This is an article written by Dr. Emily Tierney for FractionalC02.com and may not be republished without the written consent of FractionalC02.com or Dr. Tierney. Dr. Tierney has no financial incentive to write this article from FractionalC02.com, the laser companies, or Boston University. This article is intended to provide the readers of Fractional Co2.com with the knowledge and understanding to make an informed decision.
This article covers the efficacy of Fractional co2 lasers vs non ablative more traditional laser resurfacing options. It also includes a comparison of traditional ablative Co2 laser resurfacing and the new fractional co2 laser resurfacing options. Dr. Tierney also covers her clinical studies on the efficacy of the SmartXide Dot Fractional Co2 Device. She has extensive experience working with various laser modalities including many fractional co2 lasers.
The Smart Xide DOT Laser is an ablative fractionated CO2 laser with significant versatility in a diverse range of skin conditions including diverse facets of skin changes associated with photoaging, including dyschromia, rhytids, skin texture abnormalities, poikiloderma and generalized skin laxity.
We have published two studies highlighting the utility of the device in the treatment of pigmentation and laxity of neck skin:
Tierney EP, Hanke CW. Ablative Fractionated CO2 Laser Treatment of Poikiloderma of Civatte: Prospective Study and Review of the Literature. J Drugs Dermatology. June 2009
(Poikiloderma of Civatte is a rather common, benign condition affecting the skin. Many consider it to be a reaction pattern of the skin and not a disease. The term poikiloderma refers to the combination of atrophy, telangiectasia, and pigmentary changes (both hypopigmentation and hyperpigmentation).BACKGROUND: Previous laser treatments for Poikiloderma of Civatte (PC) (i.e., Pulsed dye (PDT), Intense Pulsed Light(IPL), KTP and Argon) are limited by side effect profiles and/or efficacy. Given the high degree of safety and efficacy of ablative fractional photothermolysis (AFP) for photoaging, we set out to assess the efficacy of PC with AFP. DESIGN: A prospective pilot study for PC in 10 subjects with a series of 1-3 treatment sessions. Treatment sessions were administered at 6-8 week intervals with blinded physician photographic analysis of improvement at 2 months post-treatment. Evaluation was performed of five clinical indicators, erythema/telangiecatasia, dyschromia, skin texture, skin laxity and cosmetic outcome. RESULTS: The number of treatments required for improvement of PC ranged from 1 to 3, with an average of 1.4. For erythema/telangiecatasia, the mean score improved 65.0% (95% CI: 60.7%, 69.3%) dyschromia, 66.7% (95% CI: 61.8%, 71.6%), skin texture, 51.7% (95% CI: 48.3%, 55.1%) and skin laxity, 52.5% (95% CI: 49.6%, 55.4%). For cosmetic outcome, the mean score improved 66.7% (95% CI: 62.6%, 70.8%) at 2 months post treatment. CONCLUSION: In this prospective study, AFP was both safe and effective for the treatment of the vascular, pigmentary and textural components of PC. The degree of improvement observed in wrinkling, creping and laxity after AFP has not been reported with prior laser treatments for PC.
Tierney EP, Hanke CW. Ablative Fractionated CO2 Laser Resurfacing for the Neck: Prospective Study and Review of the Literature. J Drugs Dermatol. Aug 2009
Objective: A prospective pilot study for neck resurfacing in 10 subjects with a series of one-to-three treatment sessions.
Methods: Treatment sessions were administered at six-to-eight week intervals with blinded physician photographic analysis of improvement at two months post-treatment. Blinded physician photographic evaluation was performed of four clinical indicators, skin texture, skin laxity, rhytides and overall cosmetic outcome.
Results: The number of treatments required for improvement of neck texture and laxity ranged from 1 to 3, with an average of 1.4. For skin texture, the mean score improved 62.9% (95% CI: 57.4%, 68.4%), skin laxity, 57.0% (53.2%, 60.8%), and rhytides, 51.4% (48.3%, 54.5%). For overall cosmetic outcome, the mean score improved 59.3% (55.1%, 63.5%) at two months post treatment.
Conclusion: In our prospective study, AFP was both safe and effective for the treatment of neck laxity, rhytids and skin texture. The degree of improvement observed in wrinkling, texture and laxity after AFP coupled with the benign side effect profile has not been reported with previous trials of ablative laser resurfacing of the neck.
Description of Ablative Fractionated CO2 Laser technology
Ablative Fractional Photothermolysis (AFP), creating confluent columns of thermal inury in a random array extending from the stratum corneum to the reticular dermis, has demonstrated significant effects on skin tightening and texture beyond that seen with the original generation of non ablative Fractional Photothermolysis (NAFP) devices. Additionally, the safety profile seen with AFP marks a significant advantage over the traditional ablative resurfacing devices, associated with prolonged post-operative erythema and risk of post-inflammatory pigmentary change and scarring.
Several recent studies have compared NAFP with AFP and have found that AFP produces greater improvements in skin tightening and texture. 1-2 Weiss et al reported a comparative split face trial with one half treated with fractionated CO2 laser and the contralateral half treated with 1550 nm non-ablative fractional erbium laser.14 Significantly greater improvement in peri-ocular rhytides (75% improvement) were observed in 10 patients treated with fractionated CO2 laser relative to the 1550 nm Erbium side (25% improvement) on blinded photographic analysis. Similarly, Lomeo et al15 reported the results of a split-face comparative trial of microfractional non-ablative Er:Yag versus microfractional ablative CO2 laser in 10 patients. A significantly higher improvement in skin texture and color was demonstrated on the side treated with microfractional CO2 laser relative to microfractional Er:Yag laser.
In 2009, Rahman Z et al3 reported a high degree of safety and efficacy in photoaging with an AFP device in the FDA studies leading to approval of the device (Fraxel Repair, Reliant Technologies, Mountain View, CA). Patients were treated on both the face and neck with settings of fluence/MTZ of 10-40mJ/MTZ and densities of 400-1,000 MTZ/cm2). Even at aggressive fluences and high densities, the side effect profile was limited to erythema, edema and mild crusting with no incidence of scarring of dyspigmentation. 16 Average improvement in indices of skin texture and tightening (on a quartile scale were 2.30 (rhytides), 2.42 (texture) and 1.65 (laxity). 16
Berlin L et al4 performed a study in 10 subjects with 1 treatment with an ablative fractionated CO2 laser (UltraPulse Encore, Lumenis Inc., Santa Clara, CA). The authors evaluated clinical change in photoaging as well as histologic and ultrastructural change in collagen deposition on both light and electron microscopy. Blinded investigator assessment of skin textural alterations and rhytid reduction revealed a mean improvement of 1.8 (on a 5-point scale) at 4 weeks and 1.6 at 24 weeks post-treatment. Post-treatment biopsies documented greater fibrosis in the papillary dermis. Additionally, electron microscopy revealed a decrease in the average diameter of the collagen fibrils, consistent with greater deposition of collagen type III, suggesting new collagen deposition induced by fractionated laser resurfacing.
A recent study by Tierney EP and Hanke CW5 demonstrated significant improvement in neck skin tightening with a 63% improvement in skin texture, a 57% mean improvement in skin tightening and a 51.4% improvement in skin rhytides. This degree of improvement in skin tightening of the neck has only previously been reported with ablative CO2 laser resurfacing.
It is generally assumed that the efficacy of CO2 laser fractional resurfacing, with only 20-35% of the skin cross section being treated, is dependent upon the depth of the MTZ, i.e., deeper damage results in larger treated volume and hence better clinical efficacy.6 These zones of coagulated and tightened collagens induce a long-lasting wound healing process resulting in skin shrinkage and thereby, wrinkle reduction. Hantash et al, hypothesized that for a constant treatment density, the depth of the lesions becomes the dominant predictor of final tissue shrinkage.6 Given significant preliminary efficacy reported for AFP treatment of a diversity of skin conditions (dyschromia, poikiloderma, rhytids, laxity, scars), future studies evaluating indications, settings and treatment mechanisms of actions with a diversity of AFP devices will be highly instructive.
References:
1 Weiss R, Weiss M, Beasley K. Prospective split-face trial of a fixed spacing array
computed scanned fractional CO2 laser versus hand scanned 1550nm fractional for
rhytides. Abstract presented at American Society for Laser Medicine and Surgery
Conference, April 2008, Kissimee, FL.
2 Lomeo G, Cassuto D, Scrimali L, Sirago P. Er:YAG versus CO2 ablative fractional
resurfacing: a split face study. Abstract presented at American Society for Laser
Medicine and Surgery Conference, April 2008, Kissimee, FL.
3 Rahman Z, MacFalls H, Jiang K, Chan KF, Kelly K, Tournas J, Stumpp OF, Bedi V,
Zachary C. Fractional deep dermal ablation induces tissue tightening. Lasers Surg Med.
2009;41(2):78-86.
4 Berlin AL, Hussain M, Phelps R, Goldberg DJ. A prospective study of fractional scanned nonsequential carbon dioxide laser resurfacing: a clinical and histopathologic evaluation. Dermatol Surg. 2009;35(2):222-8.
5 Tierney EP, Hanke CW. Ablative Fractionated CO2 Laser Resurfacing for the Neck: Prospective Study and Review of the Literature. Journal Drugs Dermatol. Article in Press.
6 Hantash BM, Bedi VP, Kapadia B, Rahman Z, Jiang K, Tanner H, Chan KF, Zachary CB. In vivo histological evaluation of a novel ablative fractional resurfacing device. Lasers Surg Med. 2007;39(2):96-107.
7 Saluja R, Khoury J, Detwiler SP, Goldman MP. Histologic and clinical response to varying density settings with a fractionally scanned carbon dioxide laser. J Drugs Dermatol. 2009;8(1):17-20.
