Facial Lasers’ Future: Shorter Downtimes, Darker Skin Types

JAMES SCHLETT, EDITOR, james.schlett@photonics.com

When Dr. Mark Schwartz started performing laser facial rejuvenation treatments, he had regularly advised his patients that they should expect a month of downtime, meaning they’d experience redness, crustiness and swelling from the full-field, ablative carbon dioxide (CO₂) laser he used. That was 1997, and his patients back then seemed willing to tolerate such long periods of downtime for the sake of looking years younger. Not so much anymore.

Figure 1. Dr. Mark Schwartz uses Sciton’s hybrid fractional laser, the Halo, on a patient. The Halo is the first facial laser to deliver both ablative and nonablative wavelengths. Courtesy of Sciton.

“People just seem very busy now. Even those who are retired. It’s just rare that people will give me that kind of time, for good reason,” said Schwartz, who has an office on the Upper East Side in New York City.

Now Schwartz braces most of his patients for far shorter downtimes, thanks to a hybrid ablative and nonablative fractional laser called Halo, by Sciton in Palo Alto, Calif. The laser system uses a 1470-nm diode for the nonablative delivery of 100- to 700-µm of coagulation to the epidermis and dermis as well as a 2940-nm erbium-doped yttrium aluminum garnet (Er:YAG) laser for the ablation of up to 100 µm of the epidermis (Figure 1).

“I’m seeing really nice results with little downtime,” said Schwartz.

In the Milwaukee suburbs, Dr. Andrew Campbell, another plastic surgeon, started using the Halo in August 2014, a few months after its release. When he previously used Sciton’s ProFractional, a 2940-nm Er:YAG laser, he advised patients being treated for skin texture and wrinkles to expect four to five days of weeping, during which their face would bleed and makeup would be prohibited. They would need to undergo three treatments that were one month apart, meaning the total downtime would range from 12 to 15 days (Figure 2). But with the Halo, he said there is no downtime and that only one to two treatments are necessary. Now, only his “toothpick” patients — those with wrinkles so deep a toothpick can be stuck in them — receive the more intensive full-field ablative treatment with an Er:YAG laser.

Figure 2. A woman before being treated with Sciton’s hybrid fractional laser, the Halo (a) and one week after treatment (b). Courtesy of Sciton.

“My number of deep resurfacing [patients] drops every time we get a new technology,” said Campbell.

Fractional photothermolysis

Since their emergence in 2005 with the Fraxel SR750 by Reliant Technologies, now known as Solta Medical in San Francisco, fractionated lasers have reshaped the facial rejuvenation industry as much as they have celebrities’ faces. Cosmetic laser companies are now looking to push the bounds of fractionated technology to further reduce costs and downtime by, for example, introducing systems with multiple and new wavelengths as well as faster and more powerful devices such as picosecond and diode lasers.

“Old-time CO₂ laser treatments were not fractionated and very aggressive, leading to unwanted effects like scarring or alabaster white-colored skin. More gentle versions of CO₂ lasers, including the use of fractionated treatments, have greatly reduced the risks,” said Dr. Ramsey Markus, an associate professor of dermatology and director of laser surgery at Baylor College of Medicine in Houston.

Through a process known as fractional photothermolysis (FP), fractionated lasers in many ways bridged the gap that cosmetic surgeons commonly encountered between the too-powerful CO₂ and Er:YAG lasers and not-powerful-enough near-infrared, nonablative lasers. The former delivered nice results but resulted in a lengthy recovery period while the latter had lower downtimes but fell short on results¹.

As researchers from Reliant and Harvard Medical School’s Wellman Laboratories of Photomedicine noted in their seminal 2004 paper on FP, this skin treatment creates microscopic thermal wounds referred to as microscopic treatment zones (MTZs), leaving uninjured tissue around each wound (Figure 3). The MTZs are usually arranged in a grid pattern and are invisible to the naked eye. This patterned approach is less intense than the nonfractionated methods in which all of the skin surface is treated. The MTZs create smaller injuries and shorter migratory pathways of wound-filling keratinocytes, resulting in faster skin repair.²

Figure 3. Fractional laser treatments are based on fractional photothermolysis, in which a laser beam is fractionated into a pattern, allowing it to create microscopic thermal wounds referred to as microscopic treatment zones (MTZs), which are surrounded by uninjured tissue. The MTZs create smaller injuries and shorter migratory pathways of wound-filling keratinocytes, resulting in faster skin repair. Courtesy of Solta Medical.

While the first fractionated laser to receive clearance from the U.S. Food and Drug Administration was nonablative, they were soon followed by fractionated, ablative variants, such as Solta’s CO₂ Fraxel Re:pair and the ActiveFX for the UltraPulse platform by Lumenis Ltd. in Yokneam, Israel. These fractionated and nonfractionated lasers were CO₂-based, working at 10,600 nm, but similar Er:YAG lasers were later introduced, such as Sciton’s 2940-nm ProFractional³.

“The fractional approach to treatment has revolutionized much of how clinicians approach treating aging and sun-damaged skin. This concept is agnostic to energy source or wavelength, and I believe it will continue to grow as robustly as we have seen in the last 12 years,” said Vladimir Paul-Blanc, the general manager of Solta Medical, which is a division of Valeant Pharmaceuticals International.

Diversity

Factors driving the development of the next generation of cosmetic lasers include aging baby boomers and millennials. A 2015 survey by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) found that 64 percent of member facial plastic surgeons reported an increase in treatments of patients under 30. Eighty-two percent of surgeons said their patients’ decisions to undergo treatment were influenced by celebrities. Fifty-one percent said patients pursued cosmetic surgery to remain competitive in the workforce.

Age, however, is not the only factor influencing cosmetic laser development. Executives at several cosmetic laser companies emphasized a need to help surgeons better treat darker skin types, mostly those with Fitzpatrick skin types (FSTs) V and VI. (FST is used to gauge a person’s risk to sunburn.) Sciton Project Manager Dan Sullivan pointed out that individuals with these skin types, such as people of Asian, African or Indian decent, represent an increasingly large share of the U.S. population.

Prior to adopting the ablative and nonablative Halo, Schwartz said he was able to treat FST V patients but not FST VI patients with the ablative ProFractional. Whether using the Halo or ProFractional, Schwartz required his darker-skinned patients to be treated with hydroquinone for the two-week period prior to lasering. However, he said the ProFractional “did not provide the ‘global’ treatment to the complexion that patients experience with the Halo.”

It is the abundance of pigment-producing cells called melanocytes that results in darker skin. The greater concentration of the melanin pigment produced by these cells in dark-skinned individuals results in a greater absorption energy, making them prone to post-inflammatory pigmentation. Sullivan said surgeons are able to treat these darker skin types with the Halo through its ability to change the laser’s percent coverage, for example, from 30 percent for a person of northern European descent with FST I, to 5 percent for a person of Indian decent with FST V (Figure 4). He did note that the 1064-nm wavelength — currently not available in the Halo but offered in the Sciton’s Clearscan YAG — has proved effective at hair removal on darker skin types.

Figure 4. To better treat patients with darker skin, surgeons can change, or tune, the Halo hybrid fractional laser’s percent coverage. Courtesy of Sciton.

“This was one of the motivations for us to be the first to market with a 1064-nm picosecond product,” said Jayant Bhawalkar, vice president of research and development for the Yokneam, Israel-based Syneron Medical Ltd.

Picosecond and diode lasers

Syneron in October 2015 announced the launch of a 532/1064-nm picosecond laser for facial rejuvenation called PicoWay Resolve. Syneron had initially selected the latter wavelength for its ability to remove black, brown, green, blue and purple ink. The original PicoWay platform was launched in 2014 for tattoo removal applications. Coincidentally, the 1064-nm wavelength also proved effective at treating deep lesions. In addition to removing red, yellow and orange ink, the 532-nm wavelength also treats shallow lesions.

Wavelengths aside, picosecond lasers’ approach to skin rejuvenation is markedly different from other facial lasers, such as CO₂, Er:YAG, neodymium-doped yttrium aluminium garnet (Nd:YAG) and diode. Unlike these technologies, a picosecond laser does not deposit heat in the skin.

Rather than heating the skin, the PicoWay’s high-intensity pulses cause laser-induced optical breakdown (LIOB), during which electrons are stripped from tissue and a plasma cloud is formed. As it absorbs the remaining energy, the electron-free plasma cloud expands and ablates tissue in the process (Figure 5). The end result is the creation of a vacuole, which spurs the formation of new collagen as part of the LIOB healing process⁴.

Figure 5. Hematoxylin and eosin stain on skin tissue showing 0.2-mm vacuoles in the upper dermis, the result of laser-induced optical breakdown. Courtesy of Syneron.

While picosecond lasers have managed to distinguish themselves in the area of tattoo removal, that is not the case with facial rejuvenation. While picosecond LIOB on biological tissue has been studied for ophthalmological applications since the late 1980s⁵, it was not until 2013 that the Westford, Mass.-based Cynosure Inc. introduced the first picosecond aesthetic laser for benign pigmented lesions. Bhawalkar acknowledged that picosecond aesthetic lasers are at a nascent stage and their costs remain high. However, costs will decrease as the technology matures, and “the big advance here is not that the results are significantly better, but that the downtime is minimal.”

“They [picosecond lasers] are trying to break into aesthetics, but I have not seen a paradigm shift,” said Campbell, the Milwaukee-area facial plastic surgeon who also chairs the AAFPRS’ Emerging Trends Committee.

Even without a paradigm shift, picosecond lasers have caught the attention of Solta, which in 2014 was acquired by Valeant Pharmaceutical in Laval, Quebec, Canada. At Solta, Paul-Blanc said picosecond lasers are an “area we’re watching as they mature.” In the meantime, the company is eyeing more powerful and reliable diodes for replacing other lasers in its devices to help drive down costs. Solta’s nonablative, fractionated Clear + Brilliant device consists of a diode laser, with the original version delivering a 1440-nm wavelength, and its subsequently released Perméa delivering at 1927 nm.

“It is an important acknowledgment of the space and industry that diode technology has evolved. This gives a manufacturer some exciting opportunities to re-evaluate technology decisions,” said Paul-Blanc.

More wavelengths

Solta is also preparing to shake up its wavelength offerings. In addition to venturing into the visible light wavelength rage, the company is considering expanding the number of wavelengths it offers in its single-wavelength and double-wavelength devices. The Fraxel DUAL is an example of the latter. It is a nonablative device that has a 1550-nm erbium fiber laser and a 1927-nm thulium fiber laser.

“We believe that multiple-wavelength technology offers significant value to target both different indications of the skin as well as different focal depths. Also, the concept of multimode delivery is interesting and could have some potential for historically difficult-to-treat indications. We see these as potential improvements for both the Fraxel DUAL and Re:pair product lines,” said Paul-Blanc.

Bhawalkar at Syneron also expects to see the emergence of cosmetic laser systems with more than two wavelengths and multiple modalities, including short- and long-pulse options. An example of a tri-wavelength system is the recently released third wavelength, 785-nm, for the PicoWay, though it is only approved for tattoo removals, particularly for blue and green inks. But whatever combination of wavelengths or modalities that cosmetic laser companies settle on, the goal will remain the same.

“People want that subtle but noticeable improvement, and a big part of that is not only results but also the downtime,” said Sullivan.

References

1. M. Gold (January 2010). Update on fractional laser technology. J Clin Aesthet Dermatol, Vol. 3, pp. 42-50.

2. D. Manstein and G. Scott Herron, et al. (2004). Fractional photothermolysis: A new concept for cutaneous remodeling using microscopic patterns of thermal injury. Lasers Surg Med, Vol. 34, pp. 426-438.

3. M. Gold (January 2010).

4. K. Schomacker and J. Bhawalkar (2015). Mechanisms of action of fractionated 532nm and 1064nm picosecond laser for skin rejuvenation. Syneron-Candela Clinical Bulletin.

5. Ibid.

Faceoff: Fractional Lasers vs. Fractional Microneedle Radiofrequency

Last year, when Plastic Surgery Practice magazine and Yahoo Beauty published their lists of breakthrough beauty products, the Yokneam, Israel-based Syneron Medical Ltd.’s Profound landed on both lists. Profound is a fractional microneedle radiofrequency (FMR) device for skin tightening and facial rejuvenation. Noticeably absent from these lists were fractional nonablative and ablative laser systems, such as the Fraxel lines by Solta Medical in San Francisco, that years earlier had revolutionized facial cosmetic surgery.

The acclaim that Profound has received highlights how FMR, though still a nascent technology, could seriously compete with lasers in certain areas of the facial rejuvenation market. Since 2013, the U.S. Food and Drug Administration has approved at least one FMR device each year, starting with the Infini by Lutronic in Seoul, South Korea; followed by the Intensif by EndyMed Medical Ltd in Caesarea, Israel in 2014; the Profound in 2015; and the VIVACE by Sung Hwan E&B in Seoul, South Korea, last January.

The Infini fractional microneedle radiofrequency system by Lutronic. Courtesy of Lutronic.

“It seems like everyone and their mother is coming out with a radiofrequency microneedle,” said Dr. Andrew Campbell, a Milwaukee-area facial plastic surgeon who also chairs the Emerging Trends Committee of the American Academy of Facial Plastic and Reconstructive Surgery.

Radiofrequency (RF) facial treatment systems actually predate fractional laser systems, with Thermage releasing its namesake RF system in 2002. It was not until 2005 that Thermage’s successor, Reliant Technologies, released its first fractional ablative laser, the Fraxel 750. While the Fraxel, now offered by Solta, and similar devices promote skin tightening by using laser energy to denature collagen and stimulate new collagen growth, FMR devices do the same by using electromagnetic energy. The oscillation of charged particles in the tissue has a heating effect¹.

Wanting to minimize the extent of damage caused by this volumetric bulk heating, RF device makers later adopted the fractional approach to facial rejuvenation, in which the healing process is quickened by using energy to create microscopic treatment zones (MTZs) that are surrounded by unaffected tissue². Except, where the laser beam is split into a fractional pattern, the RF’s electromagnetic energy is fractionally delivered through the use of multiple external electrodes. In both cases, the energy must travel through the epidermis to get to the dermis, though RF has the advantage of passing through the skin without heating it and achieving deeper penetration³.

In recent years, FMR has emerged as a more precise method for achieving more predicable electrothermal damage depth⁴. Devices use arrays of microneedle electrodes that penetrate the epidermis by a few micrometers to create precise thermal injuries in the dermis, making FMR an invasive technique, whereas fractional laser treatments are noninvasive. For example, Infini’s microneedles have a diameter of 200 µm and the Intensif’s microneedles are are 300-µm thin.

“FMR bypasses heat to the epidermis so there is less risk and downtime with it. It also can go deeper — up to 3.5 mm — than a laser. For some reason, RF induces collagen and elastin, whereas lasers induce only collagen,” said Dr. Steven F. Weiner, a Santa Rosa Beach, Fla., facial plastic surgeon who uses the Intensif.

Jayant Bhawalkar, Syneron’s vice president of research and development, said the insertion of the Profound’s microneedles necessitates the use of local anesthesia and results in several days of recovery. He noted that carbon dioxide (CO₂) and erbium-doped yttrium aluminium garnet (Er:YAG) lasers have the highest downtime; nonablative fractionated lasers, such as erbium-doped glass, call for only a few days downtime; and picosecond lasers have virtually no downtime — just a few hours.

“But because it [FMR] is more invasive, the number of treatment sessions required to see results is lower. So there are trade-offs between downtime and results,” Bhawalkar said.

Dan Sullivan, the product manager for Sciton in Palo Alto, Calif., the maker of the fractional ablative and nonablative Halo laser, said he does not see FMR as posing a major threat to lasers. He said FMR lacks lasers’ “level of capability or versatility” and is “an inexpensive supplement to a more powerful laser resurfacing suite.” Vladimir Paul-Blanc, the general manager of Solta, said FMR’s staying power rests in its “longevity with consistency and safety, as well as good evolution of dosage and future development improvement.”

“While sometimes not as exciting, longevity is a premium in the aesthetics space when it comes to devices, and fractional laser technology has a validated and heavily researched history … I do believe that well-designed studies with peer-reviewed publications that comparatively assesses FMR and fractional devices will help determine FMR’s place in a clinician’s tool bag, as well as the continued research and development of fractional technology,” said Paul-Blanc.

Fractional laser and FMR technologies, however, may not have a strictly adversarial relationship. Studies have shown combinations of the two technologies can yield positive results for the treatment of acne and traumatic scars⁵.

“The idea of combining the two technologies sounds promising as long as there is minimal downtime,” said Dr. Mark Schwartz, a New York City plastic surgeon who has used fractional lasers but not FMR.

References

1. J. Preissig and C. Hamilton, et al. (August 2012). Current laser resurfacing technologies: A review that delves beneath the surface. Semin Plast Surg, Vol. 26, pp. 109-116.

2. S. Weiner. A review of radio frequency for skin tightening. (Finally! A radiofrequency system that makes sense: The Infini from Lutronic), white paper.

3. J. Preissig and C. Hamilton, et al. (August 2012).

4. S. Weiner.

5. M. Loesch and A.-K. Somani et al. (2014). Skin resurfacing procedures: New and emerging options. Clin Cosmet Investig Dermatol, Vol. 7, pp. 231–241.