“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

Acne scarring results when the healing process after an acne infection goes array.  After the skin is inflamed by the acne lesion fibrosis can occur.  This is made worse when patient repeatedly pick or squeeze their lesions.  Picking causes repeated trauma and increased inflammation while squeezing can drive infectious material deep into the wound again causing more inflammation.  Fibrotic repair of the lesions lead to the textural changes associated with acne scarring. 
Anatomy of Acne Scarring:
The main thing to understand is that acne scarring lesions tend to be very deep in the skin.  To give an idea of scale, most human hairs are about 100-200 microns thick.  Acne lesions normally extend between 800-2000 microns (.8mm-2mm) into the skin.  This fact alone explains why most acne scar treatment are minimally effective.

Solutions to Acne Scarring:
The most obvious solution to acne scarring is prevention.  Scarring develops during the inflammatory and healing stages of the lesion so there are a couple of ways to prevent it.  First is to keep acne, especially cystic acne under control.  This involves a visit to the doctor and normally some type of education and prescription topical or oral medication.  TV infomercials are not a replacement for a visit to your physician. There are many patients whose acne goes from very controllable to fairly severe because they try months or years of over the counter treatment options that never quite work.  The second part is simply not to pick or squeeze acne lesions.  Picking and squeezing are both inflammatory and make lesions worse.

Acne Treatment Options:
Tretinoin (Retin-A) is one of the very few topicals that has been shown to improving the appearance of acne scarring in peer reviewed clinical trials.  Patients should be very suspicious of any product claims that do not compare their product to either a placebo or Tretinoin. 

Microderm and Superficial Chemical Peels:
Mild fruit acid peels such as Glycolic, Lactic, Salicylic and microderm are often offered up as treatments for acne scarring.  Most of these treatments penetrate from 10-30 microns into the skin, remember acne scarring normally goes from about 800-2000 micros into the skin.  That means even at their best, these treatments only effect the top 5% of the scar.  With multiple repeated treatments this can be slightly increased but even after 10-20 treatments with these modalities there are only modest results at best.

Deeper Peels:
TCA, multiple layer Jessner ‘s Solution can penetrate through the epidermis over 100 micros into the skin.  These products use a chemical reaction to literally burn a thin layer of skin off.  The deeper the lesion caused by the peel, the longer the downtime will be. Peels that do deep enough to completely remove the epidermis will normally take about 7-10 day to recover from but still will only treat about the top 10-20% of an acne scar.  Phenol peels are very deep peels which although they can get moderate results are not used very often any more do to their potential for scarring.
Non Ablative Lasers:
This a large category which includes any light based technology that heats the skin to stimulate collagen synthesis which helps fill in depressions in the skin.  The heat also helps rearrange the abnormal architecture of collagen fibrils that are already present.  Light sources such as Cutera’s Laser Genesis and the Fraxil Re:store fall into this category.  With all of the light sources the energy of the laser is absorbed by water in the tissue and turned into heat.  These procedures require multiple treatment but can provide moderate results with little to no downtime.

Shallow Ablative Lasers:
An ablative laser actually vaporizes (destroys) an area of tissue.  The shallow lasers are normally Erbium devices such the Cutera Pearl and Sciton Contour or Profactional.  These lasers come in versions that treat the entirety of the skin and in fractional versions which only treat a small portion of the skin (like aerating a lawn).  The advantage of the fractional devises is that they tend to go deeper which treats deeper pathology and significantly decrease both heeling time and side effects.  Erbium lasers will tend to product about 30-150 microns of ablations in the full forms and about 600-800 microns in their fractional forms.   The fractional version of these lasers can provide nice improvement in acne scarring but have two draw backs.  The first is that even the fractional versions of Erbium lasers to not get to base of most acne scars and second is these lasers do not provide as much heat to tissue as a CO2.  This heat is necessary to induce remodeling of the tissue that is not ablated and is a major factor in the final outcome that a patient sees in the mirror.

Deep Ablative Devices:
Almost all of the lasers currently in this category are CO2 lasers.  This is the gold standard in revising acne scarring.  The newest devices are fractionated like their more shallow counterparts.  There are many devices in this category including, Pixel, Affirm, Dot, Fraxil Re:pair and Lumenis Active and Deep FX.  Unfortunately most of them are grossly underpowered.    Underpowered lasers need to use very long laser pulses to get the same amount of energy into the tissue as  a short pulse with a properly powered laser.  These long pulses can lead to excessive tissue heating and side effects such as discoloration and even scarring.  These underpowered devices are cheap to build and more affordable to purchase so they have become very common in the medi-spa industry.  I will only go into detail about the appropriately powered devices such as the Lumenis Active FX, Deep FX and Fraxil Re:pair.  These devices can penetrate 2000 microns into the skin or more and thus are the only devices that can reach the entire scar region.  Although good results can be obtain with both devices the clear  king of the mountain is the Lumenis laser.  In a study done a Johns Hopkins 9 out 10 patient preferred both the procedure and results from the Active FX when compared to the Fraxil Re:pair.
Other Treatments:
There are many other treatments including subcision, needling, punching out lesions and adding filler that can all be used to improve the texture of acne scarring.  Although these modalities can be effective, they tend to be more useful for less extensive lesions.

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.

The simple answer is yes it does. We have had the benefit of using this laser for over two years now and have also had great success with scars. Using the Active FX and Deep FX we have successfully treated acne scars, burn scars, surgical scars, keloid scars and those from just about any other kind of trauma. The patient below had skin cancer removed from his nose about five year earlier. After 3 treatments, each lasting only about 20 minutes, the scar was virtually gone.

Cancer Removal Scar Treated with Active FX and Deep FX

This is another patient who had severe acne scarring. This photo shows the improvement after a single Active FX and Deep FX treatment. The patient when on to get a second treatment and his skin is almost smooth at this point.

Acne Scarring After a Single Treatment with Active FX and Deep FX

Although swelling can be significant (especially with more aggressive treatments), there is only minor discomfort during the days following the procedure. Patient routinely tell me that they took a single Vicodin to sleep the night after their procedure and have not required anything stronger than ibuprofen after that.  Depending on the amount of swelling, oral steroids such a Prednisone are usually offered to the patients. Patients who have a history of cold sores should also be placed on antiviral medication such as Acyclovir or Valtrex.

The Active FX uses a CO2 laser to removal a small core of tissue (about 1 hair thick) which literal decreases the amount of skin. During a face lift approximately 30 square cm of skin are removed, during an Active FX procedure approximately 20-25 square cm of skin are removed.  There is also a significant thermal effect from the Active FX which causes the tissue around the removal site to shrink and also stimulates new collagen deposition. Although there is very little discomfort most patient prefer to take between 5-7 days off before returning to social activities. A single Active FX treatment can tighten tissue from 10-35% depending on the aggressiveness of the treatment. Results last several years.

You should cover the treated area with an occlusive ointment like Silkses (less milia and acne) or Auqaphor.  You may notice mild to significant swelling, especially around the eyes.  The more aggressive the treatment, the greater the swelling is likely to be.  In many cases we put our patients on prednisone (oral steroids) to help decrease this swelling.  Most swelling starts to significantly improve by about day 3. During this time you can wash your face with Aquanil (cuts the grease of the ointment well) and/or one tbsp plain white vinegar to 1-2 cups cold water.  The water/vinegar combination is weak ascetic acid and will act as an antibiotic and sooth the skin. 

You may also notice some minor itching, if itching is more than mild and not controlled with Benadryl, Claritin or Zyrtec call you doctor as this can be a sign of dermatitis or infections.  If you have a history of cold sores you should be taking an antiviral such as Valtrex or Acyclovir.  Some patients do get breakouts after a few days of having the occlusive ointment on their skin.  This is also were the milia can come into play.
Somewhere between day 5 and 7 you should be able to start back with mineral make-up and stop the topical ointment. After a week or so the Active FX areas will look pretty normal but you will likely be pink in the areas of the Deep FX for at least two or three more weeks depending on how aggressive your provider does the procedure.