Newer lasers, older modalities find their niche for resurfacing

New York - Although use of older resurfacing modalities is falling in favor of fractional lasers and fillers, experts say, dermabrasion and chemical peels continue to play a role for some operators.

Roy Geronemus, M.D., says that in his opinion, recognized advantages of ablative fractional resurfacing (AFR) versus older modalities - including fully ablative lasers, chemical peels and dermabrasion - include safety, consistency of results and the ability to vary patients’ response based on the technology and parameters chosen. He is director of the Laser & Skin Surgery Center of New York and clinical professor of dermatology at New York University Medical Center.

Conversely, says New York-based plastic surgeon Daniel C. Baker, M.D., “Dermabrasion, which has around for more than 50 years, can produce comparable results - and even better results - than just about anything on the market today. Most plastic surgeons and dermatologists would agree with that.”

Both physicians agree regarding the drawbacks of fully ablative CO₂ laser resurfacing. In this regard, Dr. Geronemus says that for postprocedural hypopigmentation, “We reported an incidence of 16 percent with nonfractional CO₂ lasers (Bernstein L, Kauvar A, Grossman M, Geronemus RG. Dermatol Surg. 1997;23(7):519-525). And I believe this is an understatement compared to what happens in typical practices.”

Dr. Baker adds, “The older CO₂ lasers used to generate a lot of heat” that penetrated beyond the epidermis, accounting for the risk of post-treatment hypopigmentation. But because dermabrasion produces a cold-induced injury that does not extend beyond the skin’s surface, “It tends to produce less hypopigmentation than a phenol peel or a fully ablative CO₂ laser.”

Side effects and results

Dr. Baker says his practice stopped doing fully ablative CO₂ laser treatments because of their side effects and prolonged healing periods. In the latter area, Dr. Geronemus says ablative technologies and deeper peels produce postprocedural peeling that lasts up to 10 days, and erythema that lasts from weeks to months. Conversely, he says, “Healing following AFR is significantly faster than with nonfractional ablative treatments. While wounding does occur with AFR, re-epithelialization often occurs within a few days, and in most cases postoperative redness is reduced from months to weeks.”

For nonfacial treatments as well, Dr. Geronemus says, “With the older techniques, the risk of scarring and pigmentary change was so high that in many cases, these devices were contraindicated.” Similarly, he says, “The incidence of hypertrophic scarring that we saw with older techniques was considerably higher than what we see today with AFR.”

Regarding the ability to modify treatments, Dr. Geronemus says, AFR allows physicians to factor in the patient’s condition and skin type. Conversely, he says, “Darker skin types have always been extremely challenging for chemical peels and dermabrasion. We worry about hyper- or hypopigmentation as a result of these aggressive procedures.”

In contrast, he calls AFR’s ability to alter treatment techniques for darker skin types a major breakthrough. Before the advent of AFR, Dr. Geronemus says, treating scars, lines and pigmentation problems in skin types IV through VI was so difficult that he would not even attempt it.

“Now we do these treatments routinely,” Dr. Geronemus says. For superficial problems, “I might treat Caucasian patients with lighter skin types using a density of 50 to 70 percent. I may cut that in half if I’m treating somebody with a darker skin type.”

Nonablative advantages

Similarly, Dr. Geronemus says that nonablative resurfacing techniques provide significant advantages for all skin types in treating acne scars, photodamage, actinic keratoses (AKs), surgical scars and burn scars. Side effects are mild and include dryness, scaling and erythema that can last up to four to five days, he adds.

Likewise, Dr. Geronemus says that compared to dermabrasion and deep chemical peels, nonablative resurfacing is safe and free of concerns for pigmentary changes and, usually, significant downtime.

“Patients can go about their lives without being encumbered by an open wound or prolonged healing time,” he says.

Nevertheless, “One downside of the fractional technology is that the duration of cosmetic benefit may not be quite as long for treatment of photodamage or for skin tightening,” Dr. Geronemus says.

For these indications, “Perhaps you’re better off with the older, fully ablative technologies. But still you must balance that off with the risk of pigmentary change, the higher risk of scarring and the longer healing time required,” he says.

Therefore, Dr. Geronemus says, “There’s a trade-off between having to repeat a treatment and having a higher level of safety. On the other hand, results with many of the scars that we treat with fractional technologies tend to be more permanent.”

Addressing AKs

For AKs, a study that included six months’ follow-up showed that, “The nonablative fractional 1,927 nm thulium laser is as good as anything out there, with no wounding of the skin (Weiss ET, Brauer JA, Anolik R, et al. J Am Acad Dermatol. 2013;68(1):98-102),” he says.

Dermabrasion, meanwhile, provides the most value in treating very deep lines around the lips and in the perioral region - often with a single treatment, Dr. Baker says. While other modalities usually require multiple treatments for this indication, “For a physician with experience and skill, usually one treatment will provide improvement anywhere from 75 percent to 90 percent.”

Any of the other modalities can handle superficial lines, he says. “For general fine lines and sun damage, the Fraxel (Solta) laser is excellent, as are TCA (trichloroacetic acid) peels and phenol peels. But the side effect profile of deep laser treatments, deep peels and deep dermabrasion includes hypopigmentation.”

Logistically, dermabrasion requires little equipment investment, upkeep and floor space. Nevertheless, says Dr. Baker, who has performed thousands of dermabrasion procedures over 30 years, “I use less dermabrasion today.”

Patients with deep perioral lines increasingly want fillers, he explains. However, “You can only do so much with a filler without creating distortion.” Therefore, he finds dermabrasion - which he usually performs in the same session as a facelift - to be most effective for patients who want to address these deep lines with a single treatment.

However, Dr. Baker says that like surgical procedures, dermabrasion carries a learning curve: 50 to 100 cases before one achieves proficiency. “There’s a certain technical expertise required in terms of using your hands and being able to accurately analyze the depth of the peel.”

United against hype

It’s not that dermatologists or plastic surgeons as a whole favor one technology over the other, Dr. Baker says. Rather, “Because lasers are new technology, there’s tremendous marketing and hype behind them. But for those of us who’ve tried many of the lasers, there’s a bit of disappointment between what’s promoted and the results.”

Some patients get excellent results with fractional ablative or nonablative lasers, Dr. Baker notes. Furthermore, he says that generally, “Younger plastic surgeons probably find the lasers a little easier and perhaps more predicable when they haven’t had as much experience. There’s a greater comfort level with the lasers, where you choose a certain setting based on patient needs to produce a predictable result.”

As laser resurfacing technology continues to improve, Dr. Baker says, “There may come a time when that's the only thing we do” for patients who want resurfacing treatments. But for now, “There’s really no single absolutely best technique. It varies with the operator, the patient and how he or she responds.”

Whatever one’s preference, he advises, “Become skilled in several techniques so you have options available in your armamentarium. And you need to be familiar with each modality’s capabilities, and what types of skin each modality works best with. That way, you have different treatments to offer your patients.”

Disclosures: Drs. Geronemus and Baker report no relevant financial interests.