W, pitch: 500 um, and pulse duration: 500 micro-seconds. It should be explained to patients thatposttreatment erythema on the neck can last for7–14 days posttreatment when treated at prolongedpulse durations (<500 microseconds). Notably, inover 500 treatments by our group with this device atthese conservative treatment parameters, no inci-dence of scarring or dyspigmentation has beenreported.
Prior to the procedure, the treatment area isthoroughly cleansed before the procedure with agentle skin cleanser. A bupivicaine/lidocaine/tetracaine topical local anesthetic mix was applied45–60 minutes before treatment. Forced cold airis administered during treatment for anesthesiautilizing the Zimmer Cooler device (LaserMed,Shelton, CT, USA) at a setting of 5. This machineuses a compressor system with a flow of 500–1000 L/minute and a temperature as low as -30°C,depending on the desired cooling level (range 1–6),with the handpiece held between 2 and 3 inchesfrom the patient’s skin. The air nozzle is held off tothe side of the area being treated, and the cool airbeam was delivered toward the skin at an angle ofapproximately 90° to the direction of movement ofthe laser handpiece.
A prospective split-face study by Tierney andHanke (42) evaluated the effect of cold air anes-
thesia on patient comfort during ablative fraction-ated CO2 laser treatment for photoaging. For theside of the face treated with topical anesthesiaalone, the mean patient-reported pain score was7.47. On the side treated with cold air anesthesiaand topical anesthesia, the mean pain score was4.27 (p < 0.01). For the side treated with topicalanesthesia alone, the mean physician-reportedpain score was 7.8, relative to the side treated withcold air anesthesia and topical anesthesia, forwhich the mean physician-reported pain scorewas 3.73 (p < 0.01). In our prospective study, theuse of forced cold air device in conjunctionwith topical anesthesia provides a practical, inex-pensive, and well-accepted modality for patientanesthesia during ablative fractionated CO2 resur-facing. Importantly, no difference in efficacy oflaser resurfacing was noted in the side of the facetreated with fractionated CO2 resurfacing in con-junction with cold air and topical anesthesia rela-tive to the side treated with topical anesthesiaalone. This technique has been utilized to date inthe treatment of over 1000 patients for fraction-ated CO2 laser resurfacing, with no adverse eventsreported.
Illustrations of patients treated with the Smart-xide DOT are demonstrated in FIGS 1–4.
Candela Quadralase (lasering MiXto SX)
The Quadralase (Candela) is a dual-spot size(180 um/300 um) ablative fractionated CO2 laser(10,600 nm). The Quadralase is one of five AFLdevices (Table 1) to have both superficially ablative(300 um) and deeper ablative (180 um) spot sizeparameters built into the same device. The scanneron the Quadralase produces an array of sequen-tial laser pulses in four adjacent quadrantssimultaneously.
The present authors have found that the300 um setting is useful for treating pigmentation,superficial rhytids, and mild skin laxity. The180 um spot is primarily utilized for treatment ofdeep rhytids, scars, and areas of moderate tosevere skin laxity.
For treatment of mild photoaging (dyschromiaand fine rhytids), suggested settings are: spot size:300 um, power: 8–12 W, density: 20–40% (adminis-tered with one or two passes) coverage, and pulseduration: 3.0 milliseconds. For facial resurfacing ofmoderate to severe photoaging (dyschromia, andmoderate rhytids and skin laxity), settings utilizedare: spot size: 180 um, fluence: 15 W, density: oneto two passes at 20% coverage or one pass at 40%coverage, and pulse duration: 3.0 milliseconds.
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Some practitioners have used combinations oftreatment parameters for facial resurfacing ofsevere photoaging (dyschromia, and severe rhytidsand skin laxity). Settings utilized are first pass withspot size: 300 um, fluence: 25 W, density: 30% cov-erage, and pulse duration: 3.5 milliseconds, with asecond pass on areas of deep rhytids/scars (i.e.,periorbital rhytids): 180 um spot, fluence: 20 W,density: 30% coverage, and pulse duration: 3.5milliseconds.
Illustrations of patients treated with theCandela Quadralase are demonstrated in FIGS 5and 6.
Fraxel Re:pair
The Fraxel Re:pair laser (Solta Medical, Inc.) is anablative fractionated laser (10,600 nm) that deliv-ers pulse energies from 5 to 70 mJ that can beadjusted by increasing the treatment level (TL) tocover 10–70% of the treated area in increments of5%. At 70 mJ, the laser delivers MTZ to a depth ofup to 1.6 mm. The pulse width is preset and auto-matically adjusts, with change of energy settings,from 0.5 milliseconds to a maximum of 2 millisec-onds. The laser has a 135 um spot size. Optional600-um spot, 0.2-mm incisional, and 2-mm spot
FIG. 1. Pre (left) and post (right) two treatments of the neck in a 74-year-old Caucasian male with ablative fractional photother-molysis, Smartxide DOT (DEKA) at settings of 30 W, 1500 microseconds, and 500 um. Photos used with permission from C.William Hanke, MD, MPH.
FIG. 2. Pre (left) and post (right) Caucasian female status post two treatments with ablative fractional photothermolysis, Smart-xide DOT (DEKA) at settings of 30 W, 1000 microseconds, and 500 um. Photos used with permission from C. William Hanke, MD,MPH.
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ablative handpieces are also available. The laserhas a rolling optical tracking system that automati-cally adjusts according to the operator’s handspeed, allowing for consistent delivery of laserMTZs. Multiple passes are utilized to produce thedesired final density of MTZs over the treatmentsurface. Unlike scanning and stamping devicesutilized by other AFP devices, which are designedto deliver MTZs in a regular pattern in one pass, themultiple passes of the Fraxel Re:pair create arandom pattern of injury to the treated area, reduc-ing the likelihood of bulk heating.
Disposable treatment tips are available in twosizes. The larger 15-mm tip allows for quick andefficient treatment of large areas, whereas the7-mm tip allows for treatment of difficult to treatareas, such as the nose and lip. The Fraxel Re:pair isthe only AFP system with a built-in smoke evacua-tor, making it possible to perform treatments
without additional assistance. The treatment tipmust be replaced after each treatment, and thesmoke evacuator module must be replacedperiodically.
For treatment of mild photoaging on the face(dyschromia and fine rhytids), suggested settingsare: spot size: 600 um, energy: 40–70 mJ, and TL(coverage): 8–12 (30–50%).‡
The 135-um spot may also be used to treat finerhytids and dyschromia. Suggested settings are asfollows: (i) face: 5–20 mJ, TL (coverage) 8–12 (30–50%); (ii) eyelids: 5–10 mJ, TL (coverage) 8–10 (30–40%); and (iii) neck: 5–10 mJ, TL (coverage) 6–8(20–30%).
‡For treatment of dyschromia on the face, neck, and chest, thepresent authors prefer to use the Fraxel re:store (ReliantTechnologies) DUAL 1927 nm laser.
FIG. 3. Pre (left) and post (right) two treatments of the neck in a 71-year-old Caucasian female with ablative fractional photo-thermolysis, Smartxide DOT (DEKA) at settings of 30 W, 500 microseconds, and 500 um. Photos used with permission from C.William Hanke, MD, MPH.
FIG. 4. Pre (left) and post (right) two treatments of the neck in a 71-year-old Caucasian female with ablative fractional photo-thermolysis, Smartxide DOT (DEKA) at settings of 30 W, 500 microseconds, and 500 um. Photos used with permission from C.William Hanke, MD, MPH.
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FIG. 5. Right lateral view. Pre (left) and 3 months post (right) treatment of acne scars and photoaging with ablative fractionatedCO2 laser (Quadralase, Candela, Wayland, MA, USA). Deep scars and rhytids on medial cheek were treated with 180-um spot;remainder of cheek, nose, eyelids, forehead, and chin were treated with the 300-um spot. Photos used with permission from EmilyTierney, MD.
FIG. 6. Left lateral view. Pre (left) and 3 months post (right) treatment of acne scars and photoaging with ablative fractionatedCO2 laser (Quadralase, Candela, Wayland, MA, USA). Deep scars and rhytids on medial cheek were treated with 180-um spot;remainder of cheek, nose, eyelids, forehead, and chin were treated with the 300-um spot. Photos used with permission from EmilyTierney, MD.
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For facial resurfacing of moderate to severephotoaging (dyschromia, and moderate rhytidsand skin laxity), settings utilized are: (i) forehead/cheeks – spot size: 135 um, energy: 20–40 mJ, TL(coverage): 10–R1 (40–60%.); (ii) eyelids – 135 um,energy: 10–15 mJ, TL (coverage) 10–12 (40–50%);(iii) neck – spot size: 135 um, energy: 15–25 mJ, TL(coverage) 8 (30%); and (iv) perioral rhytids – spotsize: 135 um, energy: 25 mJ, and TL (coverage)12-R1 (50–60%). Care should be taken to avoidoverlap of MTZs with adjacent laser passes. Fortreatment of Fitzpatrick skin types IV and V, the TLsettings should be reduced to decrease the risk ofpost-inflammatory hyperpigmentation.
Although some practitioners advocate usinghigher energies to achieve deeper tissue injury, inour experience, excellent clinical results in thetreatment of deep rhytids can be achieved withoutproducing tissue injury in the deep dermis. Avoid-ing deep dermal treatments may also result in alower incidence of complications.
Conclusions
AFP has become the most promising new optionfor safe, nonsurgical improvement in rhytides,photodamage, and scarring. With proper tech-nique, results approaching those seen with tradi-tional CO2 laser resurfacing can be achieved withan exceedingly low risk of scarring and hypopig-mentation. The relatively short recovery periodsrequired after AFP treatments, combined with itssafety and an expanding array of applications, arelikely to ensure AFP’s place in the cosmetic thera-peutic arsenal for years to come.
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