Micro-fractional Laser Skin Rejuvenation : Enhanced Outcomes with Novel Multi-Modality and Multi-Wavelength Treatment Paradigms J. David Holcomb, MD Sarasota Memorial Hospital, Florida, USA
------------------------------------------------------------------------------------------------------------------------------------------- Micro-fractional Laser Skin Rejuvenation : Enhanced Outcomes with Novel Multi-Modality and Multi-Wavelength Treatment Paradigms J. David Holcomb, MD Sarasota Memorial Hospital, Florida, USA -------------------------------------------------------------------------------------------------------------------------------------------- ACKGROUND The ability of non-ablative micro-fractional laser skin rejuvenation treatments to improve skin quality (e.g. dyschromia, photodamage, fine rhytids, pore size, acne scarring) with minimal downtime relative to traditional ablative laser treatments has been accepted. Non-ablative micro-fractional laser skin rejuvenation revolutionized the aesthetic services industry in providing useful minimal downtime treatments for any medical office or spa-type clinical environment as well as in expanding the eligible patient base with inclusion of darker skin types. However, variable treatment outcomes with multisession, single modality (e.g. static only or dynamic only), non-ablative micro-fractional laser skin rejuvenation, along with a desire for greater improvement of skin laxity and more advanced rhytidosis, spurred intense interest in fractionated delivery of ablative laser energy. Despite detailed knowledge concerning ablative laser tissue interaction (in the context of traditional ablative laser skin resurfacing), optimum treatment parameters for ablative micro-fractional laser skin rejuvenation (e.g. spot size, pulse width, ablation depth, density of microscopic ablation channels, energy delivery mode) remain to be more clearly defined. LUTRONIC INNOVATION Lutronic Corporation, with an arsenal that includes non-ablative (1550 nm, MOSAIC, Lutronic Corporation, Korea) and ablative (10,600 nm, eco2, Lutronic Corporation, Korea) microfractional lasers, both with several unique and highly advanced features to be described herein, intends to contribute significantly to the optimization of microfractional laser skin rejuvenation. The MOSAIC and eco2 laser systems both have dual micro-fractional treatment modes (static and dynamic), advanced non-linear, non-sequential microbeam delivery (Controlled Chaos Technology), variable microbeam delivery speed, skin sensing treatment tips (safety feature that prevents laser firing without skin contact) and user friendly treatment interfaces that enable real-time tracking of microbeam delivery (automatic total density counter) in dynamic mode. This latter feature enables greater uniformity of treatment within and across treatment sessions. In addition, the MOSAIC laser offers the greatest treatment energy range (up to 120 mj*) among similar wavelength devices on the international market while the eco2 laser offers unparalleled versatility. In addition to micro-fractional mode the eco2 laser offers a precision surgical mode and a traditional ablative skin resurfacing mode. An additional feature of the eco2 laser is the option for a random (versus regular) pattern in microfractional mode (minimizes if not eliminates the posttreatment stamped or checker board appearance seen with some competing devices). Patient comfort and treatment efficacy are of paramount importance to the successful practitioner. Active in both static and dynamic micro-fractional modes, Lutronic s Controlled Chaos Technology (CCT ) improves patient comfort by minimizing bulk tissue heating with proprietary non-linear, nonsequential scanning technology. Randomized microbeam delivery allows for microenvironment tissue cooling before placement of adjacent MNCs (micro necrotic columns) or MACs (microscopic ablation channels). This feature enables high energy static mode treatment (e.g. MOSAIC up to 120
mj* or eco2 exceeding 100 mj) with topical anesthesia and little or no discomfort. In addition, CCT may decrease the likelihood of development of post-inflammatory hyperpigmentation in patients with darker skin types. Another extremely valuable feature, variable microbeam delivery speed, helps to maintain maximum patient comfort and treatment efficacy. The ability to decrease microbeam delivery speed in dynamic mode WITHOUT ADJUSTING TREATMENT ENERGY preserves the intended efficacy of the treatment. Treatment energy should not be decreased as an initial measure for comfort with dynamic mode treatment with either the MOSAIC or eco2 laser. Together, these innovations have enabled novel treatment paradigms for both the MOSAIC and eco2 laser systems. MOSAIC laser dual mode treatment improves single treatment efficacy and may decrease the total number of sessions necessary to achieve treatment goals. In addition, improved single treatment efficacy leads to results that are visible early on in the treatment series, a valuable asset for maintaining patient confidence and optimism. The multi-modality treatment options of the eco2 laser enable tailoring of treatments appropriate to Fitzpatrick skin type, skin condition and patient expectations. Topical anesthesia (e.g. Pliaglis Comfort Mask) is typically applied for 1 hour before the treatment. Decreasing treatment speed during dynamic mode treatment provides a second measure for patient comfort. For preservation of treatment efficacy, treatment energy is reduced only as a last measure. An external cooling device (e.g. Zimmer Laser Cooling System) facilitates patient comfort with posttreatment cooling (note that significant cooling before and/or during treatment may decrease treatment efficacy). Oral or injectable anxiolytic and/or analgesic medications may rarely be necessary. A Fig1. Marked improvement acne scarring and dyschromia after DUAL MODE treatment of MOSAIC (A)efore () After MOSAIC DUAL MODE MICRO-FRACTIONAL LASER SKIN REJUVENATION A Dual mode treatment with the MOSAIC laser typically begins with static mode and concludes with dynamic mode. For acne scarring and diffuse photodamage static mode treatment is generally performed with HIGHER ENERGY (e.g. up to 120 mj*) and LOWER DENSITY (e.g. 50 or 100 MNCs/CM2) with one to three passes over each treatment area. Mild edema and erythema will typically be evident immediately after this initial treatment. Dynamic mode treatment is then performed with LOWER ENERGY (e.g. up to 30 mj) and HIGHER DENSITY (e.g. ultimately totaling 15% or greater coverage) until the appropriate clinical endpoint is achieved. Fig2. Marked improvement scarring after single DUAL MODE treatment of MOSAIC (A)efore () After A Fig3. Marked improvement dyschromia 7 days after 1st DUAL MODE treatment of MOSAIC (A)efore () After
eco2 MULTI-FUNCTIONAL CO 2 LASER Multi-mode treatment with the eco2 laser provides superior clinical outcomes. Switching between treatment modes is as simple as toggling the STATIC / DYNAMIC treatment mode button on the touch screen and/or switching the interchangeable treatment tips. Each treatment tip series is available in two styles (skin sensor and standard) that have the same focal length. Depending on indications, Fitzpatrick skin type and patient expectations safe start protocols have been developed that incorporate use of the 120 μm tip series (micro-fractional mode), the 1000 μm tip series (traditional ablative mode) or a combination of the two. Note that a 300 μm tip series is in late stages of development at the time of writing. Effective approaches for treatment of facial and nonfacial areas include: Skin types I III Dyschromia low energy, moderate density treatment with 1000 μm tip Skin Laxity and Rhytidosis higher energy, moderate density treatment with 120 μm tip series with single pass in static mode followed by treatment in dynamic mode for increased coverage and blending Acne and Other Scarring high energy, moderate density treatment with 120 μm tip series with single pass in static mode followed by treatment in dynamic mode for increased coverage and blending Multiple Conditions multi-modality treatment with 120 μm tip series (e.g. skin laxity) preceded or followed by 1000 μm tip (e.g. dyschromia) Skin types IV - V Dyschromia lower energy, lower density treatment with 120 μm tip series with single pass in static mode Skin Laxity and Rhytidosis intermediate energy, lower density treatment with 120 μm tip series with one to two passes in static mode; another option involves increasing coverage with dynamic mode treatment following an initial single pass in static mode Acne and Other Scarring intermediate energy, lower density treatment with 120 μm tip series with one to two passes in static mode; another option involves increasing coverage with dynamic mode treatment following a single pass in static mode
Fig4. Marked improvement skin laxity and texture face and neck 1 month after 2 nd treatment of eco2 (140mJ 100spot/ cm2 ) (A)efore () After A A Topical anesthesia (e.g. Pliaglis Comfort Mask) is typically applied for 1 hour before the treatment. A Fig5. Several month after treatment of eco2 (80mj 200 spot/ cm2 ) (A)efore () After A Fig6. 1 month after single pass 1000 μm tip treatment of eco2 (A)efore () After Depending on the planned depth of treatment and individual patient tolerability, regional nerve blockade (e.g. supra-orbital, infra-orbital, mental branches of trigeminal nerve and greater auricular nerve) may facilitate comfortable treatment. Oral or injectable anxiolytic and/or analgesic medications are recommended for treatment of large areas. Decreasing treatment speed during dynamic microfractional mode energy delivery provides a third measure for patient comfort. For preservation of treatment efficacy treatment energy is reduced only as a last measure MULTI-MODALITY, MULTI-WAVELENGTH COMINATION TREATMENT The efficacy and extremely well-tolerated nature of MOSAIC and eco2 micro-fractional laser skinrejuvenation naturally led to the concept that certain conditions (e.g. acne scarring and photoaging) may be treated more efficiently and with enhanced results by utilizing both 1,550 nm and 10,600 nm wavelengths. Synergistic outcomes from same session or alternate session combination treatment with the MOSAIC and eco2 micro-fractional
lasers have been achieved. In contrast to a typical individual MOSAIC or eco2 laser treatment with more limited MNC or MAC skin coverage (percentage of skin surface area treated), significantly greater skin coverage (e.g. 50 65% versus 20 35%) may be safely obtained in a single session wherein MOSAIC AND eco2 laser skin rejuvenation are performed together. A general guideline for this multi-modality, multi-wavelength combination treatment follows (Note that nonablative treatment with the MOSAIC laser precedes ablative treatment with the eco2 laser): Skin Type I III Step 1: MOSAIC high energy (up to 120 mj*), low density static mode treatment with one to three passes Step 2: MOSAIC lower energy, higher density (15%+ coverage) dynamic mode treatment Step 3: eco2 high energy, moderate density static mode treatment with single pass (e.g. 100 mj, 200 density or 21.5% coverage) Step 4: eco2 high energy dynamic mode (e.g. 100 Hz) treatment for blending and enhanced coverage (e.g. additional 10 15%) A A Fig7. 1 month after of MOSAIC and eco2 Combination therapy (A)efore () After
A Fig8. Marked improvement skin tone & texture 1 month after treatment of. MOSAIC and eco2 Combination therapy (A) efore () After CONCLUSIONS Achieving superior outcomes in laser skinrejuvenation begins with appropriate matching of Fitzpatrick skin type, indications and patient expectations with the wavelength(s) most likely to achieve the desired outcome. This goal is greatly facilitated by choosing devices that interact with tissue with precision and in a reproducible manner and by selecting the appropriate treatment parameters. The innovative features of the MOSAIC and eco2 laser systems described herein are among the reasons that Lutronic Corporation will continue to do well in the international aesthetic services marketplace. *MOSAIC currently FDA approved up to 70 mj in USA (120 mj MOSAIC HP pending FDA clearance)
J. David Holcomb, MD Sarasota Memorial Hospital, Florida, USA Medical School School of Medicine University of Texas Medical ranch Galveston, Texas Residency Department of Otolaryngology - Head and Neck Surgery University of Iowa Hospitals and Clinics Iowa City, Iowa AAFPRS Fellowship Advanced Cosmetic Facial Plastic Surgery: McCollough Plastic Surgery Clinic Gulf Shores, Alabama Rousso Facial Plastic Surgery Clinic irmingham, Alabama Hospital Affiliations: Sarasota Memorial Hospital oard Certifications: American oard of Facial Plastic and Reconstructive Surgery American oard of Otolaryngology - Head and Neck Surgery