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Posts Tagged ‘fractional laser resurfacing’

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

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

Fully Ablative vs Fractional Facial Laser Resurfacing – Which Is Better?

Saturday, January 19th, 2013


Facial laser resurfacing has evolved over the past twenty years from in both how the energy is delivered to what depths into the skin that is treated. When initially introduced laser resurfacing was known as ‘fully ablative’, meaning that at any energy level it treated 100% of the skin’s surface. While many of the results a fully ablative laser resurfacing treatment creates can be impressive in the amount of wrinkle reduction and skin tightening, it can be associated with loss of skin pigment and long healing and recovery times.

Such skin resurfacing concerns led to the development of fractionated or a ‘fractional’ laser technique. In this approach the laser only treats a part or fraction of the skin’s surface. By leaving untreated or skipped zones of skin, there is less traumatized tissue which substantially reduces the risk of hypopigmentation and shortens the recovery time. Treating less skin may seem counterproductive to getting a good skin result (less wrinkles) but this is compensated for by having each penetrating laser light column go much deeper. This is why fractional laser treatments create pinpoint bleeding areas while fully ablative lasers do not.

The theoretical benefits of fractional laser resurfacing is that these deeper penetrating columns of laser light cause at least an equal amount of increased collagen formation and skin tightening as that of more superficial fully ablative laser treatments. This would seem to make perfect sense given the greater depth of dermal injury and it has always been assumed to be true. It also accounts for its popularity as a widely used treatment.

In the October 2012 issue of Dermatologic Surgery, a human study was done to directly compare the molecular changes that result from fractional vs fully ablative carbon dioxide (CO2) laser resurfacing in skin damaged skin. In 34 adults with substantial facial skin damage, matched facial areas with treated between the two laser types. Real-time reverse transcriptase polymerase chain reaction technology and immunohistochemistry were used to quantify molecular responses to each type of laser treatment. Their results show that both fully ablative or fractional laser resurfacing resulted in significant skin changes of dermal remodeling and the creation of new collagen. After one treatment, however, fractional laser resurfacing effects were only about half of that seen by a fully ablative treatment. The fully ablative laser treatments created greater changes with more pronounced collagen formation.

What this study indicates is that the fractional laser approach is not superior to fully ablative treatments (in a single treatment) as many may believe or purport that it is so. This is no surprise given that much less skin surface is treated, often 78% to 95% less.  The value of fractional laser resurfacing is that it has less risks of skin problems particularly in patients with more natural skin pigment.Whether better skin results, particularly in its tightening effect, may occur with repeated treatments can not be determined from this one study. The value of fractional laser resurfacing is that such repeated treatments can be safely done.

Dr. Barry Eppley

Indianapolis, Indiana

Treatment Options for Facial Acne Scars

Saturday, January 5th, 2013


Acne is a common skin condition that results in a wide variety of scars types and patterns. Even though there are a number of available treatments for acne scars, they are not always universally successful. Acne scars represent a difficult challenge for improvement and every option must be considered in each patient. Often different treatment approaches may be used on the same patient based on the type of acne scars that they have.

When evaluating acne scars, there are three main types based on their shapes. Ice pick scars are the most common acne scar and are semi-round in shape but narrow and deep. They occur most commonly on the nose and cheeks. Rolling hill scars are wide deep scars that roll into the skin. They often occur in bunches and are the result of large and deep cysts. Boxcar (atrophic) scars are somewhat similar to ice pick scars but are not as deep and are wider. The morphology of acne scars goes a long way in determining the correct treatment choice.

The options available for acne scar treatments include injectable fillers, subcutaneous incision/subcision, punch excision, punch elevation and fractional laser resurfacing. Which of these approaches is best? Again, the shape and depth of the acne scar is the determinant.

Hyaluronic acid injectable fillers work by lifting up the depth of the scar depression and trying to make it more level with the surrounding unscarred skin.  In essence, try and raise the valley to get closer to height of the surrounding mountains. Fillers may stimulate collagen regeneration in the skin but this is more theoretical than ever actually seen on a consistent basis. This acne scar technique works best for broad and shallow scars. Deep pitted scars are too fibrotic to be elevated by the push of a filler. While the improvement occurs immediately with injectable fillers, it is a temporary effect that will last as long as the composition of the filler.

Subcision is a technique that inflicts injury to the skin at the base of the scar. This causes the scar to release and accumulate blood underneath it. This is done by using the beveled edge of a small needle like a miniature scalpel. This will result in some bruising and swelling. The dermal collagen injury and bleeding may act as a stimulant for new collagen growth. This technique works best in rolling hill type scars. Multiple sessions are often needed for the best results.

Punch excision is a very well known acne scar technique that does exactly what it describes, it cuts the scar out in a circular pattern. This is done using punches which are small cooker-cutter tools with varying diameters. (1 to5mms) Once the scar is removed, the circular hole is then treated by one of two closure techniques, small suture closure or the hole is filled in with a full-thickness skin graft of the exact size usually cut with the same tool. (punch elevation) Once healed, laser treatments are often done for the smaller scars left behind from excision and closure or the raised scars from the punch graft.  Punch excision works best for ice pick and boxcar scars.

Laser resurfacing works best for the most number of acne scar types. The laser fundamentally works by removing the top layer of skin so that shallow scars may be eliminated and deeper scars appear more shallow. But in a 100% ablative laser, where top layers of skin are removed in even unscarred skin, no net gain may often be seen. The better technique for acne scars is fractional laser resurfacing where just a portion of the skin is treated but the penetration is much deeper. The deep skin channels cut by the fractional laser stimulates the skin to contract and get tighter, narrowing the diameter of the scar. Multiple fractional laser treatments are almost always needed.

The challenge of improving facial acne scars is met with a variety of treatment techniques. While perfectly smooth skin is never possible, mixing and matching  several of these treatment techniques almost always provides visible improvement for most patients.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? Laser Resurfacing at a Fraction

Tuesday, May 1st, 2012

Laser skin resurfacing has now been around for several decades and involves a simple treatment principle…uniform removal of the outer layers of the skin. This can be done from very superficial to deep depending upon the power settings of the laser and the depth of the skin contour problem. Fractional laser treatment represents a paradigm shift in laser skin resurfacing by treating just a fraction of the skin’s surface, hence the name. But each area treated or laser dot penetrates much deeper creating vertical columns down into the deeper layers of the skin. This results in much greater collagen stimulation. But because less skin is injured (5% to 22%), it heals much faster. This has been a revolutionary advance in the treatment of previously difficult problems like scars.

Fractional Laser Treatments Of Acne Scars

Sunday, April 15th, 2012

While many methods for skin rejuvenation have been developed, few such methods are helpful for acne scars. The typical skin treatments of microdermabrasion, chemical peels, intense pulsed light and even ablative CO2 laser resurfacing do not produce substantative improvements in the unique contour problems caused by acne. Traditional CO2 laser resurfacing is the best of the bunch but results are often left wanting. The most effectve treatment is dermabrasion but it carries with it risks of hypopigmentation and even hypertrophic scarring.

Acne scars can be divided into two main types; atrophic and proliferative. Atrophic acne scars are identified as either ice-pick or macular-type forms. Proliferative or hypertrophic acne scars are raised and are more like keloids. Atrophic acne scars are particularly difficult to improve because the collagen degeneration extends down into the dermis. Regeneration of the dermal layers is virtually impossible so traditional ablative laser resurfacing has tried to bring down the surrounding more normal skin layer to the depth of the dermal depression…with limited success.

Fractional laser resurfacing has introduced a new concept in skin surface treatments. Rather than bringing down the entire outer surface layer of the skin, it only treats a portion of it hence the name fractional. In essence think of a dot pattern of individual laser spots penetrating the skin distributed over a grid pattern by a computer delivery system. But each laser spot penetrates much deeper, reaching the dermis and causing collagen stimulation/regeneration. While each laser spot goes deeper, the smaller portion of skin treated (anywhere from 5% to 22% of the total surface area) results in more rapid epithelial healing and a faster recovery.

Fractional laser resurfacing has been shown in numerous studies to be very effective for atrophic acne scars. Delivered in a punctuate pattern, the epidermis and a part of the dermis is vaporized. At the same time, collagen contraction occurs by its heating effect causing skin tightening. This skin tightening effect is thought to be very beneficial for acne scars. Multiple fractional laser treatments will be needed and they should be spaced about a month apart to allow for complete epithelial regeneration. Histologic and electron microscopic studies have shown the regeneration of elastic-like fibers with fractional treatments, a sign of dermal remodeling.

The fractional laser allows for different parameters to be set including power, pulse width, and dot pitch being the distance between each laser point. It is not clear as to the optimal setting for any individual patient and consideration has to be given to the patient’s concern for recovery. Given the challenge of atrophic acne scars, deeper depths of penetration up to 350 microns are best used.

Dr. Barry Eppley

Indianapolis, Indiana

Common Questions about Skin Rejuvenation

Sunday, February 7th, 2010

1.      What is the best approach to make my skin look better?


To make your skin look and feel more healthy and attractive, one must reduce or prevent wrinkles, sun spots and loose skin, improve skin texture and color, and remove blotches or damaged blood vessels.


Such total skin rejuvenation requires a program approach. Skin care is very similar to exercise and dieting…there is not one single thing that makes the big difference. It is a combination of different methods over the long-term which attains improved and better looking skin. One needs to avoid the idea that a single product applied daily is what works the best.


A comprehensive skin care program includes a daily topical regimen (at-home products), periodic exfoliative maintenance and refreshening (microdermabrasion and superficial chemical peels) and therapeutic laser and light treatments if needed. (deeper wrinkles, brown spots, and red lesions and vessels) Putting a individualized program together with the right products and types of treatments requires a skin care professional. (aesthetician) The skin care world is full of thousands of products and treatments. Knowing which is best for you requires a professional guide.

2.      How does microdermabrasion work?


The concept of microdermabrasion (often referred to as getting a  microderm) is to remove the most outer layer of the skin. (known as the stratum corneum which is dead skin cells) This is done by light abrasion usually using a wand with a roughened surface. It is not a painful procedure and requires no anesthetic. It is done either as a stand alone procedure but more commonly, and effectively, as part of a comprehensive facial treatment procedure.


Besides being a refreshening skin procedure, removal of the outer skin cells allows applied topical products, like light chemical peels, to penetrate deeper for more of an effect. It is part of a periodic maintenance facial skin treatment which is done every six to twelve weeks. Microdermabrasion is often touted has having benefits for scars and other superficial skin lesions but this is not true. It simply doesn’t go deep enough or remove enough skin layers to have any significant effect on these problems.There is no evidence that it can stimulate collagen formation either so it does not have a ‘rejuvenative’ effect on skin. Microdermabrasion can also be used as part of a treatment program for acne but chemical peels are usually more effective and less irritating. Because it is a superficial exfoliation treatment, there is no recovery needed.


Microdermabrasion should not be confused with dermabrasion, a much deeper form of skin removal. This requires some form of anesthesia, is effective for deeper scarring and wrinkles and requires a recovery period.


3.      How effective are IPL (photofacials) and what skin problems are they good for?


Light-based treatments are non-invasive procedures that are known by a variety of names, most popularly IPL or intense-pulsed light or BBL. (broad- based light) Unlike focused wavelength light (lasers), IPL treatments use non-focused broad-spectrum light targeting red and brown pigment which commonly develops from sun-damaged and aged skin. These treatments can leave skin with a more even colored complexion.  They are a safe and effective method to improve the signs of aging from the face, neck, chest, arms and hands.


Pulsed-light treatments have been credited for improving fine wrinkles and skin texture but theses effects are minor and not their primary benefits. One newer use for pulsed light is to help tighten skin. Without damaging the skin’s surface, pulsed light can safely heat the inner layer – dermis – of the skin, inducing the formation of collagen causing some mild skin contraction.


4.      What is a good skin product?


The plethora of over-the-counter skin care products is overwhelming and certainly confusing. Yet there are some significant similarities amongst many of them. The majority of them are basically moisturizers with additional components of sunscreen and botanicals. The moisturizer component (petrolatum, dimethicone and/or glycerin) acts both as a humidifier for the skin as well as a delivery vehicle for the other active agents.


The botanicals, such as soy, silymarin, curcumin, green tea and retinol  provide antioxidant properties that may help in the reduction of facial lines and wrinkles. The botanicals have tremendous marketing appeal but they are not the most important component of the skin care preparation.


Whether the product is an anti-aging night cream or a facial foundation, find one that does not irritate your skin and contains sunscreen protection and some antioxidant agent.


Prescription skin care products have significant proven potency, particularly in wrinkle treatment and prevention and in skin lightening. (bleaching) Vitamin A (Retin-A) and hydroquinone and kojic acid are well known for their effectiveness. A prescription product used with a moisturizing over-the-counter cream can be a very useful combination.


5.      How do lasers help reduce wrinkles and improve skin texture?


Removing layers of the skin, like sanding wood, can help get a  more even and smooth skin surface. Lasers do this by literally burning off the outer layers. Unlike microdermabrasion, lasers go much deeper being capable of removing up to one-third of the skin’s thickness. This is known as deep or CO2 laser resurfacing and requires some form of anesthesia. The effects of the heat of the laser on the dermis can also cause some skin tightening. It will usually take a week for the skin to heal after this laser treatment.


To decrease the recovery and make it an office-based procedure without anesthesia (topical is still needed), the concept of microlaser or erbium peeling has become popular. Going less deep than the CO2 laser, this treatment requires a series of laser peels done every six to eight weeks. They require just a few days to heal and, when done over time, can create a skin result that may approximate a single deep laser peel in some cases.


A newer variation of laser skin treatments is that of fractional skin resurfacing. It strives to decrease the time it takes for the skin to heal after a treatment but to stimulate the deeper collagen layers of the skin. Fractional laser does this by only treating a small percent of the skin’s surface but goes much deeper. By cutting deeper holes in the skin that are spaced out (like aerating a lawn), less skin surface is treated but those areas that are have deeper channels cut into them.


Laser skin resurfacing today can be done at different depths which can be tailored for the patient’s lifestyle. Significant wrinkle reduction and skin texture improvement can be achieved by computer-controlled skin layer removal.


6.      What role does chemical peels have in improving skin?


Chemical peels have a long history of use as a skin improvement treatment. They work by the acid acting with the top layer of the skin, ultimately resulting in it being sloughed off. The acid penetrates into the skin until it is neutralized. This controls its depth of penetration.


Chemical peels come in three basic types based on how deep they penetrate, superficial, medium, and deep. Salicyclic lactic, and glycolic acids are superficial, trichloroacetic acid (TCA) is medium, and phenol is deep. They are differing concentrations of each. Superficial peels are part of most aesthetic facial and at-home treatments, require no anesthetic and heal in a day. Medium-depth TCA peels are done by physicians, require at least a topical anesthetic, and heal in less than a week. Phenol is a deep chemical peel that has largely been replaced by CO2 laser resurfacing.


How deep a chemical peel goes is affected by a variety of factors other than the concentration of the acid. Chemical peeling is very much an art form that requires a lot of experience to get consistent and safe results. Medium and deep depth chemical peels should only be done by an experienced physician.


7.      Which is better for improving wrinkles, chemical peels or laser resurfacing?


Both can significantly improve wrinkles and the quality of facial skin depending upon the type and concentration of the chemical peel and the depth of laser resurfacing. In well-trained and experienced hands, both treatment methods are effective. Laser resurfacing is better for the treatment of scarring and skin irregularities.  


Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

Skin Rejuvenation: Percutaneous Collagen Induction (PCI) vs. Laser

Friday, August 14th, 2009

Skin rejuvenation is the most frequently requested cosmetic facial procedure, largely by women of ages 35 and above. As the skin starts to look dull and develop those first few wrinkles, doing something to help the skin look better becomes a consideration. The term, skin rejuvenation, encompasses a wide variety of office-based procedures that all aim to make the skin look fresher and reduce wrinkles.

Most commonly, the most effective skin rejuvenation methods include those that exfoliate (remove) the outer layers and allow it to heal with a new outer layer. These methods include traditional chemical peels and different forms of laser resurfacing. All of these procedures can be done in a wide variety of depths, which are individually chosen based on the patient’s tolerance for recovery and the speed at which they want to see improvement.

Laser and peels, however, remove skin layers through a thermal (heat or acidic) process which induces an injury. Healing of that injury results in a new outer skin layer but is also responsible for the recovery seen. (redness, peeling, tenderness, etc.) Enter the concept of percutaneous collagen induction (PCI) therapy, a different method of skin rejuvenation that uses a somewhat different approach. This procedure uses a rolling device with protruding needles to create thousands of tiny punctures into the outer layers of the skin. (very much like aerating your lawn) These microscopic injuries induce the release of growth factors and cytokines, recognized wound healing agents, that help to stimulate new collagen regeneration. Because the ‘cuts’ are done without heat, they heal faster with less recovery than any thermal method.

PCI is best compared to fractional laser resurfacing is that it creates tiny holes or cuts in the skin. Fractional laser procedures makes these cuts with the heat of the laser which leaves behind a wider zone of dead tissue (estimated to be 3 to 8 times wider than the hole) which must also heal. The ‘cauterized’ hole edges theoretically are sealed from releasing cell factors that are helpful in the regenerative process. In essence, some scar is left behind from the process.. PCI, conversely, simply clefts the skin without any heat, which more readily allows valuable cell factors to be released and work on the exposed collagen, resulting in regeneration with less scar healing.

The debate between a high-tech approach (fractional laser) and a low-tech approach (PCI) for skin rejuvenation is ongoing and may become more hotly (no pun intended!) contested in the future. Until a direct comparison in patients is done, this debate will be based on conjecture, extrapolated science, and economics until then. Those issues aside, I find PCI theoretically appealing and with some real clinical benefits. And when I talk about clinical benefits, I am not talking about which is better in terms of skin rejuvenation.

PCI offers less recovery than any laser method and that, for some patients, is a real plus. Many patients would embark on more aggressive skin rejuvenation programs if they didn’t have persistent redness and peeling…not to mention the discomfort of the procedure. (and all laser procedures involve some discomfort, no matter how it is managed, due to the heat) Furthermore, because PCI does not strip off the outer layer of the skin, it offers an advantage of safety and virtual elimination of complications. You can’t have a burn injury if you aren’t doing any burning. This indicates that PCI can be used anywhere on the body unlike laser methods. Also, with no outer layer of skin removed, even partially, this exposes the patient to no risk for skin sensitivity after and has no potential for any pigment changes. (it can be used on all skin types)

Several non-burning questions remain, however, on the effectiveness of PCI? How many treatments are needed to see improvement? What is the best depth of needles and the spacing of them on the wheel? What topical products should ideally be used afterward? The science of PCI remains a fertile area for investigation and much of this information is not yet known. The role of PCI  in skin rejuvenation has not been defined, unlike laser technology. This is largely a function of economics. The large number of lasers that are marketed and exist in clinical practices provides a disincentive for the PCI bandwagon.

Despite these drawbacks, I remain both intrigued and encouraged about PCI in my Indianapolis plastic surgery and spa practice. PCI and laser treatments are not mutually exclusive. Light laser micropeeling (less than 50 microns) combined with PCI may capture the best of both worlds.

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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