REVIEW ARTICLE

Evolution of Laser Skin Resurfacing: From Scanning to Fractional Technology Arif Aslam, MBChB, MRCP (UK),* and Tina S. Alster, MD†

BACKGROUND Laser skin resurfacing was popularized for photoaged and scarred skin 2 decades ago. Since then, several technologic advancements have led to a new generation of delivery systems that produce excellent clinical outcomes with reduced treatment risks and faster recovery times. OBJECTIVES To review the evolution of laser skin resurfacing from pulsed and scanned infrared laser technology to the latest techniques of nonablative and ablative fractional photothermolysis. MATERIALS AND METHODS

All published literature regarding laser skin resurfacing was analyzed and collated.

RESULTS A comprehensive review of laser skin resurfacing was outlined and future developments in the field of fractionated laser skin treatment were introduced. CONCLUSION Laser skin resurfacing has evolved such that excellent clinical outcomes in photodamaged and scarred skin are achieved with rapid wound healing. As newer devices are developed, the applications of this technology will have a dramatic effect on the delivery of medical and aesthetic dermatology. The authors have indicated no significant interest with commercial supporters.

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uring the mid-to-late 1990s, the gold standard laser treatment for facial rhytides and acne scars was the carbon dioxide (CO2) laser treatment. This laser was used by most practitioners in a pulsed or scanned mode and resulted in removal of the entire epidermis and a controlled section of the dermis. Postoperative recovery required 7 to 10 days for reepithelialization and several additional weeks for complete resolution of erythema. Potential adverse effects such as skin infections and pigmentary changes were observed as a consequence of the extended recovery period. The erbium: yttrium aluminium garnet (Er:YAG) laser was introduced during the same period to counter these drawbacks. Its higher water absorption coefficient was capable of more superficial ablation than the CO2 laser, but resulted in reduced heat-induced collagen contraction and dermal remodeling. The

prolonged recovery and potential side effects from ablative skin resurfacing using CO2 and Er:YAG laser systems led to the development and use of infrared nonablative lasers. Whereas recovery rates and side effects were minimized with these nonablative systems, they exerted even less impact on dermal collagen and were unable to produce equivalent clinical results to the ablative laser systems. In the early new millennium, a laser skin resurfacing renaissance occurred with the development of fractionated laser technology with its unique ability to produce microscopic zones of thermal injury in the skin that enabled rapid healing without sacrificing clinical effect. Fractionated lasers have now become the mainstay of skin resurfacing treatment with excellent cosmetic outcomes and low risk profile (Table 1).

*Department of Dermatology, Salford Royal NHS Foundation Trust, Salford, Manchester; †Washington Institute of Dermatologic Laser Surgery, Washington, DC

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© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2014;40:1163–1172 DOI: 10.1097/01.DSS.0000452648.22012.a0

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LASER SKIN RESURFACING: SCANNING TO FRACTIONAL

TABLE 1. Summary of Different Laser Skin Resurfacing Technologies

Laser Category Pulsed/scanned ablative

Treatment Protocol

Laser Specifics CO2 (10,600 nm)

Single treatment

Er:YAG (2940 nm)

Clinical Indications Facial photodamage (dyschromia/lentigines/ rhytides) Facial atrophic scars Epidermal lesions (seborrheic keratoses/ verrucae) Dermal lesions (xanthelasma/syringomas/ rhinophyma)

Infrared nonablative

1320-nm Nd:YAG

Treatment series (3–6 monthly)

1450-nm diode

Mild facial/nonfacial photodamage Mild facial/nonfacial atrophic scars

1540-nm Er:glass Fractionated ablative

Fractional CO2 (10,500 nm)

Single treatment

Fractional Er:YAG (2940 nm)

Facial/nonfacial photodamage (dyschromia/ lentigines/rhytides) Facial/nonfacial scars (atrophic/traumatic/ burns) Epidermal lesions (seborrheic keratoses/ verrucae) Dermal lesions (xanthelasma/syringomas/ rhinophyma)

Fractionated nonablative

Fractional diode (1410 nm)

Treatment series (3–5 monthly)

Fractional Nd:YAG (1440 nm, 1540 nm)

Facial/nonfacial scars (atrophic/traumatic/ burns)

Fractional erbium-doped fiber (1550 nm)

+/2 Melasma

Fractional thulium fiber (1927 nm)

Striae atrophicae

Ablative Laser Skin Resurfacing Carbon dioxide lasers emit light at 10,600 nm in the far infrared electromagnetic spectrum. The emitted energy is preferentially absorbed by intracellular water, which leads to rapid heating and vaporization of tissue. Carbon dioxide lasers were introduced in the 1960s and were initially used in the continuous wave (CW) mode for cutting tissue.1 These CW systems produced significant (unwanted) thermal damage to the surrounding tissue and thus spurred the development of highenergy pulsed and scanned systems in the early 1990s.2–8 The latter pulsed CO2 lasers caused discrete areas of tissue vaporization while minimizing collateral thermal injury that was associated with fewer undesirable side effects such as scarring and hypopigmentation.9–13 The Er:YAG laser was approved for skin resurfacing by the Food and Drug Association (FDA) in 1996. Its

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Facial/nonfacial photodamage

2940-nm wavelength has an even higher coefficient of absorption in water than does the CO2 system, thereby permitting it to ablate tissue both superficially and deeply with reduced collateral thermal damage.14–19 At typical Er:YAG treatment parameters, not only is dermal heating limited with subsequent reduced effect on tissue tightening, but postoperative healing times are shortened and fewer side effects are seen compared with CO2 lasers.20 Cosmetic Applications of Pulsed and Scanned Ablative Lasers (CO2, Er:YAG) The most common use of pulsed and scanned laser skin resurfacing was for photoaged skin characterized by irregular texture, color, and rhytides. Numerous studies using CO2 and Er:YAG lasers have been performed to evaluate the efficacy and safety of this technique. Most studies demonstrated marked (80% or greater) improvement in treated areas, with the

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ASLAM AND ALSTER

observed, particularly with CO2 laser resurfacing,21 such that dermatochalasis was shown to improve.22 The significant collagen shrinkage seen clinically (and histologically) after CO2 laser treatment (which was associated to some degree with the amount of residual thermal damage in the dermis) proved to be responsible for the tightening effect.12

Side Effects and Complications of Ablative Lasers

Figure 1. Photodamaged facial skin with prominent rhytides before (A) and 6 months after 1 pulsed CO2 laser skin resurfacing procedure (B).

periorbital and perioral regions showing the best results and areas of dynamic wrinkling, such as the glabella, showing the least3–7,17,18 (Figure 1A,B). Treatment of similarly photodamaged nonfacial (neck/chest) skin was limited because of concerns of slow re-epithelialization in these areas with untoward side effects. However, atrophic acne and traumatic scars were significantly diminished from ablative laser skin resurfacing and, as such, the laser technique was adopted by many to replace older scar revision techniques including dermabrasion and surgical excision.8,9,19 Measurable collagen tightening was

Both short-term and long-term side effects have been reported to occur after ablative laser skin resurfacing using either CO2 or Er:YAG lasers.20,23–27 Commonly expected reactions include exfoliation, fragility, edema, and erythema, which can last more than 6 months24 Milia and acne are short-term side effects that are more commonly seen in patients with a history of acne and in those receiving laser scar revision.23 Bacterial infections are infrequent, but have a higher incidence when occlusive postoperative dressings are used or with poor postoperative wound management.28 Reactivation of latent herpes simplex infection is also possible and warrants the use of prophylactic oral antiviral therapy for perioral treatment.29 One of the most common side effects is transient hyperpigmentation, which varies in severity and longevity with intrinsic skin phototype, but is relatively frequent in patients with darker skin tones. The use of either laser at less aggressive treatment parameters typically results in a lower rate of postinflammatory hyperpigmentation.27 More rarely, delayed hypopigmentation can occur and manifest 6 to 12 months after post-treatment (when erythema has resolved).23 Again, the risk of hypopigmentation is rarer after Er:YAG laser treatment.26 Hypertrophic scarring is another rare complication that has been attributed to aggressive laser technique, poor postoperative care, untreated infection, or a combination thereof. Finally, ectropion formation is another potentially serious (but rare) complication, and those who have had previous lower eyelid surgery are at increased risk.28 Nonablative Laser Skin Resurfacing Nonablative laser technology was subsequently developed in an attempt to limit the prolonged postoperative

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LASER SKIN RESURFACING: SCANNING TO FRACTIONAL

recovery period associated with ablative laser skin resurfacing. Most of the nonablative systems emit light in the infrared portion of the electromagnetic spectrum including the intense pulsed light (500–1200 nm), Nd: YAG (1064 and 1320 nm), diode (980 and 1450 nm), and Er:glass (1540 nm) lasers. These nonablative laser systems target dermal water, which leads to collagen heating and subsequent dermal remodeling, but without production of an external wound due to concomitant application of epidermal cooling that prevents tissue vaporization from occurring. Cosmetic Applications of Nonablative Lasers Facial and nonfacial rhytides and scars have been successfully treated with nonablative lasers. Because nonablative lasers have limited thermal tissue effect, treatments are commonly delivered in a series of 3 or more monthly sessions to produce mild clinical results. Most studies reported clinical improvement averaging 30% to 50% after a series of treatments.29–35 Side Effects and Complications of Nonablative Lasers The biggest advantage of nonablative laser systems is their relatively low incidence of adverse effects and negligible postoperative recovery periods.36 Immediate post-treatment erythema and edema is typically observed and spontaneously resolves within 24 hours. Rarely, blister formation is seen as a consequence of inadequate tissue cooling during laser irradiation. In contrast to the ablative systems, nonablative lasers can be safely applied to nonfacial areas because there is no epidermal disruption and, thus, areas with a relative paucity of pilosebaceous glands necessary for reepithelialization (such as the neck and anterior chest) can be safely treated. Despite their clinical limitations, the use of nonablative lasers is often favored by patients who are unwilling or unable to schedule the requisite time for recovery. Fractionated Laser Skin Resurfacing Fractional resurfacing is a novel variation on the theory of selective photothermolysis in which

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microscopic treatment zones of controlled width, depth, and densities are created in the skin.37 Fractional photothermolysis involves the delivery of narrow beams of high-energy light to the skin in a pixilated pattern. Only fractions of skin are treated by inducing small 3-dimensional zones of thermal damage known as “microscopic thermal zones” (MTZs). There is sufficient energy in the fractionated columns of the laser beam to induce thermal damage without compromising the adjacent tissue. The surrounding skin acts as a structural reservoir that allows fast epidermal repair through migration of the untreated viable tissue. Similar to the ablative and nonablative lasers discussed above, the target chromophore for the fractionated devices is watercontaining tissue. Both ablative and nonablative fractionated devices have been developed with the key difference being the preservation of the stratum corneum and precisely confined epidermal and dermal coagulation without vaporization in nonablative systems. In contrast, fractionated ablative systems involve epidermal and dermal vaporization of microscopic columns of tissue with a surrounding layer of coagulation. The concept of focal microscopic treatment zones surrounded by islands of spared skin is the fundamental unifying theme of fractionated photothermolysis and is essential for the improved safety profile and shortened recovery times seen with these devices. Histologic studies detailing the effects of nonablative fractionated laser treatment (using a 1550-nm erbiumdoped fiber laser) on skin have shown well-defined columns of epidermal and dermal thermal damage (microthermal zones or MTZs) under an intact stratum corneum within 1 hour of laser irradiation.38 Within 24 hours, there is migration of viable cells from the periphery of the MTZs and the formation of microscopic epidermal necrotic debris (MENDs). The composition of MENDs (thermally damaged epidermal and dermal cells including elastin and melanin) is the likely mechanism for the efficacy of fractionated photothermolysis in the treatment of surface textural irregularities (rhytides and scars) and pigmentary conditions. The MENDs undergo transepidermal extrusion between 3 and 7 days (commensurate with reepithelialization).39 Cellular markers of dermal

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wound healing and neocollagenesis such as heat shock protein 70, collagen III, proliferating cell nuclear antigen, and alpha-smooth muscle actin are expressed within the treatment areas.40 Heat shock protein 47, required for collagen remodeling and maturation, becomes generalized throughout the dermis at 1 month and may persist for up to 3 months, indicating ongoing tissue remodeling. Similar histologic results have been reported with ablative fractionated lasers, but with epidermal and stratum corneum involvement.41 The well-defined areas of epidermal coagulation and vaporization are quickly repaired by the surrounding and underlying viable (untreated) cells, thereby significantly shortening the recovery period compared with pulsed and scanned systems. Ablative and nonablative fractionated lasers have been developed and are being used to treat a variety of conditions. Fractionated technology has virtually replaced pulsed and scanned ablative and nonablative systems due in large part to their excellent clinical effects and low risk profiles.

Cosmetic Applications of Nonablative Fractional Photothermolysis Significant improvement of facial and nonfacial rhytides, scars, and dyspigmentation has been demonstrated in several published studies. By increasing the energy delivered, greater depth of dermal penetration (and tissue effect) is achieved. Similarly, increasing the density (or area of coverage) also serves to increase the clinical effect without significantly altering postoperative recovery. In general, nonablative laser skin treatment of facial skin has shown superior results to nonfacial (e.g., neck, chest, dorsal hand) skin; however, good clinical outcomes have been achieved in a variety of conditions and treatment areas (including traumatic scars and abdominal striae). Clinical assessment scores corresponding to 50% to 75% improvement or more are typically reported after a series of 3 or more treatments on facial rhytides42,43 (Figure 2A,B). Similarly, atrophic acne scars have shown remarkable improvement (50% and higher) after a treatment series using either a 1550-nm erbium-doped fiber laser or a number of other fractionated diode and Nd:YAG lasers (1410– 1540 nm)44–47 (Figure 3A,B). Additionally, nonablative

Figure 2. Photodamaged skin with rhytides and lentigines before (A) and after 3 nonablative fractionated laser treatments (B).

fractionated lasers have been used with success to improve the appearance of large pores and hypertrophic scars from a variety of causes.48–51 Clinical experience with nonablative treatment of melasma has been mixed, with the risk of pigment recurrence or worsening an ongoing concern.52–55 Reduced number of melanocytes in post-treatment specimens may account for the favorable clinical responses observed, but further controlled clinical trials are indicated to better determine the mechanisms at play.56 In general, improvement in skin tone is less pronounced in patients with darker skin tones and is influenced by seasonal variations (ultraviolet light exposure). As such, it remains critical to counsel patients with melasma on the importance of ongoing sun protection.57,58 Topical skin brighteners also can

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nonablative fractionated devices.59–61 A single ablative laser treatment typically produces equivalent or greater clinical improvement than a series of nonablative treatments. As such, ablative fractionated laser skin resurfacing is performed as a single procedure (but can be repeated at a later date if clinically necessary). Minor differences in clinical outcomes have been observed between fractionated CO2 and Er:YAG systems, but have generally yielded similar improvements in skin color and texture with quick recovery times and high patient satisfaction.62 Ablative CO2 and Er:YAG fractionated lasers have also been used to treat acne scars with excellent clinical results.63–65 Even severe scars and those located in body locations previously off-limits for ablative laser treatment (eg, back, shoulders, chest) have shown significant improvement66 (Figure 4A,B).

Figure 3. Atrophic facial acne scars before (A) and 6 months after 3 nonablative fractionated laser treatments (B).

be used synergistically with nonablative fractional resurfacing to enhance the overall clinical effect. In general, a gentle treatment approach (e.g., lower laser fluences/densities, fewer passes) is recommended to minimize the risk of postinflammatory hyperpigmentation.

Cosmetic Applications of Ablative Fractional Photothermolysis Even more impressive improvement of photoaged skin has been demonstrated with ablative CO2 and Er:YAG fractionated laser technology compared with the

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Figure 4. Atrophic acne scars on the back before (A) and 1 month after 1 ablative fractionated CO2 laser treatment (B).

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after nonablative treatment is defined as redness lasting more than 4 days and has been reported in less than 1% of patients. Erythema that persists longer than 1 month after ablative fractional resurfacing is considered prolonged and affects nearly 12.5% of patients.70 The intensity and duration of post-fractional laser erythema has been shown to diminish with the use of a 590-nm wavelength light-emitting diode system.71

Figure 5. Photodamaged neck and chest skin before (A) and 1 month after 1 ablative fractionated CO2 laser treatment (B).

Similarly, although other delicate areas (e.g., neck) and patients with darker skin tones have been successfully treated with ablative fractionated technology, caution is advised because of the relative paucity of pilosebaceous units in the former and risk of postinflammatory hyperpigmentation in the latter67,68 (Figure 5A,B). Side Effects and Complications of Fractionated Lasers Fractionated lasers have proven to be safer for skin resurfacing with fewer side effects than pulsed and scanned ablative lasers. Complications can still occur, but tend to be less severe and shorter in duration. Immediate post-treatment erythema and edema after nonablative fractional resurfacing is expected and usually resolves within 3 days.69 Prolonged erythema

Herpes simplex virus (HSV) infection is the most common infectious complication after ablative or nonablative fractional laser resurfacing with reported incidences of up to 2%.70 The clinical picture is often obscured by postoperative erythema and edema such that patients may simply demonstrate superficial erosions accompanied by pain. Antiviral prophylaxis can minimize the rate of reactivation to less than 0.5% and should be administered in patients with a history of facial HSV or whenever perioral laser treatment is performed.70 In contrast, the incidence of bacterial infection after fractionated laser treatment is extremely low with an incidence of 0.1% of all treated cases.70 Antibacterial prophylaxis is not typically necessary for nonablative treatment; however, it is often recommended for ablative fractionated laser resurfacing. Transient acneiform eruptions after fractional skin resurfacing occur at a rate of 2% to 10% and are particularly common in patients with a history of acne.70 In moderate-to-severe acne flares, a short course of an oral tetracycline-based antibiotic is often helpful and can be prescribed during subsequent treatments to prevent outbreaks.70 Milia may occur in nearly 20% of treated patients and can be reduced by avoidance of occlusive emollients.70 In contrast to pulsed and scanned skin resurfacing lasers, fractional lasers produce much lower rates of postinflammatory hyperpigmentation. The incidence depends on the system used, the parameters applied, and the skin types treated, but can be above 12% in patients with darker skin phototypes (Fitzpatrick III–VI).72 Delayed onset hypopigmentation is an extremely rare complication of ablative fractional resurfacing with only 1 case of transient hypopigmentation reported.73

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LASER SKIN RESURFACING: SCANNING TO FRACTIONAL

Hypertrophic scarring is a known and rare complication of ablative skin resurfacing and has also been rarely reported with fractional devices.74,75 Vertical and horizontal bands have been described after ablative fractional resurfacing of the neck. The use of high-energy densities on skin that contains fewer pilosebaceous units and poor vasculature (such as on the neck and anterior chest) are potential explanations. The periorbital and mandibular ridge can also be scar-prone and should be treated with more conservative parameters.

Future Developments Ablative fractional lasers can create microscopic vertical holes in the epidermis that serve as open channels into which topically applied drugs can migrate down to the dermis.76,77 Topical methylaminolevulinic acid has been successfully delivered through fractional CO2 laser channels in animal models in amounts and depths far greater than that of intact skin.78 This method of fractional laserassisted drug uptake induces large amounts of porphyrin synthesis throughout the skin’s depth 15 to 50 times higher than that produced through intact skin. Clinical trials are underway to determine the safety and feasibility of enhanced dermal drug delivery in humans after ablative fractional resurfacing.79 Two home fractionated laser devices have been introduced to the market: Palovia (Palomar Medical Technologies, Inc., Burlington, MA), a 1410-nm wavelength device with a maximum energy of 15 mJ and ReAura (Solta Medical, Inc., Hayward, CA), 1425-nm device with an output of 1.2 W. The Palovia has been FDA-approved for the treatment of periorbital rhytides and, in its pivotal study, 90% of patients demonstrated some clinical improvement.80

Conclusion The concept and development of fractional photothermolysis represents one of the most exciting technologic discoveries in laser skin resurfacing in the last 20 years. The microscopic patterns of thermal injury produced by fractional laser technology trigger rapid

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wound healing and demonstrate clear efficacy in the treatment of skin surface texture abnormalities, rhytides, scarring, and multiple other cutaneous conditions. As newer devices are developed, the applications of this technology will continue to grow and have a dramatic effect on the delivery of medical and aesthetic dermatology.

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Address correspondence and reprint requests to: Tina S. Alster, MD, Washington Institute of Dermatologic Laser Surgery, 1430 K Street NW, Suite 200, Washington, DC 20005, or e-mail: [email protected]

DERMATOLOGIC SURGERY

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Evolution of laser skin resurfacing: from scanning to fractional technology.

Laser skin resurfacing was popularized for photoaged and scarred skin 2 decades ago. Since then, several technologic advancements have led to a new ge...
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