MedEsthetics magazines offers business education and in-depth coverage of the latest noninvasive cosmetic procedures for physicians and practice managers working in the medical aesthetics industry.
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GOING DEEPER Before MICRO VS. MACROABLATIVE Nonablative procedures may be more popular but there is no question that ablative procedures are more effective. A review done by Ong and Bashir (British Journal of Dermatology, June 2012) showed that NFR resulted in 26% to 50% improvement, while AFR resulted in 26% to 83% improvement. The review covered 26 studies of ablative and nonablative treatments for acne scars published between 2003 and 2011. AFR devices ablate rather than coagulate the epidermis 36 NOVEMBER/DECEMBER 2013 | MedEsthetics The ClearLift nonablative Q-switched YAG fractional laser was used to tighten loose skin on this patient's neck. and the dermis. "Ablative means removing skin, which requires high energy 2940nm, 2790nm or 10,600nm to create real holes," says Dr. Ross. "With ablative resurfacing, there is an open wound; it is not ablative unless there is some immediate or delayed oozing." The original AFR devices were carbon dioxide or erbium (er:YAG) lasers that used a combination of computer software, smaller spot sizes and scanning attachments to create intermittent laser pulses. Lumenis (aesthetic. lumenis.com) introduced the first of these devices, the Active FX, using the UltraPulse platform, in 2007. It was soon followed by a half dozen more lasers designed to produce distinct columns of injury deep into the dermis while ablating the skin surface. These included CO2 devices, such as the Fraxel Re:pair (Solta Medical, fraxel. com), DEKA SmartXide (dekalaser.com), Lutronic eCO2 (lutronic.com) and Slim Mix SX from Lasering USA (laseringusa.com), and er:YAG-based devices, such as the Alma Pixel (almalasers.com), Sciton ProFractional (sciton.com), NaturaLaserEr (Focus Medical, focusmedical.com) and the Starlux 2940 from Palomar Medical (Cynosure/Palomar, palomarmedical.com). Initially, much of the discussion centered on whether carbon dioxide or erbium lasers were the best base for AFR. More recently, physicians have begun suggesting that it makes more sense to categorize AFR devices based on their depth of penetration. "There are two categories of ablative resurfacing—microablative and macroablative, with the latter requiring more recovery and greater anesthesia," says Dr. Narurkar. Microablative lasers produce skin damage to a depth of less than 750µ. Anything producing deeper wounds is macroablative. Lumenis Active FX is microablative while Deep FX is macroablative, for instance. "Ablative now includes the 1927nm wavelength that is a component of the Fraxel Dual and the Clear + Brilliant Laser System, and fractionated bipolar radiofrequency devices," says Eric F Bernstein, MD, Main Line Center for . Laser Surgery, Ardmore, Pennsylvania. PHOTOS COURTESY OF BRUCE KATZ, MD Ten years ago Reliant Technologies (now Solta Medical, solta.com) introduced the Fraxel, the first fractional laser, which was FDA-cleared for soft tissue coagulation, periorbital rhytids, pigmented lesions, melasma, skin resurfacing, acne scars and surgical scars. Now there are dozens of nonablative fractional lasers FDA cleared for a wide range of cosmetic and medical applications. We have also seen the introduction of several high-powered ablative fractionated lasers with the ability to provide impressive resurfacing results while requiring only five to seven days of downtime compared to the weeks of healing and months of redness associated with traditional full-face CO2 resurfacing. In most practices nonablative fractional resurfacing (NFR) is used far more often than ablative fractional resurfacing (AFR), but ablative procedures have an important niche. "We do a lot of skin resurfacing in my practice," says Vic Narurkar, MD, dermatologist and founder of the Bay Area Laser Institute, San Francisco, "but 90% of it is nonablative. In our urban setting few patients have the luxury for weeks of recovery time. They are busy professionals who need to get back to work quickly. We also have a more diverse clientele, and NFR is definitely safer for patients with darker skin types." "We do several AFR procedures a day, as well as several NFR procedures," says Suzanne L. Kilmer, MD, founding director of the Laser and Skin Surgery Center of Northern California and associate clinical professor at the University of California, Davis. "We choose ablative or nonablative depending on the patient's problems—level of scarring or wrinkling—downtime tolerance and fear factor. While she might have some swelling and brown skin for a few days from NFR, with AFR resurfacing she is facing three to seven days of wound care, depending on how deep we go." "We use AFR primarily for acne scars and scars from injuries or surgery. About 80% of our ablative procedures are for scars and 20% for wrinkles. We will also use AFR for women who have had conventional resurfacing for wrinkles in the past and need a tune up. In these cases AFR reduces the risk of hypopigmentation," says E. Victor Ross, MD, director, Scripps Clinic Laser and Cosmetic Dermatology Center, Carmel Valley, California. After