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Arch Facial Plast Surg. 2005 Jul-Aug;7(4):251-5

Authors: Carniol PJ, Vynatheya J, Carniol E

OBJECTIVE: To evaluate the efficacy of treatment of established acne scars with a sequential combination of treatment using a 1450-nm, midinfrared, nonablative diode laser with dynamic cooling spray and 30% trichloroacetic acid peels.

METHODS: In this prospective study 9 patients with atrophic rolling, boxcar, or both types of scars received 4 monthly treatments using a 1450-nm, midinfrared, nonablative, diode laser with dynamic cooling spray followed by 2 bimonthly treatments with 30% trichloroacetic acid peels. Blinded evaluators and the patients rated the results.

RESULTS: The group of patients in this study had a greater improvement in their acne scars than has been reported for nonablative laser treatments by other authors. Comparing the results of treatment 2 months after the laser treatments with 2 months after the chemical peels, the patients had a greater improvement after the additional chemical peels. There were no complications in this study. The patients were able to continue all of their regular activities throughout the study.

CONCLUSION: This sequential treatment regimen using the 1450-nm, midinfrared, nonablative diode laser with dynamic cooling spray and 30% trichloroacetic acid peels produced a noticeable improvement in the acne scars without any associated morbidity.

PMID: 16027346 [PubMed - indexed for MEDLINE]

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  • Filed under: Device Review, LT | acne, LT | combination
  • Acne Scar Resurfacing Techniques

    This is a short review of a new study by a group of Indian reserchers:
    Kubba R, Bajaj AK, Thappa DM, Sharma R, Vedamurthy M, Dhar S, Criton S, Fernandez R, Kanwar AJ, Khopkar U, Kohli M, Kuriyipe VP, Lahiri K, Madnani N, Parikh D, Pujara S, Rajababu KK, Sacchidanand S, Sharma VK, Thomas J. Acne in India: Guidelines for management – IAA Consensus Document: Acne scars. Indian J Dermatol Venereol Leprol 2009;75(Suppl 1):S52-S3. Available from: http://www.ijdvl.com/text.asp?2009/75/7/52/45487 .

    LaserOffers.com reviewed the part of the study that directly pertains to our focus on the use of lasers.

    Acne scars are classified as atrophic and hypertrophic. Atrophic acne scars are further classified as ice-pick, rolling, and boxcar. The European acne group (ECCA) has renamed the atrophic acne scars as V-shaped (ice-pick), U-shaped (boxcar), and W-shaped (rolling). Scar characteristics can be further assessed with specialized techniques such as silicon elastomer mold which is then examined under a light microscope. Proper classification of acne scars is essential to assess the severity of cosmetic disfigurement and to choose the appropriate therapeutic intervention.

    Resurfacing techniques

    These include TCA peeling, phenol peeling, microdermabrasion, laser abrasion, selective thermolysis with Fraxel laser, and resurfacing by radiofrequency and electrosurgery.

    The objective of any of the skin/scar resurfacing treatments is to restore skin contour by inducing neocollagenosis (new collagen growth). Resurfacing is indicated in U and W scars. The main complication is erythema which persists for weeks. There is also risk of pigmentation.

    Spot TCA peeling is a good technique for V and deep U scars. A sharp stick (toothpick) soaked in 62% or 100% TCA is brought in contact with the target and the contact is maintained till whitening appears. It is a painful procedure and multiple sessions are required.

    Microdermabrasion involves planing of the skin by mechanized means utilizing the projection of micromarbles consisting of aluminum oxide on scars. Six to seven sessions, at two week intervals are needed. In one session, twenty passes are made on each area until superficial bleeding appears. Six to seven session microdermabrasion has low efficacy and may be useful in superficial U scars. Chemabrasion is when microdermabrasion is combined with a peeling agent.

    Lasers are increasingly being used to treat acne scars. Intense Pulse Light (IPL) acts by heating the dermis and stimulating neocollagenosis. It has weak activity and may be helpful in red, hypertrophic scars. Light-Emitting Diode (LED) does not warm but acts by photomodulation. It is a safe and painless procedure but the efficacy is low. It is being used for superficial U scars, erythema (acne macules), and pigmentation. Ablative laser resurfacing, although effective, is associated with excessive tissue reaction as erythema and edema, and complications such as pigmentation and scarring. It is less suited for skin types V-VI. Fractional photothermolysis, a new concept, using 1,550-nm erbium-doped fiber laser (Fraxel® ) appears to be very promising. Fractional photothermolysis creates microscopic thermal wounds to achieve skin rejuvenation without significant side effects. In a study from USA, 53 patients (skin types I-V) with mild to moderate atrophic facial scars were treated with three treatment sessions at monthly intervals. Clinical improvement averaged 51-75% in nearly 90% of patients. Clinical response rates were independent of age, gender, or skin type. Side effects included transient erythema and edema in most patients, but no dyspigmentation, ulceration, or scarring. It was concluded that atrophic scars can be effectively and safely reduced with 1,550-nm erbium-doped fiber laser. Fractional thermolysis is an expensive treatment, and typically 4-8 sittings are required depending on the depth of scars. A single treatment with Fraxel® in the U.S. may cost $1,500.

    Actifirm Post Laser Gel combines skin-soothers like Aloe and Chamomile with a Mushroom-derived, exfoliating enzyme, Mucor Miehi Extract, to inhibit pain and inflammation, while helping renew your skin to its freshest form. You’ll be looking your best in no time.


    More skin care recommendations by LaserOffers.com

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  • Filed under: LT | acne, LT | scars, LT | skin resurfacing
  • Laser skin resurfacing

    In laser resurfacing, sometimes called “laser peel,” a carbon dioxide (CO2) or and Erbium (Er:YAG) laser is used to remove areas of damaged or wrinkled skin, layer by layer. The procedure is most commonly used to minimize the appearance of fine lines, especially around the mouth and the eyes. However, it is also effective in treating facial scars or areas of uneven pigmentation. Laser resurfacing may be performed on the whole face or in specific regions. Often, the procedure is done in conjunction with another cosmetic operation, such as a facelift or eyelid surgery.

    Laser resurfacing is still a very new procedure. However, it has been shown that in some cases, this surgical method produces less bleeding, bruising and post-operative discomfort than is typically seen with other resurfacing methods.

    About the laser

    Laser resurfacing is performed using a beam of laser energy which vaporizes the upper layers of damaged skin at specific and controlled levels of penetration.

    It’s clear that laser resurfacing may offer a number of advantages over other resurfacing methods: precision, little (if any) bleeding and less post-operative discomfort. However, laser resurfacing isn’t for everyone. In some cases, an alternative skin resurfacing treatment, such as dermabrasion or chemical peel, may still be a better choice.

    All resurfacing treatments work essentially the same way. First, the outer layers of damaged skin are stripped away. Then, as new cells form during the healing process, a smoother, tighter, younger-looking skin surface appears. Laser resurfacing is a new method being used by plastic surgeons to remove damaged skin. Because it is new, there are no long-term data on this technique. However, a number of studies using microscopic examination have shown that the physical changes that occur to laser-treated skin are essentially identical to those that occur with either dermabrasion or chemical peel. Ask your plastic surgeon about the latest facts concerning long-term follow-up.

    For superficial or medium resurfacing, the laser can be limited to the epidermis and papillary dermis. For deeper resurfacing, the upper levels of the reticulas dermis can also be removed. Varied penetration allows treatment of specific spots or wrinkles.

    It’s also important to consider the length of recovery when choosing among the skin-resurfacing alternatives. In general, the more aggressive the resurfacing procedure is, the more prolonged the recovery is likely to be. “Light” resurfacing procedures, such as superficial chemical peels or superficial laser resurfacing, offer shorter recovery times. However, these lighter procedures may need to be repeated multiple times to achieve results comparable to those achieved with more aggressive techniques.

    The best candidates for laser resurfacing

    Men and women of all ages can benefit from laser resurfacing. The ideal patient for laser resurfacing has fair, healthy, non-oily skin.
    In many cases, facial wrinkles form in localized areas, such as near the eyes or around the mouth. The laser can be precisely controlled so that only these specific areas are targeted.

    Patients with olive skin, brown skin or black skin may be at increased risk for pigmentation changes no matter what type of resurfacing method is recommended. Your plastic surgeon will evaluate your skin characteristics and make recommendations accordingly.

    Also, individuals who have taken accutane in the past 12-18 months or are prone to abnormal (keloid-like) scarring or those with active skin infections on the treatment area may not be appropriate candidates for this procedure.

    When healing is complete, the face has a more youthful appearance.

    Remember, having laser resurfacing can help enhance your appearance and your self-confidence, but it won’t completely remove all facial flaws or prevent you from aging. Lines that occur as a result of natural movements of the face – smiling, squinting, blinking, talking, chewing – will inevitably recur. Your plastic surgeon can suggest ways to help you preserve your results by protecting yourself from sun exposure or using maintenance treatments, such as light chemical peels or medicated facial creams. Before you decide to have laser resurfacing, think carefully about your expectations and discuss them with your surgeon.

    All surgery carries some uncertainty and risk

    When laser resurfacing is performed by a qualified, experienced surgeon, complications are infrequent and usually minor. However, because individuals vary greatly in their anatomy, their physical reactions and their healing abilities, the outcome is never completely predictable.

    Risks associated with laser resurfacing include: burns or other injuries from the heat of the laser energy, scarring, and obvious lightening or darkening of the treated skin. Also, laser resurfacing can activate herpes virus infections (“cold sores”) and, rarely, other types of infection.

    Additional corrective measures and treatment may be required if healing seems abnormal or delayed or if there is any evidence of abnormal pigmentation or scarring.

    You can reduce your risks by choosing a qualified plastic surgeon who has received special training in laser surgery.

    Planning your surgery

    Not every practitioner who offers laser surgery has the same level of experience and skill with laser use. That is why it is especially important that you find a plastic surgeon who is adequately trained in the procedure.

    One safety measure is to find out whether your surgeon has privileges to perform laser resurfacing with a CO2 laser at an accredited hospital. Even if the operation is to be conducted in your doctor’s private facility, the fact that he or she has privileges to use that same laser in a hospital ensures that the doctor has been reviewed by the institution’s experts.

    In your initial consultation, be frank in discussing your expectations with the surgeon and don’t hesitate to ask any questions you may have. Your surgeon should be equally frank with you, explaining the factors that could influence the procedure and the results – such as any abnormal skin condition which has been diagnosed or previously treated, medications you are taking or have taken in the past, previous skin injuries or previous operations.

    Your surgeon will discuss your medical history, perform a routine examination and photograph the area to be treated. He or she should explain the procedure in detail, along with its risks and benefits, the recovery period and the costs.

    Remember, cosmetic laser treatments can be expensive and are usually not covered by medical insurance. On rare occasions, the procedure can be used for modification of scars or the removal of pre-cancerous skin growths. These conditions could meet the criteria for “medical necessity,” usually required by insurance companies before coverage will be provided. Your plastic surgeon can advise you how to contact your insurance carrier to determine whether benefits will be allowed in such instances.

    Preparing for the laser procedure

    Fine, vertical creases or “lipstick lines” are commonly treated with laser resurfacing.
    Depending on your individual needs, your surgeon may recommend that you begin a pre-treatment plan to prepare the skin for resurfacing.

    At the time of the procedure, you will be given specific instructions on how to care for your skin immediately following your laser treatment. Your surgeon may also instruct you to follow a specific maintenance regimen for long-term care of the skin to maximize the benefits of the procedure.

    Within about five weeks after treatment, the upper lip is noticeably smoother.
    While you are making plans, be sure to make arrangements for someone to drive you home if you will be given tranquilizers or sedation for your laser treatment.

    Types of anesthesia

    Laser resurfacing is most commonly performed under local anesthesia with sedation, especially when it’s used to treat localized areas of the face. You’ll be awake but relaxed, and will feel minimal discomfort. For more extensive resurfacing, your surgeon may prefer to use general anesthesia, in which case you’ll sleep through the procedure.

    The procedure

    Laser resurfacing is a relatively quick procedure. It usually takes anywhere from a few minutes to 1 1/2 hours, depending on how large of an area is involved.

    When the imperfections are especially deep, your surgeon may recommend that the resurfacing be performed in two or more stages.

    During the procedure, the activated laser is carefully passed back and forth over the skin until the surgeon reaches the level that will make the wrinkle or scar less visible.

    When the procedure is over, your surgeon may choose to treat the resurfaced skin with applications of protective creams or ointments until healing is complete. Some surgeons choose to apply a bandage over the treated areas which will cover and protect the healing skin for the first five to ten days.

    After your treatment

    You are likely to experience some mild swelling and discomfort after laser resurfacing. However, this can be controlled with ice packs and medications prescribed by your surgeon.

    If a bandage was applied after your procedure, it may be replaced with a fresh one after a day or two. After about a week or so, your bandage will be removed and a thin layer of ointment may be applied to the skin. Once this stage is reached, your surgeon will provide instructions on how to gently wash and care for your healing skin.

    During this phase of healing, it is very important that you not pick the crusts off the treated area or scarring may result. Most patients are free of crusts by about 10 days post-operatively. Redness may persist for several weeks.

    Getting back to normal

    Your new skin will usually remain bright pink to red in the weeks following the procedure. Your surgeon may prescribe medications to make this color subside more rapidly. After about two weeks or so, most patients can safely apply makeup to conceal this temporary color change. However, some pinkness may remain for up to six months.

    It is rare, some patients may find that their healing skin is unusually sensitive to the makeup that was regularly used prior to treatment. In such instances, makeup should be avoided until a substitute can be found or until the healing progresses to a point at which the makeup no longer causes a reaction.

    Above all, in the months following treatment, it’s important to protect the treated area from the sun until all the color has returned to normal. Using sun protection regularly will help to maintain your results and reduce the chance of any new sun damage to your skin.

    If you must be in the sun, apply a strong sun block with an SPF of 15 or higher and shade your face with a hat or visor. If resurfacing was performed around the eyes, it’s best to also wear good quality sunglasses with UVA and UVB 100 percent filters.

    Your new look

    The final result from laser resurfacing may take several months to fully appear. However, once the pinkness fades, patients usually notice a significant improvement in the quality of their skin and a fresher, smoother appearance.

    It’s important to understand that your results will be long-lasting, but not permanent. Remember, your new skin is not immune to the effects of aging. In the months and years following your laser treatment, your natural facial movements will eventually cause any “expression” lines to recur.

    As with other methods of skin rejuvenation, laser treatments can usually be repeated. However, by protecting yourself from the sun and following a skin-care regimen recommended by your plastic surgeon, you can help maintain your rejuvenated look.

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  • Filed under: Laser Treatments, LT | skin resurfacing
  • The early 1980s brought about a revolution in dermatologic laser treatment with Anderson and Parrish’s1 publication detailing the theory of selective photothermolysis. Selective photothermolysis describes the use of specific absorptions of laser energy to achieve temperature-mediated localized injury in a target. This theory led to the invention of pulsed lasers that are target-specific and highly selective. Increased selectivity decreased the amount of thermal damage to healthy tissue, thereby decreasing scarring and other adverse effects.

    The first laser used in the treatment of hypertrophic scars and keloids was a continuous-wave argon laser. While initial reports were encouraging, subsequent studies did not confirm its efficacy. Similarly, use of the continuous wave neodymium:yttrium-aluminum-garnet (Nd:YAG) laser (1064 nm), which selectively inhibits collagen production by a direct photobiologic effect and creates tissue infarction with subsequent charring and sloughing of the treated area, also showed initial clinical improvement. Results, however, were transient and scar recurrences were common. Similar recurrences were observed when hypertrophic scars and keloids were excised or vaporized with a continuous-wave carbon dioxide laser (CO2). When treated with the carbon dioxide laser, scars universally recurred within 1 year.

    By the early 1990s, the effectiveness of the vascular-specific 585-nm pulsed dye laser (PDL) in treating a variety of vascular lesions (eg, port-wine stain, telangiectasia) was widely known. The first series of studies on the successful use of the 585-nm flashlamp-pumped PDL in the treatment of hypertrophic scars and keloids had been published. In 1993, Dr. Alster and colleagues reported prolonged improvement in argon laser–induced port-wine stain scars treated with PDL irradiation. Skin surface texture analysis performed by optical profilometry with accompanying clinical assessment revealed that laser-irradiated scars approximated normal skin characteristics. No scar recurrences were noted 4 years following treatment.

    In 1994, Alster reported clinical and textural improvement in long-standing erythematous and hypertrophic scars. An improvement rate ranging from 57-83% was observed following 1-2 PDL treatments, respectively. Dierickx and colleagues corroborated these findings the following year; they reported an average scar improvement of 77% after 1.8 laser treatments. Not surprisingly, in 1995, Alster and Williams compared the clinical, textural, histologic, and symptomatic responses of irradiated scar halves with untreated control halves. Significant improvement was observed for all clinical parameters. Histologic evaluation revealed increased numbers of regional mast cells. Because mast cells also elaborate a variety of cytokines, the presence of mast cells following laser irradiation and accompanying tissue revascularization may provide an explanation for the therapeutic outcome following microvasculature destruction in terms of stimulating collagen remodeling.

    Subsequent studies also showed improvement in keloid scars following PDL treatment. In 1996, Alster and McMeekin also reported improvement in erythematous and hypertrophic facial acne scars following 585-nm pulsed dye irradiation.

    Improvement in nonerythematous, minimally hypertrophic scars was also achieved following combination treatment involving pulsed dye technology and carbon dioxide laser vaporization. In 1998, Alster and Lewis treated selected scars by performing carbon dioxide laser de-epithelialization followed by PDL irradiation. Significant and prolonged clinical and textural improvement was observed in all treatment areas. In a 1995 report, Goldman and Fitzpatrick also described a combination approach to scar management. They used intralesional corticosteroids concomitantly with 585-nm PDL irradiation in 11 of 37 patients with hypertrophic scars.

    No consensus exists regarding the mechanism by which PDLs achieve these additional clinical effects. Plausible explanations include laser-induced tissue hypoxia (leading to collagenesis from decreased microvascular perfusion), collagen fiber heating with dissociation of disulfide bonds and subsequent collagen realignment, selective photothermolysis of vasculature, suppression of TGF-β1 expression, and mast cell factors (eg, histamine, interleukins, various immunofactors) that may affect collagen metabolism.

    In 1996, McDaniel and colleagues reported using the same 585-nm PDL to effect an improvement in the appearance of striae. They observed an improvement not only in skin surface appearance, but also in increased dermal elastin after low-fluence laser irradiation. In a 1998 report, Alster and colleagues7 also found that low-fluence PDL irradiation was superior compared with pulsed dye treatment at regular (scar) fluences and pulsed carbon dioxide vaporization. Both groups postulate that the improvement may be due to laser-induced effects on elastin, collagen, or other undiscovered factors.

    In 2003, Nouri and colleagues showed that the 585-nm PDL can improve the quality and appearances of surgical scars when used as early as the day of suture removal. Scars were treated 3 times at monthly intervals and were significantly more improved compared with controls in overall Vancouver Burn Scar Scale (ie, vascularity, pliability, height, and cosmetic appearance) comparisons.

    More in Laser Revision of Scars (April 2008)

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  • Filed under: Laser Clinics, LT | scars, Research
  • Many patients who undergo cosmetic and plastic surgery procedures experience significant scarring from the incisions. Procedures such as the tummy tuck, breast augmentation and facelift surgery typically leave behind large, noticeable scars that are difficult to cover up with makeup. Scars can take weeks, months and even years to heal completely and there are a number of topical scar gels and creams available to reduce the appearance of the traumatized skin.

    However, results from a recent study completed at the Cosmetic Surgery and Skin Health Center at the University of Pittsburgh Medical Center (UPMC) in Pittsburgh indicate that laser therapy may be used as an early intervention plan for scar formation. Lasers can be used to stop the growth of scars by delivering high-energy waves to the skin and lightening any discoloration on the traumatized skin. Pulse-dyed lasers and fractionated lasers have been the most effective at reducing the appearance of scars after surgery so far, and lasers such as Fraxel may even help reduce the appearance of mature scars

    Dr. Suzan Obagi, assistant clinical profesor of dermatology at UPMC explains that the best time to treat scars with this type of therpay is right when the sutures are removed. This helps reduce the risk of dark scar formation, and may also speed up the body’s natural healing process. Increasing collagen and elastin production helps the skin recover rapidly and restore itself to its natural state.

    Younger patients tend to heal faster than older patients regardless of the type of treatment used, and overall health and diet also play a role in wound healing and scar development. Individuals who are deficient in vitamins and proteins may not be able to heal as fast or as effectively; however, laser therapy may help to reduce the risk of deep scar formation and improve the healing process overall. (Source: ModernMedicine.com)

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  • Filed under: LT | scars
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