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Archive for the ‘laser resurfacing’ Category

HALO The Hybrid Fractional Laser Resurfacing Method

Monday, May 30th, 2016

 

Facial laser resurfacing traditionally consist of two fundamental approaches, a fully ablative surface treatment or a deeper fractional method. Fully ablative laser resurfacing creates extended downtimes but fewer treatments are needed. Conversely, fractional laser resurfacing is associated with less downtime but requires more treatments. The newest generation of non-ablative fractional lasers, which coagulate tissues instead of vaporizing them, allows for rapid healing but often does not produce the desired results.

HALO Hybrid Fractional Laser Dr Barry Eppley IndianapolisThe face of laser resurfacing has changed with the emergence of the HALO hybrid fractional laser. The HALO combines non-ablative and ablative fractional lasers into a single dual-wavelength laser. It allows the delivery of both 1470nm and 2940nm wavelengths to the same microscopic thermal zone. HALO works by delivering ablation sequentially followed by coagulation to the treatment zone. The 2940nm wavelength delivers pure ablation from 0 to 100 microns into the epidermis. The 1470nm wavelength delivers pure coagulation between 100 to 700 microns to the epidermis and dermis. This ability to precisely deliver energies to the epidermis and dermis allows for customized treatments.

Beyond its hybrid technology, HALO has several other features that improves its usability. HALO uses intelligent energy-based parameters to ensure that there is a consistent and even treatment by taking the size of the treatment area and creating the exact amount of energy to treat it. Dynamic Thermal Optimization technology ensures that the treatments are even from beginning to end through skin temperature monitoring.

HALO laser resurfacingClinical tests have repeatedly shown remarkable improvements in skin texture and pigment reduction. There is even improvements in pore size and number. In a few treatments HALO produces results that are typically seen in 2 or 3 times as many treatments as with older non-hybrid lasers. Patients report less overall pain after the treatment compared other lasers. They also have a very short duration of peeling and are able to put on makeup the next day.

HALO has become the next great advance in laser resurfacing by offering a treatment experience and results that are clearly superior to existing laser resurfacing methods.

Dr. Barry Eppley

Indianapolis, Indiana

Sciton HALO Hybrid Fractional Laser Resurfacing

Monday, December 21st, 2015

The introduction of CO2 lasers in the mid-1990s largely replaced the traditional of chemical peels like TCA and phenol. They initially created a deep resurfacing effect and were associated with a hypopigmentation effect in some patients and a prolonged recovery. Modern day skin resurfacing laser have gotten around these issues through the use of pulsed and scanning technology as well as the use of ‘lighter’ power sources than CO2. (Er:Yag) This Erbium technology allows for better control of the laser energy with improved results and less downtime and risk of complications.

Fractional laser resurfacing is the gold standard of facial laser treatments today. By treating just a fraction of the facial skin’s surface, recovery is very quick and the risk of complications is virtually eliminated. But it does require more laser treatments to achieve the final resurfacing result. Combining full coverage ablative resurfacing in conjunction with a fractional treatment simultaneously removes a thin layer of epithelium as well as cuts/removes small vertical columns of epithelium and dermis which leads to tissue remodeling. But recovery is often not as quick as the patient would like and multiple treatments are still needed.

th-1Now along comes Sciton’s Hybrid Fractional laser resurfacing technology which combines an ablative fractional laser with a non-ablative fractional laser. This allows patients to get an ablative result with a non-ablative quick recovery. Known as the HALO or hybrid fractional laser, it works by delivering ablation followed by coagulation. This is done by using a 2940nm Er:YAG which delivers ablation up to 100 microns of epidermal depth with a 1470nm diode to deliver coagulation from 100 to 700 microns into the dermis. This is a novel approach being able to deliver separate treatments to the epidermis and dermis in the same treatment.

The Sciton HALO device has undergone years of testing to perfect the Hybrid Fractional Laser technology. During this testing it was discovered that patients treated with the HALO had a much better skin texture and pigment improvement than expected. These results were obtained in just one to two treatments compared with four to six treatments with older non-hybrid lasers. In addition pore size and number had unexpected improvements not seen before.

thThe Sciton Halo Hybrid Fractional Laser is the future of facial laser resurfacing. It produces targeted and effective improvement in the appearance of skin damage with little to no side effects. Patients prefer the HALO treatments over other forms of laser resurfacing due to the improved healing experience. The treatment is also less uncomfortable and does not require local anesthetic nerve blocks. Patients can wear makeup in just one day after treatment with a short duration of skin peeling

Dr. Barry Eppley

Indianapolis, Indiana

Combining Laser Resurfacing and Facelift Surgery

Sunday, April 5th, 2015

 

Facelift surgery addresses sagging and loose tissues that have fallen due to aging. To a large degree facelifts are a tissue resuspension method which uses some tissue excision (skin and fat) to create the effect. However, a facelift in and of itself, does not change many of the more superficial lines and wrinkles on the overlying skin. Some wrinkle reduction occurs near the incisions in and around the ears due to the pull of the tissues but more central facial wrinkling remains unchanged.

Laser Resurfacing Face Dr Barry Eppley IndianapolisLaser resurfacing is well known to be the best treatment for superficial lines and wrinkles that we currently have. It is an ideal complement to a facelift as it addresses an aging problem that tissue rearrangement will not improve. Historically it has been often done at the time of a facelift around the mouth area…not only because it addresses a facial area that a facelift does not but also because it is safe do as the skin area treated has not been undermined. (partially devascularized)

In the March 2015 issue of Plastic and Reconstructive Surgery, the article entitled ‘Laser Resurfacing at the time of Rhytidectomy’ was published. Over a fourteen year period the authors performed eight-five (85) facelifts with concurrent erbium laser resurfacing.  Some patients were treated just around the mouth while others had full face treatment. No wound healing complications occurred in the perioral resurfacing group. One patient had moderate hyperpigmentation. There was one case of delayed wound healing and prolonged swelling in the group that had their full face resurfaced. No instances of hypopigmentation or flap necrosis occurred. The overall complication rate was just under 4%. There was a statistically significant difference when comparing number of complications between the facial laser resurfacing area with the full face group potentially being significant. (p = 0.037). Though a significant difference in the number of complications between treatment groups existed, the authors were not able to attribute this exclusively solely to the extentof laser resurfacing.

This paper’s experience as well as that of others shows that, for the most part, simultaneous laser resurfacing and a facelift can be safely performed. The key is that the depth of the laser should not be very deep over the undermined lateral facial skin flaps. The more superficial its depth near the ear, there is little risk of skin flap devascularization.

The other issue to consider with laser resurfacing in the facelift patient is its impact on recovery. The laser injury to the skin causes greater swelling and a more difficult first few days after the procedure when done in a full face manner. When done only around the mouth this is less of a concern.

Dr. Barry Eppley

Indianapolis, Indiana

Early Fractional Laser Treatment Of Surgical Scars

Tuesday, February 17th, 2015

 

Early treatment of scars by some method is certainly preferred by patients whether the scars  are from traumatic injury or elective aesthetic surgery. A variety of such scar strategies exist from topical gels and tapes to pulsed dye and ablative laser treatments. All of these methods have shown long-term scar appearance benefit with topical treatments being the most economical. But whether similar benefits are seen with fractional laser resurfacing has not been similarly studied.

Fractional Laser Resurfacing of scars Dr Barry Eppley IndianapolisFractional laser resurfacing would seem to offer scar benefits, at least theoretically, because it stimulates collagen creation in the deeper dermis with deeply cut channels. This is the location which causes many scars to widen or become depressed due to loss of collagen structures deep in the dermis. Stimulation of deeper dermal collagen formation during the early healing phase could prove to help prevent these adverse dermal changes and improve the final appearance of the scar.

In the January 2015 issue of Lasers in Medicine and Surgery journal, a study was published entitled ‘Early Postoperative Single Treatment Ablative Fractional Lasing of Mohs Micrographic Surgery Facial Scars: A Split-Scar, Evaluator-Blinded Study’. In this study, a prospective randomized split scar study was done on twenty (20) patients between the ages of 20 to 90 years old. The scars created were from Mohs surgery for facial skin cancers. Studied scars had a linear length of 4 cms or more. On the day of suture removal half of the scar was treated with a fractional laser. (spot 7mm, 10% density  at 10mJ) The other half of the scar was left untreated to serve as a control. Three months laters the scars were evaluated and graded by both the patients and an independent observer. While all portions of the scars improved with healing time, the laser treated scar halfs were seen to be improved by patient assessments but not so much by independent assessment. No adverse effects of the laser treatments were seen.

The fractional laser settings used in this study were very conservative. Improved scar appearances would likely be obtained by more aggressive settings, particularly if a single laser treatment was going to be used. While the optimal laser settings for prophylactic scar treatment are unknown, I prefer to use a density of 22% at 50 mJ as a single pass to help the scars get better faster.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Products: Dermapen 3 for Skin Needling

Sunday, January 25th, 2015

 

Almost everyone is familiar with laser resurfacing and its improvements offered by today’s concept of fractional laser resurfacing. By cutting into the skin layers in closely spaced holes created by a laser beam, improved skin quality results through collagen regeneration and remodeling. While there is no question about the benefits of fractional laser resurfacing, other non-laser devices can create similar patterns of skin ‘holes’

Dermapen Skin Needling Dr Barry Eppley IndianapolisOne of these devices is Demapen 3. This is a mechanized device use to fractionally rejuvenate the skin. Its tip contains 12 microneedles in a spring loaded sterile cartridge which is single patient use. The depth of needle penetration can be adjusted to go as deep as 2.5mms if desired. With 12 needles and an oscillating vertical motion with a top speed of 108 movements per second, 1,296 skin holes can be created per second to create a fractional skin rejuvenation effect. With the creation of some many skin holes, topical nutrients/agents (e.g., PRP) are applied and theoretically absorbed into the skin via the open channels. Interestingly, the oscillation movements helps dampen the transmission of nerve pain fibers making the treatments possible with little or no topical anesthetic.

Because Dermapen 3 does not create heat to make the channels (unlike a laser), it is safe to use on all skin types with no risk of post-inflammatory hyperpigmentation and a more rapid recovery period.

Like fractional laser resurfacing, Dermapen can treat a variety of skin issues from the treatment of wrinkles, skin texture irregularities and acne scars.  Its use is being increasingly used for hypertrophic scars, vitiligo and in the treatment of alopecia for hair regeneration.

The role of skin needling, which has been around for decades, has taken a quantum leap forward with Dermapen technology. This mechanized handpiece offers a more consistent method of making skin channels and has a real role to play alongside fractional laser resurfacing. For those patients who want less recovery and a lower treatment cost than that of lasers, Dermapen skin needling offers an effective alternative.

Dr. Barry Eppley

Indianapolis, Indiana

Platelet-Rich Plasma (PRP) Use In Facial Laser Resurfacing

Sunday, January 4th, 2015

 

Fractional Laser Resurfacing Face Dr Barry Eppley IndianapolisLaser resurfacing is a long-standing treatment that can have a profound rejuvenative effect on wrinkled and sun damaged facial skin. By burning off the top layer of skin and allowing it heal, a fresh skin surface is created with fewer surface imperfections.While effective, it is associated with a significant healing time, discomfort and  temporary facial redness. This has been improved by changing from a fully ablative laser treatment, which treats the entire skin surface, to a fractional approach.

Fractional laser resurfacing treats a portion or fraction of the skin surface’s  (usually 5% to 22%) but with deeper channels cut down into the thickness of the skin. This has the dual effect of shortening healing time due to less injured skin surface and causing greater collagen regeneration and tightening. But despite the advantages and reduced recovery time of the fractional laser, adjuvant treatments are still sought to reduce healing time and facilitate a faster recovery. One such treatment is that of platelet-rich plasma. (PRP)

Platelet Rich Plasma PRP Therapy Dr Barry Eppley IndianapolisPlatelet-rich plasma (PRP) has been used for many applications in various surgical fields for its ability to improve wound healing, hemostasis, and graft survival. It is a blood concentrate that is full of platelets. Platelets contain many different growth factors and cytokines in high concentrations which serve as the theoretical basis for the use of PRP in tissue repair. Studies are mixed as to its true effectiveness across a broad spectrum of applications. But the superficial nature of laser resurfaced skin seems like a good application for it.

In the Online First edition of the November/December 2014 issue of JAMA Facial Plastic Surgery, a study was pubished entitled ‘Evaluation of the Effect of Platelet-Rich Plasma on Recovery After Ablative Fractional Photothermolysis’. This was a blinded study using small human forearm test sites that were treated with fractional laser treatments at consistent depths in both arms. The treated sites were immediately treated with either topical PRP or saline. (control) Significant improvement was seen in PRP-treated arms compared to controls in all 15 treated patients. Improvement was defined as the erythema rating of the untreated arm minus the erythema rating of the PRP-treated arm. Patients noticed a reduction in the amount of redness, swelling, itching and pain in the PRP-treated sites.

These study results suggest that PRP can improve the healing rate of facial laser resurfacing sites. It presumably does so by creating a faster rate of skin cells growing across the injured skin surface through earlier induction of cell turnover. It is interesting that such positive results were seen with just one application immediately after the laser resurfacing. Given the reduced cost to acquire a single concentrate of PRP today, it should enjoy broader useage.

Dr. Barry Eppley

Indianapolis, Indiana

Combining Facelift, Cheek Implants and Laser Resurfacing for Total Facial Rejuvenation

Monday, November 3rd, 2014

 

When most people think of facial rejuvenation undertandably the thought a facelift emerges. But contrary to popular perception, a facelift only addresses the lower third of the face. While smoothing out the neck and the jawline provides a youthful improvement, it does not address the middle of the face. Even if it could pulling the middle of the face outward would produce an unnatural distortion and is rarely the answer to midface rejuvenation.

Loss of facial volume and removal of tissue support is a well recognized mechanism of facial aging. Thus volume restoration is a very useful approach to helping to reverse midface deflation. This can be done by either malar/submalar implants or fat injections and there are advocates for each approach. Implants tend to produce a more consistent augmentation method that is stable long-term.

Neither a facelift or the addition of volume restoration to the midface will improve the texture of the skin. Chemical peels and laser resurfacing are the known effective approaches for smoothing out fine wrinkles and improving the look of the skin.

A more complete facial rejuvenation approach would include all of these elements from a facelift, midface augmentation and skin resurfacing. In the September 2014 issue of the American Journal of Cosmetic Surgery, an article appeared entitled ‘Total Face Rejuvenation: Simultaneous 3-Plane Surgical Approach Combined With Ablative Laser Resurfacing’. In this paper, a retrospective review of 21 female patients (age 58 to 71 years old) undergoing combined extended-SMAS facelift, mid-ace augmentation with implants, and full-face ablative laser resurfacing by a single surgeon was done. None of the facelift skin flaps suffered any healing problems. The skin healed (re-epitheliazed) within ten days and makeup was able to be worn again within two weeks. One hematoma occurred as well as one implant infection. This study showed that all three facial procedures can be performed at the same time.

It has been historically thought that combing certain procedures, such as laser resurfacing and a facelift, runs the risk of skin loss and other healing problems. But this study shows what has been known now for some time that combining multiple facial rejuvenation procedures is not only safe but necessary in most cases to have the best results. As long as the laser resurfacing is not done too deep over the raised skin flaps of the facelift, a negative effect of skin and incisional healing does not occur.

Dr. Barry Eppley

Indianapolis, Indiana

Fractional Laser Treatments for Traumatic Burn Scars

Sunday, December 22nd, 2013

 

Many disfiguring and debilitating scars, particularly those of a burn origin, are often associated with pain and itching in addition to their appearance. The use of fractional laser resurfacing, which is now about a decade old, has become a very valuable treatment method for these types of traumatic scars. To those experienced in using it, its functional and cosmetic benefits have become viewed as a breakthrough scar treatment method.

Fractional Laser Resurfacing of scars Dr Barry Eppley IndianapolisIn the online first publication of the December 2013 issue of JAMA Dermatology, an article was published entitled ‘Laser Treatment of Traumatic Scars With an Emphasis on Ablative Fractional Laser Resurfacing – Consensus Report’. Eight independent, self-selected academic and military dermatology and plastic surgery physicians with extensive experience in the use of lasers for scar treatment assembled for a 2-day ad hoc meeting. Consensus was based largely on expert opinion and relevant medical literature reports.

The consensus of these eight experienced multidisciplinary practitioners is that laser treatments, particularly that of fractional laser resurfacing, deserves a prominent role in scar treatments, with the possible inclusion of early intervention for contracture avoidance and assistance with wound healing. Its results are not only very promising but is an underused tool in the multidisciplinary treatment of traumatic scars. Changes to existing scar treatment paradigms should include extensive integration of fractional resurfacing and other combination therapies guided by future research.

What is most important is this consensus report is that it speaks to the treatment of traumatic burn scars, one of the most challenging of all burn scar problems. Significant hypertrophy, contracture and pain are the hallmarks for these scars. A fractional laser approach, which ‘punches’ thousands of tiny slits in the scar, serves as a mechanism of scar release. When combined with immediate physical therapy to further release the contracture and increase range of motion, significant scar improvement occurs regardless of any appearance change.

This report of fractional laser treatments should not be confused with many other types of scars that are more favorable, albeit still distressing to many patients. The role of the fractional laser in fresh incisions and early traumatic non-burn scars is more speculative and not yet proven and needs further clinical study to determine potential effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Laser Resurfacing for Facial Brown Spots

Sunday, December 1st, 2013

 

Background: Solar lentigines, also called age spots and liver spots, are brown colored skin patches that can appear anywhere on the face and body. They most commonly appear on those skin areas that have a long history of sun exposure. As a result, these brown spots usually do not appear until age 40 and older although they can appear in younger people as well. Brown spots vary in size and depth of color and can often be seen on the face given that it is a highly sun exposed area.

???????????While brown spots may appear ominous for skin cancer, they are harmless and are treated for their unsightly aesthetic appearance. They occur as the result of concentrations of melanin triggered by the sun’s ultraviolet radiation waves. Thus they are focused areas of hyperpigmentation. They are a wide variety of hyperpigmentation treatments for brown spots including lightening by topical bleaching creams (e.g., hydroquinone), chemical peel exfoliators (salicyclic and glycolic acids), and intense pulsed light (IPL) therapies.

But not all brown spots come off with these treatments and, even if they have a positive effect, take time to work and often multiple treatments are needed. Some very dark brown spots or those patients with a large number of them may consider laser resurfacing to create a more immediate and complete effect. As much of the hyperpigmentation lies in the deeper layers of the epithelium, its removal is assured of making a significant reduction in their appearance.

Case Study: This 55 year-old female had developed a large number of brown spots all over her face. She was a heavy sun bather in your youth and never wore any sun protection. Her brown spots continued to develop and get darker as she aged to the point that she wore heavy makeup to hide them. She had tried many lightening creams and IPL treatments but their effects were minimal.

Brown Spot Laser Removal result side view Dr Barry Eppley IndianapolisUnder general anesthesia, a full face ablative laser resurfacing was done. Only a first pass  laser treatment was needed as when the epithelium was removed, all of the brown spots came off with it. Light antibiotic ointment was used for dressing.

Brown Spot Laser Removal results oblique view Dr Barry Eppley IndianapolisWhen seen one month after the procedure, all of her brown spots remained gone. It is now critically important that she wear sun protection at all times and avoid even moderate sun exposure as some recurrence of them or new areas will develop if she does not.

Case Highlights:

1) Brown spots are benign sun-related areas of hyperpigmentation that commonly occur in patches on the face.

2) Facial brown spots are typically and effectively treated by a variety of external therapies design to reduce and fade hyperpigmentation.

3) Refractory facial brown spots that are present in large numbers can be removed by ablative laser resurfacing that removes the top layer of the skin.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Product Review: Dermapen for Acne Scars

Wednesday, August 14th, 2013

 

The concept of treating a variety of skin irregularities with a fractional skin injury approach is seen from the use of laser to dermaroller therapies. The basic premise is that deep small channels are cut into the skin which creates a subsequent healing cascade that causes new collagen formation in the holes and ultimately thicker skin that is smoother. Such an approach has proven useful for a variety of scar problems including those caused by acne.

A new fractional approach is that of the Dermapen. This hand-held device is about the size of a large felt-tip pen and it uses microneedles to cause the fractional skin injury. The tip of the pen as an array of 11 tiny steel microneedles that can achieve depths anywhere from 0.25mm to 2.5mm based on the head chosen. The microneedles are driven into the skin vertically by a frequency-adjustable piston for consistent wounding depths. To prevent cross-contamination between patients the microneedle tips are single use. It does require topical anesthesia to be used and is FDA cleared for acne scar treatments.

The skin microneedling effect caused by Dermapen generates no additional thermal injury to the skin like that caused by a laser. Because there is no heat generated, recovery is quicker, there is virtually no risk of after treatment hyperpigmentation and treatments can be spaced very close together and can be repeated as much as one desires. For patients with greater skin pigments this approach offers a virtually complication-free treatment option. In addition, because Dermapen technology is just a fraction of that of lasers, one would presume that the cost of an individual treatment would also be appreciably lower.

A very relevant but unknown question about Dermapen is how it’s effectiveness compares to the current gold standard of fractional laser treatments for acne scars, stretch marks, wrinkles and surgical and traumatic scars. To date, the safety and efficacy profiles between the two have not been published in any peer-reviewed journal.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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