Fundamentals: Instrumentation, and Skin Type Paul M. Friedman, M.D. Director, Dermatology & Laser Surgery Center Clinical Assistant Professor University of Texas Medical School, Houston, TX Clinical Assistant Professor Weill Medical College of Cornell University, The Methodist Hospital, Houston, TX Disclosures Advisory Board Allergan, Inc. Solta Medical Syneron-Candela Speakers Bureau Allergan, Inc. Research Grant Sienna Biopharmaceuticals, Inc. Options for Cutaneous Scarring Laser Treatment of Scars 585-nm or 595-nm pulsed dye laser (PDL) 532-nm potassium titanyl phosphate lasers (KTP) Intense pulsed light (alternative) Ablative fractional resurfacing (AFR) Laser-assisted drug delivery (LADD): AFL + 5-FU +/- TAC 1,064/1,320 Nd:YAG, 1,450-nm diode Conventional CO2/Er:YAG resurfacing Non-ablative fractional resurfacing (NAFR) Bipolar fractional radiofrequency microneedling (Insulated) Picosecond lasers with diffraction array or hologram Balaraman B, Geddes ER, Friedman PM. Best Reconstructive Techniques: Improving the Final Scar. Dermatol Surg Oct 2015; 41:265-275. Hypertrophic / Erythematous Atrophic Hyperpigmented Hypopigmented Surgical Burn or Traumatic Laser Treatment of Erythematous Scars Low fluence (4 to 5 J/cm 2 ), short pulse (.45ms), large spot size 10-12mm, 30/30 DCD May be initiated within 2-3 weeks of injury Treatment intervals of 4-6 weeks Easily combined with intralesional corticosteroids or antimetabolites if hypertrophy present Oliaei S, Nelson, JS, Fitzpatrick R, Wong BJF. Laser Treatment of Scars. Facial Plast Surg 2012;28:518-524. February 17, 2018 1
Benefits of Intralesional 5-Fluorouracil for Hypertrophic Scars 595-nm LPDL Improve scar softness and pliability Reduce scar height Improve scar color Enhanced efficacy without side-effects associated with higher concentration TAC Easily combined with other modalities (laser) Traumatic Scar 3 Treatments Manuskiatti W, Fitzpatrick RE. Arch Dermatol. 2002 Sep; 138(9):1149-55 Asilian A, Darougheh A, Shariati F. Dermatol Surg. 2006 Jul; 32(7):907-15. 595-nm LPDL + NAFR + IL TAC/5-FU Hypertrophic Scar 595-nm PDL +1450-nm Diode Laser 1-month after breast augmentation. 1-year after completing treatment. Hypertrophic Scar Oliaei S, et al. Laser Treatment of Scars. Facial Plast Surg 2012;28:518-524. Hypertrophic / Erythematous Atrophic Hyperpigmented Hypopigmented Surgical Burn or Traumatic Treatment of Atrophic Acne Scars Multi-modality approach achieves the best outcome Filler injections for atrophic, distensible scars Subcision for release of tethered scars Punch elevations, punch excision, cross technique for ice pick scars February 17, 2018 2
Lasers Options For Flat/Atrophic Scarring 595-nm Pulsed dye laser (PDL) Infrared (1,064/1,320 Nd:YAG, 1,450 nm diode) Non-ablative fractional resurfacing (NAFR) ~25-50% improvement after 5 treatment sessions. Ablative fractional resurfacing (AFR) ~50-75% improvement after 2-3 treatment sessions. Conventional CO2/Er:YAG resurfacing Dermatol Surgery. 2004 August; 30:8. Non-ablative Fractional Resurfacing (NAFR) Intact stratum corneum Thousands of microscopic wounds completely surrounded by viable tissue for rapid healing Immediate and delayed therapeutic results Epidermal and dermal coagulation for resurfacing Collagen denaturization for deep remodeling up to 1400µm Safe on neck, trunk, extremities and in darker skin types Manstein D, Herron GS, Sin RK, Tanner H, Anderson RR. Lasers Surg Med 2004;34:426-38. Non-ablative Fractional Photothermolysis Non-ablative Fractional Laser Treatment of Atrophic Scars Acne Scars and PIE 6 treatments 20-70 mj, Tx level 8 Chrastil B, Glaich AS, Goldberg LH, Friedman PM. Second-Generation 1550-nm Fractional Photothermolysis for the Treatment of Acne Scars. Dermatol Surg. October 2008; 34(10):1327-32. Treatment density (coverage) - 5% to 40% coverage Lower density in darker skin types Consider longer intervals between treatment sessions February 17, 2018 3
NAFR Ablative Fractional Resurfacing Acne Scars 1 Month after 4 treatments 40 mj, Tx level 5-7 Chrastil B, Glaich AS, Goldberg LH, Friedman PM. Second-Generation 1550-nm Fractional Photothermolysis for the Treatment of Acne Scars. Dermatol Surg. October 2008; 34(10):1327-32. Atrophic, Acne Scars 2 years after 1 treatment Avram M, Friedman PM, Avram M. Laser & Light Source Treatments for the Skin. Jaypee Brothers Medical Publishers LTD, New Delhi, India, 2014. 88. Ablative Fractional Resurfacing Non-Ablative Fractional Photothermolysis Atrophic Scar 4 Months 1 Treatment Striae Rubra 3 treatments 1550-nm, 25-70 mj, tx level 8-10 Avram M, Friedman PM, Avram M. Laser & Light Source Treatments for the Skin. Jaypee Brothers Medical Publishers LTD, New Delhi, India, 2014. 88. Katz TM, Goldberg LH, Friedman PM. Nonablative fractional photothermolysis for the Treatment of Striae Rubra. Dermatol Surg. 2009 Sep; 35:1430-3. Other Non-ablative Fractional Approaches for Atrophic Scars Picosecond lasers with diffraction array or hologram High intensity focused radiofrequency Microneedling +/- PRP JAMA Dermatol. 2015 Mar;151(3):278-84. February 17, 2018 4
Hypertrophic / Erythematous Atrophic Hyperpigmented Hypopigmented Surgical Burn or Traumatic Hyperpigmented and Hypopigmented Scars Hyperpigmented Scars: QS laser (pigment or tattoo) Picosecond laser (pigment or tattoo) 1927-nm Fractional Low-Power Diode 1550 or 1927-nm NAFR Hypopigmented Scars: NAFR AFR 1064-nm QS Nd:YAG Laser Fractional Photothermolysis Traumatic Tattoo Postinflammatory Hyperpigmentation 7 months after 3 treatments 1550-nm, 15 mj, Tx level 6 Katz TM, Goldberg LH, Firoz BF, Friedman PM. Fractional Photothermolysis for the treatment of postinflammatory hyperpigmentation. Dermatol Surg. 2009 Nov; 35:1844-8. 1927-nm Fractional Low-Power Diode Postinflammatory Hyperpigmentation 4-weeks after 3 treatments February 17, 2018 5
Non-ablative Fractional Photothermolysis Non-ablative Fractional Photothermolysis Atrophic, Hypopigmented Scars 4 treatments 1550-nm, 20mJ, Tx Level 7 Glaich AS, Rahman Z, Goldberg LH, Friedman PM. Fractional resurfacing for the treatment of hypopigmented scars. Dermatol Surg 2007;33:289-94. Atrophic, Hypopigmented Scar 3 sessions 1550-nm, 4-50mJ, 7%-23% coverage Balaraman B, Geddes ER, Friedman PM. Best Reconstructive Techniques: Improving the Final Scar. Dermatol Surg Oct 2015; 41:265-275. Ablative Fractional Photothermolysis Atrophic, Hypopigmented Scar 9/24/2015 Balaraman B, Geddes ER, Friedman PM. Best Reconstructive Techniques: Improving the Final Scar. Dermatol Surg Oct 2015; 41:265-275. Hypertrophic / Erythematous Atrophic Hyperpigmented Hypopigmented Surgical Burn or Traumatic Fractional Photothermolysis Kunishige JH, Katz TM, Goldberg LH, Friedman PM. Fractional Photothermolysis for the Treatment of Surgical Scars. Dermatol Surg. 2010 Apr;36(4):538-41. Atrophic, Surgical Scar 3 treatments 1550-nm, 40 mj, tx level 9-10 Avram M, Friedman PM, Avram M. Laser & Light Source Treatments for the Skin. Jaypee Brothers Medical Publishers LTD, New Delhi, India, 2014. 73. February 17, 2018 6
1,550-nm Non-ablative Laser for Facial Surgical Scars Prevention of Thyroidectomy Scar Using a New 1,550-nm Fractional Erbium-Glass Laser Facial Surgical Scars 2-weeks 1 Treatment 1550-nm, 8mJ, density of 2000 MTZ/cm 2** 2-3 weeks after surgery (Pre-treatment) 5 months after 4 treatments Behroozan DS, Goldberg LH, Dai T, Geronemus RG, Friedman PM. Fractional photothermolysis for the Treatment of surgical scars: A case report. J Cosmetic Laser Ther, 2006; 8:35-38. Capon A, Iarmarcovai G, Mordon S. Laser-Assisted Skin Healing (LASH) in hypertrophic scar revision. J Cosmet Laser Ther, 2009; 11:220-23. NAFR for Abdominoplasty Scar Lasers Surg Med. 2011 Apr;43(4):265-72. Mature hypertrophic, surgical scars Two arms: 10 subjects each High density: 40 mj/mb, 26% coverage Low density: 40 mj/mb, 14% coverage Total 4 treatment sessions, every 2 weeks Low-density treatment as effective as high density Younger scars responded better 6-months after 4 treatment sessions with 1550-nm, 20-30mj, 32% density starting 1-month after surgery Oliaei S, et al. Laser Treatment of Scars. Facial Plast Surg 2012;28:518-524. Hypertrophic / Erythematous Atrophic Hyperpigmented Hypopigmented Surgical Burn or Traumatic 595-nm LPDL Early Burn Scar Early Burn Scar February 17, 2018 7
595-nm Long Pulsed-Dye Laser and 1450-nm diode laser 595-nm LPDL + IL TAC Hypertrophic Scar 11 Treatments Katz TM, Glaich AS, Goldberg LH, Friedman PM. 595-nm long pulsed dye laser and 1450-nm diode laser in combination with intralesional triamcinolone/5-fluorouracil for hypertrophic scarring following a phenol peel. J Am Acad Dermatol. 2010 Jun;62(6):1045-9. Burn Scar Balaraman B, Geddes ER, Friedman PM. Best Reconstructive Techniques: Improving the Final Scar. Dermatol Surg Oct 2015; 41:265-275. Burn Scars 1,550-nm NAFR 5 sessions at 4-week intervals 40-70 mj/pulse, density 6-13* 1550-nm NAFR 90% had overall improvement 60% had moderate to excellent improvement Improved skin texture: 90% Improved dyschromia: 80% Improved hypertrophy/atrophy: 80% Waibel J, Wulkan AJ, Lupo M, Beer K, Anderson RR. Treatment of Burn Scars with the 1,550 nm Nonablative Fractional Erbium Laser. Lasers in Surg Med, 2012 Aug;44(6):441-6. Burn Scar 1550-nm NAFR 1550-nm NAFR Traumatic Surgical Scar 2 Treatments 1550-nm, 40 mj, Tx level 10 Atrophic, Hypopigmented Burn Scar Kunishige JH, Katz TM, Goldberg LH, Friedman PM. Fractional Photothermolysis for the Treatment of Surgical Scars. Dermatol Surg. 2010 Apr;36(4):538-41. February 17, 2018 8
595-nm PDL and Ablative Fractional Photothermolysis Fractional Ablative Lasers and Topical Drugs Fast uptake of many topical agents - large or small molecules Depth of uptake depth of laser holes (0.5-1.5 mm) Massaging made no difference Possible drug depot in each channel Drug uptake is strongly enhanced for ~3 days Future applications will include drug-device combinations Before 3-months 1 Treatment Avram M, Friedman PM, Avram M. Laser & Light Source Treatments for the Skin. Jaypee Brothers Medical Publishers LTD, New Delhi, India, 2014. 89. M Haedersdal, et al Fractional CO2 laser-assisted drug delivery. Lasers in Surgery and Medicine 42:113,(2010) : Summary Pulsed Dye Laser (585-595-nm) Hypertrophic & Erythematous Scars Pre-Scars Early striae Fractional (ablative and non-ablative) Atrophic scars Burn or traumatic scars Match depth laser to depth of scar with low density (optical coherence tomography) Laser-assisted drug delivery Early or late striae Summary Several laser techniques are available for the safe and effective treatment of various types of scars. Individualize and combine devices to customize the treatment to the characteristics and depth of the scar. Although long-standing scars will respond to laser therapy, new scars are more amenable to treatment; therefore, prompt treatment is recommended. Debate remains on the best timing for treatment initiation. Thank you! drpaul@dermlasersurgery.com + + @drpaulmfriedman February 17, 2018 9