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Fractional Laser Skin Resurfacing

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Laser skin resurfacing (LSR) has evolved over the past 2 decades from traditional ablative to fractional nonablative and fractional ablative resurfacing. Traditional ablative LSR was highly effective in reducing rhytides, photoaging, and acne scarring but was associated with significant side effects and complications. In contrast, nonablative LSR was very safe but failed to deliver consistent clinical improvement. Fractional LSR has achieved the middle ground; it combined the efficacy of traditional LSR with the safety of nonablative modalities. The first fractional laser was a nonablative erbium-doped yttrium aluminum garnet (Er:YAG) laser that produced microscopic columns of thermal injury in the epidermis and upper dermis. Heralding an entirely new concept of laser energy delivery, it delivered the laser beam in microarrays. It resulted in microscopic columns of treated tissue and intervening areas of untreated skin, which yielded rapid reepithelialization. Fractional delivery was quickly applied to ablative wavelengths such as carbon dioxide, Er:YAG, and yttrium scandium gallium garnet (2,790 nm), providing more significant clinical outcomes. Adjustable laser parameters, including power, pitch, dwell time, and spot density, allowed for precise determination of percent surface area, affected penetration depth, and clinical recovery time and efficacy. Fractional LSR has been a significant advance to the laser field, striking the balance between safety and efficacy. J Drugs Dermatol. 2012;11(11):1274-1287.
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November 2012 1274 7ĚėĠĘĐƆƆr*ĞĞĠĐƆƆ
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SPECIAL TOPIC
Fractional Laser Skin Resurfacing
Macrene R. Alexiades-Armenakas MD PhD,a,b Jerey S. Dover MD,a-c and Kenneth A. Arndt MDc-e
aDepartment of Dermatology, Yale University School of Medicine, New Haven, CT
bDermatology and Laser Surgery Center, New York, NY
cDepartment of Surgery, Dartmouth Medical School, Hanover, NH
dSkinCare Physicians, Chestnut Hill, MA
eDepartment of Dermatology, Harvard Medical School, Boston, MA
Laser skin resurfacing (LSR) has evolved over the past 2 decades from traditional ablative to fractional nonablative and fractional abla-
tive resurfacing. Traditional ablative LSR was highly effective in reducing rhytides, photoaging, and acne scarring but was associated
with signicant side effects and complications. In contrast, nonablative LSR was very safe but failed to deliver consistent clinical im-
provement. Fractional LSR has achieved the middle ground; it combined the efcacy of traditional LSR with the safety of nonablative
modalities. The rst fractional laser was a nonablative erbium-doped yttrium aluminum garnet (Er:YAG) laser that produced microscopic
columns of thermal injury in the epidermis and upper dermis. Heralding an entirely new concept of laser energy delivery, it delivered the
laser beam in microarrays. It resulted in microscopic columns of treated tissue and inter vening areas of untreated skin, which yielded
rapid reepithelialization. Fractional delivery was quickly applied to ablative wavelengths such as carbon dioxide, Er:YAG, and yttrium
scandium gallium garnet (2,790 nm), providing more signicant clinical outcomes. Adjustable laser parameters, including power, pitch,
dwell time, and spot density, allowed for precise determination of percent surface area, affected penetration depth, and clinical recov-
ery time and efcacy. Fractional LSR has been a signicant advance to the laser eld, striking the balance between safety and efcacy.
J Drugs Dermatol. 2012;11(11):1274-1287.
ABSTRACT
INTRODUCTION
Procedural treatments for rhytides, photoaging, and acne
scars have ranged from aggressive and highly effective to
conservative with minimal efcacy. Traditional or standard
ablative laser skin resurfacing (LSR) with carbon dioxide (CO2) and
erbium-doped yttrium aluminum garnet (Er:YAG) lasers were high-
ly effective in reducing rhytides, photoaging, and acne scars but
were associated with signicant side effects and complications.1
Dermabrasion and chemical peeling were also very effective, but
their side effects and complication rates were high.2,3 In an effort to
increase safety and decrease side effects and complications, nonab-
lative lasers and light-based devices, which neither ablate nor va-
porize tissue, were developed. Nonablative technologies targeted
chromophores in the epidermis and dermis and induced dermal
thermal injury without epidermal wounding.1 Although nonablative
modalities proved to be very safe, requiring no recovery time and
rarely causing side effects or complications, they provided low
or inconsistent efcacy, particularly in the reduction of rhytids.1
Fractional Laser Resurfacing
Most recently, a resolution of this therapeutic challenge was de-
veloped with fractional LSR, which treated a fraction of the skin
surface with microscopic arrays of laser- or light-mediated effects
at higher dosages than nonablative LSR, but with intervening
zones of untreated skin for rapid recovery and excellent safety.4
By targeting microscopic spots of the skin with individual micro-
beams of laser light, and sparing skin and stem cells in between,
rapid recovery and increased safety were achieved (Figure 1). Ar-
rays of microscopic columns of focal areas of energy-mediated
effects were created, such as to focally target a fraction of the
skin with many separate microbeams of laser or light.4 The mi-
croscopic columns were termed microthermal treatment zones
(MTZs), extending from the epidermal layer into the dermis at
varying depths, and determined by several parameters, includ-
ing laser energy output and spot size.4 The categories of fractional
LSR included nonablative fractional LSR, which neither ablated
nor vaporized tissue, but caused microcolumns of thermal injury
in the dermis with a relatively intact superimposed epidermal
layer left in place. The second category was the ablative type,
which ablated or vaporized microcolumns of epidermis and der-
mis. Of the 2 types of fractional lasers, nonablative and ablative,
the latter yielded higher efcacy with a small sacrice in safety.
Fractional Nonablative Resurfacing
Technologic Properties
The rst fractional laser was the nonablative 1,550-nm Er-doped
ber laser delivering 2,000 MTZs per cm2 (Fraxel, Solta, Hayward,
CA; formerly Reliant Technologies).4 Microscopic laser spots were
scanned across the skin through an optical scanner that laid
down an array onto the skin. As the rst attempt at implement-
ing the fractional concept, the new technology, while clever, was
cumbersome. It used an optical scanner that originally required
the application of a blue dye to the patient’s skin to facilitate track-
ing. Even with the application of topical anesthesia and the use
of cool air, many found it unreasonably uncomfortable (Figure 2).
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M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
dermis. Periorbital treatments were well tolerated with minimal
erythema and edema. Linear shrinkage of 2.1% was measured 3
months after the last treatment. The wrinkle score improved 18%
(P<.001) 3 months after the last treatment.4
The original 1,550-nm Er-doped ber fractional nonablative la-
ser (Fraxel, Solta) was subsequently assessed in several studies.
In a 50-patient clinical study of mild to moderate photodamage,
rhytides, and dyspigmentation, 3 successive treatments were
administered at 3- to 4-week intervals.5 Clinical improvement
was determined by 2 blinded evaluators from paired photo-
graphs at baseline, 3, 6, and 9 months posttreatment using a
quartile grading scale. Mean improvement at 3 months was
2.23 for face and 1.85 for nonfacial skin (P<.001); at 6 months
was 2.10 for face and 1.81 for nonfacial skin (P<.001); at 9
months was 1.96 for face and 1.70 for nonfacial skin (P<.001).
At least 51% to 75% improvement in photodamage at 9-month
follow-up was reported in 73% and 55% of facial and nonfacial
treated skin, respectively. Side effects were limited to transient
erythema and edema in the majority of patients.5
The device was also reported to be efcacious in the treatment
of scars.6 The 1,550-nm Er-doped ber laser was used to treat 53
patients (skin phototypes I-V) with mild to moderate atrophic facial
acne scars in 3 monthly treatments with up to 6-month follow-
up. Clinical outcome was assessed by 2 independent investigators
who employed a quartile grading scale, with improvements aver-
aging 51% to 75% in nearly 90% of patients.6 Mean improvement
scores increased proportionately with each successive laser ses-
sion. Side effects included transient erythema and edema, but no
dyspigmentation, ulceration, or scarring were observed.6
Additional versions of nonablative fractional resurfacing lasers
(Afrm 1,440 nm, Cynosure, Chelmsford, MA; StarLux, Lux 1540,
Lux 1440, Lux DeepIR, Palomar, Burlington, MA; 1,550 Er, Sel-
las; Matrix RF, Syneron, Yokneam, Israel) followed. Recently, the
1,927-nm thulium laser was developed to deliver more super-
cial fractional nonablative energy.
The 1,540-nm nonablative Er fractional laser was assessed in
the treatment of acne scars in a randomized controlled trial of
10 subjects.7 For each subject, 2 matched contralateral anatomi-
The device was subsequently modied, eliminating the blue dye,
and changes to the energy and pattern reduced pain. Compelling
magnied, serial images of the skin surface demonstrated the
gradual wound healing of the microlesions following treatment
at 3, 7, 11, 14, and 21 days (Figure 3).
Clinical Results
In the rst published study, 2 prototype devices emitting the
1.5-µm wavelength provided a pattern of microexposures with
variable MTZ density, tested on the forearms of 15 subjects and
on the periorbital area of 30 subjects who received 4 treatments
during a 2- to 3-week period.4 Clinical and histologic evaluations
were assessed up to 3 months after treatment. Pattern densities
with spacing of 250 µm or more were well tolerated. Microther-
mal treatment zone diameter was typically 100 µm and penetrated
300 µm into the skin. Reepithelialization was complete within 1
day. Histology at 3 months showed enhanced undulating rete
ridges and increased mucin deposition within the supercial
FIGURE 1. Schematic of fractional resurfacing concept. This illustration
shows the principle of fractional laser resufacing, wherein microscopic
columns of laser-mediated effects are delivered into the skin by frac-
tionated delivery of the laser beam.
FIGURE 2. The first fractional nonablative resurfacing laser: an erbi-
um-doped 1,550-nm fiber fractionated laser. In the original version,
blue dye was applied to the patient’s face before laser treatment. Fol-
lowing the procedure, erythema and edema gradually resolves over a
2- to 3-day period.
FIGURE 3. Compelling images demonstrating the healing of microlesions
on the skin surface following fractional nonablative laser resurfacing.
© 2012-Journal of Drugs in Dermatology. All Rights Reserved.
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M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
microbeam energies up to 60 mJ/microbeam and 5 passes. Rela-
tive to baseline, 73% of treated scars improved 50% or more, and
43% improved 75% or more. Side effects included mild swelling
(95% of subjects), erythema (94%), and purpura (5%), which all
resolved within 2 to 3 days.9
Recently, the thulium laser, emitting 1,927-nm wavelength, was
assessed in a preliminary study for the treatment of actinic kerato-
ses.10 Four monthly treatments were administered with 6 months
follow-up. Actinic keratosis clearance of 86.8% was reported.10
In the authors’ experience and based on the published data, in
order to achieve maximal improvement of rhytides, dyspigmen-
tation, or acne scars, multiple treatment sessions (4 to 6) are
required (Figure 4). An important advantage of fractional nonab-
lative LSR is that it is safely applied to the neck, chest, limbs, as
well as the hands and feet. These anatomic areas were historically
at a high risk of side effects and complications from ablative and
nonablative (eg, intense pulsed light) modalities. In contrast, frac-
tional nonablative resurfacing effects excellent improvement in
photoaging, such as lentigines and textural changes, without the
extent of reported risks with other modalities (Figure 5).
A controversial topic is the application of fractional LSR to the
treatment of melasma and the results of the published data pre-
sented here. Initial ndings suggested that fractional nonablative
LSR was effective for the treatment of melasma for the rst several
cal regions were randomized to 3-monthly 1,540-nm fractional
laser (StarLux, Palomar) treatments vs no treatment. Blinded
clinical evaluations at baseline, 4 weeks posttreatment, and 12
weeks posttreatment were performed. End points were overall
change in scar texture (from 0 = even texture to 10 = worst pos-
sible scarring), adverse effects, change in skin color (from 0 =
absent to 10 = worst possible), and patient satisfaction (from
0 = no satisfaction to 10 = best imaginable satisfaction).7 Be-
fore treatment, scars were moderately atrophic and uneven in
texture on both treated and untreated sides (median score 6.5,
interquartile range 4.5-8; P=1). After treatment, laser-treated
scars appeared more even and smooth than untreated control
areas (4.5, 2-6.5, vs 6.5, 4.5-8, P=.0156, at 4 weeks; 4.5, 2.5-6.5,
vs 6.5, 4.5-8, at 12 weeks; P=.0313).7 Side effects of moderate
pain, erythema, edema, bullae, and crusts were reported.7
In a prospective, single-blind, randomized trial of subjects with
acne scars, 15 subjects with skin types IV to VI were treated with
a 1,550-nm Er-fractionated nonablative laser.8 Patients were di-
vided into 2 groups: one was treated with 10 mJ and the other
with 40 mJ in 5 monthly laser sessions. There was a signi-
cant improvement in the acne scarring and overall appearance
(P<.001). No signicant difference was found between 10 and
40 mJ. Patients were highly satised with their results. Signi-
cant postinammatory hyperpigmentation (PIH) was seen; pain
was signicantly higher in darker skin.8
In another study, the treatment of surgical and posttraumatic
scars with fractional nonablative 1,540-nm Er:glass laser was
assessed.9 Histologic ndings demonstrated rapid reepitheli-
alization of the epidermis within 72 hours posttreatment. Scar
remodeling with renewal and reorganization of collagen bers in
the dermis was noted 2 weeks posttreatment. Clinical subjects,
with Fitzpatrick skin types II to V, received 3 to 7 treatments with
FIGURE 4. Photographic examples of clinical outcome following
fractional nonablative 1,550-nm erbium-doped fiber laser resurfacing
(Fraxel, Solta). The improvement in photoaging, primarily lentigines
and dyspigmentation, following 4 treatment sessions with fractional
nonablative laser resurfacing is evident in this example.
FIGURE 5. Fractional nonablative laser resurfacing for the treatment
of photoaging on the neck and chest. Pretreatment and posttreatment
photographs demonstrating significant improvement in photoaging
following 4 treatments with fractional nonablative laser resurfacing.
© 2012-Journal of Drugs in Dermatology. All Rights Reserved.
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No reproduction or use of any portion of the contents of these materials may be made without the express written consent of JDD.
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M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
acneiform eruptions occurred in 1.87% and herpes simplex virus
occurred in 1.77% of patients.16 Postinammatory hyperpigmen-
tation was observed in darker skin types and in patients with
melasma.14 Prolonged erythema has infrequently been reported
with fractional nonablative LSR, particularly when manifesting
with ushing.
17
Histologic Findings
Histologic evaluation following fractional 1,550-nm Er laser
(Fraxel, Solta) resurfacing demonstrated columnar thermal mi-
crolesions extending from the epidermis to a depth of 100 µm into
the dermis, without ablation.18 Microcolumns show partially dena-
tured collagen in the papillary dermis (Figure 6).
Alternate versions of fractional nonablative technologies show
similar histologic ndings. The nonablative laser system (Afrm,
Cynosure) delivering 1,000 micropulses of 1,440-nm energy within
months posttreatment. In a 10-subject study, 1,535- and 1,550-nm
fractional nonablative lasers were used in 4 to 6 treatment ses-
sions, with signicant short-term improvement.11 However, as has
been observed with many other treatment modalities, recurrence
rates of melasma are high, and higher-skin-type patients tend not
to respond particularly well. Most recently, a comparative trial
demonstrated that long-term (12-month) sustained improvement
was only achieved when fractional LSR was combined with topi-
cal therapy, relative to either treatment alone.12 In another study
of 8 female patients (Fitzpatrick skin types II-IV) with melasma, 2
to 7 fractional nonablative laser treatments were performed with
the 1,550-nm Er-doped laser (Fraxel SR, Solta) at 3- to 8-week in-
tervals.13 Treatment levels ranged from 3 to 10, corresponding to
9% to 29% surface area coverage (8-10 passes per treatment; ener-
gies 6-40 mJ). Physician and patient assessments were recorded
at each visit and at a follow-up visit 7 to 36 months (mean 13.5
months) after the last treatment session, and revealed greater
than 50% clinical improvement in melasma in 5 of 8 patients.
Recurrence was reported in 3 patients.13 Recently, a randomized,
split-face trial comparing fractional nonablative 1,550-nm laser
with topical therapy demonstrated that the topical therapy side
yielded better improvement in melasma, while the fractional re-
surfacing side demonstrated a 31% incidence of PIH.14
Fractional nonablative LSR was shown to improve the residual
textural changes from involuted infantile hemangiomas.15 Signi-
cant improvement was achieved after 5 treatment sessions.15
A summary of the published clinical trials assessing fractional
nonablative LSR are presented in Table 1. While there have been
no head-to-head comparative trials of the 1,550-nm, 1,540-nm,
and 1,440-nm nonablative devices, clinical experience suggested
that when used optimally, results are similar.
Side Effects and Complications
The side effects and risks of complications of fractional nonab-
lative LSR were low, with an average of 3 days postoperative
erythema and edema and a low complication rate. In a study of
73 treatments with the fractional nonablative 1,550-nm Er laser,
FIGURE 6. Histologic evaluation following fractional nonablative 1,550-
nm erbium laser resurfacing (Fraxel, Solta). This skin biopsy taken
immediately following laser irradiation demonstrates columnar thermal
microlesions extending from the epidermis to a depth of 100 μm in the
dermis, without ablation. Microcolumns show partially denatured col-
lagen in the papillary dermis.
TABLE 1.
Fractional Nonablative Laser Resurfacing Published Clinical Data
Study Device Efficacy
Manstein et al, 200441,550-nm erbium, 4 Tx 18% rhytid reduction at 3 months
Wanner et al, 200751,550-nm erbium, 3 Tx 50%-75% improvement in photodamage in 73% of facial skin, 55% of nonfacial skin, 9 months
Alster et al, 200761,550-nm erbium, 3 Tx 50%-75% “improved” acne scars in 90% of subjects, 6 months
Hedelund et al, 201071,540-nm erbium, 3 Tx Improved acne scars using scale, 3 months
Mahmoud et al, 201081,550-nm erbium, 5 Tx “Improved” acne scars
Vasily et al, 200991,540-nm erbium, 3-7 Tx 73% of scars improved by 50%
Weiss et al, 201010 1,927-nm thulium, 4 Tx 79% actinic keratosis clearance, 3 months
Tx, number of treatments.
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M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
with the trade-off of increased discomfort and recovery time.
Ablative lasers—10,600 nm emitted by the CO2 laser, 2,940 nm
emitted by the Er:YAG laser, and 2,790 nm emitted by the yt-
trium scandium gallium garnet (YSGG) laser—were used to
vaporize and ablate tissue because their wavelengths are in-
tensely absorbed by tissue water. The Er:YAG wavelength is
absorbed with such a high coefcient by water that the cells va-
porize immediately without thermal injury, therefore failing to
achieve adequate hemostasis during treatment. In contrast, the
CO2 laser wavelength has a much lower absorption coefcient
for water, such that a signicant amount of collateral thermal
injury occurs. The advantage is excellent hemostasis; the disad-
vantage is an increased risk of causing excessive thermal injury,
charring, and scar formation. The YSGG laser wavelength’s in-
termediate absorption coefcient causes enough collateral
thermal injury to maintain adequate hemostasis, but without
the degree of thermal damage of the CO2 laser (Figure 8).
Technologic Properties
The parameters and differences among the fractional ablative
CO2 technologies available to date are presented in Table 2. The
vast majority used an optical scanner to scan a very small laser
spot across the skin. Others employed a stamping method of
delivery where the laser spot is “stamped” onto the skin though
a 10-mm spot size demonstrated wider and shallower MTZs of
thermal injury extending from the epidermis, but relatively more
supercially into the papillary dermis. One pass with this device
treated a larger percent surface area, more supercially.
The fractional nonablative 1,540-nm laser (StarLux) delivered
energy output directly correlated with the depth of the microle-
sion incurred. As the energy output was increased from 15 mJ to
100 mJ, the penetration depth of the microlesions extended from
400 µm to 1.1 mm (Figure 7).19
Summary
Fractional nonablative LSR offered the advantages of: 1) rapid
recovery; 2) minimal side effects and complications; 3) clinical
efcacy in treating photoaging, rhytides, and acne scars; and 4)
the ability to safely treat the neck and chest. The disadvantages
were: 1) multiple treatment sessions required; 2) the economic
cost of the laser technology; and 3) lower efcacy compared
with traditional LSR.
Fractional Ablative Laser Resurfacing
Given the disadvantages of fractional nonablative LSR, the next
logical step was the development of fractional ablative LSR. Frac-
tional ablative LSR took the fractional concept to the next level
and achieved the goals of maximizing efcacy and safety. Instead
of MTZs, microscopic columns of ablated tissue are generated,
extending from the epidermis into the dermis. It offered the best
of both worlds—the advantages of standard ablative LSR without
the side effects and risk prole. Fractional ablative LSR achieved
greater efcacy per treatment than fractional nonablative LSR,
FIGURE 7. Direct correlation of laser energy output with penetration
depth of nonablative laser. Another fractional nonablative 1,540-nm
laser (StarLux, Palomar) delivers adjustable penetration depths. In the
figure, histologic evaluation demonstrates microlesions created with
this device. The images show that the energy output of the device is
directly correlated with the depth of the microlesion incurred. As the
energy output is increased from 15 mJ to 100 mJ, the penetration depth
of the microlesions extends from 400 μm to 1.1 mm.
FIGURE 8. The comparison of the 3 fractional ablative wavelengths
with respect to percent ablation vs thermal coagulation of tissue. The
erbium laser results in 95% ablation (blue bar) and only 5% thermal
injury (red bar). This explains the poor hemostasis immediately follow-
ing each erbium pulse. The nonablative devices caused exclusively
thermal coagulation without ablation, which was associated with
minimal efficacy. The CO2 lasers induce mostly thermal coagulation
(80% for high power, 95% for low power) and little relative ablation (20%
and 5%, respectively). The advantage of the CO2 lasers was the excel-
lent hemostasis during treatment; however, the disadvantage was the
risk of excessive thermal injury, potentially causing charring and poor
outcome. In the center is the , which provides a balance between abla-
tion (60%) and coagulation (40%), resulting in significant tissue ablation
while maintaining hemostasis. (Source: Cutera, Brisbane, CA)
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M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
a microlens array. The wavelength delivered by all is 10,600 nm.
The diameter of each microbeam (termed microspot size) varies
from 125 µm (eg, Lumenis DeepFX, Yokneam, Israel) to 1.25 mm
(eg, ActiveFX, Lumenis). The density of the microscopic beams
differs and is adjustable for several of them, extending from 5%
surface area coverage to 100%, depending on the device. The en-
ergy output differs among the devices and is shown in Table 2
per microbeam. The penetration depth of the microlesions varies
among the devices from 300 µm to 1.6 mm, depending on the
device (Table 2). The pulse duration is adjustable and plays a role
in the degree of thermal damage that is induced. With one of the
fractional CO2 devices (Fraxel Repair, Solta), the diameter of the
beam increases as uence increases. The net histologic effect of
increasing uence is both a wider area and deeper zone of ther-
mal damage. Some manufacturers employ a fractional scanner
attached to a continuous wave (CW) or superpulsed CO2 laser.
One example of such a device (Matrix Laser, Sandstone Medical
Technologies, Birmingham, AL) emits a microspot size of 150 µm
and an ablative depth of 100 to 600 µm, with an adjustable pulse
duration from 0.02 to 2 ms. For such technologies, increasing the
dwell time also results in proportional increases in microbeam
uence, which in turn results in increased ablative depths.
Key Parameters
The 4 key parameters of fractional ablative LSR are: 1) power,
2) pitch, 3) dwell time, and 4) microspot diameter (Table 3).
Their manipulation with each device determines the extent of
surface area treated, the penetration depth of the microbeam,
the diameter of the microlesion, and the degree of ablation
vs thermal injury that is induced. The precise manipulation of
these 4 parameters in turn predetermines the number of days
of healing time required by the patient, which represents an
important practical advantage. The rst parameter is the power
(wattage), which is the energy delivery per microbeam. This
varies from 5 to 100 mJ/microbeam per device (Table 2). The
power output and penetration depth are directly proportional
for a set microspot diameter. The second parameter is the pitch
or microspot spacing. As the pitch or spacing is decreased,
the density or surface area of skin treated increases. Some
devices have adjustable pitch, whereas others are xed. At a
given microbeam uence, the dwell time or pulse duration of
each micropulse correlates with the degree of thermal injury.
Finally, the microbeam diameter, which is xed for each device,
nevertheless varies signicantly among devices and plays an
important role in penetration depth (Table 3).
The relative inuences of laser power output and dwell time (pulse
duration) are shown in Figure 9. As power output is increased, the
TABLE 2.
Fractional Carbon Dioxide (CO2) Laser Resurfacing Technologies
Solta Fraxel
Repair
Lumenis
ActiveFX
Lumenis
DeepFX
DEKA SmartXide
DOT
Lasering
MiXto Alma Pixel CO2Ellipse Juvia
Delivery IOTS paintbrush Scanned
stamping
Scanned
stamping
Scanned stamping Scanned
stamping
Stamping Stamping
Wavelength (!)10,600 nm 10,600 nm 10,600 nm 10,600 nm 10,600 nm 10,600 nm 10,600 nm
Spot size 135 µm 1,250 µm 125 µm 350 µm 300 µm 120-250 or 350 µm 500 µm
Density 5%-70% 55%-100% 5%-25% 5%-40% 20% 20%
Energy 5-70 mJ/MTZ 80-100 mJ/
MTZ
5-30 mJ/
MTZ
1-60 mJ/dot 5-20 mJ/dot 74 or 122 mJ/pixel 5-15 mJ/
MTZ
Depth <1,600 µm 80-100 µm <450 µm <350 µm 500 µm 150-250 to 400 µm <300 µm
Pulse duration 0.15-3 ms 0.5-5 ms 0.5-5 ms 0.2-2 ms 0.2-2 ms 50-300 ms 5-7 ms
Pulse delivery UltraPulsed UltraPulsed UltraPulsed SuperPulse Pulsed Pulsed SuperPulse
Consumables Tip & cartridge NA Tip & lens NA NA NA Handpiece
Microdot delivery Sequential Random Random Random Random
Scan areas Square Round Round Adjustable shape,
size, ratio
Square Round or square
IOTS, Intelligent Optical Tracking System; MTZ, microthermal treatment zone; NA, not applicable.
TABLE 3.
Key Parameters for Fractional CO2 Systems
Parameter Units Effects
Power Watts Ablation
Pitch 1/Density=Total area/
Treated area
Recovery time,
discomfort
Dwell time Pulse duration (ms) Thermal damage
Microspot
diameter
µm Penetration depth
© 2012-Journal of Drugs in Dermatology. All Rights Reserved.
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1280
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/ĚġĐĘčĐĝrėĠĘĐr*ĞĞĠĐ
M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
ablative penetration depth is increased. As dwell time or pulse dura-
tion is increased, so rises the degree of collateral thermal injury that
is incurred. Ideally, for reasons of maintaining adequate hemostasis
and potentially inducing greater neocollagenesis, a combination of
both ablative and thermal injury appears to be desirable.
The effects of microspot diameter on penetration depth are sig-
nicant. At a set energy level, a small microspot diameter results
in far greater depth of ablation; a large diameter results in very
supercial ablative depth. For example, one of the smallest mi-
crospot diameters among fractional CO2 devices is 0.135 µm
(Fraxel Repair, Solta), which achieves a reported penetration depth
of 1.6 mm. In contrast, the largest microspot diameter for a frac-
tional CO2 laser is 1.25 mm (ActiveFX, Lumenis), which correlates
with a penetration depth of only 80 to 100 µm.
Microspot density is an important parameter that is adjustable
in many fractional ablative devices and determines the amount
of surface area that is treated (Figure 10). The microspot density
is equivalent to the treated area divided by the total surface
area. It is the inverse of the microspot pitch or spacing. As the
pitch or spacing is decreased, the density of microlesions and
the treated surface area increases. As the pitch or microspot
spacing is increased, the density of treated skin decreases, and
this correlates with decreased patient discomfort and faster re-
covery time (Figure 10).
In at least one of the fractional CO2 devices, the scanning spot
size and shape are adjustable (eg, SmartXide DOT, DEKA, Firenze,
Italy). This device is able to scan various shapes, including rectan-
gles, triangles, hexagons, and parallelograms. The sizes and ratios
of each shape are also adjustable. The signicant advantages of
this exibility include the precise delivery of energy. It has been
shown that additional passes conned to the acne scars augment
clinical improvement of the scars, much in the manner that tri-
chloroacetic acid placement within acne scars has been shown to
yield improvement through neocollagenesis.20 In the case of striae
distensae, it is possible to treat the affected areas while leaving
normal adjacent skin untreated, though the clinical outcomes
are variable, as described in Clinical Findings below. Finally, the
adjustable shapes allow for precise treatment of cosmetic areas,
such as accurate coverage along the mandible and periorbital
regions. For example, one may employ large rectangles for cover-
age of the majority of the face followed by triangles to ll in the
gaps to create a perfect line across the jaw. Skilled operators may
work with the set shapes and sizes of other fractional ablative de-
vices to achieve excellent lay-down of scans. The features of the
fractional CO2 devices are shown in Table 2.
Clinical Findings
Immediately following pulsing with fractional ablative LSR, white
<1-mm macules appear on the skin surface (Figure 11). They change
within minutes to erythematous macules, which correlate clinical-
ly with mild to moderate erythema. With several devices, pinpoint
or multifocal hemorrhage may occur immediately posttreatment.
Postoperative erythema may increase in the subsequent 1 to 3
days (Figure 12). If low power is employed, erythema may be mild
and resolve within 1 day; at high power settings and dwell times,
erythema may be pronounced with accompanying edema for up
to 7 days or more. In cases where periprocedural hemorrhage oc-
curs, crusting is expected, typically resolving within 7 days.
The procedure is more painful than nonablative fractional, but
less than traditional LSR. Each device may be employed across
a spectrum of settings from gentle to aggressive, with increasing
power, dwell time, and microspot density resulting in increasing
discomfort and recovery time. When performing an aggressive
fractional ablative procedure, topical anesthesia is required with
FIGURE 9. The relative influences of laser power output and dwell time
(pulse duration). As power output is increased, the ablative penetra-
tion depth is increased. In contrast, as dwell time or pulse duration is
increased, this increases the degree of collateral thermal injury that is
incurred. Ideally, for reasons of maintaining adequate hemostasis and
potentially inducing greater neocollagenesis, a combination of both
ablative and thermal injury appears to be desirable.
FIGURE 10. The relationship of microspot density to surface area
treated. This schematic demonstrates the relationship of microspot
spacing or pitch to microspot density. The microspot density = treated
area/total surface area and =1/pitch.
© 2012-Journal of Drugs in Dermatology. All Rights Reserved.
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No reproduction or use of any portion of the contents of these materials may be made without the express written consent of JDD.
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1281
+ĚĠĝęČėĚđ%ĝĠĒĞĔę%ĐĝĘČğĚėĚĒĤ
/ĚġĐĘčĐĝrėĠĘĐr*ĞĞĠĐ
M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
cold air during the procedure. Within 1 hour of the procedure end-
ing, the pain typically subsides completely. Worsening pain in the
postoperative period may signify infection. No pain medication is
required once the procedure is completed.
Clinical outcomes from fractional CO2 LSR depend on the 4 key
parameters, as well as the system and number of treatment ses-
sions. In Figure 13, clinical outcomes from a deeply penetrating
fractional CO2 device are shown. Signicant improvement in rhyt-
ides and photoaging are typically observed, improving gradually
over a 6-month follow-up interval.
A 4-quadrant study comparing 4 fractional ablative lasers, including
3 CO2 and a YSGG failed to demonstrate differences in efcacy in
the treatment of photoaging among the devices.21 One of the early
published reports of a deeply penetrating fractional ablative CO2 de-
vice (ActiveFX, Lumenis) evaluated the clinical outcomes following
a single treatment at 1-month and 3-month follow-up.22 Fifty-ve
patients were evaluated and demonstrated statistically signicant
improvements in rhytides and photoaging, which improved sig-
nicantly between the 1- and 3-month follow-up intervals.22 These
ndings reproduced those obtained from traditional ablative CO2
LSR, which manifest progressively over the course of months.
In one study of fractional CO2 LSR of photoaging, 10 subjects
with Fitzpatrick skin types I to III underwent a single treatment
using a scanning handpiece.23 Blinded evaluator and subject
assessment documented clinical improvement in cutaneous
photoaging. Light microscopy revealed wound repair, and elec-
tron microscopy conrmed neocollagenesis.23 No signicant or
long-term complications were reported.
In another study of fractional CO2 LSR for the treatment of neck
rhytides and laxity, Tierney and Hanke24 utilized the validated Alex-
iades-Armenakas quantitative grading scale of rhytides, laxity,
and photoaging1 and conducted blinded evaluations of pretreat-
ment and posttreatment photographs of 10 subjects treated with
fractional CO2 LSR. They demonstrated improvement of neck
texture and laxity following 1 to 3 treatments, with an average of
1.4. Mean texture score improved 62.9% (95% condence interval
[CI]: 57.4%, 68.4%); skin laxity, 57.0% (53.2%, 60.8%); and rhytides,
51.4% (48.3%, 54.5%). For overall cosmetic outcome, the mean
score improved 59.3% (55.1%, 63.5%) at 2 months posttreatment.24
In another trial, a series of 32 consecutive patients underwent a
single fractional CO2 LSR procedure.25 Subjects were followed
for >6 months and completed patient satisfaction questionnaires
and photographic evaluation by an independent physician was
performed. Data were graded and reported on a quartile scale.
Greater than 50% improvement was reported in almost all pa-
tients, with wrinkles, pigment, and solar elastosis deriving the
greatest improvement (>75%).25
Fractional CO2 LSR has also been evaluated for the treatment of
acne scars.26 Thirteen subjects (skin types I-IV, aged 28-58 years)
with moderate to severe acne scars underwent 2 to 3 treatments at
1 to 2 months intervals with up to 3 months of follow-up. Posttreat-
ment side effects were mild to moderate and transient, resolving
rapidly. No hypopigmentation or permanent scarring was ob-
served. Quartile grading scores correlating to at least 26% to 50%
improvements in texture, atrophy, and overall improvement in all
patients. Topographic imaging analysis performed on scars was
FIGURE 11. Immediate postpulse white macules. Immediately following
fractional ablative laser resurfacing, white dotlike macules are appar-
ent on the skin surface. These gradually become erythematous over the
course of minutes.
FIGURE 13. Clinical photographs of a patient with rhytides and photoaging
a) before and b) following treatment with fractional CO2 laser resurfacing.
FIGURE 12. Posttreatment erythema following fractional CO2 laser
resurfacing. Following fractional ablative laser resurfacing, moderate
erythema and mild edema are evident and resolve over the course of 7
to 14 days, depending on the settings used.
a) b)
© 2012-Journal of Drugs in Dermatology. All Rights Reserved.
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No reproduction or use of any portion of the contents of these materials may be made without the express written consent of JDD.
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1282
+ĚĠĝęČėĚđ%ĝĠĒĞĔę%ĐĝĘČğĚėĚĒĤ
/ĚġĐĘčĐĝrėĠĘĐr*ĞĞĠĐ
M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
reported to demonstrate improvement in the depths of acneiform
scars ranging from 43% to 79.9%, with a mean of 66.8%.26
A 13-subject study of fractional CO2 LSR in 3 sessions for the
treatment of atrophic acne scars in Asian skin demonstrated at
6-month follow-up that 85% of subjects were rated at 25% to 50%
improvement.27 Improvement signicantly progressed from the
1- to 6-month follow-up (P=.002). At 1 month, surface smoothness
(P=.03) and scar volume (P<.001) signicantly improved, compared
with baseline measurements. Sixty-two percent of subjects rated
themselves as having 50% improvement. Mild PIH was the most
common adverse effect in 92% of the subjects, or 51% of treatment
sessions, and was completely resolved in an average of 5 weeks. 27
A multicenter clinical trial of 52 subjects evaluated fractional CO2
LSR at 3 study centers for rhytides and photoaging, and at another
site, for acne scars, scars, and striae distensae.28 Using a quantita-
tive grading scale for rhytides and photoaging,1 the mean grade
improvement on a 4-point scale was ranged from 0.42 to 1.63
grade improvements, which were directly proportional to dosing
parameters, such as power, dwell time, and pass numbers.28 Scars
and striae were graded on a 4-point improvement grading scale
(0 = none, 1 = minimal, 2 = moderate, 3 = advanced, and 4 = com-
plete resolution of scars). The mean grade improvement for scars
was 2.25. However, for striae distensae, improvement varied sig-
nicantly among subjects from none to advanced, with an overall
average minimal improvement of 1 grade.28
Poikiloderma of Civatte was effectively treated with fractional CO2
LSR. A prospective pilot study was performed in 10 subjects with
a series of 1 to 3 treatment sessions.29 Treatments were adminis-
tered at 6- to 8-week intervals with blinded physician photographic
analysis of improvement at 2 months posttreatment using a grad-
ing scale of erythema/telangiectasia, dyschromia, texture, laxity,
and cosmetic outcome.1 The number of treatments required for
improvement of poikiloderma of Civatte ranged from 1 to 3, with
an average of 1.4. For erythema/telangiectasia, the mean score im-
proved 65.0% (95% CI: 60.7%, 69.3%) dyschromia, 66.7% (61.8%,
71.6%), skin texture, 51.7% (48.3%, 55.1%) and skin laxity, 52.5%
(49.6%, 55.4%). For cosmetic outcome, the mean score improved
66.7% (62.6%, 70.8%) at 2 months posttreatment.29
A recent report combined QS neodymium:YAG laser with frac-
tional ablative LSR in the treatment of tattoos.30 In the 2 cases, the
subjects presented with allergic contact dermatitis to the tattoo
ink. This combined treatment protocol was reported to result in
complete removal of the tattoo along with a resolution of their
allergic symptoms.30 In another report, fractional LSR was com-
bined with QS ruby laser treatment of tattoos.31
Side Effects and Complications
While the side effect and complication rates are much lower than
those of standard ablative resurfacing, fractional ablative LSR is
not without side effects, recovery and the small but real risk of
pigment and textural changes, particularly when the energy out-
put or pass counts are high. The adverse events include erythema,
edema, crusting, dyspigmentation, infection, and scarring.
Risk of infection is higher than for nonablative LSR, but lower
than that of traditional LSR. The risk of herpes simplex virus
reactivation necessitates premedication with antivirals. Good
postoperative wound care is essential. It is important to moni-
tor closely for posttreatment infections and to advise patients to
call and follow up in the ofce should redness, pain, yellow dis-
charge, or oozing occur, though the incidence of this is far lower
than with standard ablative LSR.
Postoperative erythema, which may manifest in a dotlike pattern,
may persist for weeks or months following fractional ablative
LSR. With deeper penetrating devices, postoperative erythema, in
a dotlike pattern, typically lasts an average of 3 months, but subtle
erythematous micromacules may persist for up to 12 months. A
recall phenomenon, where the redness reappears with histamine
release or increased blood ow, for example, as during exercise,
has also been reported.17
While occurring at a rate much lower than with traditional ablative
LSR, scarring following fractional ablative resurfacing has been
reported. Hypopigmented scarring and hypertrophic scarring of
the neck have been reported in cases of patients treated with frac-
tional CO2 lasers.17,32 In one case series, scarring and ectropion
was reported to the lower eyelids following fractional CO2.33 In
another case, linear erosions and erythematous plaques on the
neck developed into a tender, bandlike scar over 1 month.33 A
third case developed yellow exudate in multiple areas of the neck
3 days postoperatively, which grew methicillin-resistant Staphy-
lococcus aureus.33 Despite appropriate therapy, multiple areas of
irregular texture and linear streaking ultimately developed into
scars. Another case developed an asymptomatic patchy, soft es-
char with yellow change on the left side of the neck. Azithromycin
was started; however, at 2-week follow-up, the patient had brotic
streaking, which developed into horizontal scars and a vertical
platysmal band.33 In all these cases, the authors attributed the
scarring after fractional CO2 laser therapy to overly aggressive
treatments in sensitive areas (including excessive energy, density,
or both), lack of technical skill, associated infection, or idiopathic.
Care must be taken when treating sensitive areas such as the eye-
lids, upper neck, and especially the lower neck and chest, by using
"Fractional laser skin resurfacing has
become a treatment of choice in the
management of photoaging, rhytides,
and acne scarring."
© 2012-Journal of Drugs in Dermatology. All Rights Reserved.
This document contains proprietary information, images and marks of Journal of Drugs in Dermatology (JDD).
No reproduction or use of any portion of the contents of these materials may be made without the express written consent of JDD.
If you feel you have obtained this copy illegally, please contact JDD immediately.
Do Not Copy
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1283
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/ĚġĐĘčĐĝrėĠĘĐr*ĞĞĠĐ
M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
lower energy and density. Postoperative infections may lead to
scarring and may be prevented by careful taking of history, vigi-
lant postoperative monitoring, and/or prophylactic antibiotics.
Postprocedural dermatitis, eczematous dermatitis, and allergic
contact dermatitis have been reported. Acneiform eruptions, ei-
ther due to the thermal effect or occlusive hydrophobic wound
dressings, may also occur.
Histological Studies
Histological evaluations of fractional CO2 LSR have demonstrat-
ed the direct correlation between energy output and ablative
depth of penetration. As shown in Figure 14, the ablative pene-
tration depth immediately following treatment with a fractional
CO2 device emitting a 135-µm microspot diameter ranged from
100 µm to 1.6 mm as the uence was increased from 10 J/cm2
to 75 J/cm2.18 The wound healing that ensued during the rst
30 days following treatment with a fractional ablative CO2 la-
ser demonstrated granulation tissue at 1 to 3 days, followed
by progressive neocollagenesis and dermal remodeling to 30
days posttreatment (Figure 15). Neocollagenesis continued for
several months posttreatment, as had been demonstrated for
standard ablative CO2 LSR.1
Fractional Ablative Non-CO2 Systems
The fractional ablative non-CO2 laser systems include the erbium
(2,940 nm) and YSGG (2,790 nm) lasers. The same characteristics
and parameters that differentiate the fractional CO2 lasers are also
used to differentiate the non-CO2 systems (Table 4). The YSGG
emits a wavelength of 2,790 nm, whereas all the erbium devices
emit 2,940 nm. Among the multiple fractional erbium lasers, the
main differentiating characteristics include the microspot sizes,
penetration depths, and energy output.
One key difference among the fractional erbium devices is the
microspot size, which varies from 100 to 430 µm (Table 4). The abla-
tive penetration depth varies from 50 µm (Pixel 2940, Alma Lasers,
Caesarea, Italy) to 1.5 mm (ProFractional, Sciton, Palo Alto, CA).
An additional important technological feature of some fractional
erbium devices (eg, ProFractional, Sciton) is the additional thermal
coagulative pulse that may be administered immediately follow-
ing the ablative pulse. This provides for additional hemostasis.
The fractional YSGG also achieves a depth of 1.6 mm of ablative
penetration. This is largely due to the high energy output, ranging
from 60 to 320 mJ/pulse. In spite of a 300-µm microspot diam-
eter, the balance between ablation and thermal injury allows for
greater penetration depth than fractional CO2 devices at the same
energy setting (Tables 2 and 4).34
The comparison of the 3 ablative wavelengths with respect to
percent ablation vs thermal coagulation of tissue is shown in
Figure 8. As shown in Figure 8, the Er:YAG laser results in 95%
coagulation (blue bar) and only 5% thermal injury (red bar).
This disparity is responsible for poor hemostasis immediately
following each Er:YAG pulse. In contrast, nonablative devic-
es caused exclusively thermal coagulation without ablation,
which was associated with minimal efcacy (Figure 8). The
CO2 lasers induce mostly thermal coagulation (80% for high
power, 95% for low power) and little relative ablation (20% and
5%, respectively). This resulted in CO2 lasers achieving excel-
lent hemostasis during treatment; however, they also carried
risk of excessive thermal injury, potentially causing charring
and poor outcome. The YSGG wavelength laser provides a bal-
ance between ablation (60%) and coagulation (40%), resulting
in signicant tissue ablation while maintaining hemostasis
FIGURE 15. Histologic findings over 30 days following fractional CO2
laser resurfacing. Over the 30 days, the ablative column is replaced
by granulation tissue, which then results in neocollagenesis evident
by postoperative day 30. (Source: Solta)
FIGURE 14. Histologic findings immediately following fractional CO2 la-
ser resurfacing. Immediately following irradiation, columns of ablation
(vaporization) are evident, extending from the epidermis into the dermis
with adjacent collateral thermal denaturation of collagen. The depth
of penetration of the column correlates with the energy output of the
device. (Source: Solta)
© 2012-Journal of Drugs in Dermatology. All Rights Reserved.
This document contains proprietary information, images and marks of Journal of Drugs in Dermatology (JDD).
No reproduction or use of any portion of the contents of these materials may be made without the express written consent of JDD.
If you feel you have obtained this copy illegally, please contact JDD immediately.
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1284
+ĚĠĝęČėĚđ%ĝĠĒĞĔę%ĐĝĘČğĚėĚĒĤ
/ĚġĐĘčĐĝrėĠĘĐr*ĞĞĠĐ
M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
(Figure 8). What role, if any, the ratio of ablation to thermal co-
agulation plays in the efcacy and safety of fractional ablative
LSR needs to be elucidated.
Clinical Findings
Fractional Er:YAG
During the perioperative and immediate postoperative period,
bleeding is observed more commonly with the fractional Er:YAG
devices. They do have a slightly longer coagulative pulse that
has been added following the ablative pulse, which helps to limit
hemorrhage. Controlling for penetration depth, a similarly deeply
penetrating fractional Er treatment result is shown in Figure 16.
Rhytid reduction is signicant, suggesting that greater clinical ef-
cacy may correlate with penetration depth, though this nding
needs to be directly tested through comparative studies.
Karsai et al35 performed a comparative study of fractional CO2
and Er:YAG lasers. Twenty-eight patients were enrolled and
completed the entire study. Patients were randomly assigned
to receive a single treatment on each side of the periorbital re-
gion, one with a fractional CO2 and one with a fractional Er:YAG
laser. The evaluation included the prolometric measurement
of wrinkle depth, the Fitzpatrick wrinkle score (both before and
3 months after treatment), as well as the assessment of side
effects and patient satisfaction (1 day, 3 days, 6 days, and 3
months after treatment). Both modalities showed a roughly
equivalent effect. Wrinkle depth and Fitzpatrick score were re-
duced by approximately 20% and 10%, respectively, with no
appreciable difference between lasers.32 Side effects and dis-
comfort were slightly more pronounced after Er:YAG treatment
in the rst few days, but in the later course, there were more
complaints following CO2 laser treatment. Patient satisfaction
was fair, and the majority of patients would have undergone the
treatment again without a clear preference for either method.35
Fractional Er:YAG LSR was assessed in another published re-
port for the treatment of photoaging. A total of 28 patients (27
women and 1 man) aged 28 to 72 years (mean 54.2 years) with
Fitzpatrick skin types II to IV were treated for mild to moderate
actinic damage using a fractional Er:YAG laser (2,940 nm).37 Pa-
tients underwent 1 to 4 monthly treatment sessions (mean 3.2).
The initial reaction consisted of erythema and minimal swelling.
On clinical assessment by 2 physicians using a grading scale 2
months after the nal treatment, the results were rated excellent
by 21 patients (75%) and good by 7 (25%).36 Nineteen of the 21
were also evaluated 6 to 9 months after nal treatment without
any signicant change in the results.
A 30-patient clinical trial on the treatment of photoaging with
fractional ablative Er:YAG LSR (Pixel, Alma Lasers) evaluated the
results at 2 months following a single treatment.37 Fluences of
800 to 1,400 mJ/cm2 were administered at pulse durations (dwell
times) of 1 to 2 ms in 4 to 8 passes. Patient satisfaction was em-
ployed for clinical assessment and demonstrated 83% of patients
were satised with the treatment. One case of PIH was observed
in a type IV–skinned subject.37
Fractional YSGG
In contrast to fractional Er:YAG treatment, the fractional YSGG
results in only pinpoint perioperative bleeding at several limited
sites on the skin surface. Continual pressure applied to the areas
for 10 to 20 minutes eliminates the pinpoint bleeding. The patient
should be advised that in the infrequent instance that pinpoint
postoperative bleeding should occur, continual pressure with
TABLE 4.
Fractional Carbon Dioxide (CO2) Laser Resurfacing Technologies
Cutera Pearl
YSGG (2,790 nm)
Palomar Lux
2940
Sciton
ProFractional XC
Sciton
ProFractional Alma Pixel 2940 Alma High Power
Pixel 2940
Delivery 2,790 nm 2,940 nm 2,940 nm 2,940 nm 2,940 nm 2,940 nm
Wavelength (!)300 µm 100 µm 430 µm 250 µm 150 µm 200 µm
Spot size 4%-32% 55%-100% 5.5% or 11% 1.5%-30% 20%
Density 60-320 mJ/pulse 80-100 mJ !400 J/cm2!400 J/cm2300-1,400 mJ/pulse
(17-28 mJ/pixel)
300-2,500 mJ/pulse
(31-51 mJ/pixel)
Energy <1,600 µm 80-100 µm 25 µm - 1.5 mm 25 µm -1.5 mm 50-150 µm 70-220 µm
Depth 0.15-3 ms 0.5-5 ms 100 µs - 50 ms 0.2-2 ms 50-300 ms
Pulse duration UltraPulsed UltraPulsed Pulsed Pulsed Pulsed SuperPulse
Pulse delivery Tip & cartridge NA NA NA Handpiece Handpiece
Consumables Sequential Sequential Sequential – –
Microdot delivery Square Square Square Round Square
Scan areas Square Round Round Square Round or square
NA, not applicable.
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1285
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/ĚġĐĘčĐĝrėĠĘĐr*ĞĞĠĐ
M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
gauze pads should be applied for a 20-minute period. Postopera-
tive erythema is pronounced and persists for at least 7 to 10 days.
Residual subtle erythema may persist for 1 to 3 months. In rare
instances, a subtle pattern of erythematous dots may persist be-
yond this time point up to 1 year. Regardless of which fractional
ablative device is used, resolution of prolonged erythema may be
accelerated by supercial chemical peeling or light-emitting diode
treatment. The clinical efcacy of fractional YSGG in rhytid reduc-
tion is signicant, as shown in Figure 17.
A study assessed the fractional YSGG for the treatment of acne
scars.8 Patients were divided into 2 groups: one treated with
10 mJ and the other with 40 mJ. Five monthly laser sessions
were performed. A statistically signicant improvement in the
acne scarring and overall appearance was reported and found
to be statistically signicant (P<.001).8 No signicant difference
was found between 10 and 40 mJ. Patients were highly satised
with their results. Signicant PIH was seen; pain was signi-
cantly higher in darker skin.8
In another published report, 9 patients were treated with fractional
ablative YSGG LSR for rhytides and photoaging.38 Two monthly
treatments were performed with 1 month follow-up. Improve-
ments in dyspigmentation and rhytides were reported following
blinded evaluation.38 Further clinical trials are under way with long-
term follow-up, demonstrating continued clinical improvement to
12-month follow-up (M.R.A-A., manuscript in preparation).
The summary of the clinical trials and published reports of frac-
tional ablative LSR is shown in Table 5.
Histological Findings
A comparison of the histological ndings immediately post-
treatment with each of the 3 fractional ablative wavelengths
illustrates the relative percentages of ablation vs coagulation
(Figure 18). The YSGG with a 300-µm spot size when applied
at 160 J/cm2 (half-maximum output) and 3-ms pulse duration
results in a 600- to 800-µm ablative depth, 60 µm of coagula-
tion at the bottom margin, with 40 to 50 µm of coagulation
anking each lateral edge (Figure 18a).38 In contrast, the frac-
tional CO2 (SmartXide DOT, DEKA) with a 300-µm microspot
size at 20 watts and a 1-ms dwell time results in 300-µm abla-
tive depth when 3 stacked pulses are administered, with 250
µm of thermal coagulation at lateral and deep margins (Figure
18b).25 Finally, the fractional Er:YAG results in a 160-µm abla-
tive depth, and with the additional coagulative pulse, affords
70 µm of bottom-edge coagulation and only 5 µm of upper-
lateral-edge coagulation, therefore resulting in limited edge
hemostasis (Figure 18c).
In a study of 10 subjects with photoaging, a fractional ablative
Er:YAG laser (Pixel, Alma Lasers) was administered at 1,400 mJ/
cm2 a 850-µm microbeam diameter, with pass counts ranging
from 4 to 8.39 Skin biopsies and histological evaluation were per-
formed. The degree of residual thermal damage increased with
pass numbers, as did increased epidermal and dermal thermal
injury.39
As is the case for fractional CO2 lasers, treatment is followed
by rapid reepithelialization, granulation tissue and wound
healing with gradual, progressive neocollagenesis. Table 5
compiles the published trials evaluating fractional ablative
non-CO2 lasers to date.
Over-the-Counter Fractional Resurfacing Devices
One of the newest applications of fractional LSR are the
over-the-counter, or at-home, fractional devices intended for
photorejuvenation. The rst such example is the 1,410 nm, 15
mJ, 10-ms pulse duration handheld, fractional nonablative di-
ode laser (PaloVia Skin Renewing Laser, Palomar). It has attained
U.S. Food and Drug Administration (FDA) approval for reduction
of ne lines and wrinkles around the eyes. A pilot study of 34
subjects used the device daily for 4 weeks, followed by twice-
weekly treatments for 4 weeks.40 In a second study of 90 subjects,
the device was used daily for 4 weeks, followed by twice-weekly
treatments for 12 weeks. Blinded evaluation of subjects demon-
strated at least 1 grade improvement in facial rhytides among
79% of subjects at the end of the trials.41
FIGURE 16. Clinical photographs of a patient before and following frac-
tional Er:YAG laser resurfacing.
FIGURE 17. Clinical photographs of a patient before and following frac-
tional YSGG laser resurfacing.
a) a)b) b)
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/ĚġĐĘčĐĝrėĠĘĐr*ĞĞĠĐ
M. R. Alexiades-Armenakas, J. S. Dover, K. A. Arndt
Another at-home fractional laser not yet FDA-approved for pho-
torejuvenation is a 1,435-nm laser employing a high-speed
scanner that produces fractionated microscopic columns of 200
µm in depth (Solta; Philips, Einthoven, Holland). An 80-subject
study of twice-weekly treatments to the face, neck, chest, and
arms for 8 to 12 weeks demonstrated improvements in photoag-
ing at 1 to 4 weeks following treatment41 Thus, over-the-counter
devices employing fractional LSR underscore the maximization
of safety and efcacy of such devices, such that they appear to
be safely employed at home, while still affording demonstrable
improvement in rhytides and photoaging.
CONCLUSION
Fractional LSR has been a revolutionary change in laser medi-
cine. It has become a treatment of choice in the management of
photoaging, rhytides, and acne scarring. Better understanding
the relationship of penetration depth and thermal coagulation
relative to ablation will help to ensure better results with even
fewer side effects.
DISCLOSURES
Dr. Alexiades-Armenakas has received research grants from
Cutera, DEKA, Sciton, Primaeva, Alma Lasers, and Candela. Dr.
Dover has received research grants or equipment or serves as a
consultant for Cynosure, Lumenis, Merz, Palomar, and Solta. Dr.
Arndt has stock options from Solta.
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TABLE 1.
Fractional Ablative Laser Resurfacing Published Clinical Data
Study Device Efficacy
Karsai et al, 201035 Split-face CO2 vs Er:YAG 20% decrease in rhytid depth 10% decrease in Fitzpatrick score, no difference at 3 months
Berlin et al, 200923 CO2Descriptive
Tierney and Hanke, 200924 CO2, 1-3 Tx 51% rhytid improvement on blinded quantitative grading scale
Gotkin et al, 200925 CO2>50% improved rhytides on quartile scale
Chapas et al, 200826 CO226%-50% improved acne scars on quartile scale
Lapidoth et al, 200836 Er:YAG Patient assessment
Trelles et al, 200937 Er:YAG Patient reporting
Abbasi et el, 201021 CO2 vs YSGG No difference
Mahmoud et al, 20108YSGG Improved acne scars
CO2, carbon dioxide; Er:YAG, erbium-doped yttrium aluminum garnet; Tx, number of treatments; YSGG, yttrium scandium gallium garnet.
FIGURE 18. Comparison of histologic findings immediately following treatment with the 3 fractional ablative wavelengths. The fractional CO2
device results in an ablative column with a significant degree of collateral thermal injury. In contrast, the fractional Er:YAG results in an abla-
tive column with relatively little collateral thermal injury evident. The fractional YSGG results in an ablative column with collateral thermal
injury to a degree midway between the other 2 wavelengths. Courtesy of E. Victor Ross MD and Jason Pozner MD.
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/ĚġĐĘčĐĝrėĠĘĐr*ĞĞĠĐ
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AUTHOR CORRESPONDENCE
Macrene Alexiades-Armenakas MD PhD
E-mail:....................................................dralexiades@nyderm.org
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... In a study following fractional CO 2 laser resurfacing, it was observed that 1-3 days posttreatment, the wound healing process showed granulation which was followed by dermal remodeling and neocollagenesis upto 30 days after the treatment. Neocollagenesis was observed to continue for several months thereafter as it has been seen after the treatment with standard ablative CO 2 laser [107] . ...
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Postmenopausal women and events like childbirth, and aging may cause structural and functional changes in women genitalia. The arising indications do not only cause psychological distress to women but negatively affect the sexual well-being and deteriorate the quality of their lives. Regenerative/ cosmetic gynecology procedures enable women to treat the functionality issues and modify the physical structure of vagina. This review discusses the latest developments in this field with regards to various kinds of procedures that are available, particularly the use of energy-based devices, and adipose tissue derived stem cells therapy for fat grafting which have revolutionized the regenerative gynecology procedures. These offer non-invasive modalities to treat the conditions like urinary incontinence among others which occur in high prevalence among women. Despite the advancements made in this field, it lacks regulatory guidelines and standardized procedures which imposes one of the biggest challenges of the field. Alongside, we have documented a procedure called Intimacell® which has been standardized for fat grafting procedures in vulvovaginal region.
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Fractionated laser resurfacing with ablative lasers gives better results compared to non‐ablative lasers. Carbon dioxide and erbium: yttrium aluminum garnet lasers are available in two forms: confluent and fractionated. The thermal effect of the CO 2 laser acts on dermal collagen stimulating neocollagenesis and tightening of facial skin. Cosmetic surgeons regularly combine ablative laser resurfacing with other problem‐specific non‐ablative technologies to address multiple cosmetic concerns for the patient in a single treatment session. Physicians have had the ability to perform fractionated CO 2 laser resurfacing since the development of the scanning UltraPulse hand‐piece in 1994. The Active and Deep FX fractionated CO 2 laser delivers a peak power of 240 and 60W, respectively to the tissue. The eCO 2 laser has a variable microbeam delivery speed, skin sensing treatment tips, and user‐friendly treatment interfaces that enable real‐time tracking of microbeam delivery in dynamic mo.
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Acne vulgaris is a chronic inflammatory condition of the pilosebaceous unit. It can be seen as open or closed comedones or both, and as inflammatory lesions – including papules, pustules, or nodules. Scarring, as a physical disfigurement, is a frequent complication of acne. Acne scars have always been challenging to treat. Different factors, for example. color, texture, and morphology, can affect the treatment choice for each individual scar. Microneedling (MN), also known as collagen induction therapy, is a new option for treatment of acne scars. The reported high efficacy, safety, and minimal post‐treatment recovery rates associated with microneedling have increased its popularity among patients and clinicians. Light emitting microneedling device incorporate titanium microneedles. Microneedle delivery systems offer a minimally invasive and painless method of transdermal drug administration. Microneedle radio frequency systems deliver energy directly to the dermis via a number of microneedle electrodes and create a microthermal zone (MTZ), providing untouched areas between MTZs.
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Background Topical adjuncts have been investigated to improve clinical outcomes associated with laser resurfacing for photodamage and cutaneous aging. One such product is a tripeptide/hexapeptide serum, which has been shown to increase dermal collagen and elastin as well as improve postprocedural recovery following treatments. Aims A randomized, blinded, split‐face, comparative trial was performed to assess the utility of a tripeptide/hexapeptide serum as a peri‐procedural adjunct to nonablative fractional laser resurfacing. Patients/Methods A total of 20 subjects were enrolled. Each hemiface was randomized to either tripeptide/hexapeptide serum or bland moisturizer for twice daily application starting 14 days prior to first laser treatment and continuing until 60 days after. All subjects received 2 treatments to entire face approximately 1 month apart with 1927 nm thulium nonablative fractional laser. Clinical measures and immediate postprocedural recovery were assessed. Results For each hemiface, scores improved for all measures, including global photodamage, lentigines, pores, radiance, texture, and tone at 30 and 60 days. The tripeptide/hexapeptide serum had greater improvements for all measures at both time points, except for radiance at 60 days, which was equal. In cases where clinical ratings differed between sides, tripeptide/hexapeptide serum more frequently had the superior outcome. Overall, subjects were satisfied with tripeptide/hexapeptide serum. No significant adverse events were observed. Conclusion Addition of tripeptide/hexapeptide serum as a peri‐procedural adjunct to nonablative fractional laser resurfacing improved various clinical measures of photodamage and cutaneous aging and the immediate postprocedural recovery. The tripeptide/hexapeptide serum was demonstrated to be safe, well‐tolerated, and well‐liked by subjects.
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The erbium:yttrium-aluminium-garnet (Er:YAG) laser has recently been used in the fractional resurfacing of photo-aged skin. Our study evaluated the results after one single session of fractional resurfacing with Er:YAG. Thirty women participated in the study, with an average age of 46years, skin types from II to IV, and wrinkle grades I to III. The 2,940nm Er:YAG system used (Pixel, Alma Laser, Israel) had variable pulse durations (1ms to 2ms) and energy densities (800mJ/cm2 to 1,400mJ/cm2) which, together with the number of passes (four to eight), were selected as a function of wrinkle severity. All patients received only one treatment. Postoperative side effects were evaluated. The number of wrinkles was documented with clinical photography and was scored. Histological assessment was carried out on two patients before and 2 months after treatment. All patients completed the study. Of the patients, 93% reported good or very good improvement of the degree of their wrinkles, with a satisfaction index of 83%. Pain was not a problem during treatment, and there were no side effects except for in one phototypeIV patient, who had hyperpigmentation. Histology 2months after the single treatment demonstrated younger morphology of both the epidermis and dermis, with improvement of the pretreatment typical elastotic appearance. At the parameters used in our study, only one treatment session of Er:YAG laser could achieve effective skin rejuvenation, with effects recognized in both the dermis and, more importantly, the epidermis. This regimen offers an interesting alternative to the conventional approach of multi-session fractional resurfacing.
Article
Background: Actinic keratoses (AK) are precancerous epidermal proliferations commonly present on chronically sun-damaged skin. These lesions are among the most often treated dermatologic conditions. Objective: We sought to investigate the 6-month safety, tolerance, and efficacy of nonablative 1927-nm fractional resurfacing of facial AK. Methods: This was a prospective clinical trial of 24 individuals with facial photodamage and AK receiving up to 4 treatments with the fractionated 1927-nm nonablative thulium laser. Results: At 6 months, an 86.6% reduction in absolute number of lesions was noted by independent physician assessment. In addition, at this same time point, patients reported marked or noticeable improvement in overall photodamage. Limitations: This prospective study does not provide safety, tolerance, and efficacy data beyond 6 months of follow-up, nor does it identify the precise mechanism of action involved in AK clearance after 1927-nm resurfacing. Conclusion: The clinical and histologic findings, as well as the reported patient satisfaction and safety, suggest that the treatment of AK and photodamage with a fractionated 1927-nm nonablative thulium laser is a promising new therapeutic option.
Article
Background Melasma is a uichronic, often relapsing skin disorder, with poor long-term results from all current therapies.Objective To assess efficacy and safety of non-ablative 1,550 nm fractional laser therapy (FLT) as compared to the gold standard, triple topical therapy (TTT).Study designTwenty-nine patients with melasma were included in a randomized controlled observer-blinded study with split-face design. Each side of the face was randomly allocated to either 4–5 non-ablative FLT sessions (15 mJ/microbeam, 14–20% coverage) or TTT (hydroquinone 5%, tretinoin 0.05%, triamcinolone acetonide 0.1% cream). TTT was applied once daily for 15 weeks until the last FLT session. After this last treatment, patients were asked to apply TTT twice weekly on both sides of the face during follow-up. Improvement of melasma was assessed by patient's global assessment (PGA), patient's satisfaction, physician's global assessment (PhGA), melanin index, and lightness (L-value) at 3 weeks, and at 3 and 6 months after the last treatment.ResultsMean PGA and satisfaction were significantly lower at the FLT side (P<0.001). PhGA, melanin index, and L-value showed a significant worsening of hyperpigmentation at the FLT side. At the TTT side, no significant change was observed. At 6 months follow-up, most patients preferred TTT. Side effects of FLT were erythema, burning sensation, edema, and pain. Nine patients (31%) developed PIH after two or more laser sessions. Side effects of TTT were erythema, burning sensation, and scaling.Conclusions Given the high rate of postinflammatory hyperpigmentation, non-ablative 1,550 nm fractional laser at 15 mJ/microbeam is not recommendable in the treatment of melasma. TTT remains the gold standard treatment. Lasers Surg. Med. 42:607–612, 2010. © 2010 Wiley-Liss, Inc.
Article
Background and objectives: Fractional ablation offers the potential benefits of full-surface ablative skin resurfacing while minimizing adverse effects. The purpose of this study was to evaluate the safety, damage profile, and efficacy of erbium fractional lasers. Materials and methods: Histology from animal and human skin as well as clinical evaluations were conducted with erbium YAG (2,940 nm) and erbium YSGG (2,790 nm) fractional lasers varying pulse width, microbeam (microb) energy, number of passes, and stacking of pulses. Results: Single-pulse treatment parameters from 1 to 12 mJ per 50-70 microm diameter microbeam and 0.25-5 milliseconds pulse widths produced microcolumns of ablation with border coagulation of up to 100 microm width and 450 microm depth. Stacking of pulses generated deeper microcolumns. Clinical observations and in vivo histology demonstrate rapid re-epithelization and limited adverse side effects. Facial treatments were performed in the periorbital and perioral areas using 1-8 passes of single and stacked pulses. Treatments were well-tolerated and subjects could resume their normal routine in 4 days. A statistically significant reduction in wrinkle scores at 3 months was observed for both periorbital and perioral wrinkles using blinded grading. For periorbital treatments of four passes or more, over 90% had > or =1 score wrinkle reduction (0-9 scale) and 42% had > or =2. For perioral wrinkles, over 50% had substantial improvements (> or =2). Conclusion: The clinical observations and histology findings demonstrate that micro-fractional ablative treatment with 2,790 and 2,940 nm erbium lasers resulted in safe and effective wrinkle reduction with minimal patient downtime. The depth and width of the ablated microcolumns and varying extent of surrounding coagulation can be controlled and used to design new treatment procedures targeted for specific indications and areas such as moderate to severe rhytides and photodamaged skin.
Article
Background and Objectives Ablative fractional resurfacing shows promise for skin resurfacing and tightening and also to improve treatment of epidermal and dermal pigmentary disorders. This study aimed at determining any correlation between epidermal ablation and effects on the dermis when using an Er:YAG laser in ablative fractional resurfacing mode.Materials and Methods Ten female subjects participated in the study, mean age 52 years, Skin phototypes: 1 Fitzpatrick type II; 8 type III and 1 type IV. The degree of wrinkles (Glogau scale II or III) was similar in all cases. The laser used was the Pixel Er:YAG system (Alma Laser™, Israel) which delivers the laser beam via a hand-piece equipped with a beam splitter to divide the 2,940 nm beam into various microbeams of 850 µm in diameter in an 11 mm×11 mm treatment area. Using a constant energy of 1,400 mJ/cm2, on a test area of 4 cm×2 cm. Two, 4, 6, and 8 passes on the preauricular area of the face were evaluated immediately after treatment. In all cases, the handpiece was kept in the same position, and rotated slightly around its perpendicular axis between passes, then moved on to the next spot. Biopsies were performed and tissue samples were routinely processed and stained with hematoxylin and eosin (H&E).ResultsNo patient reported any noticeable discomfort, even at 8 passes. The histological findings revealed that, independent of the degree of the wrinkles, more laser passes produced more ablative removal of the epidermis. Residual thermal damage (RTD) with 2 laser passes was not observed but with 4 and 6 passes increased thermal effects and vacuole formation in the epidermal cells were noticed. With 8 laser passes, total epidermal removal was seen together with frank RTD-related changes in the upper part of the papillary dermis.Conclusion In this study, we have demonstrated that high density fractional Er:YAG laser energy in a single session with multiple passes targeted not only the skin surface with elimination of the epidermis, but could also achieve heat deposition in the upper dermis. When performing ablative fractional resurfacing with an Er:YAG laser, treatment of varying degrees of damage could be achieved by varying the number of passes. Laser Surg. Med. 40:174–177, 2008. © 2008 Wiley-Liss, Inc.
Article
Until now, nonablative fractional treatments could only be delivered in an office setting by trained professionals. The goal of this work was to perform clinical testing of a nonablative fractional laser device designed for home-use. This multicenter trial consisted of two clinical studies with slightly varying treatment protocols in which subjects performed at-home treatments of periorbital wrinkles using a handheld nonablative fractional laser. Both studies included an active treatment phase (daily treatments) and a maintenance phase (twice-weekly treatments). In all, 36 subjects were followed up for as long as 5 months after completion of the maintenance phase and 90 subjects were followed up until the completion of the maintenance phase. Evaluations included in-person investigator assessment, independent blinded review of high-resolution images using the Fitzpatrick Wrinkle Scale, and subject self-assessment. All 124 subjects who completed the study were able to use the device following written instructions for use. Treatments were well tolerated with good protocol compliance. Independent blinded evaluations by a panel of physicians showed Fitzpatrick Wrinkle Scale score improvement by one or more grades in 90% of subjects at the completion of the active phase and in 79% of subjects at the completion of the maintenance phase. The most prevalent side effect was transient posttreatment erythema. Lack of a control group and single-blinded study groups were limitations. Safety testing with self-applications by users demonstrated the utility of the device for home use. Independent blinded review of clinical images confirmed the device's proficiency for improving periorbital wrinkles.
Article
Over the past several years, a number of home-use laser and light skin devices have been introduced for various indications, including photorejuvenation, hair growth, hair removal and acne treatment. Although these devices allow for privacy and a significant cost advantage, they are typically underpowered and afford lower efficacy than their in-office counterparts. A number of these devices have recently received FDA clearance. Although large clinical trials are lacking, dermatologists should familiarize themselves with the various options to help patients assess their clinical value.
Article
Background: Acneiform scarring after severe episodes of acne is a common cosmetic concern, treatable by a variety of modalities with varying degrees of success. Ablative CO(2) laser resurfacing, while effective, is associated with an undesirable side effects profile, lengthy recovery period, and risk of infection as well as potential pigmentary alterations. Newer modalities using the principles of fractional photothermolysis (FP) create patterns of tiny microscopic wounds surrounded by undamaged tissue beneath the skin with an erbium-doped 1,550 nm laser. These devices produce more modest results in many cases than traditional carbon dioxide (CO(2)) lasers but with fewer side effects and shorter recovery periods. A novel ablative 30 W CO(2) laser device uses a technique called ablative fractional resurfacing (AFR), combines CO(2) ablation with a FP system. Methods: Thirteen subjects (skin types I-IV, aged 28-58 years) with moderate to severe acne scars underwent two or three treatments with the AFR device at 1-2 months intervals. Post-treatment erythema and edema as well as improvements in texture, atrophy, and overall satisfaction with appearance were graded on a quartile scale by subjects and investigators after each treatment and 1 and 3 months after the final treatment. Petechiae, oozing and crusting, dyschromia, and scarring were graded as present or absent 3 days, 1 week, 1 month, and 3 months following each treatment. A three-dimensional optical profiling system (Primos imaging) was used to generate a high resolution topographic representation of the acneiform scar in order to measure the depths of 10 scars from each cheek prior to the first treatment and 3 months after the last treatment. Results: Post-treatment side effects were mild to moderate and transient, resolving rapidly within the study period. No delayed onset hypo-pigmentation or permanent scarring was observed. Quartile grading scores correlating to at least 26-50% improvements in texture, atrophy, and overall improvement were noted in all patients. Primos topographic analysis showed that all patients had quantifiable objective improvement in the depths of acneiform scars that ranged from 43% to 79.9% with a mean level of improvement of 66.8%. Conclusion: Successfully combining ablative technology with FP, AFR treatments constitute a safe and effective treatment modality for acneiform scarring.
Article
Q-switched lasers are the gold standard for tattoo treatment. Allergic tattoo reactions present a treatment dilemma. We present the application of ablative fractional resurfacing (AFR) as a novel method for tattoo removal. We describe two patients with tattoo allergies, referred to us for treatment. AFR was used in a series of treatments to remove the allergic-ink portion of a multicolored tattoo on the upper extremity of a 52-year-old man. In a 31-year-old woman with a red and black tattoo on her lower extremity, AFR was combined with a Q-switched neodymium:yttrium-aluminum-garnet laser. After a series of treatments, both patients experienced significant to complete removal of the offending tattoo inks with substantial or complete resolution of their symptoms. This uncontrolled observational series is based on two patients. AFR appears to be safe and effective for removal of allergic tattoos. AFR can be combined with other treatments such as Q-switched lasers. The potential for a series of AFR treatments to remove tattoos, including allergic tattoos and inks of any color, merits further study.