LAS VEGAS The new 1,550-nm erbium Fraxel laser, by creating minuscule dots of destruction in the surface of the skin, produces color and texture changes, and may have the ability to significantly reduce wrinkles at high fluences, Mark Rubin, M.D., said at a facial cosmetic surgery symposium.
"This, in my mind, is a therapy in flux. It's where Thermage was 2 years ago," said Dr. Rubin at the symposium, which was sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence.
The Fraxel laser was approved by the Food and Drug Administration in March.
Using company-suggested parameters, the device can deliver perceptible improvement in the skin with significantly less traumatic healing than is required after carbon dioxide (CO2) laser treatments.
Still, "the color and texture is really what knocks you out," said Dr. Rubin, who has no financial interest in, and receives no funding from, Fraxel manufacturer Reliant Technologies Inc.
"The big issue for me is what's happening wrinklewise. So far, my experience has been very variable," Dr. Rubin said.
It may be that very high fluences are necessary to dramatically alter wrinkles with the novel system. Dr. Rubin noted that a colleague had been experimenting with aggressive settings, and was finding "much more profound changes" than could be produced by a nonablative laser.
He suggested that it may take some time to work out the ideal ways to use the Fraxel laser for different purposes.
"Nobody really knows how to use it correctly," he said, urging colleagues to "look at it again in 6 months."
Dr. Rubin, who practices dermatology in Beverly Hills, Calif., purchased a Fraxel laser in hopes of finding the holy grail of skin resurfacing: a device capable of smoothing moderate to deep wrinkles without provoking a lengthy, complication-ridden healing period.
"The ablative therapies are spectacular, but no fun for you or the patient. There's risk. There's [a] nasty-looking [healing period] when you have to see patients every couple of days. There are reasons not everyone is dying to do this."
Nonablative devices seemed like a good ideaDr. Rubin bought several of thembut they proved to be poor substitutes for the steamroller effect that ablative lasers had on deep wrinkles.
Fraxel seemed to him to be a potential bridge between the two types of skin rejuvenation therapies, creating "little islands of ablated skin in a sea of normal skin."
"Rather than burning everything off, can we burn just little tiny bits at a time to sort of fool the skin into thinking it's not been wounded so badly?" he asked.
The answer ismaybe.
The epidermis remains intact, even when the laser's energy reaches depths of 700 micrometers and beyond, a level deep enough to promote collagen remodeling. But are the pinpoints of energy enough? And are the surface areas of each microthermal zone (estimated to number 2,000 per cm
About 20% of the facial surface area is impacted during each treatment session at a low fluence, typically four to six passes, Dr. Rubin said. However, "in reality, as you go back and forth like this, you're never really where you're supposed to be. In certain places you hit the same spot two times, three times, four times, who knows? And in other places, you skip."
It may be that the microscopic zones of destruction are so small that overlap does not matter, either in terms of results or side effects, he said. However, it remains to be seen whether consistency will be achieved as the laser makes its way into general clinical practice.
A clear advantage of Fraxel lasers over CO2 lasers is the healing process, according to Dr. Rubin. "These patients aren't weeping fluid. They're not bleeding," he explained.
When low fluences are used, edema typically lasts 12 days, and erythema lasts 13 days. Flaking and bronzing of the skin are common. Makeup can be worn because there is no open wound, but most patients need heavy makeup to cover the transient effects of the treatment.
"They certainly don't look normal enough to be fully functional a day or 2 days later. It's nonablative, but there is an impact on patient's lives as a result of this," Dr. Rubin said.
A topical anesthetic is used, and some patients require supplemental oral pain medications. A blue dye is used to enhance skin surface contours for optical scanning.
Patients, said Dr. Rubin, "look like [performers in] Blue Man Group," but the dye washes away within a day.
A grid is used to guide the laser.