Aesthetic Devices: Splitting Energy

The best fractional devices for your patients and practice.
MedEsthetics July/August 2019

In the Medical Aesthetics Industry, few technologies have taken hold quite as quickly as fractional photothermolysis. Rox Anderson, MD, PhD, and Dieter Manstein, MD, PhD, introduced the concept of “applying an array of microscopic treatment zones (MTZ) of thermal injury to the skin” as a lower risk alternative to fully ablative laser skin resurfacing in 2003. One year later, the 1,550nm Fraxel laser was released.

Today, there are three main types of energy-based fractional devices—ablative lasers, nonablative lasers and radiofrequency (RF)-based devices, which are often coupled with microneedling—and more than 50 branded systems. With so many options available, how do you know which ones to select and when? Here, physicians break down their preferences based on some of the most common skin concerns.

Skin Concern: Aging

Choosing the best fractional device for facial rejuvenation largely depends on the patient’s skin type and degree of damage.“For white skin with severe wrinkling and photodamage, an ablative CO2 or fractional CO2 laser would give better results than nonablative,” says Christine Lee, MD, of The Skin and Laser Treatment Institute in Walnut Creek, California. However, for darker skin types, Dr. Lee opts for a fractional Er:YAG laser or fractional RF microneedling because they pose less risk of hyperpigmentation problems.

Laurel Morton, MD, a dermatologist with SkinCare Physicians in Chestnut Hill, Massachusetts, prefers fractional CO2 and Er:YAG treatments for deep wrinkling. “Unfortunately, the nonablative lasers and RF options do not usually induce enough collagen remodeling to notably affect deep rhytides,” she explains. “Some patients may require more than one treatment with the fractional ablative laser, and for certain locations, such as the perioral region, it can be useful to combine this with fully ablative erbium.”

Dr. Morton recommends RF microneedling devices with insulated needles for patients with darker skin types, and says that picosecond fractional array devices are another option. “They are generally used at a low-energy setting and have been used in all skin types, though there may be a risk of hyperpigmentation in skin types V-VI,” she says.

When considering fractional CO2 and Er:YAG, it’s important to understand that individual devices can vary significantly. In order to reduce deep wrinkles, you need to achieve thermocoagulation in addition to ablation, explains Dr. Lee. “But most erbium lasers only cause ablation with no thermocoagulation,” she says. “Fotona and Sciton have dual-pulsed erbium lasers, which mimic the effects of CO2 by offering a coagulation mode in addition to an ablative mode. These lasers have higher power and longer pulse durations than the other less powerful erbium lasers, which cause superficial heating of the epidermis and lack the power or ability to penetrate deeper to cause the thermocoagulation you need to tighten laxity.”

Dr. Lee’s go-to CO2 laser is the Lumenis UltraPulse with MaxFX, Deep FX, ActiveFX and Scaar FX handpieces. “The Lumenis devices have the highest power, deepest penetration and, therefore, the best results,” she says, noting that lower power CO2 lasers can only go one speed—slow. “High-power lasers allow you to customize the treatment, giving you total control over what type of tissue effect you want to achieve,” she says.

A secondary concern in aging skin is laxity—and, unfortunately, effective noninvaisve options are lacking, according to Joely Kaufman-Janette, MD, a dermatologist at Skin Associates of South Florida in Coral Gables. “Fractional CO2 and fractional RF microneedling would be my best bets, but, I prefer to use Ulthera or nonfractional RF for skin tightening,” she says.

Dr. Morton agrees that there is no perfect noninvasive device for skin tightening. “The preferred fractional device would be RF with microneedling because of the heat delivered to deeper tissue,” she says. “Other options include nonfractional RF devices, including minimally invasive RF devices that deliver subcutaneous heat but require a higher skill level.”

Skin Concern: Scarring

Fractional devices—both ablative and nonablative—have proved effective tools for both acne scarring and burn scars. “Acne scarring is extremely challenging,” says Dr. Lee. “Deep pitted, ice-pick and rolling or crater form scars are difficult to treat. It helps to combine many different modalities along with subcision and fillers. Combining fractional RF microneedling with PRP and subcision and trichloroacetic acid (TCA) cross is a popular approach for patients with severe acne scarring. These patients usually also need noninvasive lasers to address vascular and pigmentary issues along with resurfacing.”

RF microneedling is an acne scarring treatment of choice for Mitchel P. Goldman, MD, medical director of West Dermatology and volunteer clinical professor of dermatology at the University of California, San Diego. “For acne scars, we have evolved into using bipolar RF microneedling and presently believe that the INTRAcel (Perigee Medical) system is the best,” he says. An additional benefit of RF microneedling for acne scar patients is that it has shown promise in controlling active acne as
well as decreasing scar depth and improving skin texture. “Improvement may be due to the reduction in some sebaceous glands and reduction of perifolliculitis,” says Dr. Goldman.

Meanwhile, Dr. Kaufman-Janette opts for either a fractional CO2 laser, fractional 1,540nm or 1,550nm nonablative laser, or fractional RF microneedling with the Lutronic Infini or Genius to address acne scars. “For darker skin types, I would steer away from fractional CO2 due to the higher possibility of postoperative pigmentation abnormalities, including hypo- and hyperpigmentation,” she says. “I do try to do lower energy treatments on darker skin, as opposed to high energy one-session plans.”

Dr. Morton also prefers nonablative fractional lasers—1,540nm or 1,550nm—for acne scarring. “Fractional ablative devices, such as CO2 and Er:YAG lasers may provide more marked results with one to two sessions, but the downtime associated with them (weeks) and the risk of side effects, such as infection, scarring and discoloration, make them less appealing options,” she says.

Treatment regimens with nonablative fractional devices usually include five to six monthly sessions. The downtime is a week or less and mostly limited to redness, swelling and scaling. “There is some risk of hyperpigmentation in darker skin types, but this generally resolves within two to three months,” says Dr. Morton.

Picosecond lasers with fractional array handpieces are another potential treatment for acne scarring in patients with darker skin. “Picosecond fractional array devices, including 532nm, 755nm and 1,064nm wavelengths, can also be used at low energies in a majority of skin types,” says Dr. Morton. “They have shown efficacy for acne scarring with minimal down time and, often, minimal discomfort.”

As with acne scars, treating burn scars can be challenging because they often involve multiple concerns, including hypertrophy, atrophy, contractures and discoloration. “Again, combining many different modalities usually yields the best results, depending on the type of scar, the patient’s skin type and location on the face or body,” says Dr. Lee.

Dr. Morton adds that the device and settings used will largely depend on the depth of the scar. “Most people who treat burn scars would likely agree that the fractional ablative devices—CO2 or Er:YAG—are important for collagen remodeling and softening of thickened scars,” she says. “The ablative fractional lasers have led to great improvements in quality of life for people with scars secondary to burns or other traumatic events.”

The deeper and thicker the scar, the more powerful the laser should be, notes Dr. Goldman. “For deep, thick scars, the Lumenis Scaar FX fractional CO2 is the best device,” he says.

Skin Concern: Hyperpigmentation

When treating pigmentation concerns, identifying the cause is the first step in choosing your treatment modality. “Lentigines typically respond very well to multiple treatment modalities,” says Dr. Morton. “Regarding fractionated options, we most often use the nonablative 1,927nm fractional laser. After one to two sessions, we see reliable and marked results with one week or less of downtime that consists of redness, swelling and mild scaling of skin.”

Because the nonablative options work so well for improving discoloration, Dr. Morton rarely considers the more aggressive ablative lasers. “In addition to the fractional 1,927nm devices, numerous nonfractional, nonablative lasers are very effective for brown spots, including the alexandrite, Nd:YAG, ruby and even KTP lasers,” she says.

If melasma is the main concern, however, lasers are not first line treatments. Lasers and other light-based devices can exacerbate the condition and must be used with caution. “The expected recurrence of melasma can sometimes make a large monetary investment for laser treatments difficult for patients,” says Dr. Morton. “When patients do opt to proceed with laser treatment, it is wise to choose lower, conservative energy settings. The 1,927nm wavelength is available in a low-power device called the Clear + Brilliant (Solta Medical), which can be helpful for melasma with less risk of exacerbation.”

Joan Vos MacDonald is a freelance writer based in Kingston, NY.

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