NOV-DEC 2013

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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"In New York City, our patients want no downtime. Some physicians tell me their patients would rather come in for one treatment and take some time off, so it depends on your patient population," he says. What about patients with actinic keratoses (AKs)? "There is evidence that fractional devices can improve AKs and also actinic cheilitis of the lips," says Dr. Zachary. "There has always been some concern that fractional treatments might aggravate precancerous lesions by not removing them completely. That is not what we are seeing in practice. It's like aerating your lawn: You punch holes several inches apart but the grass shows universal improvement. So too with the skin, where fractionated treatments can have a universally beneficial result on 100% of the skin, including improving pre-cancers." COMBINING AFR AND NFR In an effort to offer effective treatments for all areas of the face, many physicians are now combining NFR with AFR or fractional resurfacing with other modalities. "We are finding we can tailor the devices we use to the patient's needs for the best results," says Dr. Zachary. "We can combine Active and Deep FX or use Re:pair with the 135µ and/ or the 600µ handpiece to create deep or more superficial wounding. We can also use these devices in combination with chemical peels, IPL or the 532nm and 755nm lasers." "For many patients I combine ablative and nonablative, using ablative settings around the eyes and mouth and Re:store everywhere else," says Dr. Narurkar. For most ablative cases, Dr. Ross uses the Active FX and Deep FX. "Its versatility allows me to go deeper for scars "Effect depends on the size of the microbeam, the space between beams and the depth of penetration." and deep wrinkles. I can use aggressive settings for deep wrinkles and 10 to 12 days of recovery or turn down the density and pulse energy for mild to moderate sun damage and two to four days of recovery. It allows me to titrate the level of treatment. "We also use the SmartXide Dot, Palomar er:YAG and Syneron CO2RE, which is good for conventional as well as fractional resurfacing. All CO2 or erbium lasers are capable of producing effective treatments at appropriate depth and density settings," adds Dr. Ross. "Effect depends on the size of the microbeam, the space between beams and the depth of penetration. For deeper scars you have to 42 NOVEMBER/DECEMBER 2013 | MedEsthetics increase density and depth settings. For less severe scarring we would decrease density by 40% and decrease the depth to 500µ to 1,000µ." Dr. Kilmer also uses a number of different devices, but says she prefers the Fraxel Re:pair, the Deep FX and the Lutronic eCO2 . "The Re:pair offers more heat and tightening, and the rolling technique is great for cosmetic resurfacing and photodamge. The Deep FX allows me to easily vary spot size and depth, and since there are no consumables, it can help control costs for price sensitive patients. It is especially great for small areas or areas with contour changes. For large scars, I love the spray pattern offered with the eCO2 ; it also uses no consumables. Each of these devices has a good niche, making it better for a specific group of patients," she explains. "Learning what settings to use for specific situations requires good training and lots of experience," adds Dr. Kilmer. "It is especially important with ablative procedures to recognize complications. Infections can occur and they may look different than with fully ablative procedures. If pain persists, it's important to consider infections and treat quickly." "Anyone wielding a laser needs appropriate training," says Dr. Zachary. "Even fractional lasers can cause problems if misused. I recently saw a woman who had been treated much too aggressively with a fractionated ablative laser, and was left with depressed scars around her mouth. Such a complication is induced by bulk heating, the enemy of fractionated devices. It is distressing to me that with all the available education, there are still medical professionals out there who are cavalier with these devices. It is all about safety, knowing your instrument and your patient. It is not like cooking; you can't simply follow a recipe. You need to be aware of laser/tissue interaction from start to finish. In this regard, too many devices are handed over to physician extenders or those without appropriate training and supervision, in some cases with dire consequences." Linda W. Lewis is a contributing editor of MedEsthetics. © ISTOCKPHOTO.COM GOING DEEPER

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