Sandy Tsao, MD
There is a lot of information out there and our patients are coming to us with questions about the various devices. Remember, there isn’t one clear-cut way to manage your patients.
What’s the rationale for fractional resurfacing?
- Safer for non-facial areas; beard area
- Safer for darker skin phonotypes
- Efficacy greater compared with other non-ablative technologies
- Safer side effect profile c/w ablative devices
- Recovery time markedly reduced
- No permanent lines of demarcation to date
- Non-ablative and ablative devices
There are a variety of fractional technologies for rejuvenation currently available to the practicing dermatologist.
The Goal of Thermal Injury
Thermal injury is thought to be key for tissue repair. Heat-induced inflammation results in immediate collagen shrinkage and tissue contraction and subsequent fibroblast stimulation. There is a zone of irreversible thermal damage and associated inflammation must heal before re-epithelialization begins. Prolonged inflammation due to infection, hypersensitivity, or extensive thermal damage due to vigorous treatment can result in complications.
How does fractional resurfacing work?
- One pulse produces one MTZ
- Thermally induced coagulation, not vaporization
- Columnar shape
- Diameters are variable
- 1:5 width to depth ratio
- 5-48% total skin coverage – each treatment
It is important to remember to match treatment depth with the indication.
Pigment-Superficial to mid dermis
Mild rhytids- Mid reticular dermis
Moderate rhytids – Deep reticular dermis
Surgical scars and acne scars- Deep remodeling
Fractional non-ablative laser treatment in a cross section of human tissue demonstrated complete re-epithelialization within 24 hours. There was clear collagen denaturation from the papillary dermis into the mid reticular dermis. Healing occurs from viable tissues. Zones of spared tissue contain clusters of epidermal stem cells and Transit Amplifying (TA) cells.
Ablative Fractional Resurfacing
These work like the nonablative devices; however, you lose the epidermis.
- Ablative tissue coagulation with loss of stratum corneum
- Multiple microthermal zones of injury surrounded by viable tissue
- Resurfacing with replacement of skin in 5-7 days
- More thermal damage with longer healing time
- Immediate and delayed therapeutic benefits greater
- Epidermal and dermal coagulation for resurfacing
- Collagen denaturation for tissue remodeling
The downside to laser treatment can be the downtime associated with the procedures and patients should be aware of this. Estimated downtimes are:
Microlaser peel– 7 days peeling, 2 weeks of a pink hue
1410nm- 1 day of mild erythema and edema
1550nm- 2-3 days of erythema and edema
1927nm- 4-5 days of erythema and edema
2940nm- 7 days of erythema and edema. 2 weeks of pink hue
Fractionated ablative– 7 days of erythema and edema; 4-6 weeks of pink hue
Ablative– 14 days of erythema and edema; 2-3 months of pink hue
Laser Treatment of the Periorbital Region
When treating around the eyes with laser therapy, less aggressive treatment is needed. When treating the lids, a metal protective lens is necessary. For lens placement, use alcaine anesthesia and erythromycin. Be sure to use particular caution in patients with prior surgical history.
Darker Skin Types
- Less is more (Fluence, density, passes)
- Consider a laser test site
- Stress the need for strict photoprotection
- Discuss the increased risk of PIH
- Consider pre-treatment use of retin-a or hydroquinones
- Use caution with ablative fractional devices
Charities and Laser Treatment
Michael Gold, MD
There are many charities throughout the world that are providing laser treatment for scars due to injuries and/or accidents to those who cannot afford the treatment.
The Wounded Warrior Project, here in the United States, is providing laser treatment to our wounded troops. This effort is really helping to improve the quality of life of veterans.