Fraxel Laser Indications and Long-Term Follow-Up

xxx-xxxc_YMAJ587_Tanzi_1P
10/20/08
1:39 PM
Page 1
Special Topic
Fraxel Laser Indications and
Long-Term Follow-Up
Elizabeth L. Tanzi, MD; Rungsima Wanitphakdeedecha, MD, MA, MSc; and Tina S. Alster, MD
Fractional photothermolysis, based on creating spatially precise microscopic thermal wounds, is performed
using a 1550-nm erbium fiber laser that targets water-containing tissue to effect the photocoagulation of narrow, sharply defined columns of skin known as microscopic thermal zones. According to the authors, Fraxel
resurfacing has been shown to be both safe and effective for facial and nonfacial photodamage, atrophic acne
scars, hypopigmented scars, and dyspigmentation. Because only a fraction of the skin is treated during a single session, a series (typically 3 to 6 treatments) of fractional resurfacing at 2- to 4-week intervals is required
for the best clinical improvement. It is the authors’ experience that a series of Fraxel treatments can achieve a
similar clinical result for atrophic scars compared with traditional ablative laser skin resurfacing. However, the
improvement seen after a series of Fraxel treatments for perioral laxity and rhytides often falls short of the
impressive results that can be achieved with ablative laser skin resurfacing. (Aesthetic Surg J 2008;28:***.)
EVOLUTION OF ABLATIVE AND NONABLATIVE
SYSTEMS
Ablative laser skin resurfacing with either carbon dioxide (CO2) or erbium:yttrium-aluminum-garnet (Er:YAG)
laser systems is a well accepted treatment for facial rejuvenation, predictably improving the appearance of photoinduced rhytides and dyschromia.1 However, complete
epidermal ablation induced by these systems results in
loss of cutaneous barrier function and an extended postoperative recovery period. Untoward side effects include
prolonged erythema, pigmentatry alteration, infection,
and, in rare cases, fibrosis and scarring.2-4 Furthermore,
because of the high risk of scarring in nonfacial areas
because of a relative paucity of pilosebaceous units in
nonfacial skin, the use of ablative laser skin resurfacing
is limited to facial areas.
Nonablative Systems
To address the risks associated with ablative laser skin
resurfacing, nonablative laser systems were developed.
Nonablative laser or light-based systems (including
1064- and 1320-nm Nd:YAG, 1450-nm diode, 1540-nm
erbium glass lasers, and intense pulsed light systems)
combine epidermal surface cooling with infrared or
near-infrared wavelengths that create a controlled thermal injury. In studies using various nonablative devices,
neocollagenesis was evident on histologic evaluation
with minimal side effects, but clinical improvement was
AQ1
Drs. Tanzi and Alster are in private practice in Washington, DC.
Dr. Wanitphakdeedecha is from the Department of Dermatology,
Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok,
Thailand.
Aesthetic Surgery Journal
modest and often inconsistent.5-9 Moreover, photoinduced dyschromia, which is often seen in conjunction
with wrinkles, is not adequately addressed with completely nonablative laser systems.
FRACTIONAL PHOTOTHERMOLYSIS
Introduced by Manstein et al10 in 2003, fractional photothermolysis was developed to overcome the aforementioned shortcomings associated with cutaneous laser
resurfacing and is based on the creation of spatially precise microscopic thermal wounds with sparing of the surrounding tissue. Fractional resurfacing is performed using
a 1550-nm erbium fiber laser (Fraxel; Reliant
Technologies, Mountain View, CA) that targets watercontaining tissue to effect photocoagulation of narrow,
sharply defined columns of skin known as microscopic
thermal zones (MTZs), at depths of 200 µm to 500 µm
and spaced at 200- to 300-µm intervals. Histologic evaluation of the MTZ demonstrates homogenization of dermal matrix and the formation of microscopic epidermal
necrotic debris (MEND) that corresponds to the extrusion
of damaged epidermal components by viable keratinocytes at the lateral margins of the MTZ. The depth
of penetration of each MTZ is energy dependent and can
be tailored to the characteristics of the treatment area (ie,
facial vs nonfacial skin). Increases in pulse energy lead to
increases in MTZ depth and width without compromising
the structure or viability of interlesional tissue.11
The MEND exfoliates several days after treatment,
lending the skin a bronzed appearance.12 The wound
healing response differs from ablative techniques because
the epidermal tissue that is spared between thermal
zones contains viable transient amplifying cells, capable
Volume 28 • Number 6 • November/December 2008 • 1
xxx-xxxc_YMAJ587_Tanzi_1P
10/20/08
1:39 PM
Page 2
of rapid reepithelialization. Furthermore, because the
stratum corneum has a low water content, it remains
intact immediately after treatment, thereby maintaining
epidermal barrier function and reducing the risk of infection. In addition, fractional resurfacing can provide an
advantage over purely nonablative laser treatments
because of the gradual exfoliation of the epidermis with
resultant improvement in superficial dyspigmentation.
Investigators have shown Fraxel laser resurfacing to be
both safe and effective for a variety of indications,
including facial and nonfacial photodamage, atrophic
acne scars, hypopigmented scars, and dyspigmentation
AQ2 (Figures 1 through 3).13-21 Because only a fraction of the
skin is treated during a single session, a series (typically
3 to 6 treatments) of fractional resurfacing at 2- to 4-week
intervals is required for the best clinical improvement.
Side Effects and Complications
Side effects of fractional resurfacing are typically mild
and transient, including erythema and periocular edema,
A
AQ5
and a slight darkening of the skin (bronzing) as the
MEND desquamate. The overall complication rate is significantly lower with fractional skin resurfacing than
that reported after ablative laser skin resurfacing.1-4
A retrospective evaluation of 961 successive 1550-nm
Fraxel laser treatments in patients with various skin phototypes (Fitzpatrick types I through V) was conducted in a
single clinical center.22 There were 73 reported complications in 961 treatments (7.6%). The most frequent complications were acneiform eruptions (n = 18; 1.87%),
herpes simplex virus (HSV) outbreaks (n = 17; 1.77%),
and erosions (n = 13; 1.35%). Less frequent side effects
included postinflammatory hyperpigmentation (n = 7;
0.73%), prolonged erythema (n = 8; 0.83%), prolonged
edema (n = 6; 0.62%), and dermatitis (n = 2; 0.21%).
To reduce the risk of HSV outbreak, oral HSV prophylaxis
is recommended for those patients with a strong history
of herpes labialis. Acne-prone patients were more likely to
experience posttreatment acne, presumably because of the
disruption of follicular units during treatment and reep-
B
Figure 1. A, Pretreatment view of a ***-year-old female with periocular rhytides. B, Posttreatment view 3 months after a series of three Fraxel
laser treatments.
A
B
Figure 2. A, Pretreatment view of a ***-year-old male with periocular rhytides. B, Posttreatment view 3 months after a series of five Fraxel laser
treatments.
2 • Volume 28 • Number 6 • November/December 2008
Aesthetic Surgery Journal
AQ3
xxx-xxxc_YMAJ587_Tanzi_1P
10/20/08
1:39 PM
Page 3
A
B
Figure 3. A, Pretreatment view of a ***-year-old male with atrophic scars. B, Posttreatment view 3 months after a series of four Fraxel laser treatments.
ithelialization. The use of oral antibiotics (eg, doxycycline,
20 mg daily) during subsequent treatments prevented
future outbreaks in these patients.
To date, permanent pigmentary alteration and scarring have not been reported. However, when an aggressive treatment protocol is used, placing a high density of
MTZ, the risk of visible epidermal ablation is increased
along with the side effects and complications associated
with ablative laser procedures.
CONCLUSIONS
As demand grows for minimally invasive treatments to
address the signs of aging and photodamage, clinicians
will be challenged to develop procedures that combine
reliable clinical results with minimal posttreatment
recovery. Based on its demonstrated clinical efficacy and
excellent side effect profile in a wide range of skin types,
fractional photothermolysis is considered a first-line
treatment for cutaneous resurfacing. To date, there are
no published reports evaluating the clinical efficacy of
traditional ablative laser skin resurfacing compared with
nonablative fractional resurfacing. It is the authors’
experience that a series of Fraxel treatments can achieve
a similar clinical result for atrophic scars compared with
traditional ablative laser skin resurfacing. However, the
improvement seen after a series of Fraxel treatments for
perioral laxity and rhytides often falls short of the
impressive results that can be achieved with ablative
laser skin resurfacing.
Over the next several years, variations on the theme
of fractional photothermolysis, including ablative fractional photothermolysis with highly advanced CO2 and
Er:YAG laser systems, will continue to advance cutaneous laser resurfacing toward the ultimate goal of maximum clinical improvement coupled with minimal
recovery and side effects. ◗
AQ4 DISCLOSURES
REFERENCES
1. Alster TS. Cutaneous resurfacing with CO2 and erbium:YAG lasers: preoperative, intraoperative, and postoperative considerations. Plast
Reconstr Surg 1999;103:619–632.
2. Alster TS, Tanzi EL. Laser and light source treatment of clinical manifestations of photodamage. In: Goldberg DB, ed. Photodamaged Skin.
New York: Marcel Dekker; 2004:115–143.
3. Tanzi EL, Alster TS. Side effects and complications of variable-pulsed
erbium:yttrium-aluminum-garnet laser skin resurfacing: extended experience with 50 patients. Plast Reconstr Surg 2003;111:1524–1529.
4. Tanzi EL, Alster TS. Single-pass carbon dioxide versus multiple-pass
Er:YAG laser skin resurfacing: a comparison of postoperative wound
healing and side-effect rates. Dermatol Surg 2003;29:80–84.
5. Alster TS, Tanzi EL. Laser skin resurfacing: ablative and nonablative.
In: Robinson J, Sengelman R, Siegel DM, Hanke CM, eds. Surgery of
the Skin. Philadelphia: Elsevier; 2005:611–624.
6. Goldberg DJ, Samady J. Intense pulsed light and Nd:YAG laser nonablative treatment of facial rhytides. Lasers Surg Med 2001;28:141–144.
7. Lupton JR, Williams CM, Alster TS. Nonablative laser skin resurfacing
using a 1540 nm erbium:glass laser: a clinical and histologic analysis.
Dermatol Surg 2002;28:833–835.
8. Tanzi EL, Williams CM, Alster TS. Treatment of facial rhytides with a
nonablative 1450 nm diode laser: a controlled clinical and histologic
study. Dermatol Surg 2003;29:124–128.
9. Tanzi EL, Alster TS. Comparison of a 1450-nm diode laser and a 1320nm Nd:YAG laser in the treatment of atrophic facial scars: a prospective
clinical and histologic study. Dermatol Surg 2004;30:152–157.
10. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional
photothermolysis: a new concept for cutaneous remodeling using
microscopic patterns of thermal injury. Lasers Surg Med
2004;34:426–438.
11. Bedi VP, Chan KF, Sink RK, Hantash BM, Herron GS, Rahman Z, et al.
The effects of pulse energy variations on the dimensions of microscopic
thermal treatment zones in nonablative fractional resurfacing. Lasers
Surg Med 2007;39:145–155.
12. Fisher GH, Geronemus RG. Short-term side effects of fractional photothermolysis. Dermatol Surg 2005;31:1245–1249.
13. Geronemus RG. Fractional photothermolysis: current and future applications. Lasers Surg Med 2006;38:169–176.
14. Tannous ZS, Astner S. Utilizing fractional resurfacing in the treatment
of therapy-resistant melasma. J Cosmet Laser Ther 2005;7:39–43.
15. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with fractional
photothermolysis: a pilot study. Dermatol Surg 2005;31:1645–1650.
16. Wanner M, Tanzi EL, Alster TS. Fractional photothermolysis: treatment
of facial and nonfacial cutaneous photodamage with a 1550-nm
erbium-doped fiber laser. Dermatol Surg 2007;33:23–28.
The authors have no financial interest in and receive no compensation from the manufacturers of products mentioned in this article.
Fraxel Laser Indications and Long-Term Follow-Up
Volume 28 • Number 6 • November/December 2008 • 3
xxx-xxxc_YMAJ587_Tanzi_1P
10/20/08
1:39 PM
Page 4
17. Alster TS, Tanzi EL, Lazarus M. The use of fractional laser photothermolysis for the treatment of atrophic scars. Dermatol Surg
2007;33:295–299.
18. Lee HS, Lee JH, Ahn GY, Lee DH, Shin JW, Kim DH, et al. Fractional
photothermolysis for the treatment of acne scars: a report of 27 Korean
patients. J Dermatolog Treat 2008;19:45–49.
19. Jih MH, Goldberg LH, Kimyai-Asadi A. Fractional photothermolysis for
photoaging of hands. Dermatol Surg 2008;34:73–78.
20. Glaich AS, Rahman Z, Goldberg LH, Friedman PM. Fractional resurfacing for the treatment of hypopigmented scars: a pilot study. Dermatol
Surg 2007;33:293–294.
21. Waibel J, Beer K. Fractional laser resurfacing for thermal burns. J
Drugs Dermatol 2008;7:59–61.
22. Graber EM, Tanzi EL, Alster TS. Side effects and complications of fractional laser photothermolysis: experience with 961 treatments.
Dermatol Surg 2008;34:1–7.
Accepted for publication September 16, 2008.
Reprint requests: Elizabeth L. Tanzi, MD, 1430 K St. NW, Ste. 200,
Washington, DC 20005. E-mail: [email protected].
Copyright © 2008 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$34.00
doi:10.1016/j.asj.2008.09.006
4 • Volume 28 • Number 6 • November/December 2008
Aesthetic Surgery Journal
xxx-xxxc_YMAJ587_Tanzi_1P
10/20/08
1:39 PM
Page 5
AQ1: Please provide Dr. Wanitphakdeedecha’s appointment within the department (Associate Professor,
Clinical Professor, et cetera).
AQ2: Is it okay to cite all 3 figures here?
AQ3: Is the addition of “Fitzpatrick types” okay?
AQ4: Please verify that no authors have any financial
interest in Reliant Technologies. Thank you.
AQ5: For Figures 1, 2, and 3, please provide the ages of
the patients. Thank you.
Fraxel Laser Indications and Long-Term Follow-Up
Volume 28 • Number 6 • November/December 2008 • 5