JUL-AUG 2019

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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SPLITTING ENERGY 42 JULY/AUGUST 2019 | Med Esthetics © GETTY IMAGES "For white skin with severe wrinkling and photodamage, an ablative CO 2 or fractional CO 2 laser would give better re- sults than nonablative," says Christine Lee, MD, of The Skin and Laser Treatment Institute in Walnut Creek, California. However, for darker skin types, Dr. Lee opts for a fractional Er:YAG laser or fractional RF microneedling because they pose less risk of hyperpigmentation problems. Laurel Morton, MD, a dermatologist with SkinCare Physicians in Chestnut Hill, Massachusetts, prefers fractional CO 2 and Er:YAG treatments for deep wrinkling. "Unfortu- nately, the nonablative lasers and RF options do not usually induce enough collagen remodeling to notably affect deep rhytides," she explains. "Some patients may require more than one treatment with the fractional ablative laser, and for certain locations, such as the perioral region, it can be useful to combine this with fully ablative erbium." Dr. Morton recommends RF microneedling devices with insulated needles for patients with darker skin types, and says that picosecond fractional array devices are another option. "They are generally used at a low-energy setting and have been used in all skin types, though there may be a risk of hyperpigmentation in skin types V-VI," she says. When considering fractional CO 2 and Er:YAG, it's important to understand that individual devices can vary signifi cantly. In order to reduce deep wrinkles, you need to achieve thermocoagulation in addition to ablation, explains Dr. Lee. "But most erbium lasers only cause ablation with no thermocoagulation," she says. "Fotona and Sciton have dual-pulsed erbium lasers, which mimic the effects of CO 2 by offering a coagulation mode in addition to an ablative mode. These lasers have higher power and longer pulse durations than the other less powerful erbium lasers, which cause superfi cial heating of the epidermis and lack the power or ability to penetrate deeper to cause the thermo- coagulation you need to tighten laxity." Dr. Lee's go-to CO 2 laser is the Lumenis UltraPulse with MaxFX, Deep FX, ActiveFX and SCA AR FX handpieces. "The Lumenis devices have the highest power, deepest penetration and, therefore, the best results," she says, not- ing that lower power CO 2 lasers can only go one speed— slow. "High-power lasers allow you to customize the treatment, giving you total control over what type of tissue effect you want to achieve," she says. A secondary concern in aging skin is laxity—and, unfortu- nately, effective noninvaisve options are lacking, according to Joely Kaufman-Janette, MD, a dermatologist at Skin As- sociates of South Florida in Coral Gables. "Fractional CO 2 and fractional RF microneedling would be my best bets, but, I prefer to use Ulthera or nonfractional RF for skin tightening," she says. Dr. Morton agrees that there is no perfect noninvasive device for skin tightening. "The preferred fractional device would be RF with microneedling because of the heat de- livered to deeper tissue," she says. "Other options include nonfractional RF devices, including minimally invasive RF devices that deliver subcutaneous heat but require a higher skill level." SKIN CONCERN: AGING Choosing the best fractional device for facial rejuvenation largely depends on the patient's skin type and degree of damage. "High-power lasers allow you to customize the treatment, giving you total control over what type of tissue effect you want to achieve."

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