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BACKGROUND Fractionalised CO2 laser skin resurfacing with newer type la-sers such as the Lumenis ActiveFx or the Deka SmartXide DOT has recently become an important part of facial rejuvenation as patients continue the trend of seeking less invasive procedures with less downtime and lower risks. This change in attitude has largely been prompted by the realisation of both doctors and patients that many recently hyped devices, especially radiofre-quency types were often subject to extravagant claims in terms of their effect. In essence, many skin tightening devices are not comparable with the older skin resurfacing lasers. During the late nineties, CO2 laser resurfacing was considered the ‘gold standard’ for the treatment of wrinkles and photodam-aged facial skin. The first CO2 laser device developed for skin resurfacing was actually approved by the U.S. Food and Drug Administration in 1996. The earliest systems were non so-phisticated continuous-wave lasers, which were very effective for gross skin destruction. However, these systems were not advanced enough to do fine work because of the level of tissue damage and they produced unacceptably high rates of scarring and pigmentation problems. In 1999, we saw the introduction of pulsed lasers, which made it possible to safely apply higher energy with greater safety. These lasers also reduced the risk of damaging surrounding skin tissue. My first exposure to these devices was in Australia, where I used the Lumenis UltraPulse 5000. I later bought another Lumenis Silk-Touch laser from a colleague in the Blackrock Clinic when I set up the Ailesbury Clinic in Dublin. He was using it for ENT work but decided to switch over to doing hair transplants and has never looked back since. The differences between the two lasers are of historical interest to those that are technically minded. The Australian UltraPulse was like a boxing kangaroo, which emitted individual CO2 laser punches of one power that were only allowed to touch the skin for a certain amount of time. In contrast, the Dublin SilkTouch device was more like a magic leprechaun with a computerised ray-gun, which moved the laser beam so that it could not dwell on any one area for more than 1 millisecond. Many proceduralists of this period thought the ultrapulsed CO2 lasers were the most effective means for repairing photodamaged skin after years of sun exposure to harmful ultraviolet light.

This damaging effect is seen clinically as a gradual deterio-ration of skin structure and function. It gives the outer layer of skin a roughened surface texture as well as making it lax, wrinkled and full of blood vessels and brown pigmentation. However all was not well in the patient camp, for although, ultrapulsed CO2 laser skin resurfacing was considered the best treatment option for this type of photoaged facial skin, it had certain problems, including prolonged postoperative recovery, pigmentary changes and a high incidence of adverse side effects, including acne flares, herpes simplex virus (HSV) infection. Many patients also complained of oedema, burning, and redness, which sometimes lasted for many months. The delayed healing, the implied risks and long downtime made many patients reluctant to readily accept this method.

SEEKING SAFETY As we moved into the twenty first century another type of laser called the short-pulsed Erbium YAG laser was introduced as an alternative to the CO2 laser for skin resurfacing in an attempt to shorten the recovery period and limit side effects while maintaining clini-cal benefit. While it is true the first of these devices were approved by the FDA as early as 1996 for use in skin resurfacing, they only gained popularity at the expense of the problem created by the pulsed CO2 lasers. These new kids on the block emitted a new wavelength of light making them eighteen times more efficient at being absorbed by water containing tissue. They also were more precise in removing skin than the CO2 laser but they suffered from having a shorter punching time on the skin making them less effec-tive in sealing blood vessels. This in turn increased intraoperative bleeding, which was favoured by neither doctor nor patient. As the years passed it became evident that the new safer Erbium YAG laser was not as good at making new collagen as the previous CO2 device and the cosmetic world waited with interest on the new radiofrequency devices that promised a whole new era of collagen growth and no side effects. In the early years of the twenty first century we saw the introduction of heating devices for deeper dermal treatment such as Thermage®, Polaris® and the Titan®. These devices had a role in skin tightening but quickly fell into disfavour as they created a level of non-responders after quite expensive treatments that often required multiple painful sessions. The Ailes-bury Clinic, Dublin was the first European centre to introduce RF technology and our clinic studies showed it performed best at 3-5 treatments.

The next technological advance was the introduc-tion of the Fraxel laser by Reliant after some years of University studies. Although I always thought the com-pany used the wrong wavelength, the introduction of fractionalised laser pulses was the breakthrough that everyone was waiting for. The new method meant that only a fraction of the skin needed to be removed to achieve new collagen formation. The skin bridges that were left behind immediately reduced the possibility of damage to the melanin layer of the skin and the risk of scarring. It was an obvious next move to merge this technology with the previous proven wavelength of the CO2 and the Erbium YAG laser. It was a bit like giving the kangaroo the leprechaun’s magic laser gun with an upgrade that reduced all side effects. To give it its full title NS-LFSR “non-sequential fractionalised laser skin resurfacing” technology was here to stay.

FACE

Fractionalised

laser skin resurfacing (FLSR)

COby Dr. Patrick Treacy

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Which device is best?There are presently several high-energy, fractionalised carbon dioxide (CO2) lasers currently available for skin resurfacing. Al-though each laser system adheres to the same basic principles there are significant differences between lasers with respect to their technology that result in variable clinical and histological tissue effects. The ActiveFx (although technically the name of a set of param-eters) is actually an upgrade of the older Ultrapulse Encore with a smaller spot size and a new computer pattern genera-tor giving a random beam pattern. The random beam pattern effectively reduces the possibility of having several adjacent spots with resultant heat accumulation and tissue damage to the one area, especially the melanin zone. The application of random rather than sequential beams is termed ‘Cool Scan’ and this feature should be switched on when it is used.

The SmartXide DOT laser is a 30W fractionalised CO2 laser with computerized scanner which enables the user to deliver a customised scanned pattern with adjustable parameters. The word DOT stands for Dermal Optical Thermolysis. Again this technology allows the physician to deliver a range of treat-ments, including a soft superficial treatment with no downtime, a moderate treatment requiring a few days of downtime, or a fully ablative traditional laser resurfacing treatment.

BENEFITS OF FRACTIONALISED C02 LASERSAlthough LFSR is relatively new, its benefits of faster recovery time, more precise control of resurfacing depth, and reduced risk of post-procedural problems are already clear. These advances have led to many new fractional resurfacing lasers reaching the market at the same time. Damage to the outer layer of skin is less apparent because unlike in previous de-vices some of the horny layer remains intact during treatment and acts as a natural bandage. This ‘bandage’ also allows the skin to heal much faster than if the whole area was treated as the ‘healthy’ untreated tissue surrounding the treated zones also helps to fill in the damaged area with new cells. Redness is also minimised and downtime is reduced, permitting pa-tients to apply cosmetics five days after treatment. Fractional-ised C02 lasers are also extremely versatile, in that they can be used for the treatment of wrinkles, acne scars, surgical scars, melasma and photodamaged skin.

Post resurfacing

Day 2 laser resurfacing Day 7 post resurfacing

C Neocollagenesis seen histologically at 3 months using hematoxylin and eosin

Before the treatment begins For anxiety and analgesia. For full face resurfacing, I prescribe Valium and Tylex (Paracetemol Codeine) to be given 45 minutes prior to the procedure. One hour before, the patient applies a thin layer of topical anaesthetic to the entire facial area. This is used with particular care in the areas around the eyes and other facial regions not easily covered by an injectable local anaes-thetic.

For herpetic infection: If the patient has a strong history of cold sores, Famvir or Valtrex is given for 10 days starting five days before surgery.

For bacterial infection: If the patient has a strong history of acne, I give Keflex or Augmentin Duo for 7 days, starting the day of surgery.

I do not routinely prescribe antibiotic and antifungal medication. Prior to resurfac-ing, the nurse washes the patient’s entire face and neck to remove the topical anaesthetic.

During the treatment As a dermasurgeon, I normally prefer a deeper form of anaesthesia for full-face resurfacing procedures and use regional nerve blockade and sometimes IV seda-tion to provide more complete pain relief. Since the advent of fractionalised CO2 lasers this is not required but I still feel more comfortable providing regional anaesthesia. I usually treat the cheek area and the area around the mouth first in order to get the patient used to the laser and finally extend down into the neck area. When treating the neck area, we use the lowest energy density. The patient is then placed under a special diode light to try and biomodulate fibrob-last activity, thereby leading to faster and more efficient collagen synthesis.

WHAT HAPPENS DURING A TREATMENT?

After the treatmentIf the patient has pain I resolve this with ice packs. The patients face is covered with Vaseline (petrolatum gel) using a tongue depressor and I ask them to continue doing this every few hours. I used to use dilute vinegar soaks (one teaspoon of distilled white vinegar to two cups water) applied over the layer of Vaseline petrolatum every few hours post-operatively but not with the newer fractionalised devices. Patients are reviewed at 7–10 days post-operatively, during which time the treated areas of the face have mostly returned to normal.

A recent Ailesbury study showed both the ActiveFx and the SmartXide to produce almost equivalent clinical improvement of wrinkles. It is also noted that recovery occurred in all laser treated areas by both devices by day seven. Residual red-ness can remain for a period of 14 days but this is rather unusual at the lower settings. Most patients can use camou-flage make up to cover up the erythema on Day 4-5. It should be noted that most patients do not really feel pain with these devices unless they are moved into higher energies.

Pre resurfacing of congenital nevus

Post AFX resurfacing

Dr. Patrick Treacy, Cosmetic Practitioner is Medical Director of The Ailesbury Clinics, Dublin and Cork. Dr.Treacy has worked in his profession in the United States, Australia, New Zealand, United Kingdom, South Africa, Gibraltar, and Ireland. Dr. Treacy is an international guest speaker and lectures

overseas on fibroblast transplants and the application of radiosurgery to cosmetic medicine. For further information log onto www. ailesburyclinic.ie

CONCLUSION My own conclusion is that fractional-ised laser skin resurfacing (FLSR) with minimal downtime is now considered the most advanced method of ‘softly’ treating patients for skin conditions such photoageing and mild to moder-ate wrinkles.

fractionalised laser skin resurfacing (FLSR) with

minimal downtime is now considered the most

advanced method of ‘softly’ treating patients for skin conditions such photoageing and mild to

moderate wrinkles.