Fractional Photothermolysis
Ablative resurfacing techniques have several problems. Post procedure, there can be pain, oozing, prolonged redness, infection and scarring. There can be a significant amount of time before one can go back out in public (downtime). Resurfacing can also causes scarring and pigmentary (skin coloring) problems. Nonablative treatments cool the outside layer of skin (the epidermis) to deliver more heat to the dermis (underlying layer of skin) to stimulate collagen formation and skin tightening. Improvements are more subtle.
With fractional photothermolysis, instead of across the board even spread of laser damage, the laser device lays down rows of laser spikes 50-70 microns in diameter. Each spike is surrounded by normal tissue so wound healing is accelerated. The spikes penetrate down to 400-700 microns to stimulate dermal collagen growth.
FRAXEL is approved by the FDA for wrinkles around the eyes, pigmented lesions like lentigos (age spots) and solar lentigos (age spots), melasma, and skin resurfacing procedures. FRAXEL is well tolerated with mild associated discomfort. Pain can be eased with anesthetic cream. Rapid healing occurs so treatments can be spaced 7-14 days apart. No infections, bleeding, or oozing occurs. There is no downtime. Patients can shave or wash their face immediately after treatment. Mild redness is 85% gone by 3-7 days, and completely gone by 3 weeks. There is mild swelling for 1-3 days.
Each treatment targets about 17-20% of the skin surface. A full face treatment takes 30 minutes. Neck or hands take 10 minutes. A typical course involves 3-5 treatments of 7-14 days apart or longer. There area is washed with a mild abrasive. Opti Guide Blue is applied to enhance the laser effect. An anesthetic cream is spread over the area and after 45 minutes, the laser procedure is done.
Over recent years facial rejuvenation has become an attractive option for patients looking to enhance the tone, texture and the overall appearance of their skin. Aesthetic concerns such as fine lines, wrinkles, acne scarring and pigment can be addressed and treated with excellent results using ablative treatment modalities. However, these results usually come with long periods of downtime that today’s patients won’t tolerate. The issue of downtime led to the development of non-ablative technologies that promise less downtime but not the same dramatic results.
Fractional resurfacing is a popular new choice and has been receiving a lot of attention. The first generation of fractional technology delivered non-ablative Er:Glass fractionated laser energy onto the skin, covering only a portion of the total scanned area and leaving bridges of intact skin. That sped up healing and made the procedure more comfortable. However, due to the bulk tissue heating, the procedures done with those devices are still quite painful, which is a serious issue for many patients.
When choosing a system for facial rejuvenation the question is this: which laser is delivering enough energy to actually make a visible difference without the low tolerability, long downtime, and multiple treatment series? The ideal rejuvenation procedure offers the patient a quick and relatively painless yet effective treatment of their photo-damaged skin. Patients want the results of ablative technologies with the limited downtime of non-ablative treatments.
Sciton has introduced the ProFractional, which requires little or no anesthesia, fewer treatment sessions, has no consumable components, and offers results comparable to more aggressive treatments. Many patients can return to work the next day. The ProFractional has raised the cosmetic standard for fractional facial rejuvenation and enhances Sciton’s repertoire of reliable, durable lasers that provide excellent clinical outcomes and high patient satisfaction.
Like early fractional devices, Sciton’s ProFractional works on the principle of fractionated photothermolysis. The difference lies in the delivery of the energy. Due to its efficient water absorption characteristics, ProFractional 2940-nm Er:YAG laser is able to penetrate deeply into the dermis by ablating narrow, clean channels to a selected depth and instantly removing necrotic tissue. These channels are surrounded by healthy tissue, speeding healing time and reducing downtime for the patient. As opposed to non-ablative technologies, which create large zones of thermal necrosis, ProFractional energy delivery is limited to the narrow channels, minimizing patient discomfort. The depth and density of these channels can be easily and precisely adjusted to customize treatment for each patient. This is a revolutionary advancement in fractional technology.
By delivering energy deep into the dermal tissue, ProFractional selectively injures collagen molecules, causing wound-healing response and stimulating fibroblast activity. Fibroblasts turn on new collagen production, rejuvenating the collagen matrix and plumping the skin from the inside out. That’s why with ProFractional a practitioner can effectively treat wrinkles, scars, pigment, and skin tone and texture.
Selection of patients must include evaluation of Fitzpatrick Skin Type I-VI. With ProFractional you can safely and comfortably treat patients with Fitzpatrick skin types I through IV. Profractional is an ablative procedure without the coagulation that could lead to long term or permanent hypo- or hyper-pigmentation issues. Experience with darker skin types V and VI is limited at this time. The evidence so far suggests that ProFractional can treat darker skin types without pigmentary changes but it is recommended that a test spot is done on darker skin type patients first. Some patients may experience transitory lines of demarcation with more aggressive ProFractional treatments. These lines resolve in a few days after treatment.
BEFORE TREATMENT
Patients on Retin-A, Retinol, AHA or any other acid peel treatment regimen should be advised to stop using it 3 days before the treatment. All patients, and especially those with a history of herpes simplex infections, should be put on Valtrex or another anti-viral medication.
To prevent post treatment swelling and burning sensation that may occur with some patients, a non-steriodal anti-inflammatory medication like Motrin may be administered 20 minutes prior to the treatment.
CLEAN SKIN
Use a mild cleanser to remove any dirt, makeup, or moisture from the treatment area. Follow with an alcohol wipe. Allow alcohol to evaporate before treatment. Use special care around the eyes.
ANESTHESIA
Use a topical preparation, as needed, to alleviate discomfort for sensitive patients or sensitive areas prior to treatment. Remove before treatment with mild soap and water or an alcohol swab, then plain water. Dry the area thoroughly before treatment.
TREATING AREAS OTHER THAN THE FACE
The epidermis of the neck and chest is both thinner than that of the face and has fewer adnexal healing structures. Peels beyond 100 microns in depth and 5% in density are not recommended as a single event. Re-treatment may occur as early as 8 weeks. This procedure may not be ideal for patients with known healing deficiencies.
The epidermis of the hands and general body surfaces is both thinner than that of the face and has fewer adnexal healing structures. Peels beyond 100 microns in depth and 5% in density are not recommended as a single event. Re-treatment may occur as early as 8 weeks.
The ablation depth required depends on the condition to be treated. The recommended ablation depth for general facial rejuvenation with ProFractional is 75 to 200 mocrons done in a single pass. Deeper penetration may be required for deep wrinkles, particularly for perioral or periorbital areas. The laser may be manually set to the required ablation depth.
For mild scars a shallow depth of 100 microns is effective. For aggressive treatment of deep scars, depth settings may be increased to 400 or even 800 microns. Individual scars can be treated as minimally or as aggressively as necessary to create an overall evenness of the skin. A single pass treatment is recommended for most patients with scars.
Patient response can vary. Generally, treating at higher depths accounts for higher energy delivery and longer healing. Ablation depth should be selected based on the condition treated, expected outcome, patient pain tolerance, and expected downtime for healing after assessing the individual patient needs. The desired response is erythema within a few minutes of laser application. The redness and healing (often similar in appearance to varying degrees of sunburn) will increase with the depth of ablation and will vary by patient. Setting ablation depth higher than needed may lead to undesired thermal damage and prolonged downtime.
The treatment area required depends on the condition to be treated. The recommended coverage area for facial rejuvenation with ProFractional is 2 to 15% of the scanned area. For scars, 4 or 5% treatment area is recommended.
TREATMENT GOALS
Patient response can vary. Generally, the healthier the skin and/or the patient, the less the redness from treatment and the faster the healing response, Ablation depth and treatment area should be selected based on expected outcome, patient pain tolerance, and expected downtime for healing after assessing the individual patient needs. The desired response is erythema within a few minutes of laser application. Incidental pinpoint bleeding may occur which will stop within a few minutes after the treatment. The redness and healing (often similar in appearance to varying degrees of sunburn) will increase with the ablation depth and the treatment area, and will vary by patient.
OBSERVATIONS
Erythema, edema, and a sunburn sensation will be noticed in the treatment area for a few days after the treatment. Incidental pinpoint bleeding may occur, which will subside within a short time after the treatment without any intervention. Occasional patterned hyperpigmentation may occur but it will resolve in a few days. The healing time will differ, depending on the treatment settings used.
INTERVENTION
Immediate post-treatment care includes a simple moisturizer, like Aquaphor or Elta. It should be applied for a least 24 hours after the treatment. A cooling mist spray can also help cool and comfort the skin as the moisture evaporates. It is important for the treated area to remain soft and pliable during healing. Sunscreen should be applied for a least a month after initial healing, and it is recommended to avoid sun exposure until redness has resolved. Physical blocks, such as a hat or a scarf and sunglasses, should also be used.
The day after the treatment it is recommended to wash the treated area with a mild, gentle soap-free cleanser (Cetaphil cleanser) and then apply a moisturizer (Cetaphil or Neutrogena moisturizer). The moisturizer should be re-applied as necessary to prevent the area from becoming dry and crusted. Sunscreen should be applied on top of moisturizer.
It is recommended to put patients on anti-viral medication (Valtrex or Famvir) after treatment.
Patients should be advised not to use Retin-A, Retinol or AHA for 1-2 weeks following the treatment. Patients should not participate in any strenuous physical exercise for 24 hours following the treatment.
Patients should be advised not to use any skin care products except for the ones recommended by the physician to avoid possible allergic reactions. For example, antibiotic ointments, like Bacitracin or Neopsporin, can cause extreme swelling. And it is not recommended to apply makeup prior to initial healing.
If redness persists for several days, over-the-counter Hydrocortisone 1% cream or another mild steroid may be used as directed. In case of prolonged swelling, cortcosteroids (Methylprednisolone or Medrol dosepak) can be prescribed. If itching occurs, an antihistamine (Benadryl) can be used to alleviate discomfort.
INTERVAL
Recommended time interval between treatments is 3-6 weeks with the average of 4 weeks. Re-treatment in an earlier period may create additional discomfort or sensation at time of treatment. For facial rejuvenation a short series of up to three treatments may be recommended for optimal results. Acne scars may require four or five treatments using conservative protocols.
CONCURRENT PROCEDURES
ProFractional can be comgined with Microlaser Peel for more enhanced results in one treatment. The recommended combination sequence is doing Microlaser Peel first, followed by ProFractional. This sequence provides the total maximum efficacy of the combined treatment. Pre- and post-treatment care is standardized. A topical numbing cream can be used before MLP, immediately followed by ProFractional. Moisturizer, a cooling mist spray, or both after the treatment is recommended.
CONCLUSION
Patients choose ProFractional over full face resurfacing because it provides a more comfortable treatment experience and rapid healing with very little downtime. Improvement increases after each treatment but even after just one treatment the patient will notice a difference. There is no need for the patient to commit to a large number of treatment sessions, making the procedure very patient-freiendly. Collagen remodeling takes time, so the full effect of a single treatment is not immediately apparent.
Ablative resurfacing techniques have several problems. Post procedure, there can be pain, oozing, prolonged redness, infection and scarring. There can be a significant amount of time before one can go back out in public (downtime). Resurfacing can also causes scarring and pigmentary (skin coloring) problems. Nonablative treatments cool the outside layer of skin (the epidermis) to deliver more heat to the dermis (underlying layer of skin) to stimulate collagen formation and skin tightening. Improvements are more subtle.
With fractional photothermolysis, instead of across the board even spread of laser damage, the laser device lays down rows of laser spikes 50-70 microns in diameter. Each spike is surrounded by normal tissue so wound healing is accelerated. The spikes penetrate down to 400-700 microns to stimulate dermal collagen growth.
FRAXEL is approved by the FDA for wrinkles around the eyes, pigmented lesions like lentigos (age spots) and solar lentigos (age spots), melasma, and skin resurfacing procedures. FRAXEL is well tolerated with mild associated discomfort. Pain can be eased with anesthetic cream. Rapid healing occurs so treatments can be spaced 7-14 days apart. No infections, bleeding, or oozing occurs. There is no downtime. Patients can shave or wash their face immediately after treatment. Mild redness is 85% gone by 3-7 days, and completely gone by 3 weeks. There is mild swelling for 1-3 days.
Each treatment targets about 17-20% of the skin surface. A full face treatment takes 30 minutes. Neck or hands take 10 minutes. A typical course involves 3-5 treatments of 7-14 days apart or longer. There area is washed with a mild abrasive. Opti Guide Blue is applied to enhance the laser effect. An anesthetic cream is spread over the area and after 45 minutes, the laser procedure is done.
Over recent years facial rejuvenation has become an attractive option for patients looking to enhance the tone, texture and the overall appearance of their skin. Aesthetic concerns such as fine lines, wrinkles, acne scarring and pigment can be addressed and treated with excellent results using ablative treatment modalities. However, these results usually come with long periods of downtime that today’s patients won’t tolerate. The issue of downtime led to the development of non-ablative technologies that promise less downtime but not the same dramatic results.
Fractional resurfacing is a popular new choice and has been receiving a lot of attention. The first generation of fractional technology delivered non-ablative Er:Glass fractionated laser energy onto the skin, covering only a portion of the total scanned area and leaving bridges of intact skin. That sped up healing and made the procedure more comfortable. However, due to the bulk tissue heating, the procedures done with those devices are still quite painful, which is a serious issue for many patients.
When choosing a system for facial rejuvenation the question is this: which laser is delivering enough energy to actually make a visible difference without the low tolerability, long downtime, and multiple treatment series? The ideal rejuvenation procedure offers the patient a quick and relatively painless yet effective treatment of their photo-damaged skin. Patients want the results of ablative technologies with the limited downtime of non-ablative treatments.
Sciton has introduced the ProFractional, which requires little or no anesthesia, fewer treatment sessions, has no consumable components, and offers results comparable to more aggressive treatments. Many patients can return to work the next day. The ProFractional has raised the cosmetic standard for fractional facial rejuvenation and enhances Sciton’s repertoire of reliable, durable lasers that provide excellent clinical outcomes and high patient satisfaction.
Like early fractional devices, Sciton’s ProFractional works on the principle of fractionated photothermolysis. The difference lies in the delivery of the energy. Due to its efficient water absorption characteristics, ProFractional 2940-nm Er:YAG laser is able to penetrate deeply into the dermis by ablating narrow, clean channels to a selected depth and instantly removing necrotic tissue. These channels are surrounded by healthy tissue, speeding healing time and reducing downtime for the patient. As opposed to non-ablative technologies, which create large zones of thermal necrosis, ProFractional energy delivery is limited to the narrow channels, minimizing patient discomfort. The depth and density of these channels can be easily and precisely adjusted to customize treatment for each patient. This is a revolutionary advancement in fractional technology.
By delivering energy deep into the dermal tissue, ProFractional selectively injures collagen molecules, causing wound-healing response and stimulating fibroblast activity. Fibroblasts turn on new collagen production, rejuvenating the collagen matrix and plumping the skin from the inside out. That’s why with ProFractional a practitioner can effectively treat wrinkles, scars, pigment, and skin tone and texture.
Selection of patients must include evaluation of Fitzpatrick Skin Type I-VI. With ProFractional you can safely and comfortably treat patients with Fitzpatrick skin types I through IV. Profractional is an ablative procedure without the coagulation that could lead to long term or permanent hypo- or hyper-pigmentation issues. Experience with darker skin types V and VI is limited at this time. The evidence so far suggests that ProFractional can treat darker skin types without pigmentary changes but it is recommended that a test spot is done on darker skin type patients first. Some patients may experience transitory lines of demarcation with more aggressive ProFractional treatments. These lines resolve in a few days after treatment.
BEFORE TREATMENT
Patients on Retin-A, Retinol, AHA or any other acid peel treatment regimen should be advised to stop using it 3 days before the treatment. All patients, and especially those with a history of herpes simplex infections, should be put on Valtrex or another anti-viral medication.
To prevent post treatment swelling and burning sensation that may occur with some patients, a non-steriodal anti-inflammatory medication like Motrin may be administered 20 minutes prior to the treatment.
CLEAN SKIN
Use a mild cleanser to remove any dirt, makeup, or moisture from the treatment area. Follow with an alcohol wipe. Allow alcohol to evaporate before treatment. Use special care around the eyes.
ANESTHESIA
Use a topical preparation, as needed, to alleviate discomfort for sensitive patients or sensitive areas prior to treatment. Remove before treatment with mild soap and water or an alcohol swab, then plain water. Dry the area thoroughly before treatment.
TREATING AREAS OTHER THAN THE FACE
The epidermis of the neck and chest is both thinner than that of the face and has fewer adnexal healing structures. Peels beyond 100 microns in depth and 5% in density are not recommended as a single event. Re-treatment may occur as early as 8 weeks. This procedure may not be ideal for patients with known healing deficiencies.
The epidermis of the hands and general body surfaces is both thinner than that of the face and has fewer adnexal healing structures. Peels beyond 100 microns in depth and 5% in density are not recommended as a single event. Re-treatment may occur as early as 8 weeks.
The ablation depth required depends on the condition to be treated. The recommended ablation depth for general facial rejuvenation with ProFractional is 75 to 200 mocrons done in a single pass. Deeper penetration may be required for deep wrinkles, particularly for perioral or periorbital areas. The laser may be manually set to the required ablation depth.
For mild scars a shallow depth of 100 microns is effective. For aggressive treatment of deep scars, depth settings may be increased to 400 or even 800 microns. Individual scars can be treated as minimally or as aggressively as necessary to create an overall evenness of the skin. A single pass treatment is recommended for most patients with scars.
Patient response can vary. Generally, treating at higher depths accounts for higher energy delivery and longer healing. Ablation depth should be selected based on the condition treated, expected outcome, patient pain tolerance, and expected downtime for healing after assessing the individual patient needs. The desired response is erythema within a few minutes of laser application. The redness and healing (often similar in appearance to varying degrees of sunburn) will increase with the depth of ablation and will vary by patient. Setting ablation depth higher than needed may lead to undesired thermal damage and prolonged downtime.
The treatment area required depends on the condition to be treated. The recommended coverage area for facial rejuvenation with ProFractional is 2 to 15% of the scanned area. For scars, 4 or 5% treatment area is recommended.
TREATMENT GOALS
Patient response can vary. Generally, the healthier the skin and/or the patient, the less the redness from treatment and the faster the healing response, Ablation depth and treatment area should be selected based on expected outcome, patient pain tolerance, and expected downtime for healing after assessing the individual patient needs. The desired response is erythema within a few minutes of laser application. Incidental pinpoint bleeding may occur which will stop within a few minutes after the treatment. The redness and healing (often similar in appearance to varying degrees of sunburn) will increase with the ablation depth and the treatment area, and will vary by patient.
OBSERVATIONS
Erythema, edema, and a sunburn sensation will be noticed in the treatment area for a few days after the treatment. Incidental pinpoint bleeding may occur, which will subside within a short time after the treatment without any intervention. Occasional patterned hyperpigmentation may occur but it will resolve in a few days. The healing time will differ, depending on the treatment settings used.
INTERVENTION
Immediate post-treatment care includes a simple moisturizer, like Aquaphor or Elta. It should be applied for a least 24 hours after the treatment. A cooling mist spray can also help cool and comfort the skin as the moisture evaporates. It is important for the treated area to remain soft and pliable during healing. Sunscreen should be applied for a least a month after initial healing, and it is recommended to avoid sun exposure until redness has resolved. Physical blocks, such as a hat or a scarf and sunglasses, should also be used.
The day after the treatment it is recommended to wash the treated area with a mild, gentle soap-free cleanser (Cetaphil cleanser) and then apply a moisturizer (Cetaphil or Neutrogena moisturizer). The moisturizer should be re-applied as necessary to prevent the area from becoming dry and crusted. Sunscreen should be applied on top of moisturizer.
It is recommended to put patients on anti-viral medication (Valtrex or Famvir) after treatment.
Patients should be advised not to use Retin-A, Retinol or AHA for 1-2 weeks following the treatment. Patients should not participate in any strenuous physical exercise for 24 hours following the treatment.
Patients should be advised not to use any skin care products except for the ones recommended by the physician to avoid possible allergic reactions. For example, antibiotic ointments, like Bacitracin or Neopsporin, can cause extreme swelling. And it is not recommended to apply makeup prior to initial healing.
If redness persists for several days, over-the-counter Hydrocortisone 1% cream or another mild steroid may be used as directed. In case of prolonged swelling, cortcosteroids (Methylprednisolone or Medrol dosepak) can be prescribed. If itching occurs, an antihistamine (Benadryl) can be used to alleviate discomfort.
INTERVAL
Recommended time interval between treatments is 3-6 weeks with the average of 4 weeks. Re-treatment in an earlier period may create additional discomfort or sensation at time of treatment. For facial rejuvenation a short series of up to three treatments may be recommended for optimal results. Acne scars may require four or five treatments using conservative protocols.
CONCURRENT PROCEDURES
ProFractional can be comgined with Microlaser Peel for more enhanced results in one treatment. The recommended combination sequence is doing Microlaser Peel first, followed by ProFractional. This sequence provides the total maximum efficacy of the combined treatment. Pre- and post-treatment care is standardized. A topical numbing cream can be used before MLP, immediately followed by ProFractional. Moisturizer, a cooling mist spray, or both after the treatment is recommended.
CONCLUSION
Patients choose ProFractional over full face resurfacing because it provides a more comfortable treatment experience and rapid healing with very little downtime. Improvement increases after each treatment but even after just one treatment the patient will notice a difference. There is no need for the patient to commit to a large number of treatment sessions, making the procedure very patient-freiendly. Collagen remodeling takes time, so the full effect of a single treatment is not immediately apparent.
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