Fractional Technology Brings New Life to CO₂ Laser

SANTA MONICA, CALIF. — In the world of cosmetic skin rejuvenation, what's old is new again.

Ablative laser resurfacing with CO₂ lasers—using fractionalized laser energy this time around to reduce healing time—dominated a recent cosmetic dermatology seminar sponsored by Skin Disease Educational Foundation.

"It's almost like we're rediscovering the wheel," said Dr. Mitchel Goldman, who is a dermatologist in private practice in La Jolla, Calif.

Dr. Goldman explained that he has 32 lasers in his office, but the only ones that truly smooth wrinkles and tighten the skin are the CO₂ and erbium:YAG lasers.

The others, he said, mainly address pigmentation issues and vascular changes. They demand multiple visits, multiple passes, and generate multiple complaints from patients who see little improvement in their overall appearance.

The drawback with CO₂ lasers is the downtime to allow for healing, even with fractional ablative resurfacing. "No matter what anyone says, there is some downtime," now averaging approximately 4-5 days, compared with the 1-4 weeks for first-generation CO₂ lasers, he said.

The lure of fractional CO₂ resurfacing is its reliability in producing meaningful cosmetic skin changes with less damage by creating pinpoint "drill holes" linked by tissue bridges.

Among 356 patients who have undergone fractionalized CO₂ laser procedures in his practice in the past 3 years, "we have seen virtually no complications," he said. A 1% incidence of herpes was eliminated by the addition of antiviral prophylaxis in every case. There has been a 2% rate of erythema lasting for more than 4 days.

"That was it," he said, detailing his experience with Lumenis systems.

The three big players in ablative fractional resurfacing, according to Dr. Goldman, are the Fraxel Re:pair by Reliant, and the ActiveFX and DeepFX by Lumenis.

Speakers discussed their experiences with each, coming to the conclusion that the devices induce significant nonspecific thermal damage that induces collagen remodeling, yet invite far fewer complications than traditional CO₂ lasers, including burns and pigmentation abnormalities.

"I think there's been a quantum shift back toward CO₂. The reason is, CO₂ works," said Dr. John Fezza of Sarasota, Fla.

"There's no question, there is some redness," acknowledged Dr. Fezza, who performed a real-time video laser resurfacing procedure on a 42-year-old woman with sun damage during the meeting.

Still, in more than 2 years, he has seen no lasting hyper- or hypopigmentation—common side effects associated with traditional CO₂ laser resurfacing.

Patients with realistic expectations know that if they have a fractionated CO₂ laser procedure on a Friday, they'll be ready to go out with makeup by Monday.

"They don't mind house arrest for 3 days," he said.

Dr. Goldman said he considers fractionated CO₂ lasers "safe if you go within the [recommended] parameters," but they require care and caution just like their prototypes.

Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, said he believes the reason fractionated CO₂ lasers have a measurable impact on wrinkling and skin tightening is that "they have the ability to induce a defect that is deeper than it is wide."

Dr. David Goldberg agreed. For photo damage and superficial rhytids, the key is density, but depth is what matters if the goal is skin tightening, he said.

"I'm pretty convinced," Dr. Goldberg said.

All speakers at the session disclosed grant support, laser equipment loans, and/or speakers bureau ties to companies that manufacture lasers, including Reliant and Lumenis.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.