“Since the fractionated lasers have come out, we have actually been really pushing those devices to see where we can get with burn scars,” says Dr. David Verebelyi, an aesthetic laser expert in Denver, CO. “Before, our only tool for treating scars was injection of Kenalog with steroids, pulsed dye lasers and then maybe resurfacing with a full CO2. Now we can get that tissue to really remodel at a much deeper level by using some of the fractionated lasers. Right now, we’re optimizing those treatments looking at everything from high density pulses and high fluency pulses, trying to get the best bang for the buck with those.”

Dr. Verebelyi says that he is also able to treat the scars of those with darker skin tones with fractional resurfacing, but the technology of choice depends on what kind of scar is being treated. “For superficial scars, the sublative stuff works a little bit better. For the atrophic scars, we tend to use a little bit deeper procedures. You always have to worry about discoloration, it doesn’t matter what the skin color, but any of those limiting factors normally don’t last more than a few months.”

The number of treatment sessions needed varies based on the severity of the scar. As Dr. Verebelyi describes, “Anywhere from 3-5 is pretty average, but it depends on the clinical end point that you want, and how thick the scar is. A traumatic burn scar might take more than 5 treatments whereas an acne scar might take three.” What treatment a patient receives also determines how long it is before a patient can expect to see their final result. “For lighter treatments, you know, those things will continue to remodel for at least 3-6 months. But, it will look pretty good after a few weeks. For deeper treatments, redness can last 90 days and then you might remodel as long as a year.”

There is very little pain associated with the fractional procedure. “The level of pain – it’s virtually painless. What we do with our patients, we use a topical ointment, put it under occlusion, which basically means we stick it under a piece of Saran wrap for a couple of hours. My patients do great with that. Nobody rates the pain at above a 1–2 out of 10. The recovery time on those – you might have to put some ointment on them for about a week but that’s about it. Most patients we treat about every month, about every 4 weeks we see them back for another treatment.”

Original article can be found at: http://www.americanhealthandbeauty.com/articles/?article=3225

To truly reduce facial lines is a difficult task, especially wrinkles around the mouth and eyes.  These lines can extend over a millimeter deep into the skin.  It is the depth of the damage that makes them very difficult to treat.  Most procedures for treating wrinkles are very superficial and although they may improve fine lines, they never treat the base of deep wrinkles.  In order to really get improvement one must have a procedure that treated then entire area of damage.  This is why fractionated CO2 procedures like the Deep FX are so effective.  This laser can penetrate up to 2mm into the skin assuring that even deep wrinkles will show significant improvement.  Yes, there will be a few days of downtime but we spent several decades making these wrinkles and a few days is well worth it in order to make the skin look literally years younger. 

What about tightening the skin?  There are two options here depending on the desired amount of improvement and amount of downtime a patient is willing to undergo.  The first option is using an infrared light call the Titan to heat the dermal skin which shrinks the existing collagen (much like a piece of meat shrinks on the grill when heated) and will stimulate new collagen growth.  The dermis of the skin thickens giving modest results of about 10 – 20% tightening after three treatments.  Plan on spending about $600-$1000 per treatment for a face and the results will last about 18-24 months.  The best part about the Titan is that there is absolutely no downtime.  The skin is pink for about 30 minutes after the procedure and that is it. Use this in combination with Laser Genesis which is another no downtime laser treatment that helps decrease pores and fine lines.

The other option is using a combination of Deep FX and Active FX.  A surgical facelift removes approximately 10 to 20 square cm of tissue.  Using fractionated lasers we poke microscopic holes in skin much like aerating a lawn.  After poking these holes, we have removed anywhere from 5  to 10 square cm of tissue.  That means that we can get results that are on par with a facelift without the cost or downtime of a traditional surgery.  This is the reason that many patient are choosing this procedure instead of a facelift (Denver Magazine: Death of the Facelift).  In addition to being the best wrinkle treatment and skin tightening treatment, the combination of Active FX and Deep FX will also treat enlarged pores, sun damage spot and even decrease scars.

There is a ton of confusing marketing when it comes to devices for wrinkle treatment and skin tightening.  With so many products such as Fraxel, Pixel, Matrix, Profractional, Thermage, Lux IR and more being added daily it is hard to know which one is the best.  So how does a consumer rate the different laser procedures?  It is actually very simple, just look at the pictures.  Make sure these are not the generalized pictures from the manufacturer.  Patients should stand firm and request pictures from the provider that will be performing the service.  Ask the provider if these are average results or if they are just showing their “homerun” cases.   If they cannot provide you pictures it is time to find a new provider or look at a different procedure.  Check out examples of before and after photos of Active FX  and Deep FX here.  

It is important that you both trust your provider and the technology they are using.  It takes several hundred cases to optimize clinical outcomes with any devise so make sure to choose someone who can prove that they achieve excellent, safe and consistent results.

Avoid:

Before any invasive procedure or other treatments that may alter the integrity of the skin such as Botox or Fillers make sure you should avoid certain vitamins and supplements.  Stop taking all of the following for at least one week:

NSAIDS (Advil, Motrin, Aleve)
Omega 3 fatty acids (Fish Oil)
Flax Seed Oil
Vitamin E
St. John’s Wart
Garlic
Ginko
Ginseng

A special note about aspirin:  It would need to be stopped for 10-14 days before a procedure but check with you prescribing physician first to see if it is ok to stop this medication.

Most minor bruising lasts a couple days to a couple weeks so be patients.  Keep firm pressure on any area that is obviously swelling for at least 5 minutes.  Place cool packs over the area immediately after treatment and for the first 24 hours (no hot packs).  Keep the area elevated for the first few days, especially at night.

Supplements:

There are two main supplements that have been proven to reduce the healing time of bruising and swelling.  In some studies healing times have been decreased by as much as 40%.

• Arnica Montana can be very effective, the oral forms like SinEcch are much more effective that topical gels. It is even more effective when both forms are used together. Take the tablets as directed and apply gel 4-6 times a day.
• Bromelain (an enzyme found in pineapple) also helps to minimize the bruising by helping to digest the proteins that trigger bruising and swelling. Take 250-500mg four times a day until the bruise heals.

Make-up Tips

Remember that green tinted make-ups will help decrease redness and yellow make-up will help absorb bluish discoloration.

1. Ablative (vaporized some elements of the skin)
2. Non-ablative.  

The non ablative procedures have little to no downtime and tend to cost a little less per procedure while the ablative procedure tend to provide better results but can have significant down time.

Ablative: higher cost, better results, more downtime, usually single treatment

CO2
The ”gold standard” of tissue tightening is full CO2 resurfacing.  This procedure ablates 100% of skin over the treated area.  It can range in cost from $5000-$15000 dollars and usually requires at least two weeks of downtime but usually more.  Results are normally significant and last several years.  Redness after the procedure can last months and other side effects can include permanent lightening of the skin and or scaring.

Fractionated CO2
Fractionated procedures, such as Active/DeepFX and CO2 Fraxel, normally ablate anywhere from 20-80% of the skin by punching holes about twice the diameter of a human hair into the skin.  These procedures offer many of the tightening benefits of full CO2 with less downtime, cost and risk of long term side effects.  

Although I am not aware of any head to head studies that specifically address skin tightening between full CO2 and fractioned CO2, I can say that during an Active/Deep FX procedure a provider can actually watch the skin tighten as the laser passes over the treatment area. 

Cost is about $2500-$4000.  Expect anywhere from 5 day to 2 weeks of downtime with fractionated CO2 depending on how aggressively your provider performs the treatment. The procedure provides excellent results that last several years.

Non-Ablative: Lower cost, little or no downtime, less results, usually a series of treatments

Titan
Infrared light used to heat collagen so it shrinks and simulated new collagen growth over a 3-6 month period.  I have used this machine since 2004 and works well for laxity around the eyes, cheeks and neck, so-so for jowls. 

Procedure cost about $800-$1000 for a full face. There is no downtime but plan on at least three procedures.  Results usually last about 18 months, and about 80-85% of patients are happy with results. This is a very tolerable procedure, and the side effects are limited to a very rare blister.  

The LuxIR also uses infrared light to treat skin laxity, but there seems to be slightly less consistency in the literature with this devise.

Thermage
Uses Radiofrequency to heat tissue.  Although I have seen this machine be effective the reports in the literature say that it only works well about 29% of the time. 

The treatments can be very painful and in rare cases radiofrequency can cause damage to the fat layer under the skin resulting in loss of volume over that area.  Cost range from $1000-$3500 and plan on 1-3 procedures with little to no downtime.

Resurfacing is a procedure where layers of damaged skin are removed usually by vaporization from a laser.  It can be used to get rid of brown pigment caused by sun damage, decrease wrinkles, shrink pores and tighten skin.  Vaporization is the process of using heat to instantly evaporate water out of the exposed tissue.  Resurfacing not only removes the tissue on top but also heats the tissue below the level of vaporization causing collagen contraction and stimulation.

So then what is fractional resurfacing?  If resurfacing is like mowing a lawn where every blade of grass is cut to a somewhat shallow depth then fractional resurfacing is more like aerating a lawn.  Fractional resurfacing pokes small but deep holes in the skin, but leaves a certain amount of the skin completely untouched.  Because these patch of undamaged skin patient heal much faster with minimal side effects. Fractional resurfacing was developed at The Wellman Center of Photomedicine at Harvard around 2001.  The original fractional laser did not destroy any tissue (non-ablative), it simply applied heat in order to stimulate new collagen formation.  This non-ablative (non-vaporizing) procedure required multiple treatments and has some significant limitations on efficacy.  Around 2005 we started testing fractionated ablative (tissue vaporization) CO₂ lasers (Active FX, Deep FX, Fraxel Re:pair) and found that in a single treatment we could achieve results that were not attainable after 5 or 6 treatments with the non ablative fractionated lasers. The downtime of about 5-7 day was a huge improvement over traditional CO₂ resurfacing (think mowing the law) that can take several months to heel. 

Now the market is saturated with fractionated products and it is hard for the patients to figure out which one is the best for them.  The first thing that separates these devices is the actual type of laser.  There are two main lasers used for resurfacing CO₂ and erbium.  The Active FX, Deep FX and Fraxel Re:pair are CO₂ lasers.  The Pixel and Profractional are erbium lasers.  The CO₂ lasers heat tissue much better causing more skin contraction and more collagen stimulation.  They also cause much less bleeding than erbium lasers.  The clinical results speak for themselves as much more skin damage can be removed with by a CO₂.

Between the CO₂ platforms FX (made by Lumenis) and the Fraxel (made by Reliant), the FX is much preferred by patients.  In 2007 Dr. Robert Weiss performed a split face study at Johns Hopkins using the Active FX on one side and the Fraxel Re:pair on the other.  Nine out of ten patients preferred both the comfort of the procedure and the results of the Active FX.

Ok so the Lumenis FX gives the best results and the most patient preferred procedure. So then what is the difference between Active FX, Deep FX and Total FX?  The Active and Deep FX are different heads that can be attached to the laser.  The Active FX is more shallow (about 1/3 mm) and wide which is better for skin tightening, decreasing pore size and removing pigmented sun damage.  The Deep FX is a narrow beam that goes deep (up to about 2mm) into the skin in order to treat wrinkles and scars.  The Total FX is more a marketing term that describes using both heads during the same treatment (which is how the procedure is normal done).

Deep FX: A single treatment of the new fractionated CO2 can give better results than 5 Fraxel treatments, this is simply one of the best new treatment for acne scars and wrinkles.  Patient who have had the procedure report that it makes their skin look younger than their friends who have had surgery such as a face lift.

Active FX: This is the second hand piece for the fractionated CO2 can tighten skin as much as 30 percent in a single treatment. kin tightening, melasma, moles and just about any other superficial skin issue.

SmartLipo MPX: Liposuction with little to no downtime and 40% less than traditional liposuction with better results