A dissapointing conclusion was made from a recent study:
Treatment of Melasma Using Variable Square Pulse Er: YAG Laser Resurfacing
Authors: WANITPHAKDEEDECHA, RUNGSIMA1; MANUSKIATTI, WORAPHONG1; SIRIPHUKPONG, SUJITTRA1; CHEN, T. MINSUE2
Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; 2: Department of Dermatology, MD Anderson Cancer Center, University of Texas, Houston, Texas
Source: Dermatologic Surgery, Volume 35, Number 3, March 2009 , pp. 475-482(8)

Treatment of melasma remains a challenge for dermatologic surgeons. Laser treatments show limited efficacy, with a high rate of recurrence and side effects. Variable-pulsed erbium:yttrium aluminum garnet (Er:YAG) lasers have shown favorable results in skin resurfacing, with minimal downtime and limited adverse effects.

Twenty Thai women with epidermal-type melasma were treated with two passes of variable square pulsed (VSP) Er:YAG laser resurfacing using a 7-mm spot size, pulse duration of 300 μs, and a fluence of 0.4 J/cm2. Two treatments were given 1 month apart. Visual analog scale (VAS), Melasma Area and Severity Index (MASI) score and melanin index (MI) were measured at baseline and 1, 2, and 4 months after treatment.

There was a significant improvement in VAS from baseline at 1-, 2-, and 4-month follow-up visits (p<.001). Significant improvement in MASI score at the 2-month visit from baseline (p=.004) was also observed. The average MI measured using melanin reflectance spectrometry measurements corresponded to MASI score rating.

CONCLUSIONS

VSP Er:YAG laser resurfacing effectively but temporarily improved epidermal-type melasma. Recurrence was observed after the treatment was discontinued.

We continue the coverage of the laser skin resurfacing as new data comes in and novel techniques are revealed in this rapidly growing field of cosmetic surgery.

Laser resurfacing, and in particular mild or gentle laser peel, is soaring in popularity as men and women seek quality clinics to get their wrinkles smoothed out. Over the past three years, the number of procedures has increased 456 percent among men and 215 percent among women, according to the statistical report recently published by the American Academy of Cosmetic Surgery. Publications by similar national groups confirm the dramatic growth in the number of procedures and physicians’ fees.

Laser resurfacing is performed by laser beam pulses from a carbon dioxide (CO2) or erbium (Er:YAG) laser to vaporize water molecules from the skin. The controlled damage stimulates the regrowth of new healthy skin tissue, which helps minimize wrinkles and lines. In the last couple of years fractional lasers, which produce microscopic beams in a pre-set pattern, have been upgraded by using the ablative CO2 or Er:YAG wavelengths to join the ranks of skin resurfacing lasers.

Laser peels produce very good aesthetic results at an affordable price, and seem to be more recession proof than most cosmetic surgery procedures.

Wrinkles and sagging skin are caused by a structural breakdown of connective tissue made up of proteins within the epidermis and dermis. These proteins, of which collagen is the main one, are produced from cells called fibroblasts. A fibroblast is a type of cell that synthesizes the extracellular matrix and collagen (and fibrin), the structural framework (stroma) for skin tissue.

Fibroblasts and fibrocytes are two states of the same cells, the former being the activated state, the latter the less active state, concerned with maintenance. Currently, there is a tendency to call both forms fibroblasts. The main function of fibroblasts is to maintain the structural integrity of connective tissues.

As skin ages, fibroblasts collapse and there is an increase in the production of collagenase, which breaks down collagen. For example, people in their 80s have four times more broken collagen than people in their 20s. This “dissolving” of the skin can be interrupted, or else the aging skin is just going downhill.

Our understanding of possible ways and means of the “interruption” is improving quite rapidly. Laser treatments effectively counteract the breakdown of fibroblasts by stimulating the growth of new collagen and subsequently the connective tissue.

Recent studies show that some cosmetic surgeries, such as silicone injections to the face and liposuction to remove fat (and lots of other stuff), may provide acceptable short-lived results but could be destructive and ultimately far less effective than most people expect. Bad side effects are not uncommon.

More and more studies suggest that laser skin resurfacing is the most effective, safe and long-term “interruption”. Voorhees and colleagues, in reviewing dozens of studies done since the early 1990s, found three types of treatments to be effective: topical retinoic acid, laser resurfacing and injections of cross-linked hyaluronic acid. “These treatments all improve the skin’s appearance — and its ability to resist bruises and tears — by stimulating new collagen,” the researchers wrote in the Archives of Dermatology. The work was funded by the university and the National Institutes of Health. “We have shown that if you make more collagen go in, it provides an environment in which fibroblasts recover and make more collagen,” Voorhees said.

Is it safe? Is it painful?

As it is the case with all aesthetic treatments, comfort, safety and effectiveness are determined by the provider, not the technology. Recent advances in aesthetic lasers have made them safe and very effective. The operator is ultimately responsible for the rest.

In conclusion, here is what the FDA has to say about laser resurfacing of wrinkles:

“Several manufacturers have received FDA clearance to claim treatment of wrinkles, while others may claim skin resurfacing. Patients have reported reddening of the skin, which lasted from one to four months. Pain was mild and could be treated with over-the-counter analgesics. Consumers should bear in mind that skin abrasion, whether achieved by lasers, chemicals or abrasive materials, means removing one or more layers of skin, which can be painful and could cause redness, swelling or scarring, depending on how each person heals.”

Fractional skin resurfacing technologies like Fraxel, Lumenis ActiveFX, DeepFX, Palomar Starlux 1540 and Starlux 2940, and are quickly becoming familiar to many cosmetic, dermatology, plastic surgery and medical spa practices.

The history of laser skin resurfacing goes back to 1995, when the first full face CO2 laser resurfacing for wrinkle removal was performed. The procedure was a revolution in facial laser surgery. A flock of lasers were developed primarily for plastic surgeons. The procedure was done under general anesthesia and created a burn wound, which took 7-10 months to heal. The hypo pigmentation that followed for about another 10-12 months was normal and fairly well accepted for a few years due to lack of other options.

The next advance in laser skin resurfacing was the development of Erbium (Er:YAG) lasers. They became available to plastic and dermatology surgeons around the year 2000. These were, and continue to be very effective for the resurfacing. Erbium lasers are a lot safer and cause a significantly reduced downtime for the patient. At about the same time fewer patients wanted to have a full face resurfaced as a nicely done areas around the eyes and mouth created a very comparable overall aesthetic result with even faster healing and shorter downtime. A mild laser peel will give most patients an excellent result with about one week of “take it easy” time.

Fractional laserswere introduced to the aesthetic market in 2002-2003 with a big bang and glitzy and very effective promotions by Reliant, which pioneered the fractional photothermolysis. The idea was to bring about a laser that would be non-ablative,  but as effective as the ablative lasers (the CO2 and Erbium) before it.

Fraxel laser by Reliant was the first non-ablative fractional laser for the cosmetic medical market and it gave birth to the first generation of non-ablative fractional lasers. While there were a lot of hype about these non-ablative fractional lasers, the clinical fact is that they had categorically fallen short of the goal of ‘profound results with zero downtime.’ As we have seen with these devices, patients had to tolerate painful treatment in multiple sessions while still enduring disruption of the epidermis and thus multiple episodes of downtime, before the final outcome, which also failed to meet expectations. Fraxel has been upgraded and improved by a number of other competing fractional laser skin resurfacing technologies such as the Lumenis DeepFX and ActiveFX, Palomar Starlux 1540, and Starlux 2940. The newest fractional skin resurfacing technologies employ the use of erbium lasers and may be non-ablative (Fraxel re:fine, Fraxel re:store, Palomar Starlux 1540) or ablative (the newest generation of fractional lasers). The laser beam is ‘fractionated’ into tiny micro-lasers, treating only a small portion of the skin (MTZ – microthermal zone, or sometimes called microscopic treatment zones) and leaving surrounding skin tissue undamaged. The goal is to speed up the healing.   These MTZs cause enough injury to the dermis to trigger new collagen production and stimulate the replacement of collagen damaged by aging and sun exposure. This production of new collagen ‘fills in’ or ‘plumps’ the underlying dermal tissues and smoothes wrinkles. The surrounding, untreated skin speeds the healing process to a mere 3-4 days. Since most of the pigment cells remain intact, hypo pigmentation is effectively prevented. The Fraxel re:fine, Fraxel re:store and Palomar Starlux 1540 are non-ablative lasers that don’t actually vaporize or remove the skin. Instead, the laser instantly heats MTZs, causes the thermal damage, which stimulates new collagen growth during the healing process. Results for wrinkle removal and skin tightening are less dramatic than with any ablative lasers, but some patients may appreciate the benefit of reduced recovery time and fewer side effects.

Fractional Ablative Laser Resurfacing

The newest generation of fractional lasers (Starlux 2940, Lumenis ActiveFX and DeepFx systems and Fraxel re:pair) use the ablative skin resurfacing, i.e. CO2 10600 nm or Erbium 2940 nm. They are designed to offer the best of both worlds: fractional treatments with less downtime and reduced complications and ablative laser skin resurfacing for better wrinkle removal and facial rejuvenation. These lasers actually remove tissue in the micro treatment zones, providing much better cosmetic result for patients with heavily wrinkled and sun damaged skin. These lasers provide “rapid remodeling from the inside out”: the fractional treatment results in both rapid reepitheliazation of the epidermis as well as collagen remodeling to depths of 1.6 mm. The skin heals much faster than if the entire area were treated at once, because the treatment uses the body’s natural healing process to create new, healthy tissue that replaces skin imperfections – such as wrinkles, melasma, dyschromia, actinic ketatosis, pigmented lesions, acne scars and surgical scars.

Fractional treatment works on and off the face, including delicate areas like the neck, chest and hands. This is a huge advantage over previous generations of ablative lasers, which required a truly skilled hand to work on these areas.

There is some increase in recovery time:  clinical downtime of 2-3 days (reepitheliazation of epidermis) and 5-7 days of social downtime (time for patients to resume regular activities). Thus the overall downtime is comparable to the downtime after a traditional non-fractional erbium ablative laser treatment.

LaserOffers.com comment

Leaving the laser skin resurfacing by pulsed non-fractionated CO2 lasers in the past (where it belongs now), most experts agree that the newest generation of fractional lasers, which uses ablative technologies (Erbium or CO2), have approached the clinical efficacy achieved by traditional Erbium resurfacing. The pain for the patient, downtime and potential side effects are comparable. It is up to the physician to define what patient will benefit more from the subtle difference between these lasers. In time when value and ROI are particularly important, the cost of acquisition of either type of the ablative laser will be the best helpers to the physician.