Dermatologic Therapy, Therapy, Vol. 24, 2011, 41–53 Printed in the the United States · All rights reserved reserved
© 2011 Wiley Periodicals, Inc.
DERMATOLOGIC THERAPY ISSN 1396-0296
Fractionated CO2 laser skin rej rejuvenation uvenation dth_1377 41..53
illiam H anke‡ Emily P. Tierney *†‡, *†‡, Richard F. Eisen† & C. W illiam
*Boston University School of Medicine, Boston, Massachusetts ; †South Shor Shore e Skin Center, Center, Plymouth, Massachusetts and and ‡‡Laser and Skin Surgery Center of Indiana, Carmel, Indiana
ABSTRACT: Fractional photothermolysis has been reported in the literature to improve both the pigmentary and textural changes associated with photoaging. photoaging. The objective of the study was to review the literature of non-ablative fractional laser (NAFL) and ablative fractional laser (AFL) resurfacing for the treatment of photoaging. This is a review of the Medline literature evaluating NAFL and AFL for photoaging. Review of the literature supports the use of NAFL and AFL as safe and effective treatments for photoaging. It is likely that the controlled, limited dermal heating of fractional resurfacing initiates a cascad cas cade e of eve event ntss in whi which ch no norma rmaliz lizati ation on of the col collag lagene enesis sis/co /colla llagen genoly olysis sis cyc cycle le occ occur urs. s. Th The e adv advent ent of fractionated resurfacing for the treatment of photoaging is a significant advance over ablative laser resurfacing treatments, which were complicated by prolonged erythema, delayed onset hypopigmentation, and scarring. KEYWORDS: fractional photothermolysis, photothermolysis, laser surgery, photoaging
Background For nearly 15 years, ablative resurfacing of the skin using the carbon dioxide (CO 2) laser was the gold standard for treatment of photoaging. Despite its superiority in the treatment of rhytides (1–3), photodamage (4,5), and acne scars (6,7), the CO 2 laser hass fa ha falle llen n ou outt of fa favo vorr in re rece cent nt ye year arss be beca caus use e of th the e length len gthy y re reco covery very peri period od aft after er tre treatm atment ent and the risk of serious side effects, including scarring and delayed onset hypopigmentation. The goals of decreasing recovery time, minimizing side ef effec fects, ts, and avo avoidin iding g com compli plicat cation ionss to increase patient acceptance and satisfaction with treatm tre atment ent wer were e the imp impetu etuss for the dev develo elopme pment nt of non-ablative laser treatments (8–16). Non-ablative
Address correspondence and reprint requests to: Emily Tierney, MD, South Shore Skin Center, 1 Scobee Circle, Unit 3, Plymouth, MA 02360, or email:
[email protected].
lasers heat the dermis, without injury to the epidermis, derm is, to sti stimul mulate ate derm dermal al rem remode odelin ling g (8– (8–16). 16). Altho Al though ugh very saf safe, e, the these se devi devices ces ar are e una unable ble to gen gen-erate significant dermal coagulation and are not as effective as ablative laser resurfacing (12). The concept of fractional photothermolysis (FP) (17) revolutionized laser surgery by enabling the delivery of dermal coagulative injury without confluent epidermal damage, thus decreasing the risks of sca scarrin rring g as wel welll as dec decrea reasin sing g the do downt wntime ime associated with traditional ablative resurfacing. FP is based upon the scientific concept of creating micros mic roscop copic ic the thermal rmal wou wounds nds dee deep p to the surf surface ace of the skin, which allow for tissue contraction, stimulation lat ion of col collag lagen, en, and rap rapid id wou wound nd hea healin ling g (17 (17,18 ,18). ). Fract Fr action ionate ated d las lasers ers dril drilll mic micros roscop copic ic hol holes es int into o the dermis in a grid pattern (17–19). FP has been likened to aerating a lawn (19). The “lawn plugs,” termed microscopic epidermal necrotic debris, are expelled via a transepidermal elimination process over 7–10 days (19). The consequences are twofold: (i) dermal conditions that have been approached
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indirectly in the past via epidermal wounding are now directly wounded as portions of the normal dermis are removed; and (ii) the remaining adjacent intact dermis and epidermis allow for rapid healing without relying on the presence of adnexal structures to regenerate the epidermis (19). The original prototype device was a 1550-nm erbium-doped laser, which created noncontiguous microscopic columns of thermal injury in the dermis (termed microscopic thermal zones or MTZs) surrounded by columns of normal tissue (7). As the tissue surrounding each MTZ is intact, uninjured epidermal and dermal cells at the border of each column of injury contribute to rapid healing (7). Histologic studies evaluating the pattern of injury with FP demonstrated homogenization of the dermal matrix and the presence of microscopic epidermal necrotic debris. Microscopic epidermal necrotic debris represents the extrusion of damaged epidermal keratinocytes by viable keratinocytes at the lateral margin of the MTZ. FP has known effects on tissue shrinkage and tissue texture, likely through stimulation of normalization of the collagenesis/collagenolysis cycle. Manstein et al. (17) reported significant improvements in periorbital rhytids and skin texture after initial treatments with their prototype FP device. Interestingly, Manstein et al. found a linear pattern of shrinkage along the triangular-shaped sides of tattoos of treated skin relative to control site, suggesting that thermal injury induced by FP resulted in wound contraction and tissue shrinkage (7). Initially, at 1 week, there was statistically significant shrinkage, followed by an apparent relaxation after 1 month with retightening at 3 months (17). Tissue tightening and clinical improvement of periorbital rhytides was observed; however, results were limited to 2.9% linear shrinkage correlating with a 19% clinical improvement in periorbital rhytides (17). In 2007, Hantash et al. (20) first described the use of an “ablative” CO2 fractional resurfacing device (AFP), which produces an array of microthermal zones of a customizable density and depth, with a confluent pattern of ablation and coagulation extending from the stratum corneum through the dermis (20). In the initial in vivo studies demonstrating the histologic and clinical effects of this device, Hantash et al. confirmed with immunohistochemistry that collagen remodeling occurred for at least 3 months posttreatment (20). AFP, creating confluent columns of thermal injury in a random array extending from the stratum corneum to the reticular dermis, has dem-
42
onstrated significant effects on skin tightening and texture beyond that seen with the original generation of non-ablative fractional photothermolysis (NAFP) devices (20–29). The safety profile seen with AFP marks a significant advantage over the traditional ablative resurfacing devices associated with prolonged postoperative erythema and risk of postinflammatory pigmentary change and scarring (20–29). Following full-face resurfacing with AFP, complete re-epithelialization is generally seen in 3–6 days (20–28). This is in contrast to the 2–3 weeks of recovery following full-face resurfacing with traditional CO2 laser systems (1–16). Rapid re-epithelialization after AFP treatment results in very few infections, which are further reduced with the use of prophylactic antiviral and antibiotic therapy. Faster re-epithelialization also results in patients requiring fewer days of occlusive ointment application. This greatly reduces the rate of acneiform eruptions, which are seen in up to 83% of patients treated with traditional CO2 lasers (16). Erythema, an expected side effect after treatment, also resolves much more quickly after ablative fractional resurfacing (AFR) (20–29) compared with traditional ablative CO2 laser treatments, where postoperative erythema persists for up to 3–4 months posttreatment (1–16). The present authors present herein a review of the literature of AFP for the treatment of photoaging as well as a practical guide to the treatment of photoaging with some of the currently available AFP devices. Review of the literature on AFP treatment for photoaging Review of the recent literature demonstrates significant advantages of FP in terms of decreased recovery times and benign side effect profiles relative to traditional ablative laser resurfacing devices (CO2 and Er : Yag) (17–30). Although traditional ablative laser resurfacing was able to achieve results for skin tightening, which rivaled surgical correction, the side effects of several months of erythema and swelling, and long-term risks of prolonged dyspigmentation and potential scarring significantly limited the application of this technology (11–16). Additionally, it has been speculated that fractionated resurfacing may have greater efficacy in skin tightening than traditional ablative resurfacing because of the pattern of thermal ablation, which provides for deeper dermal penetration (19,20,26,27). One possible explanation for the greater degree of tightening observed with FP is the
Fractionated CO 2 laser skin rejuvenation
greater depth of dermal penetration, which could not be achieved safely with traditional ablative devices (19,20,26,27). The rapid recovery times seen with fractionated CO2 laser marks a significant improvement over traditional CO2 and Er : Yag laser resurfacing. It is postulated that the differences in healing time between traditional ablative resurfacing and fractional resurfacing result from differences in mechanisms of wound healing (31). Traditional ablative laser wounds heal by migration of stem cells from hair follicles (31). In contrast, with fractional ablative resurfacing, it is hypothesized that re-epithelialization occurs more rapidly as recovery occurs because of migration of neighboring cutaneous stem cells (31). Additional histologic and molecular studies need to be performed to better characterize and understand the healing mechanisms involved. The mechanism of improvement in skin texture and tightening with AFP is not precisely known. It has been observed that as tissue is ablated, there is a bimodal immediate collagen contraction and a second effect at 3–6 months afterward from persistent collagen remodeling (31). There are a number of fractionated CO 2 devices currently on the market characterized by adjustable fluences and pulse durations, which allow targeting of the amount and depth of dermal heating delivered (Table 1). A number of recent studies have evaluated changes in photoaging with these devices, and both clinical and histologic data have confirmed the exciting promise of these devices in achieving improvements in skin texture and laxity, which are significantly greater than the previous generation of non-ablative FP devices (24–31). In 2009, Rahman et al. (24) reported a high degree of safety and efficacy in photoaging with an AFP device in the Food and Drug Administration studies, leading to approval of the device (Fraxel Re:pair, Reliant Technologies, Mountain View, CA, USA). Patients were treated on both the face and neck with settings of fluence/MTZ of 10–40 mJ/ MTZ and densities of 400–1000 MTZ/cm2. Average improvement in indices of skin texture and tightening (on a quartile scale) was 2.30 (rhytides), 2.42 (texture), and 1.65 (laxity) (24). A follow-up to the present study was reported by Ortiz et al. on the long-term outcomes of 10 subjects previously treated with fractional CO2 resurfacing (25). Patients returned for long-term follow-up visits at 1 and 2 years, respectively. Subjects maintained 74% of their overall improvement at their long-term visits compared with 3-month follow-up visits.
Although clinical improvement was maintained long term, the results were not as remarkable as those seen at 3-month visits. The authors speculated that results seen at 3 months may be enhanced by persistent inflammatory changes, as evidenced by heat shock protein 47 activity and ongoing collagen remodeling seen in previous histologic studies. Although fractional CO2 laser resurfacing does have long-term efficacy and persistence of improvement of acne scarring and photodamage compared with baseline, additional treatments may be necessary to maintain and/or enhance long-term results. Berlin et al. (26) performed a study in 10 sub jects who received one treatment with an AFP device (UltraPulse Encore, Lumenis, Inc., Santa Clara, CA, USA). The authors evaluated clinical change in photoaging as well as histologic and ultrastructural change in collagen deposition on both light and electron microscopy (26). Blinded investigator assessment of skin textural alterations and rhytid reduction revealed a mean improvement of 1.8 (on a five-point scale) at 4 weeks and 1.6 at 24 weeks posttreatment. Posttreatment biopsies documented greater fibrosis in the papillary dermis (26). Additionally, electron microscopy revealed a decrease in the average diameter of the collagen fibrils, consistent with greater deposition of collagen type III, suggesting new collagen deposition induced by fractionated laser resurfacing (26). A recent study by Tierney and Hanke (27) demonstrated significant improvement in neck skin tightening with the Smartxide DOT (DEKA, Calenzano, Italy), where after a series of one to two treatments with AFP, a 63% improvement in skin texture, a 57% mean improvement in skin tightening, and a 51.4% improvement in skin rhytides were observed. This degree of improvement in skin tightening of the neck has only previously been reported with ablative CO2 laser resurfacing (27). Karsai et al. (28) performed a randomized controlled double-blind split-face study to compare the effects of a single treatment with ablative fractional CO2 and Er : Yag lasers for rhytides in the periorbital region. The evaluation included the profilometric measurement of wrinkle depth, the Fitzpatrick wrinkle score, as well as the assessment of side effects and patient satisfaction. Interestingly, both modalities showed a roughly equivalent effect on wrinkle depth and Fitzpatrick score of periorbital rhytides, where both were reduced by approximately 20% and 10%, with no appreciable difference between lasers. Side effects and discomfort were slightly more pronounced after Er : Yag
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Fractionated CO 2 laser skin rejuvenation
treatment in the first few days, but in the later course, there were more complaints following CO 2 laser treatment. Patient satisfaction was fair, and the majority of patients would have undergone the treatment again without a clear preference for either method. In the present study, a single ablative fractional treatment session has an appreciable yet limited effect on periorbital rhytides, where multiple sessions are likely required for more extensive improvement. A recent report by Goldberg et al. (29) evaluated the treatment of perioral rhytides with a fractionated ablative Er : YSGG laser (2790 nm). This device, associated with a 2790-nm wavelength, has a water absorption coefficient between that of CO 2 and Er : Yag lasers. All subjects underwent a twopass full-face treatment for rhytides at 160 mJ and an 8% density. For perioral rhytides, subjects were treated with a 160-mJ first pass, and a second and third pass of 200 mJ with a 12% density. Based on the Fitzpatrick Scoring System for wrinkles at baseline and at final follow-up, a statistically significant mean reduction of 1.25 (standard deviation 0.71) was observed in overall wrinkle score (reduction from 5.88 to 4.63, p-value 0.002) and perioral wrinkle score (reduction from 5.63 to 4.38, p-value 0.002). There was no incidence of scarring, postinflammatory pigmentary changes, or infections observed. The authors reported that the Er:YSGG laser is safe and effective for photodamage and perioral rhytides. A recent study by Abbasi et al. (31) reported a comparison of four AFP devices in the treatment of the pigmentary and textural components of photoaging, 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 severe sun damage between the ages of 30 and 65, and of Fitzpatrick skin types I–IV were treated to four quadrants of the face. Blinded evaluators assessed patients at 1 month, 3 months, and 6 months posttreatment to evaluate changes in skin texture, lentigenes, pore size, and rhytides. One- and 3-month follow-up data showed improvement in photoaging in all patients studied across all quadrants. In the present study, no differences were been observed to date among the four devices studied. However, one of the significant challenges with the present study was in setting equivalent parameters across the four devices studied. In future studies, extensive preoperative trials will be likely needed to establish comparative settings in studies comparing two or more devices.
Tierney and Hanke (32) reported the results of a series of 45 patients with moderate to severe photoaging 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. Patients ranged in age from 45 to 75 years with a mean age of 58.5 years. The patients were Fitzpatrick skin types I–III, with 26.7% Fitzpatrick skin type I, 60.0% Fitzpatrick skin type II, and 13.3% Fitzpatrick skin type III. Patients received between two and three treatment sessions, with a mean of 2.4 treatment sessions per patient. The results of a total of 108 treatment sessions were included in the results of the study. For skin texture, mean improvement was 48.5% (95% confidence interval (CI): 44.6%, 52.4%) (p < 0.05). For skin laxity, mean improvement was 50.3% (95% CI: 46.1%, 54.5%) (p < 0.05); for dyschromia, mean improvement was 53.9% (95% CI: 49.5%, 58.5%) (p < 0.05); and for overall cosmetic outcome, mean improvement was 52.4% (95% CI: 47.9%, 56.9%) (p < 0.05). Tierney et al. (33) reported the results of a series of 25 patients with moderate to severe laxity and rhytids of the periorbital region treated with the Smartxide DOT (DEKA). The number of treatment sessions required for significant improvement of eyelid laxity ranged from two to three, with an average of 2.44 sessions. For skin texture, the mean score decreased from 3.6 to a mean of 1.2 at 6 months posttreatment (p < 0.05) for a 62.6% mean improvement. For skin laxity, the mean score decreased from 3.3 to 1.3 at 6 months posttreatment (p < 0.05), 65.3% mean improvement. For rhytids, the mean score decreased from 3.5 to 1.3 at 6 months posttreatment (p < 0.05), 62.1% mean improvement. For overall cosmetic outcome, mean score decreased from 3.6 to 1.2 at 6 months posttreatment (p < 0.05), 65.7% mean improvement. Moderate postoperative erythema and edema were noted by patients, which resolved by the 1-week posttreatment visit. Patients reported minor crusting and oozing, which resolved within 48–72 hours. It has been reported in the literature with FP in clinical–histologic correlation experiments that a greater depth of injury maximizes texture improvement, whereas a higher density of more superficial injuries maximizes improvement in pigmentation (17,18,26,32–36). Part of the rationale for the significant degree of improvement in skin texture and laxity obtained in this series is the long pulse duration applied (1000–1500 microseconds) (36). Clinical and histologic correlation studies by our group have identified greater improvement in tissue tightening associated with the greater depth of penetration of this AFP device at longer dwell
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Tierney et al.
times (36). Specifically, at a dwell time of 1000– 1500 microseconds, the microthermal zone of ablation extends to the depth of the deep reticular dermis ( Tierney and Hanke, unpublished data). Thus, the pattern of deep ablation into the reticular dermis and resultant stimulation of collagen contraction and synthesis likely accounts for its greater efficacy in tissue tightening and skin texture.
Complications of fractionated CO2 resurfacing Recently, three reports of complications of fractionated CO2 resurfacing have been reported in the literature, highlighting the importance of utilizing conservative treatment parameters, particularly for anatomic sites with decreased dermal thickness, such as the neck and eyelid skin. Avram et al. (36) reported on five cases of post AFP hypertrophic scarring, which likely resulted from high pulse durations and high levels of treatment coverage. These reports highlight the importance of treating with conservative fluences and pulse duration with AFP, particularly for the neck, where decreased density of pilosebaceous units can lead to prolonged times for reepithelialization and increased risk of scarring with all forms of ablative laser resurfacing. Additionally, Fife et al. (37) described four cases of post-AFP scarring, including one case where the patient developed erosions and swelling of the right lower eyelid 2 days postoperatively, which developed into scarring and an ectropion. In a subsequent commentary to this report, Biesman (38) raised the important question of whether it is really necessary to extend treatment depths to 800–1500 um for areas of thin dermis, such as the neck and eyelids, where hypertrophic scarring has been reported with AFP. Although additional study with AFP devices are highly needed, preliminary data suggest that deeper wounds increase the risk of complications and that there may be a maximum depth that should be respected when treating thinner skin. Practical tips for treatment of fractionated CO 2 laser resurfacing
consider the thickness of the skin and the depth required to ablate the skin abnormality, in order to choose safe and effective treatment settings. Published histologic studies on the thickness of the skin, and the depth and number of adnexal structures at various anatomic sites, and histologic studies showing the depth and width of tissue injury with varying laser parameters are helpful in guiding the clinician in the choice of appropriate laser settings (20,39,40). Additional guidance on appropriate protocols for treatment of various clinical conditions may be obtained from clinical trials with a specific device. There are many publications in the literature using the Fraxel Re:pair and the Active and Deep FX lasers for treatment of photoaging and scars. In one study of five ablative fractional devices, the Deep FX and Fraxel Re:pair lasers showed the deepest tissue penetration (40). Recent studies using the DEKA Smartxide are also available for guidance in the use of this device. There is a lack of published studies for many of the other AFP devices currently on the market. These devices are continuous CO 2 lasers, equipped with fractionated scanners and stamping devices. However, with a basic understanding of the pattern of tissue injury produced at various settings (i.e., spot size, pulse duration, energy, and density), the practitioner should be able to achieve effective treatment and avoid complications. All of the currently available fractional CO 2 ablative laser systems allow the operator to adjust the energy and density. Some of the laser systems also allow adjustment of the pulse duration, whereas others have a fixed or automatically adjusting pulse duration. The Lumenis system (Active and Deep Fx), Fraxel Re:pair, Lutronic eCO2, and the Candela Quadralase/Mixto have two spot sizes, allowing the operator to achieve superficial or deep ablation. It is important to note that it is currently not known if extending tissue injury to the reticular dermis results in additional clinical benefit. Additional studies are needed to establish optimal treatment parameters for a desired clinical outcome (40). Below is a brief discussion of the various laser settings and how changes to these parameters impact the laser tissue interaction. Energy. When using AFP devices with small spot
Basic principles. Prior to treating patients with any
of the available fractional ablative CO2 laser systems, it is important for the practitioner to have an understanding of the extent of tissue injury produced by the device at various settings and
46
sizes, increasing energy results in deeper tissue injury. Studies using the Deep FX, spot size 120 um, and Fraxel Re:pair, spot size 135 um, show a correlation between energy and depth of penetration. Energy settings of 5–20 mJ with the Deep FX result
Fractionated CO 2 laser skin rejuvenation
in tissue injury to depths of 500–2000 microns, whereas energy setting of 5–70 mJ with the Fraxel Re:pair resulted in tissue injury to depths of 300– 1600 microns (20). Increasing energy with both of these devices also increased the width of the zones of ablation and coagulation of tissue. Treatments utilizing higher energies increase the time required for resolution of edema and erythema following treatment. In addition, deeper treatments result in more pinpoint bleeding during and following treatment. It is important to use lower energies when treating areas with thinner skin, such as the eyelids and neck. Spot size. Spot size is another important param-
eter. In general, spot sizes <200 Um allow for deeper penetration into tissue, whereas spot sizes greater than 300 Um result in a shallower depth of penetration at the same energies. The Active FX, spot size 1.3 mm, only penetrates to the papillary dermis regardless of treatment fluence (40). When superficial treatment is the goal, as in treatment of dyschromia, the practitioner may choose a larger spot size, whereas for treatment of skin conditions, such as scars and rhytids, a small spot size will result in deeper tissue injury required to achieve a clinical result. Density. Density determines the distance between
MTZs. Increasing the density decreases the distance between MTZs, resulting in treatment of a larger percentage of the skin surface. Treatments at higher densities increase the duration of edema and erythema following treatment. It is prudent to use lower densities in areas with lower density of hair follicles, such as the neck and lower eyelid. Higher densities are necessary and can be used safely to treat deep rhytids in the perioral region. Pulse duration. In general, shorter pulse durations
are desirable. Longer pulse durations result in more collateral heating of the tissue. This results in increase of the width of the MTZ, potential for charring of the epidermis, and the persistence of a visible pattern of laser impacts on the skin for a prolonged period following treatment. When using lasers that have pulse durations greater than 2 milliseconds, the authors recommend compensating for the increase in collateral tissue heating by using lower densities. Pre-treatment preparation and anesthesia. At the
time of the consultation, patients are given prescriptions for an oral antibiotic, oral antiviral preparation.
Prior to the procedure, the skin is cleansed with a mild cleanser to remove any makeup, sunscreen, creams, or lotions. Topical anesthetic is applied to the skin 60 minutes prior to treatment. A variety of topical anesthetics are available. In the authors’ experience, the two most effective topical anesthetics are a mixture of 23% lidocaine and 7% tetracaine ointment and bupivicaine, lidocaine, tetracaine ointment. Topical anesthetic is adequate for superficial AFP treatments. However, with deeper and higher density treatments, topical anesthetic alone is not adequate to keep the patient comfortable during the treatment. Options include oral sedation, intravenous sedation, cold air, regional blocks (41), and tumescent anesthesia. During the procedure, it is important to wear a high filtration mask and use a smoke evacuator to capture plume produced by the laser. Use of a smoke evacuator is especially important when using cold air anesthesia during the laser treatment. Posttreatment care. Following AFP, patients are
instructed to compress the areas and apply a bland topical ointment. The present authors use a dilute solution of acetic acid and Aquaphor ointment (Eucerin, Beiersdorf AG, Hamburg, Germany). Benadryl (Pfizer, New York, NY, USA) and cold compresses are recommended for control of itching, which commonly develops after treatment. Cold compresses are also helpful in reducing swelling. Although the importance of avoiding rubbing, scratching, and picking the treated area may seem obvious to the practitioner, it is important to instruct patients to avoid rubbing to alleviate itching and avoid removal of coagulum and crusts that develop following treatment. Patients should alsobeinstructedtoavoidclothingthatmayrubthe skin after treatment of the neck. Manipulation of the skin by the patient after treatment will delay wound 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 aid in 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 a 350-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),
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settings utilized are fluence: 30 W, pitch: 500 um, and pulse duration: 500 microseconds. For facial resurfacing of moderate photoaging (dyschromia, and moderate rhytids and skin laxity), settings utilized are fluence: 30 W, pitch: 500 um, and pulse duration: 800–1000 microseconds. For facial resurfacing of severe photoaging (dyschromia, and severe rhytids and skin laxity), settings utilized are fluence: 30 W, pitch: 300–400 um, and pulse duration: 1500–1800 microseconds. For areas of deep rhytids (i.e., deep perioral rhytids) settings of fluence: 30 W, pitch: 200–300 um, and pulse duration: 1500 microseconds are utilized. For periorbital rejuvenation, more conservative parameters are applied, given the thin density of the skin in this area. For mild periorbital rhytids, settings utilized are fluence: 25 W, pitch: 500 um, and pulse duration: 500 microseconds; for moderate periorbital rhytids, setting utilized are fluence: 30 W, pitch: 500 um, and pulse duration: 1000 microseconds; and for severe periorbital rhytids, settings utilized are fluence: 30 W, pitch: 500 um, and pulse duration: 1200–1500 microseconds. For resurfacing of the neck and chest, more conservative parameters are applied, given the reduced density of adnexal structures in this area. For neck and chest resurfacing, settings utilized are fluence: 20 W, pitch:500 um,and pulseduration:500 microseconds. It should be explained to patients that posttreatment erythema on the neck can last for 7–14 days posttreatment when treated at prolonged pulse durations (<500 microseconds). Notably, in over 500 treatments byour group with this device at these conservative treatment parameters, no incidence of scarring or dyspigmentation has been reported. Prior to the procedure, the treatment area is thoroughly cleansed before the procedure with a gentle skin cleanser. A bupivicaine/lidocaine/ tetracaine topical local anesthetic mix was applied 45–60 minutes before treatment. Forced cold air is administered during treatment for anesthesia utilizing the Zimmer Cooler device (LaserMed, Shelton, CT, USA) at a setting of 5. This machine uses 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 inches from the patient’s skin. The air nozzle is held off to the side of the area being treated, and the cool air beam was delivered toward the skin at an angle of approximately 90° to the direction of movement of the laser handpiece. A prospective split-face study by Tierney and Hanke (42) evaluated the effect of cold air anes-
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thesia on patient comfort during ablative fractionated CO2 laser treatment for photoaging. For the side of the face treated with topical anesthesia alone, the mean patient-reported pain score was 7.47. On the side treated with cold air anesthesia and topical anesthesia, the mean pain score was 4.27 (p < 0.01). For the side treated with topical anesthesia alone, the mean physician-reported pain score was 7.8, relative to the side treated with cold air anesthesia and topical anesthesia, for which the mean physician-reported pain score was 3.73 (p < 0.01). In our prospective study, the use of forced cold air device in conjunction with topical anesthesia provides a practical, inexpensive, and well-accepted modality for patient anesthesia during ablative fractionated CO 2 resurfacing. Importantly, no difference in efficacy of laser resurfacing was noted in the side of the face treated with fractionated CO2 resurfacing in con junction with cold air and topical anesthesia relative to the side treated with topical anesthesia alone. This technique has been utilized to date in the treatment of over 1000 patients for fractionated CO2 laser resurfacing, with no adverse events reported. Illustrations of patients treated with the Smartxide 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 AFL devices (Table 1) to have both superficially ablative (300 um) and deeper ablative (180 um) spot size parameters built into the same device. The scanner on the Quadralase produces an array of sequential laser pulses in four adjacent quadrants simultaneously. The present authors have found that the 300 um setting is useful for treating pigmentation, superficial rhytids, and mild skin laxity. The 180 um spot is primarily utilized for treatment of deep rhytids, scars, and areas of moderate to severe skin laxity. For treatment of mild photoaging (dyschromia and fine rhytids), suggested settings are: spot size: 300 um, power: 8–12 W, density: 20–40% (administered with one or two passes) coverage, and pulse duration: 3.0 milliseconds. For facial resurfacing of moderate to severe photoaging (dyschromia, and moderate rhytids and skin laxity), settings utilized are: spot size: 180 um, fluence: 15 W, density: one to two passes at 20% coverage or one pass at 40% coverage, and pulse duration: 3.0 milliseconds.
Fractionated CO 2 laser skin rejuvenation
FIG. 1. Pre (left)and post (right) twotreatments of the neck in a 74-year-old Caucasian male with ablative fractional photothermolysis, 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 posttwo treatments with ablative fractionalphotothermolysis,Smart xide DOT (DEKA) at settings of 30 W, 1000 microseconds, and 500 um. Photos used with permission from C.William Hanke, MD, MPH.
Some practitioners have used combinations of treatment parameters for facial resurfacing of severe photoaging (dyschromia, and severe rhytids and skin laxity). Settings utilized are first pass with spot size: 300 um, fluence: 25 W, density: 30% coverage, and pulse duration: 3.5 milliseconds, with a second pass on areas of deep rhytids/scars (i.e., periorbital rhytids): 180 um spot, fluence: 20 W, density: 30% coverage, and pulse duration: 3.5 milliseconds. Illustrations of patients treated with the Candela Quadralase are demonstrated in FIGS 5 and 6.
Fraxel Re:pair The Fraxel Re:pair laser (Solta Medical, Inc.) is an ablative fractionated laser (10,600 nm) that delivers pulse energies from 5 to 70 mJ that can be adjusted by increasing the treatment level (TL) to cover 10–70% of the treated area in increments of 5%. At 70 mJ, the laser delivers MTZ to a depth of up to 1.6 mm. The pulse width is preset and automatically adjusts, with change of energy settings, from 0.5 milliseconds to a maximum of 2 milliseconds. The laser has a 135 um spot size. Optional 600-um spot, 0.2-mm incisional, and 2-mm spot
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FIG. 3. Pre (left) and post (right) two treatments of the neck in a 71-year-old Caucasian female with ablative fractional photothermolysis, 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 photothermolysis, Smartxide DOT (DEKA) at settings of 30 W, 500 microseconds, and 500 um. Photos used with permission from C. William Hanke, MD, MPH.
ablative handpieces are also available. The laser has a rolling optical tracking system that automatically adjusts according to the operator’s hand speed, allowing for consistent delivery of laser MTZs. Multiple passes are utilized to produce the desired final density of MTZs over the treatment surface. Unlike scanning and stamping devices utilized by other AFP devices, which are designed to deliver MTZs in a regular pattern in one pass, the multiple passes of the Fraxel Re:pair create a random pattern of injury to the treated area, reducing the likelihood of bulk heating. Disposable treatment tips are available in two sizes. The larger 15-mm tip allows for quick and efficient treatment of large areas, whereas the 7-mm tip allows for treatment of difficult to treat areas, such as the nose and lip. The Fraxel Re:pair is the only AFP system with a built-in smoke evacuator, making it possible to perform treatments
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without additional assistance. The treatment tip must be replaced after each treatment, and the smoke evacuator module must be replaced periodically. For treatment of mild photoaging on the face (dyschromia and fine rhytids), suggested settings are: 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 fine rhytids and dyschromia. Suggested settings are as follows: (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, the present authors prefer to use the Fraxel re:store (Reliant Technologies) DUAL 1927 nm laser.
Fractionated CO 2 laser skin rejuvenation
FIG. 5. Right lateral view. Pre (left) and3 months post (right) treatment of acne scars andphotoaging with ablative fractionated CO2 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 treatedwith the 300-um spot. Photos used with permission fromEmily Tierney, MD.
FIG. 6. Left lateral view. Pre (left) and 3 months post (right) treatment of acne scars and photoaging with ablative fractionated CO2 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 treatedwith the 300-um spot. Photos used with permission fromEmily Tierney, MD.
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For facial resurfacing of moderate to severe photoaging (dyschromia, and moderate rhytids and 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 – spot size: 135 um, energy: 25 mJ, and TL (coverage) 12-R1 (50–60%). Care should be taken to avoid overlap of MTZs with adjacent laser passes. For treatment of Fitzpatrick skin types IV and V, the TL settings should be reduced to decrease the risk of post-inflammatory hyperpigmentation. Although some practitioners advocate using higher energies to achieve deeper tissue injury, in our experience, excellent clinical results in the treatment of deep rhytids can be achieved without producing tissue injury in the deep dermis. Avoiding deep dermal treatments may also result in a lower incidence of complications.
Conclusions AFP has become the most promising new option for safe, nonsurgical improvement in rhytides, photodamage, and scarring. With proper technique, results approaching those seen with traditional CO2 laser resurfacing can be achieved with an exceedingly low risk of scarring and hypopigmentation. The relatively short recovery periods required after AFP treatments, combined with its safety and an expanding array of applications, are likely to ensure AFP’s place in the cosmetic therapeutic arsenal for years to come.
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