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Archive for the ‘laser resurfacing’ Category

Fully Ablative vs Fractional Facial Laser Resurfacing – Which Is Better?

Saturday, January 19th, 2013

 

Facial laser resurfacing has evolved over the past twenty years from in both how the energy is delivered to what depths into the skin that is treated. When initially introduced laser resurfacing was known as ‘fully ablative’, meaning that at any energy level it treated 100% of the skin’s surface. While many of the results a fully ablative laser resurfacing treatment creates can be impressive in the amount of wrinkle reduction and skin tightening, it can be associated with loss of skin pigment and long healing and recovery times.

Such skin resurfacing concerns led to the development of fractionated or a ‘fractional’ laser technique. In this approach the laser only treats a part or fraction of the skin’s surface. By leaving untreated or skipped zones of skin, there is less traumatized tissue which substantially reduces the risk of hypopigmentation and shortens the recovery time. Treating less skin may seem counterproductive to getting a good skin result (less wrinkles) but this is compensated for by having each penetrating laser light column go much deeper. This is why fractional laser treatments create pinpoint bleeding areas while fully ablative lasers do not.

The theoretical benefits of fractional laser resurfacing is that these deeper penetrating columns of laser light cause at least an equal amount of increased collagen formation and skin tightening as that of more superficial fully ablative laser treatments. This would seem to make perfect sense given the greater depth of dermal injury and it has always been assumed to be true. It also accounts for its popularity as a widely used treatment.

In the October 2012 issue of Dermatologic Surgery, a human study was done to directly compare the molecular changes that result from fractional vs fully ablative carbon dioxide (CO2) laser resurfacing in skin damaged skin. In 34 adults with substantial facial skin damage, matched facial areas with treated between the two laser types. Real-time reverse transcriptase polymerase chain reaction technology and immunohistochemistry were used to quantify molecular responses to each type of laser treatment. Their results show that both fully ablative or fractional laser resurfacing resulted in significant skin changes of dermal remodeling and the creation of new collagen. After one treatment, however, fractional laser resurfacing effects were only about half of that seen by a fully ablative treatment. The fully ablative laser treatments created greater changes with more pronounced collagen formation.

What this study indicates is that the fractional laser approach is not superior to fully ablative treatments (in a single treatment) as many may believe or purport that it is so. This is no surprise given that much less skin surface is treated, often 78% to 95% less.  The value of fractional laser resurfacing is that it has less risks of skin problems particularly in patients with more natural skin pigment.Whether better skin results, particularly in its tightening effect, may occur with repeated treatments can not be determined from this one study. The value of fractional laser resurfacing is that such repeated treatments can be safely done.

Dr. Barry Eppley

Indianapolis, Indiana

Treatment Options for Facial Acne Scars

Saturday, January 5th, 2013

 

Acne is a common skin condition that results in a wide variety of scars types and patterns. Even though there are a number of available treatments for acne scars, they are not always universally successful. Acne scars represent a difficult challenge for improvement and every option must be considered in each patient. Often different treatment approaches may be used on the same patient based on the type of acne scars that they have.

When evaluating acne scars, there are three main types based on their shapes. Ice pick scars are the most common acne scar and are semi-round in shape but narrow and deep. They occur most commonly on the nose and cheeks. Rolling hill scars are wide deep scars that roll into the skin. They often occur in bunches and are the result of large and deep cysts. Boxcar (atrophic) scars are somewhat similar to ice pick scars but are not as deep and are wider. The morphology of acne scars goes a long way in determining the correct treatment choice.

The options available for acne scar treatments include injectable fillers, subcutaneous incision/subcision, punch excision, punch elevation and fractional laser resurfacing. Which of these approaches is best? Again, the shape and depth of the acne scar is the determinant.

Hyaluronic acid injectable fillers work by lifting up the depth of the scar depression and trying to make it more level with the surrounding unscarred skin.  In essence, try and raise the valley to get closer to height of the surrounding mountains. Fillers may stimulate collagen regeneration in the skin but this is more theoretical than ever actually seen on a consistent basis. This acne scar technique works best for broad and shallow scars. Deep pitted scars are too fibrotic to be elevated by the push of a filler. While the improvement occurs immediately with injectable fillers, it is a temporary effect that will last as long as the composition of the filler.

Subcision is a technique that inflicts injury to the skin at the base of the scar. This causes the scar to release and accumulate blood underneath it. This is done by using the beveled edge of a small needle like a miniature scalpel. This will result in some bruising and swelling. The dermal collagen injury and bleeding may act as a stimulant for new collagen growth. This technique works best in rolling hill type scars. Multiple sessions are often needed for the best results.

Punch excision is a very well known acne scar technique that does exactly what it describes, it cuts the scar out in a circular pattern. This is done using punches which are small cooker-cutter tools with varying diameters. (1 to5mms) Once the scar is removed, the circular hole is then treated by one of two closure techniques, small suture closure or the hole is filled in with a full-thickness skin graft of the exact size usually cut with the same tool. (punch elevation) Once healed, laser treatments are often done for the smaller scars left behind from excision and closure or the raised scars from the punch graft.  Punch excision works best for ice pick and boxcar scars.

Laser resurfacing works best for the most number of acne scar types. The laser fundamentally works by removing the top layer of skin so that shallow scars may be eliminated and deeper scars appear more shallow. But in a 100% ablative laser, where top layers of skin are removed in even unscarred skin, no net gain may often be seen. The better technique for acne scars is fractional laser resurfacing where just a portion of the skin is treated but the penetration is much deeper. The deep skin channels cut by the fractional laser stimulates the skin to contract and get tighter, narrowing the diameter of the scar. Multiple fractional laser treatments are almost always needed.

The challenge of improving facial acne scars is met with a variety of treatment techniques. While perfectly smooth skin is never possible, mixing and matching  several of these treatment techniques almost always provides visible improvement for most patients.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? The Myth of Laser Scar Removal

Monday, August 6th, 2012

 

When most people think of scar revision they usually think of two things; elimination of the scar and the use of lasers to do it. The reality is that both of these perceived principles of scar revision are wrong. Scars may be able to be improved but they can almost never be removed. Plastic surgeons wish this was possible but it is not. Once the skin has been injured and healed by scar, it will be forever changed. It is merely a question of how much reduction can be obtained and how much less visible it can be. Secondly, while lasers have a role to play in scar revision it is less significant than excisional techniques. Lasers are not magical wands that work like erasers. They are most effective in prophylactic treatment of early scars and incisions. They will make little difference in well-established mature scars, particularly those that have visible surface contour issues. (wide, deep, raised) Revision of significant scars requires excision and closure, often using geometric rearrangement techniques. Laser resurfacing may then be done after to get the best camouflaged appearance.

Plastic Surgery’s Did You Know? Lip Wrinkles

Sunday, July 29th, 2012

 

Lip lines, particularly the vertical wrinkles of the upper lip, are a common problem amongst many Caucasian women. Thinner less pigmented skin is more prone to wrinkling due to repeated lip motion and less dermal thickness and elastic fiber content. The wrinkles form perpendicular to the horizontal orientation and sphincteric movement of the underlying orbicularis muscle. Regardless of how they form, they are very pesky problems to treat so prevention plays a critical role. Stopping smoking is one of the most important preventers as its toxins damage collagen, resulting in fine lines. Sun protection with lipsticks and balms that contain sun protection factors and hydrate the lips works from both the outside and inside. Pursing the lips when drinking through a straw or sipping should be avoided. But when lip lines do occur, they can be substantially reduced by injectable fillers, fractional laser resurfacing or even dermabrasion if severe enough.

Total Hand Rejuvenation

Wednesday, July 11th, 2012

While the aging of the face seems the most visible and subsequently the most treated by plastic surgery, it is not the only visible and unclothed body part that ages. I have seen many older women whose face is quite smooth because of numerous facial rejuvenation procedures but whose hands give their age away. The hands simply don’t go with their face, age or lifestyle. The hands are as much exposed to the elements as the face but are far less pampered and protected.

Like the face, the hands age in a similar way. They lose volume through fat atrophy, the skin loses elasticity and becomes wrinkled and age spots appear. As the fat layer in the hands disappears, which is already thin to begin with, the skin becomes partially translucent and thinner. This creates the classic skeletonized hand appearance where the veins and tendons are clearly visible. The rows between the hand bones become sunken in. The skin when you pinch it on the back of the hands doesn’t bounce back due to loss of elasticity.

The aging of the hands can clearly be seen in many tabloids and magazines. Famous aging women with youthful faces and great bodies have old-looking hands. Their veins can clearly be seen bulging out on their emaciated hands. This may be why some performers wear fingerless gloves in an effort to hide the back of their hands.

Treatment of the aging hands can be done through various rejuvenation methods. The most common treatment by far is for the brown age spots or sunspots. Intense pulsed light (IPL) or broad band light (BBL) can quickly remove brown spots, many of which can be eliminated in a single treatment session of about 15 minutes. It turns them dark and speckled and they then fleck off over the next week or so. A touch-up treatment may be needed a month later to clear what remains. It is important to wear sunscreen on the back of the hands afterward to prevent reflaring of some of the brown spots. A minimum of SPF50 sunscreen should be used.

These light therapies can be supplemented with laser resurfacing to help tighten the loose skin and reduce the wrinkling. Fractional is the best laser method because it has enhanced collagen stimulation effects. Laser resurfacing can be combined with light therapies to get a better overall effect than either one alone. Laser treatments take the same amount of time to do, about 15 minutes per hand.

Most so-called ‘hand lifts’ employ the use of injectable fillers to plump out the atrophic subcutaneous tissues and ‘deskeletonize’ the back of the hand. Fillers like Juvederm, Restylane and Radiesse can be quickly injected in the office for an instant filling effect. Placed right under the skin near the wrist level, they can be pushed into the indented rows once injected right under the skin. While they are not permanent the filling effect will last anywhere from six months to a year.  Fat injections are another option and generally create a better result because the volume injected is greater. It is a minor surgical procedure where fat is harvested from inside the belly button, concentrated, and then injected just like synthetic fillers. Unlike off-the-shelf fillers, fat has the potential to be longer lasting.

Other hand treatment options included the use of skin tightening devices like Exilis and the sclerosing of hand veins by injection or their actual extraction like varicose veins of the legs. One treatment option that is not used is a formal hand lift where skin is excised and the skin tightened. While it can be done by making an incision at the wrist level, the scarring is not acceptable.

A complete hand rejuvenation approach is the combination of injectable filling, light therapy for brown spots and fractional laser for wrinkling and skin tightening. Both hands can be treated in one hour in the office with complete healing in just one week.

Dr. Barry Eppley

Indianapolis, Indiana

A Structured Approach to Treatment Planning of the Aging Face

Sunday, June 3rd, 2012

Patients with facial aging concerns frequently come in and want a general overall assessment of what can be done to improve their face. Others come in because they are looking for a very specific facial rejuvenation procedure, whether it is some type of tuck-up, filler or laser resurfacing. They are driven to these procedures largely because of something they have seen online. But despite the plethora of available internet educational forums, such as websites, blogs and even YouTube videos, wanting a specific procedure does not make one very educated about it. For many, the amount of available information is so overwhelming that they have no greater understanding  after they have digested the information than before.

 

While every face is very different in shape and appearance, the aging process affects them all. But the extent and progression of the aging process differs in every face  so, while they are many predictable changes, every face has varying degrees of them over time. When combined with what bothers any particular patient, it is fair to say that every aging patient needs a unique treatment approach. Despite the need for a unique treatment plan for every patient, there are only so many known facial rejuvenation treatment options. This is exactly how a plastic surgeon thinks when looking at a face…what procedures does the patient need and which ones will make the biggest difference?

 

Translating a facial aging treatment plan to a patient requires an organized and thoughtful approach if they are to understand the logic of what they need and the procedure(s) required. I find it most helpful to divide the face into thirds and break down their concerns and what can be done. The surface texture of the skin is the fourth facial element and is always discussed last.

 

The upper face consists of the frontal hairline, forehead skin, brows and the upper eyelids. This is a unit because changing one aspect of the upper face affects all others. How much excessive eyelid skin is there, what is the position of the eyebrows, what is the vertical length of the forehead skin, how much muscle activity and lines exists in the forehead skin, and what is the location of the frontal hairline and its hair density? These determine whether only an upper blepharoplasty is needed or whether it needs to be combined with a browlift and what type of browlift would be best?

 

The middle third of the face involves the lower eyelids, cheeks and nasolabial folds. Is just a lower blepharoplasty needed and what type? Do the cheeks need lifted or will just more volume do? Does the patient have tear troughs or malar bags? How best to reduce the depth of the nasolabial folds? The relationship between the lower eyelid and the tissues beneath it is a complex and challenging one and there are many options available today.

 

The lower face includes the neck and jowls, lips, mouth and chin. Does the patient need a full facelift or only that of a more limited variety? Does the neck need platysmal muscle plication or just liposuction with the facelift? Will chin augmentation improve the shape and definition of the jawline? Do the lips need vertical wrinkle reduction, corner of the mouth lift, or vermilion lip enlargement? The central mouth area can not be separated from the neck and jowls in improvement of aging.

Lastly, skin texture must be considered. Lifts and tucks will not reduce fine wrinkles, give the skin a more youthful glow, reduce pore size or get rid of brown spots. Simultaneous or delayed skin resurfacing with laser or chemical peels is a great asset to all other tissue lifting or excisional procedures. More commonly, skin resurfacing is being done simultaneously at the time of surgery.

 

If you break down the face into its four structural elements and go through it a sequential fashion, patients are more likely to understand and retain the options given to them. This should lead to less misunderstanding and disappointment after surgery.

 

Dr. Barry Eppley

Indianapolis, Indiana

Fractional Laser Resurfacing of the Neck

Wednesday, May 30th, 2012

Resurfacing of the facial skin for wrinkle reduction is well known to be effective. Such laser improvements have been particularly enhanced by the use of fractional ablative laser treatments. The deeper penetration of the vertical laser columns, albeit on just a fraction of the skin’s surface, causes collagen production and skin tightening not previously seen. But venturing off of the face onto the neck and chest, however, is more precarious with laser resurfacing or even deeper chemical peels.


Although the neck is right under the jawline and adjacent to the face, it reacts differently to skin resurfacing efforts. Complications such as delayed wound healing and pigmentation changes are not rare and have been seen with every laser approach. The conclusion historically is that only very light laser treatments with minimal improvements can reduce the risks of these after treatment problems.

Why the neck and chest is different has been theorized due to a change in the anatomy of the skin. The dermal component of the skin is definitely thinner and has less pilosebaeous units per square centimeter. Since most skin cell regeneration (re-epithelization) comes from these hair-sweat gland follicles, healing is slower and more challenged by thermal injury. The thinner dermis also lends itself to greater thermal injury at similar laser setting that are used on the face.

Fractional laser resurfacing offers a theoretical improvement to traditional laser resurfacing of the neck. Its microscopic vertical columns leaves normal skin tissue between them, acting as a reservoir of uninjured fibroblasts and pilo-sebaceous units to provide a good healing source. With a treated to untreated skin ratio ranging from 5% to 22% (Sciton Fractional Laser), there is plenty of healing cells available to expedite wound healing. The traditional higher incidence of complications in neck resurfacing should therefore be appreciably reduced with fractional laser techniques. In my experience this is certainly true and much better skin improvements are seen. Skin texture, wrinkle reduction and small amounts of skin laxity are improved.

An important distinction, however, should be pointed out between improvements in neck skin texture and laxity. I see too many people who erroneously believe that neck laser skin resurfacing is going to create the effect of a facelift. (neck-jowl lift) This is certainly not the case except in the slightest of degrees. The amounts of improvements seen in laxity reduction will not make most of the patients I see happy. This is asking too much of laser therapy even though some make market it as a non-surgical facelift.


Dr. Barry Eppley
Indianapolis, Indiana

Plastic Surgery’s Did You Know? Laser Resurfacing at a Fraction

Tuesday, May 1st, 2012

Laser skin resurfacing has now been around for several decades and involves a simple treatment principle…uniform removal of the outer layers of the skin. This can be done from very superficial to deep depending upon the power settings of the laser and the depth of the skin contour problem. Fractional laser treatment represents a paradigm shift in laser skin resurfacing by treating just a fraction of the skin’s surface, hence the name. But each area treated or laser dot penetrates much deeper creating vertical columns down into the deeper layers of the skin. This results in much greater collagen stimulation. But because less skin is injured (5% to 22%), it heals much faster. This has been a revolutionary advance in the treatment of previously difficult problems like scars.

Fractional Laser Periorbital Rejuvenation of the Eyelids and Brows

Wednesday, April 18th, 2012

The eyes may be the window to the soul but they are also a measure of aging. Because of the expressive movement of tissues around the eye and the thinness of the skin, this area shows the first sign of aging changes on the face. The sphincteric action of the orbicularis oculi muscle generates an array of radiating wrinkles to the side and below the eye and exerts a downward pull on the eyebrow. Because we look at this area with great frequency, often the first thing we look at in a mirror, the development of wrinkling is quickly discovered.

Surgical removal of eyelid skin (blepharoplasty) and elevation of the eyebrows (browlift) are well known and effective strategies for periorbital aging. But they are best used in moderate to advanced stages of aging. In addition, some people simply don’t want surgery whether it is because of the recovery or the cost.

The use of lasers for facial wrinkle reduction is well known and has been around now for over two decades. But their use around the eyes and on the eyelids where the skin is thinner is the use of lesser depth laser treatments known as micropeels but with more restricted depths of penetration come less results as well.

The newer fractional laser treatments offer a paradigm shift is how laser energy is delivered. Rather than being ablative to 100% of the treated skin, the fractional laser treats but a portion of the surface. Rather than producing a complete layer of burn tissue, columns are created instead. This leaves a lot of uninjured skin between the vertical columns which allows for faster healing and less risk of scarring. But each column does deeper down into the dermis, creating a collagenous remodeling effect.

When fractional laser treatments are applied in the periorbital area, significant improvements have been reported in numerous clinical studies. Measurable improvements have been seen in reduction of wrinkles, skin tightening and eyebrow elevation. This was found to be true in all skin types, including those with darker pigmentations. The results come exclusively from the changes in the skin and such problems as fat herniation, significant malar and brow sagging and orbicularis muscle hypertrophy will not be improved by this or any form of laser resurfacing.

The caveat to success with fractional laser periorbital rejuvenation, and being able to treat the eyelids directly, is the use of low energies and multiple treatments. This allows for both safety with minimal risk of any adverse scarring and very quick recoveries in the order of a few days. Spaced about six weeks to eight weeks apart, a series of three or four treatments is needed to get the best results. One should anticipate a single maintenance treatment per year. It is also important to use a good topical regimen daily with both exfoliative and regenerative agents such as retinoic acid and ascorbic acids.

The use of the fractional laser offers a new treatment option for the aging eyelids and brows. Some have termed this the fractional eyelid lift or the ‘Madonna Lift’. But names aside, this laser treatment provides an intermediary step before surgery that can serve as an effective treatment for those with early sign of aging or as a delay manuever before blepharoplasty surgery is done later.

Dr. Barry Eppley

Indianapolis, Indiana

Fractional Laser Treatments Of Acne Scars

Sunday, April 15th, 2012

While many methods for skin rejuvenation have been developed, few such methods are helpful for acne scars. The typical skin treatments of microdermabrasion, chemical peels, intense pulsed light and even ablative CO2 laser resurfacing do not produce substantative improvements in the unique contour problems caused by acne. Traditional CO2 laser resurfacing is the best of the bunch but results are often left wanting. The most effectve treatment is dermabrasion but it carries with it risks of hypopigmentation and even hypertrophic scarring.

Acne scars can be divided into two main types; atrophic and proliferative. Atrophic acne scars are identified as either ice-pick or macular-type forms. Proliferative or hypertrophic acne scars are raised and are more like keloids. Atrophic acne scars are particularly difficult to improve because the collagen degeneration extends down into the dermis. Regeneration of the dermal layers is virtually impossible so traditional ablative laser resurfacing has tried to bring down the surrounding more normal skin layer to the depth of the dermal depression…with limited success.

Fractional laser resurfacing has introduced a new concept in skin surface treatments. Rather than bringing down the entire outer surface layer of the skin, it only treats a portion of it hence the name fractional. In essence think of a dot pattern of individual laser spots penetrating the skin distributed over a grid pattern by a computer delivery system. But each laser spot penetrates much deeper, reaching the dermis and causing collagen stimulation/regeneration. While each laser spot goes deeper, the smaller portion of skin treated (anywhere from 5% to 22% of the total surface area) results in more rapid epithelial healing and a faster recovery.

Fractional laser resurfacing has been shown in numerous studies to be very effective for atrophic acne scars. Delivered in a punctuate pattern, the epidermis and a part of the dermis is vaporized. At the same time, collagen contraction occurs by its heating effect causing skin tightening. This skin tightening effect is thought to be very beneficial for acne scars. Multiple fractional laser treatments will be needed and they should be spaced about a month apart to allow for complete epithelial regeneration. Histologic and electron microscopic studies have shown the regeneration of elastic-like fibers with fractional treatments, a sign of dermal remodeling.

The fractional laser allows for different parameters to be set including power, pulse width, and dot pitch being the distance between each laser point. It is not clear as to the optimal setting for any individual patient and consideration has to be given to the patient’s concern for recovery. Given the challenge of atrophic acne scars, deeper depths of penetration up to 350 microns are best used.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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