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Ablative resurfacing fractional-style
CO2 lasers could provide impressive results, but the downtime and contraindications eventually led to their replacement. Their rebirth as fractionated light sources has generated much interest, writes Stephen Mulholland MD
Ablative CO2 and erbium resurfacing was one of the mainstays of aesthetic facial wrinkle rejuvenation and scar treatment for plastics surgeons and cosmetic physicians throughout the 1990s. The early results and before/after pictures were extremely impressive, with rhytide reductions of more than 90% in even the most weathered of faces. The enhanced precision and predictability of full-face CO2 resurfacing over its predecessor phenol and chemical peels resulted in thousands of laser CO2 devices being sold around the world.
The downside of the procedure, prolonged transudative skin re-epithelisation ("oozing") for two to three weeks, followed by weeks to months of erythema, did little to dampen the enthusiastic wave of CO2 laser resurfacing. However, after several years, it became apparent that most patients treated with aggressive CO2 laser resurfacing parameters developed noticeable hypopigmentation. This often led to permanent and unattractive demarcation lines in the perioral and periorbital regions (if localised lower lid or upper lip lines had been treated) or mandibular border transition zones, which were aesthetically displeasing and difficult to camouflage. The long-term skin tone of the aggressive full-face CO2 resurfacing was often an overly white, "other worldy" unattractive alabaster colour.
The excitement for CO2 began to wane and led to a brief surge in the develop and sale of ablative erbium laser resurfacing, which, like CO2 is attracted to dermal water as its target, but even more so. The high water affinity of erbium for water meant that the erbium was almost purely ablative and far less coagulative, resulting in less erythema and downtime and far less hypopigmentation, but, unfortunately, in most hands less-impressive results.
About this time, with the disinterest in long recovery of the ablative lasers, the non-invasive era took off powered by the immediate results of the injectables Botox and Restylane. Alongside them were a whole host of non-invasive light-based therapies led by intense pulsed light (IPL), the infrared lasers (Coolthouch, Smooth Beam) and then radio frequency (Thermage, Accent, Emax).
Although these non-invasive approaches afforded little downtime for the patient, they required four to five visits over several months. While, the improvements in discolouration (melanin and vascular concerns) were impressive, the wrinkle reduction and texture improvements were not.
Fractional age
Ablatives with unacceptable recovery and complications, and the non-ablatives with no real recovery but minimal results persisted until 2005, when Fraxel was launched. The outcome was the fractional age. The brilliant but simple concept of high energy infrared lasers—too painful when applied to the entire skin surface all at once—was sent fractionated into the skin to create microthermal zones of mini-ablation within the dermis, while leaving larger percentages of the skin alone.
Fractional non-ablative lasers, had the advantage of turning up the energy with acceptable discomfort and creating a dermal thermal injury while the surrounding, un-traumatized skin acted as reservoirs of dermal remodeling. Soon, every laser manufacturer had an infrared fractional device on the market.
Generally, three to five treatments were required, the procedures could be uncomfortable, but less painful than full, non-fractionated infrared and RF therapy. The results were a nice, often noticeable improvement in wrinkles and texture (certainly better than the non-fractional non-ablatives).
The fractional concept was quickly extended back to the holy grail of wrinkle reduction—the CO2 laser. Companies such as Reliant, Lumenis, Cynosure and Deka began to release fractional CO2 ablative devices in 2006-2007. These devices appeared to offer the best of both worlds: the wrinkle reduction and texture improvement of old fashioned, full-face CO2 resurfacing but with the fractional injury concept, quick re-epithelialisation through lateral epidermal marginalisation, with less erythema and the hope of less long-term hypopigmentation. The fractional erbium laser ablatives soon followed.
Ideal candidate
The ideal candidate for fractional ablative CO2 patient is skin type 1-3, with moderate to severe wrinkles, laxity or scarring and realistic expectations. Depending on the specific laser and parameters selected, the fractional CO2 procedure may require 1-5 treatments, each 6-8 weeks apart. The downtime, depending on the aggressive nature of the parameters, may be 3-7 days into makeup.
The contraindications to fractional ablative CO2 would be skin types 4-5. There are now fractional RF ablative devices that can treat skin types 1-3, as well as darker skin types 4-5.
The advantages of the fractional ablatives are:
• Very good rhtyide and texture improvement over the non-ablatives
• Very fast and less symptomatic recovery than non-fractional ablative
• Tunable parameters to match the recovery needs of the patient
• Perhaps less long-term hypo-pigmentation
• The ability to perform fractional CO2 directly over elevated skin flaps, like facelift, browlift or blepharoplasty.
One of the advantages of fractional CO2 is the ability to treat safely "off the face" (we could never do this with non-fractionated CO2), which enables us to treat the neck, décolletage and hands so they better match the rejuvenated faces we create. The disadvantage of the fractional ablatives can be more than one treatment required and more downtime than the non-ablative fractional.
With more than 5000 fractional lasers—both ablative and non-ablative sold world wide—the proportional epidermal-dermal injury concept is here to stay because it makes sense. Why not injure a proportion of the skin and allow the uninjured neighbouring skin to speed the healing and lessen the risks of delayed or complicated recovery.
Newer generations
The future of fractional laser and dermal injury systems is bright. Newer generations of fractional ablative lasers, RF fractional and fractional mechanical needle systems are on the way. All skin types and challenging texture pathologies will be candidates for treatment.
The fractional ablative laser and RF rebirth has allowed rejuvenation physicians to "wow" our patients again with less symptomatic recovery and fewer risks. Combination therapy involving a botulinum toxin, soft tissue fillers and volumisers with fractional ablative lasers have allowed us to offer patients five to eight years of rejuvenation without a scalpel, brigning more patients to our offices who leave looking their best!
R Stephen Mulholland, MD is a plastic surgeon in private practice in Toronto and Los Angeles. W: mulhollandmd.com
