By Lois W. Stern I know exactly what you want, because I want it too: skin treatments that are less invasive, with little downtime, minimal risk and excellent, long lasting results! But this is not just a consumer ‘Wish List’. Plastic surgeons and dermatologists want to deliver skin treatments that meet those very same criteria. Popular interest in these magical ‘quick fixes’ is so huge that when Fraxel Re:pair recently debuted on the Today Show, the parent company, Reliant, had 20,000 hits on its website in 90 minutes, causing it to shut down. Given such strong public interest, Reliant was invited back on the Today Show a week later to further demonstrate its Fraxel lasers, and again their website was besieged by a deluge of visitors. Will this new breed of lasers take the place of surgical facelifts? Will they ultimately give us similar, yet kinder, gentler results than the ablative resurfacing techniques of decades past? Several manufacturers are scrambling to answer the call. Dr. Lawrence Bass, Clinical Assistant Professor of Plastic Surgery and Director of the Minimally Invasive Plastic Surgery Program at New York University Medical Center, has generously given of his time and expertise, to educate me about what is happening in the field of lasers. In this article, Lasers - Part 1, I will share what I have learned about the development of laser technology. The basic concept behind all laser technologies is the same: wound and heal. One must wound the skin to remove old surface tissue, which in turn stimulates the growth of new collagen. Stratum Corneum (the outermost surface of the Epidermis)  Remodeling is one of our twenty-first century buzzwords. You might have noticed some home remodeling taking place within your neighborhood, but skin remodeling is just as popular. The difference is that this latter type remodeling works to rejuvenate the skin covering our bodies, rather than altering interior or exterior features of our homes. “When we speak of remodeling for wrinkle treatments, we are targeting treatment within the mid-dermis. For skin-tightening devices (Titan, Thermage), we are targeting the deep dermis at the dermal/subcutaneous junction,” explains Dr. Bass, who continued by providing me with a little history on the development of lasers. The era of ablative resurfacing lasers began with Carbon dioxide lasers (CO2), which worked by vaporizing wrinkles and/or acne scars, while evening out hills and valleys on the surface of the skin. Old, damaged tissue was removed and new tissue remodeled. In other words, as these laser wounds began to heal, they stimulated the growth of new collagen through that process of wound healing, which is normally followed by the stimulation and growth of new collagen. Clinical results were excellent and surgeons found that these Carbon dioxide lasers provided more precision in depth control than the earlier method of chemical peels. The down side to these lasers was their lengthy recovery for the patient, who was left with a raw surface that healed slowly over a period of 10-14 days. Additionally, the skin remained red for 3-6 months or longer with a good risk of pigment disturbances, especially for those with darker complexions. A second option was/is Erbium:YAG ablative resurfacing. It showed remodeling improvement in some respects, but generally showed a little less improvement than CO2 resurfacing. Er:YAG healing typically takes 5-7 days with about one month of redness for a mid-intensity peel. An aggressive peel can approach the recovery time of a CO2 peel. A very light peel can heal in 3 days with about 5 days of redness. The Er:YAG is still used, especially by surgeons to resurface at the same time they are doing a facelift or eyelidplasty, as the patient can heal from resurfacing while recovering from the surgery. But today, stand alone wrinkle treatments have largely been replaced by fractional treatments. A number of nonablative remodeling treatments arrived on the scene to try to avoid creating open wounds, lengthy recovery periods and the possible pigment discolorations associated with the above devices. Cooltouch, designed to produce tissue remodeling by heating mid layers of skin while keeping the skin surface intact, was one such example. But clinical response showed minimal and unpredictable results with treatments yielding no tissue removal and inconsistent amounts of skin remodeling. The big advantage was no recovery time and no real risk of pigment problem. But multiple treatments (an average of 4) were required and results were much less effective than those achieved through ablative laser resurfacing. The big disadvantage was “no pain, no gain”. Enter: Fractional Lasers When a new breed of lasers began to emerge, we needed a way to distinguish the earlier CO2 and Yag Erbium methods described above from the fractional ones that that have since begun to emerge. Dr. Lawrence Bass explains further: “We need to rename these older resurfacing treatments ‘field resurfacing’, meaning that the entire field in which the wrinkles are contained is resurfaced. In contrast, ‘fractional ablative resurfacing’ and ‘fractional non-ablative resurfacing’ are the newer options in which only individual non-confluent spots of skin are exposed within the same field.” New lasers are appearing on the market, claiming to produce the results of older ablative “field” lasers, but with minimal downtime. First on the scene were nonablative fractional lasers. During treatment, the fractional laser penetrates the non-living protective barrier of the skin, the stratum corneum, as if it were a window, leaving it completely intact. It then creates microscopic "wounds" within the targeted areas well beneath the outermost epidermal layer of skin. Both epidermal and dermal tissue are removed. In so doing, it triggers the body's natural healing process to accelerate the production of collagen and new, healthier skin cells. To best understand how fractional lasers work, you need to think of your skin as a digital photograph in need of restoration or touch up. Just as you can alter a photographic image pixel by pixel, fractional lasers treat your skin with thousands of tiny microscopic laser spots. During treatment, these thousands of columns penetrate deeply into the dermis. What distinguishes fractional lasers is their ability to leave untouched specific skin areas while treating others. By creating microscopic treatment zones, the laser affects only a fraction of your skin at a time. For every microscopic zone the laser targets and treats intensively, it leaves the surrounding tissue unaffected and intact. This "fractional" treatment allows the skin to heal much faster than if the entire area were treated at once. Like other laser treatments, it wounds the skin and then uses the body's natural healing process to create new, healthier, tighter tissue to replace the imperfections of the older skin. Because nonablative fractional treatments spare healthy tissue, they are effective even on delicate skin areas, such as the neck, chest and hands. Nonetheless, results are still less effective than those achieved through ablative laser resurfacing. Fraxel;Restore, one popular nonablative fractional treatment should not be confused with Fraxel Re:Pair, an ablative fractional system described below. This system yields more predictable tissue removal with better results than the earlier non-ablative treatments such as Cooltouch. There is minimal risk of pigment problems, no raw wound, and minimal recovery time, but multiple treatments are required (4 sessions on average normally spaced about 2 to 4 weeks apart). Although results are immediate and progressive, with optimal improvement usually visible in about 2 to 3 months, the results obtained by fractional non-ablative treatments are generally less dramatic than those obtained by ablative laser resurfacing techniques. What to Expect During Treatment: As a first step, the treatment area is thoroughly washed. This is followed by a topical anesthetic ointment applied approximately 60 minutes prior to treatment in order to give the anesthetic time to take full effect. The actual treatment for a full face takes between 20 to 25 minutes. Most patients describe the treatment sensation as having a "prickling" feel. An air cooling system and topical anesthetic ointment alleviates most discomfort. After treatment, the anesthetic ointment is washed off and a deep hydration mask applied to your skin, possibly followed by other topical skin products as antioxidants and moisturizer. What to Expect Post-Treatment: A mild sunburn sensation normally is experienced for about an hour after treatment, with minimal discomfort thereafter. The skin will have a pinkish tone for about 3 to 5 days, a normal sign that the skin is healing. Just like a natural sunburn, the skin will bronze over the next week or two and will flake and exfoliate normally. Using a moisturizer will help reduce the appearance of dry flakes. Swelling is minimal and generally resolves in 2 to 3 days. You may apply make-up or shave soon after treatment. Some patients return to routine activities, including work and social obligations, the same day. Others require a little more time, depending upon their skin condition and treatment. New epidermal skin develops within 24 hours. The process of skin repair involves: · Bronzing: Your skin might have a bronze appearance that lasts anywhere from 3 to 14 days, depending on your treatment level. · Flaking: Your skin will naturally and vigorously exfoliate as new skin replaces dead tissue. Flaking is similar to that of minor sunburn, but without the associated pain. Use of a moisturizer will mask the appearance of flaking. Over the following weeks and months, the body continues to repair the deeper dermal tissues that have been affected by treatment, with increasingly beneficial results. Dr. Bass adds his personal oobservations based on his extensive experiences with Fraxel: "Some patients experience almost no bronzing or flaking or only for 3 days or so. Others will notice a more pronounced presence of these findings. Necks in particular and very aggressive treatments may take 1-2 weeks to clear off.” Post Treatment Precautions: Apply a moisturizing sun block with an SPF of 30 or higher twice a day without fail. Avoid direct sun exposure during the healing process and for at least 3 months after treatment. Wear wide brimmed hats outside for further shielding from the outdoor elements and especially when in direct sunlight. “While it is generally recommended to wear sunscreen and minimize sun exposure, there doesn’t seem to be any great sensitivity to the sun or need for special precautions. For example, I routinely perform Fraxel Re;store all summer long, (except for the hyperpigmentation prone patient), I suspend certain other laser treatments like Er:Yag for the summer months,” explains Dr. Bass. The fractional laser treatments we have been discussing above are non-ablative. Next month I will be discussing the more aggressive fractional ablative laser treatments, and what you can expect from them in terms of downtime and results. So tune in for more. © 2008 by Lois W. Stern You have my permission to reprint this article in part or full providing it contains the following attribution: Lois W. Stern is the author of Sex, Lies and Cosmetic Surgery, (Infinity, 2006), soon to be republished in a revised edition with a CD enclosure. Lois invites prospective cosmetic surgery patients, physicians, and media to visit her website to read other articles, sign up for her monthly newsletter, or purchase autographed copies of her book. Click here. Then use the navigation bar at the top of the screen. Lois enjoys hearing from her readers and will actually respond. Send a message: cosmeticsurgery@optonline.net |