LOS ANGELES — Non- or minimally ablative facial resurfacing offers patients the results they desire without extended downtime, said several presenters at the annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery.
"Most of my patients want nonsurgical treatments with no downtime," said Elizabeth Rostan, M.D., a cosmetic dermatologist in Charlotte, N.C. "In my community, I can't give away a CO2 laser resurfacing."
Most of Dr. Rostan's fractional resurfacing patients are women who want treatment for photoaging, acne scars, or melasma. "Many of these patients are the ones for whom you might consider intense pulsed light. It would burn off the pigmentary lesions, but it would not give you the same improvement you see in fine wrinkling."
In terms of both efficacy and recovery, fractional resurfacing falls between nonablative and ablative techniques.
"The results we get are better than what we would see with a nonablative technique, but not quite as good as what we would see with an ablative resurfacing," she said. "However, with the fractional resurfacing, patients aren't experiencing the 2 weeks of downtime that they would with a CO2 laser resurfacing, either."
The device directs its energy along the path of a computer-generated pattern, producing about 2,000 tiny holes (microthermal injury zones) per square centimeter. Because the areas of injury are so tiny, "you are treating about 20% of the skin surface, leaving 80% to renew and heal," Dr. Rostan said.
The laser intensity can be varied for different applications. The 8-J/cm
Patients require a topical anesthetic, which takes about 1 hour to achieve maximum effect. The actual resurfacing procedure lasts about 20 minutes, she said. However, three to five treatments, spaced about a week apart, are usually necessary to achieve the desired result.
Afterward, there is mild erythema and edema. "Patients are usually pink for 2 days, but it can sometimes last as long as 4 days," Dr. Rostan said. "But they can easily cover it with makeup and be back to work the day after the procedure."
Fractional resurfacing is also a good alternative for elderly patients or for those with health issues that might compromise wound healing in an ablative resurfacing, she said. "I've done a healthy 87-year-old, as well as a transplant patient, with no adverse effects."
But she said she would carefully consider patients with scleroderma or rheumatoid problems. "Anyone who you'd have concerns about for laser resurfacing, you would also have to think about for fractional resurfacing."
The in-office erbium laser provides a one-time minimally ablative resurfacing with results similar to a whole course of intense fractional resurfacing, said James Newman, M.D., a facial plastic surgeon from San Mateo, Calif.
"I began using office-based laser treatments in response to patients' wanting a treatment without much downtime or prolonged healing, but who also didn't want to come into the office four or five times to treat a brown spot," he said.
The small erbium lasers are also relatively inexpensive (about $30,000), which allows the physician to rapidly recoup the investment and offer patients a modestly priced treatment. "For the removal of brown spots from the face or hands, it would be about $300, and for a perioral regional resurfacing, maybe $1,000 or less," he said.
The small, portable lasers have lower fluences (about 5–7 J/cm
"They also have a pulse duration of about 300 milliseconds, and because they are lower powered, they can't go as fast. The maximum repetition rate is about 2 Hz," Dr. Newman said.
This makes the in-office erbium laser good for localized or regional (perioral or periorbital) resurfacing, but not appropriate for a full-face procedure, he said.
The main indications for this device are solar lentigines, early elastosis of periorbital skin, sebaceous hyperplasia, scar modification, and epidermal keratosis, Dr. Newman said. Downtime is 4–7 days, "similar to what you would expect with intense fractional resurfacing or a medium-depth chemical peel."
"If they can come in and get it over with in one treatment, and then put up with a week at most of healing, patients will be very happy with this," he said.
The plasma resurfacer gives similar results, without the epidermal sloughing that the erbium laser generates, said Edgar Fincher, M.D., a dermatologic surgeon in Los Angeles.
These devices feature a nitrogen canister that pumps the gas into a handpiece, where a radiofrequency generator heats it and delivers it through a nozzle to the skin surface. They can deliver energy ranging from 1 to 4 J/cm
Like a CO2 or erbium laser, the plasma resurfacer causes an immediate zone of thermal damage, with heat dissipation into the deeper tissues, stimulating fibroblast action.