The Aesthetic Guide Nov Dec 08 : 1
Even at the peak of ablative carbon dioxide (CO2) skin resurfacing, the aesthetic medicine market contin- ued to seek a safer, less aggressive alternative that wouldn’t sacrifice results for downtime. The advent of non-ablative fractional technology revolutionized resurfacing treatments. This led to a rapid progression of similar hybrid devices combining ablative and fractional technol- ogy in the hopes of achieving improved efficacy with less downtime. Cutera, Inc. (Brisbane, Calif.) is taking it one step further with the introduction of an alternative wavelength – the 2790 nm YSGG (Yttrium Scandium Gallium Garnet) – which was en- gineered to provide a perfect compromise between ablation of tissue and collateral thermal effect, the two main factors contributing to superior results. continued on page 3 November/December 2008 Circulation 20,000 www.miinews.com
Novel Wavelength Advances Skin Resurfacing
Kevin Wilson
Even at the peak of ablative carbon dioxide (CO2) skin resurfacing, the aesthetic medicine market continued to seek a safer, less aggressive alternative that wouldn’t sacrifice results for downtime. The advent of non-ablative fractional technology revolutionized resurfacing treatments.
This led to a rapid progression of similar hybrid devices combining ablative and fractional technology in the hopes of achieving improved efficacy with less downtime. Cutera, Inc. (Brisbane, Calif.)
Is taking it one step further with the introduction of an alternative wavelength – the 2790 nm YSGG (Yttrium Scandium Gallium Garnet) – which was engineered to provide a perfect compromise between ablation of tissue and collateral thermal effect, the two main factors contributing to superior results.
Proves Ideal for Ablative Skin Treatments
Available as a stand-alone platform or as an add-on to Cutera’s popular Xeo system, the new Pearl Fractional is most commonly indicated for photodamage and deep dermal imperfections. This device harnesses the strength of the YSGG laser to create ideal wound columns for ablative fractional therapy. According to the manufacturer, the Pearl Fractional offers high yield cosmetic enhancement with minimal downtime and efficacy equal to or better than the competition.
Instead of relying on shallow ablation of surface tissue, Pearl Fractional creates patterns of ablative wounds reaching depths of 300 ìm to 800 ìm, or even deeper depending on energy settings. Surrounding tissue is left untreated to promote more rapid healing.
According to E. Victor Ross, M.D., director of the laser and cosmetic dermatology unit at the Scripps Clinic in San Diego, Calif., the 2790 nm YSGG technology seems to be perfect for this type of treatment, “Safe and effective fractional therapy requires a balance between ablation and overall thermal effect, which is dependent on wavelength.”
There are three wavelengths used for ablative fractional therapy: Er:YAG, CO2 and YSGG. YSGG offers a balance between the absorption coefficients, which affects thermal damage and ablation. Models predict (based on heat diffusion) that YSGG allows for improved hemostasis versus erbium YAG and may reduce pain versus CO2. Depending on how aggressively you treat (particularly density or percent coverage of the skin’s surface area), results can approach those observed with traditional one to two pass CO2 resurfacing in just one or two treatments. Any concessions in wrinkle reduction versus traditional CO2 resurfacing are recouped by a shorter recovery and less risk of hypopigmentation.”
Ablative fractional technology, such as Pearl Fractional, offers physicians and patients a treatment option with the benefits of both traditional resurfacing and nonablative fractional therapies. “Traditional ablative CO2 resurfacing was the gold standard for a long time and it is still a good technology,” said Dr. Ross. “The trouble was that over treatment led to scarring and long-term hypopigmentation which eventually turned physicians away from this aggressive resurfacing.”
“Fractional CO2 has become very popular lately due to the history of CO2,” Dr. Ross said, “and it works. However since it has the lowest absorption coefficient of the three major wavelengths, coagulation and thermal damage to surrounding tissue is increased. The collagen remodeling achieved with ablative fractional therapy results from the combination of tissue ablation and collateral thermal damage. However, excessive thermal damage to surrounding tissue causes complications.
Therefore, the wound column for fractional CO2 must be very narrow, meaning less ablation of tissue.”
“We see the opposite with Er:YAG devices. The area of collateral thermal effect surrounding the wound is extremely narrow, almost non-existent. Ablation is maximized, but bleeding is increased During treatment, Dr. Ross explained. So the big question is: “What is the perfect combination of cavity width, depth and ratio of thermal damage to the cavity itself? Until longer follow-up data is available, no one knows for sure, but the Pearl Fractional satisfies many of the theoretical criteria for successful fractional ablative skin rejuvenation.”
Pearl Fractional’s 2790 nm wavelength allows the wound size to be optimized for maximum ablation, with a spot that will vaporize seven to ten times more tissue than fractional CO2 devices. Tissue reduction from ablation is paramount to overall tightening, and thermal stimulation of neocollagenesis in the surrounding tissue enhances this effect. Collateral thermal damage does not overlap and is not excessive; therefore, healing remains rapid. “The hemostasis achieved with Pearl Fractional is produced by a healthy measure of coagulation,” added Dr. Ross. “Occasionally, delayed pinpoint bleeding, similar to numerous tiny shaving cuts, may occur and that’s easy to deal with.”
According to Richard Green, M.D., of the Interlude Laser and Medical Spa in Vancouver, Wash., “The YSGG of Pearl Fractional allows the energy to be put to best use.” Through ablative fractional CO2, “a majority of the energy travels into the thermal component causing persistent redness. With an Er:YAG device, energy is almost entirely funneled into ablation and as a result bleeding is a factor. Pearl Fractional sits comfortably between those extremes.”
“An ideal patient is middle-aged with skin type I to III, presenting moderate-to-severe photodamage,” noted Dr. Ross, who also favors off-label acne scar treatment with Pearl Fractional. “Two main indications for Pearl Fractional are deeper pathologies for which conservative resurfacing efforts are typically inadequate, such as deep creases around the mouth or a wide-range of scars. Deep lines that we effectively treated with traditional CO2 lasers in the past, have continued to defy our efforts with fractional modalities, until now.”
Brian S. Biesman, M.D., medical director of the Nashville Centre for Laser and Facial Surgery in Nashville, Tenn. And current president of the American Society for Laser Medicine and Surgery (ASLMS) is currently conducting research with the Pearl Fractional. “This device is especially good for treating the periorbital, perioral and jawline areas, including treatment on both the upper and lower eyelids. We’ve seen really nice tightening in these areas.” Dr. Biesman typically performs combination treatments with both Pearl and Pearl Fractional. Pearl is used first to treat the full-face, followed by focal aggressive treatments with Pearl Fractional. This combination enables fast treatments whileminimizing discomfort. “The vastmajority of treatments are performed with topical anesthetic alone or in conjunction with an oral agent such as Ativan or Darvocet.”
“When treating the upper and lower eyelids, it is essential to keep the lids stretched and use protective corneoscleral shields under the lids,” Dr. Biesman continued. “Depending on the patient, I’ll typically do two passes on the lids, changing the orientation of the handpiece by 45° between each pass, sometimes performing a third pass on the crow’s feet area.” Dr. Biesman added that controlling the amount of topical anesthetic around the eyes is important so that it doesn’t melt and get into the eye. A little petroleum jelly along the lashes and eyebrows will help prevent scorching of hairs.
Cutera conducted a study with Dr. Ross, Dr. Green and Leonard Rasi, M.D., medical director of Senza Aesthetic Medicine in Redlands, Calif., to examine the clinical and histological results of a single Pearl Fractional treatment. Thirty subjects ranging from 43 to 73 years of age with skin types I to III and mild-to-severe wrinkling (score of 3 to 7 on the Fitzpatrick Wrinkle Severity Scale) were evaluated. Topical anesthesia was used on all patients, with additional pain management measures (nerve block or cooling) utilized at the discretion of the practitioner. Treatment energies were 160 mJ or 240 mJ per spot, with wounds applied at medium density using one or two passes, depending on wrinkle severity. Biopsies were performed immediately post treatment at four days and at two weeks on randomly selected subjects.
Overall, histological and clinical results were very impressive. Full-face treatment time ranged from 40 to 70 minutes and all patients reportedly tolerated therapy extremely well and there were no incidences of hyperpigmentation or infection. Biopsies demonstrated that ablation depth at any given treatment energy ranged from 600 ìm to 1,000 ìm and continued to increase in relation to rising energy levels. In addition, a 40 ìm radius of thermal damage surrounded each ablation column. Re-epithelialization was apparent at day four in all biopsy cases. Incidence and persistence of side effects, such as erythema and oozing were also higher at increased energy levels. Subjects with a history of previous aesthetic facial surgery seemed to experience slightly longer recovery times.
All subjects observed improvement and patient feedback revealed that 94% of subjects would recommend Pearl Fractional to friends. Of the study participants, 88% were happy to extremely happy with results; 57% reported significant to dramatic improvement in wrinkles; 75% responded that they had significant to dramatic improvement in fine lines; and 75% reported significant to dramatic improvement in skin tone and texture. There were no reported complications and make-up could be worn five days post treatment.
“Our results are preliminary but very encouraging, especially considering where we are in the process,” noted Dr. Ross. “This is still very new and we have not had time to fully explore the possibilities with Pearl Fractional. We are not treating as aggressively as we will in the very near future.” As with similar therapies, more aggressive treatment tends to increase results, but frequently means more downtime and an increased risk of side effects. “We have been trying to limit downtime to four or five days. When we extend that to seven days, we’ll consistently see even better results.”
“One of the main ideas behind Pearl Fractional is to produce a more predictable process from patient to patient,” said Dr. Green. “It is much easier with this device due to the YSGG wavelength and what it offers. The optimized treatment beam is very narrow with high energy density; therefore, each pass at a medium density setting effectively treats 8% of the skin’s surface in that area, a second pass raises that to 16%, a third pass pushes it up to 24% and so on.” Density increases have not influenced downtime, “but seem to be much more effective in enhancing results versus simply increasing treatment energy. You can safely perform multiple passes since there isn’t as much collateral damage around each wound and you have enough untreated skin in-between to promote predictable healing. Problem areas simply require additional passes,” he continued.
Dr. Ross reported reduced pain during treatment as another overall effect of the optimized wavelength compared to other ablative fractional therapies. “Topical anesthetics, oral pain medication and a cooler during treatment are enough to relieve most pain. We occasionally use nerve blocks during perioral treatment as generally that is a sensitive area to treat.”
Typically, post treatment care consists of occlusive ointment such as Aquaphor from Eucerin-Beiersdorf (Wilton, Conn.) For the first few days, which is replaced by a simple lotion to avoid post treatment acne outbreaks, Dr. Ross shared. These outbreaks can happen with any fractional technique and may be controlled with antibiotics such as tetracycline if necessary.
In addition to potential pinpoint bleeding and oozing, which occurs immediately to one day post treatment, it is normal to experience significant erythema for five to seven days after treatment and mild erythema for a few weeks, depending on the level of energy chosen for treatment. Some patients may experience swelling or edema, which typically peaks at one to two days after treatment and subsides by day five. Columns left from tissue ablation are bridged by reactions to the thermal stimulation as well as the natural healing process. Healing is rapid and downtime is comparatively minimal. Although one treatment with Pearl Fractional is usually sufficient, additional treatments may be given at four week intervals.
“Patients are extremely satisfied with Pearl Fractional and results are as good if not better than platforms employing other wavelengths,” Dr. Green reported. “A big advantage of Pearl Fractional is that you can achieve these kinds of results with one treatment and an average downtime of five days, which is important for patients,” he said. “Another really nice benefit is that I don’t have to talk patients into the procedure since treatment is tolerable and it delivers the goods. Alternatively, there are patients who come in wanting wrinkle reduction but will not go under the knife. Pearl Fractional also fills this need.”
Similar to competing systems, many of the treatment parameters are easily adjustable. Users may control the treatment energy (adjustable from 60 mJ to 320 mJ) as well as the density of spots. Variable scan patterns enable practitioners to treat hard-to-reach or small areas.
“The handpiece is easy to hold and isn’t attached to an articulated arm, which can be unwieldy,” noted Dr. Ross. “It also has a built-in attachment for a smoke evacuator, which is very convenient.”
Cutera’s Xeo platform additionally supports Pearl, Titan, LimeLight, ProWave 770, AcuTip 500, Laser Genesis and the 1064 nm Nd:YAG laser for hair and veins. Dr. Ross pointed out that all applications can be interchanged in about thirty seconds during treatment. Xeo features an intuitive, user-friendly touch screen interface and provides access to a full spectrum of laser treatment options as a flagship platform, which is becoming essential for new practitioners under the current economic conditions.
Pearl Fractional is a must-have for current Xeo owners as a powerful, costeffective entrance into the exploding ablative fractional market, explained Dr. Green. “Cost is a very important factor. Pearl Fractional’s plastic standoff, which establishes a standard distance between the tip and the skin’s surface, is the only disposable necessary and sells for $20. Some competing devices utilize disposable treatment tips that exceed $400. Minimizing the fixed cost doesn’t simply translate to reduced patient fees, it means the patient has more money to spend. Pricing a procedure so high that patients can’t afford to maximize their outcomes with adjunctive treatments is something I avoid.”
Although fractional ablative therapy can be very safe, Dr. Biesman warns that these devices are powerful and any treatment (even fractional) can be overdone. “Practitioners with traditional resurfacing experience know and appreciate the power of ablative devices. New fractional devices such as Pearl Fractional significantly reduce the complication rates of full resurfacing, but are still very powerful tools. Aggressive fractional ablative treatments can approach full resurfacing procedures in respect to downtime and risks.” However, he added, “When used properly, Pearl Fractional and similar devices offer safe and effective treatments.”
Combination treatments may yield the greatest benefit. Dr. Biesman and Dr. Green both perform combination treatments with Pearl and Pearl Fractional. Pearl utilizes the YSGG laser for more superficial (about 90 ìm depth) resurfacing of epidermal imperfections and photodamage.
According to Dr. Green, “Usually, patients who come in with dermal lines also have dyschromias and other superficial texture issues. Since the thermal and ablative components are so well balanced with the Pearl Fractional, we can then treat isolated problem areas, such as the perioral region and the neck, with the confidence that hypopigmentation will not occur.”
Dr. Green believes Pearl Fractional bridges the gap between surgical and non-surgical treatment options for facial rejuvenation. “You have the face-lift for overall tightening, less aggressive resurfacing such as Pearl for epidermal problems and Pearl Fractional for specific areas that require deeper treatments. Combination therapy takes a patient who is happy with their results and makes them ecstatic.”
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