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The concept of non-ablative fractional photothermolysis was introduced to the market in 2003 as an answer to the need for effective, yet low risk, skin resurfacing techniques. Unlike conventional ablative (CO2 and Erbium) and non-ablative lasers, fractional ablative and non-ablative photothermolysis treats only a fraction of the skin, leaving up to a maximum of 95% of the skin uninvolved. The undamaged surrounding tissue allows for a reservoir of viable tissue, permitting rapid epidermal repair.

Non-ablative fractional photothermolysis is currently approved by the US Food and Drug Administration (FDA) for the treatment of pigmented lesions, periorbital rhytides, skin resurfacing, melasma and soft tissue coagulation, acne and surgical scars, and actinic keratoses. However, its off-label use is clearly more extended. Many practitioners would agree that this first wave of fractional lasers has delivered very limited clinical efficacy.

See larger chart

fractional-ablative-laser-treatment

In 2007 the concept was further developed, and ablative fractional photothermolysis was introduced, using an erbium yttrium aluminium garnet (Er:YAG) or carbon dioxide (CO2) laser. These devices are FDA cleared to treat wrinkles, rhytides, furrows, fine lines, textural irregularities, pigmented lesions and vascular dyschromia. (more…)

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  • Filed under: Device Review, LT | fractional
  • Fraxel Re:pair versus Face Lift

    Last week, Solta Medical presented a study by Steve Weiner, MD at the annual American Academy for Dermatology meeting. The presentation sparked a few discussions among doctors who have had some experience with the “new Fraxel”.

    Fraxel Re:pair is a “non-invasive” laser treatment used for the reduction of fine to moderate wrinkles on the face, neck and chest. “As a plastic surgeon I’ve found this to be the best treatment on the market to date and I don’t anticipate anything will replace it for many years,” said Weiner. Some may argue that Dr. Weiner’s opinion is biased since he did the study on the Solta’s buck and featured his patients at several nationwide webinars promoting Solta’s lasers. However, Weiner’s research clearly shows the advantages of his technique, which are very valuable for many physicians.

    How does Fraxel Re:pair compare to a traditional face lift?

    A face-lift is a surgical procedure under general anaesthesia performed by a plastic surgeon, often in a specialized outpatient center or a hospital. The Fraxel Re:pair is considered to be a non-invasive treatment with the use of CO2 laser technology, which can be done by physicians of different specialties and in a doctor’s office. Results are expected to last up to 10 years. For most patients only one treatment is required, for deeper wrinkles two may be necessary, according to Weiner.

    The laser effectively removes portions the epidermis and heats the dermis to tighten the skin and help with collagen elasticity, referred to as resurfacing. As with other laser treatment the new skin is exposed and wound care is necessary. This is the part where one may question the definition of a non-invasive treatment. After the Fraxel treatment the patient goes home with dressings on the face. The dressings need to be changed every 3-4 hours and you have to stay indoors for 5-7 days. Most patients would arguably call this pretty invasive.

    The Fraxel Re:pair seems to work very well on mildly deep wrinkles, acne scars and brown spots, caused by the sun exposure. With some extra skill and experiens a doctor can work with Asians and Hispanics. Smokers and individuals with heavily tanned, pigmented or very dark skin types are not good candidates for this treatment.

    The cost for Fraxel Re:pair ranges from $1,300 to $6,300, approximately 1/3 the cost for a surgical face lift which can cost more than $10,000.

    LaserOffers comment

    Our medical panel agrees that leaving the issue of cost differential aside, for the vast majority of patients the CO2 fractional treatment with Fraxel will work just as well, if not better than the surgical face-lift. The additional benefit is that the laser actually improves the skin texture, whereas the lift merely stretches the skin.

    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: Laser Clinics, LT | fractional, New Lasers, Research
  • Solta Medical, the manufacturer of Thermage and Fraxel systems today announced the opening of the Solta Medical Aesthetic Center “to advance the company’s new product development, facilitate research on the innovative Thermage(R) and Fraxel(R) product lines and serve as a destination where physicians can participate in research studies and training”.

    This is a truly novel development in the industry as Solta is the first company in the aesthetic energy device space to open an in-house clinic and biomedical engineering lab.
    The company claims that more than 4,500 physicians in nearly 80 countries perform Thermage and Fraxel treatments. The Solta Aesthetic Center will serve as a central research destination for physicians around the world to access the latest findings about Thermage and Fraxel treatments.
    “The Solta Medical Aesthetic Center allows for a seamless transition from the research bench to the treatment room,” said Vic A. Narurkar, M.D., dermatologist and founder of the Bay Area Laser Institute in San Francisco, California. “Solta’s state-of-the-art clinic allows the company’s optics and biomedical engineers to share data and receive immediate clinical feedback about their work in new product development and existing product enhancement.”

    Solta Medical has a history of leadership in R&D of the aesthetic devices. Current studies being conducted at the Aesthetic Center include the recently released Thermage Body Tip 16.0 and several advancements in skin tightening, resurfacing and other dermatological applications using new, breakthrough proprietary technology.

    The grand opening of the Solta Medical Aesthetic Center occurs in conjunction with the 67th annual meeting of the AAD in San Francisco. Several physicians presenting at the AAD will discuss their clinical findings using Thermage and Fraxel systems and the effectiveness of skin tightening and skin resurfacing.

    These presentations include:

    • “Lasers, Non-Ablative Fractional Resurfacing,” by Elizabeth Tanzi, M.D., Washington Institute of Dermatologic Surgery, Washington, D.C.
    • “Advanced Lasers, Fractional Resurfacing,” by Christopher Zachary, F.R.C.P., University of California, Irvine.
    • “Skin Resurfacing & Rejuvenation, Carbon Dioxide Fractional Laser Rejuvenation,” by Christopher Zachary, F.R.C.P., University of California, Irvine.
    • “Fractional Laser and Light-based Technologies,” by Vic A. Narurkar, M.D., founder of the Bay Area Laser Institute, San Francisco, CA.
    • “Aesthetics and Cosmetic Surgical Procedures in Darker Racial Ethnic Groups, Fractional Photothermolysis & Radiofrequency Devices,” by Vic Narurkar, M.D., founder of the Bay Area Laser Institute, San Francisco, CA.
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  • Filed under: Marketing Ideas, Research
  • A very good study by doctors Kono T, Frederick Groff W, Chan HH, Sakurai H, Yamaki T of the Department of Plastic and Reconstructive Surgery in Tokyo Women’s Medical University, Tokyo, Japan (tkono@prs.twmu.ac.jp)  just came out.

    Pulsed dye laser (PDL) treatment of hypertrophic port-wine stains (PWSs) on the lips has demonstrated poor efficacy and a potential risk of dyspigmentation. PDL-resistant hypertrophic PWS can be safely treated with much greater efficacy with deeper penetrating lasers such as a 1064-nm neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. 80% of the treated patients showed good to excellent improvement without complications.

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  • Filed under: CURRENT NEWS, Laser Clinics, Laser Treatments
  • Lasers and Melasma

    Key Points

    Role of lasers in treating melasmas
    Patient selection
    Risk of recurrence, post-inflammatory hyperpigmentation

    Dr. Kaufman

    Melasma is an acquired condition characterized by hyperpigmented patches, traditionally located on the face. What the classic definition fails to mention is its chronic relapsing nature and its associated therapeutic dilemma.

    Dr. Woolery-Lloyd

    There are three clinical types of melasma: centrofacial, malar and mandibular. The clinical type does not seem to alter the treatment choices.

    There are also four types of melasma based on the location of the melanosomes in the skin, and, hence, described by their woods light pattern. They are: epidermal (accentuated by Woods light), dermal (not accentuated by Woods light), mixed and indeterminate.

    Melasma typically occurs in women, with men comprising only 10 percent of all cases. The precise etiology of melasma is not known; however, it has been associated with several other conditions. The most common association is pregnancy and oral contraceptives. Other possible inciting agents include excessive sun exposure, other endocrine abnormalities such as thyroid disease, or ovarian dysfunction. Genetic influences are also likely to contribute, though specific gene identification has not been done.

    Cosmetics, heat exposure, phototoxic drugs and anti-seizure medications have also been implicated in this disease.

    Melasma associated with an inciting factor, such as oral contraceptives, may resolve once this inciting factor is removed. In many cases, however, this is not the case, and the pigmentation persists.

    Therapeutic options for melasma have classically centered on resolving the hyperpigmentation. These have included topical retinoids, hydroquinone, kojic acid and glycolic acid, to name a few.

    More recent attention has been focused on prevention of melanosome transfer with agents including soy and niacinamide. Sun protection is an essential component of any therapeutic regimen when treating patients with melasma.

    Though readily available, topical therapies often fail to resolve the hyperpigmentation, which relapses when therapy is discontinued.

    The search for alternative forms of treatment has led to a recent focus on laser and light devices.

    Melasma is certainly more than merely a disorder of hyperpigmentation. In many cases, there is a vascular component to the lesions that generally gets left untreated. The focus of melasma treatment has been predominantly on the pigmentary aspect of the disease, essentially ignoring the other factors.

    Lasers may end up playing a role in the therapy of the vascular components of melasma, as this component is nearly impossible to treat with topical agents.

    Role of lasers

    Do lasers play a role in the treatment of melasma? There are many reports of the use of lasers for melasma, yet no well-controlled, randomized, blinded trials. There are even approvals for treatment of melasma with lasers. However, the answer to this question is definitely still up for debate.

    Lasers were first described as a therapy for melasma in 1993. Early laser choices used those wavelengths highly absorbed by melanin. There have been many case reports of successful treatment with these light devices.

    The Q-switched lasers have all been tried on melasma, including in combination with other lasers. The majority of reports have shown very high rates of postinflammatory hyperpigmentation (PIH); in some studies, as high as 100 percent.

    That being said, many of the cases of PIH were amenable to topical bleaching agents and glycolic acid peels, resulting in an overall improvement of the melasma.

    In these reports, it is difficult to ascertain whether the improvement is actually a result of the laser, or of the peels.

    Either way, most would agree that the treatment of melasma with traditional Q-switched lasers, including the ruby, alexandrite or the Nd:YAG is risky.

    Resurfacing

    Traditional resurfacing lasers have also been tried on patients with melasma. Both the Er:YAG and CO2 lasers are associated with almost universal hyperpigmentation in this population and should not be relied upon as a therapeutic option (Mandloto, Alster; Derm Surg. 1999.)

    The newer fractional resurfacing lasers so far have shown the most promise for melasma patients. They are not, however, without their shortcomings.

    In 2005, the nonablative 1,550 nm fractional resurfacing laser (Fraxel Re:store; Reliant) received a specific approval for treatment of melasma. This approval was based on two separate studies of 20 total patients.

    These studies, though promising, are the largest ones to date, clearly demonstrating our lack of research into this topic.

    That being said, fractional nonablative resurfacing does improve melasma in many cases. In other cases, it may worsen melasma.

    Patients should be treated with hydroquinone to prevent postinflammatory hyperpigmentation. In addition, density settings should be very low. Higher densities result in higher rates of postinflammatory hyperpigmentation.

    In addition, treatment sessions should be placed at least one month apart. PIH can occur up to six weeks after treatment, and careful monitoring for this, prior to retreatment, is essential.

    Nonablative fractional resurfacing

    Refractory cases of melasma can be amenable to nonablative fractional resurfacing.

    Nonablative fractional resurfacing results in a laser-induced transport of dermal constituents through the epidermis.

    In vivo studies post-nonablative fractional resurfacing indicate that this is the mechanism of action with dermal melasma (Goldberg et al., 2008.)

    Nonablative fractional resurfacing could be considered a first-line therapy for dermal melasma in select patients. In other classes of melasma, it is clearly second-tier.

    Post treatment worsening of melasma and/or postinflammatory hyperpigmentation are possible. Intervals between treatments must be longer than with non-melasma patients.

    In addition, lower fluences and lower densities are typically used. Most patients are pretreated with hydroquinones and strict sun protection with a physical sunblock.

    Intense pulsed light

    Intense pulsed light devices are also used in the treatment of melasma. Though many patients experience improvement, relapse and PIH occur frequently.

    Devices that may show promise for the treatment of melasma, but still with no published data to date, include the light-emitting diodes (Omnilux, Photo Therapeutics), the Spectra VRM dual-pulse laser (Lutronic), and the Laser Genesis (Cutera).

    Treatment protocol

    So where do laser and light devices fit into the treatment protocol for melasma? In most cases, they are still second line. Only in select cases of dermal melasma could the fractional devices be considered first line, though topical therapy is usually instituted prior to prevent PIH.

    Our lasers of choice for melasma include the Cynergy laser (595 nm, 1,064 nm, Cynosure), Fraxel Re:Store (1,550 nm) and the Cutera Limelight IPL (520 nm to 1,200 nm).

    The vascular lasers are used primarily for those cases of melasma that contain a vascular component.

    Patient selection

    Skin type is also a factor in patient selection.

    In our experience, patients with skin types I to III clinically appear to have a lower risk of recurrence after laser therapy for melasma.

    In skin types IV to V, the risk of recurrence and postinflammatory hyperpigmentation increases dramatically.

    Even with perfect patient selection, cases of worsening of melasma can occur. Explaining this possibility to patients prior to treatment is essential, as this problem often will arise.

    Role of lasers

    Do lasers play a role in the treatment of melasma? Our answer is yes, but limited to a select group of patients.

    At the University of Miami, we use these questions to help decide those who may benefit from laser treatment:
    1. Have topical therapies failed?
    2. Is the condition chronic (not a temporary inciting factor)?
    3. Is the pigmentation dermal?

    If the answer to No. 1 plus any of the other questions is “yes,” then we will consider laser therapy.

    Test spots in inconspicuous areas are an excellent option. Even with perfect patient selection, laser use on these patients must be performed conservatively.

    Dr. Kaufman is assistant professor of clinical dermatology at the University of Miami Miller School of Medicine and director of lasers for the University of Miami Cosmetic Group. The Cosmetic Group is involved in research and development of lasers and light devices as well as other aesthetic procedures, such as fillers and toxins.

    Dr. Woolery-Lloyd is director of ethnic skin at the University of Miami Cosmetic Medicine and Research Institute.

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  • Filed under: Laser Clinics, Laser Treatments, Research
  • Key Points

    Photodynamic therapy (PDT) results in a five-fold increase in levels of Ki67
    Baseline immunostaining for the tumor suppressor gene p53 may be a predictor of response to treatment
    Utility of PDT for the treatment of dermatoheliosis and the changes of skin aging

    National report — Photodynamic therapy (PDT) results in a fivefold increase in levels of Ki67, a protein important to the growth and development of new skin cells.

    Information such as this, which quantifies our understanding of how PDT works, is crucial to optimizing treatment and advancing the field, says Jeffrey S. Orringer, M.D., director of the Cosmetic Dermatology & Laser Center, University of Michigan, Ann Arbor, Mich.

    “Our study represents an attempt to quantify, on a molecular level, epidermal and dermal matrix changes following PDT,” Dr. Orringer says.

    Dr. Hirsch believes the information can help clinicians better use the skin sensitizers and lasers that are currently available, and guide future developments in the field.

     

    Trial parameters

    The trial enrolled 25 patients who were generally healthy, had clinical evidence of significant photodamage, and had no history of significant cosmetic interventions at the site examined.

    The study involved the use of the photosensitizer 5-aminolevulinic acid (5-ALA, Levulan) and a single-pass treatment with a pulsed dye laser.

    While the majority of PDT procedures occur on the face, the forearm was used in the study, because baseline and multiple follow-up skin punch biopsies held a potential for scarring.

     

    Study findings

    In addition to the increase in Ki67, researchers found a 1.4-fold increase in epidermal thickness; a 70-fold increase from baseline in cytokeratin 16 levels; and significant upregulation of procollagen I messenger RNA (2.65-fold increase) and procollagen III messenger RNA (3.32-fold).

    There also was a correlation between baseline p53 levels and subsequent production of cytokeratin 16 in response to therapy.

    “Using the topical photosensitizer clearly gave us more consistent and quantitatively greater changes in the skin compared to historical studies using nonablative laser therapy alone.

    “This tracks very nicely with the bulk of the clinical evidence in this field, including clinical split-face studies,” Dr. Orringer tells Dermatology Times.

     

    Baseline immunostaining

    Another interesting finding was that baseline immunostaining for the tumor suppressor gene p53 — an excellent indicator of the extent of photodamage — may be a predictor of response to treatment.

    Baseline staining for p53 correlated with levels of cytokeratin 16 at acute time points after treatment, and this, in turn, was linked to collagen production.

    “Patients with greater sun damage at baseline were more susceptible to a controlled injury from the treatment and, therefore, were able to produce more collagen in response to it.

    “This implies that we may be able to get greater changes from this kind of a treatment among patients who have significant sun damage,” Dr. Orringer says.

     

    Dose response curve

    “In general, our working hypothesis is that the stronger the treatment applied to the skin, the more dermal remodeling one is likely to get out of it.

    “While the concepts of less downtime and exceptionally safe treatments are terrific, we have to find that happy medium between keeping things convenient for patients and providing an intervention that is effective,” Dr. Orringer says.

     

    Collagen production

    Dr. Orringer believes that enhanced collagen production is a key response for durable improvement in photodamaged skin. He has found that the variability of response often depends on the degree of insult the procedure delivers to the skin.

    “When we use ablative carbon dioxide laser resurfacing, the wound-healing responses are very highly organized, very consistent from patient to patient.

    “At the opposite end of the spectrum, with very mild interventions like microdermabrasion or non-ablative laser treatments, some patients did very well and produced lots of collagen, and others had very little change at all,” he says.

     

    Contact time

    In the current study, Dr. Orringer says that the photosensitizer was left on for three hours “to ensure there was adequate absorption to allow for true photodynamic therapy effects, to be sure that we weren’t looking at changes that were the result of the laser therapy alone.”

    He says the clinical trend toward significantly shorter contact time for photosensitizer application prior to use of the laser, for the convenience of the patients and flow of the office, “may not be optimal and is not necessarily based on molecular and cellular biology.

    “It probably takes somewhat longer for the Levulan to be taken up by cells than most practitioners allow the material to remain on the skin prior to treatment. I’m not sure that clinicians are always taking full advantages of the PDT effect.”

     

    Ongoing research

    Ongoing research includes looking at evolving fractionated laser technologies and minimally ablative technologies, “to see what type of dermal changes, if any, we can create by simply disturbing the epidermis,” Dr. Orringer says.

    “We think that we are developing a working molecular model that may one day be used to predict the clinical value of new technologies as they arise,” Dr. Orringer says.

     

    Confirmation

    “It certainly is exciting to get molecular data that confirms anecdotal and clinical study evidence of the utility of PDT for the treatment of dermatoheliosis and the changes of skin aging,” says Ranella J. Hirsch, M.D., president of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

    “A significant next step for this line of research would be experimentation with alternative incubations to see what the molecular findings are with each,” she says.

    For more information: Orringer JS, Hammerberg C, Hamilton T, Johnson TM, Kang S, Sachs DL, Fisher G, Voorhees JJ. Molecular effects of photodynamic therapy for photoaging. Arch Dermatol. 2008 Oct;144(10):1296-302. PMID: 18936392

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  • Filed under: CURRENT NEWS, Research
  • I am amazed that SpaBusinessMD’s number one hit from on-line searches is for Spa Interior Design.  Now, needless to say, I believe that our Designer, Pia Prevost is the number 1 Interior Designer/Architect in the spa and medical spa industries.  She has designed many spas, medical spas and medical practices throughout the United States over [...]

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