Nonablative Resurfacing Treatment & Management

Updated: Sep 03, 2018
  • Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
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Treatment

Medical Therapy

The most commonly used modalities for nonablative resurfacing are the 585-595-nm pulsed-dye lasers, the 1320-nm Nd:YAG laser, the 1450-nm diode laser, the 1064-nm Q-switched Nd:YAG laser, and the intense pulsed light source. This field is rapidly evolving, and newer modalities are expected over the next few years. A novel 1,550-nm erbium-doped laser (Fraxel, Reliant Technologies Inc.) has been shown to be effective in the treatment of photodamaged skin and scars with minimal postoperative recovery. [6]  Combinations of treatments with nonablative resurfacing can yield improved cosmetic effects. [29] Nonablative lasers can be combined with topical bimatoprost to enhance repigmentation, but this effect requires further investigation. In Asians, topical corticosteroids after laser resurfacing with ablative fractional carbon dioxide laser reduce the risks of postinflammatory hyperpigmentation. [30]

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Surgical Therapy

Currently used nonablative systems are based on the studies discussed below. New systems include the 1927-nm system of fractional thulium fiber that produces laser light.

In 2012, articles noted that nonablative lasers have been used to treat burn scars, striae, macular seborrheic keratosis, actinic keratosis, and a variety of neoplastic and scarring conditions, including treatment of post-Mohs surgical scarring and skin grafting. They can be used with ablative devices to enhance effect. [31] Blinded physician global assessment for hypertrophic scars was unable to prove the clinical effect of the 1540-nm nonablative fractional system laser. [32] . Some claim that they can repigment hypopigmented scars, but the mechanism and consistency of this result must be further defined. They may play a role in hand rejuvenation.

Treatment of melasma using fractional photothermolysis (1550-nm Fraxel SR laser) achieved a greater than 50% improvement in 5 of 8 patients treated (3-8 times) with long-term follow-up. [33] However, at conferences, dermatologist with experience with this condition have indicated they have not been able to replicate this level of effect.

In 2001, Rostan et al [34] studied 15 patients using the long-pulse flashlamp pumped pulsed-dye laser (LPDL) with and without cooling to ameliorate rhytides, to stimulate collagen synthesis, and to facilitate dermal remodeling. Eleven of 15 patients showed improvement of the laser-treated cheek, while only 3 of 15 patients showed a better appearance on the cryogen-treated side. Histologic specimens had more activated fibroblasts and demonstrated more positive procollagen staining on the LPDL-treated cheek. Thus, the LPDL can be a useful nonablative modality.

Bjerring et al [35] have shown increased levels of collagen precursors following treatment with a 350-μsec pulsed-dye laser. This laser is different from the usual pulsed-dye lasers currently used in cutaneous laser treatment because it emits shorter pulse width laser irradiation at low fluences. In a recent study, the use of intense pulsed light was also evaluated in the treatment of rhytides. Thirty female research subjects aged 35-65 years with Fitzpatrick type I-II and class I-II skin phenotypes were treated. Treatment areas included the periorbital, the perioral, and the forehead regions.

Over a period of 10 weeks, 1-4 treatments were provided. Noncoherent intense pulsed light was delivered to the skin by using a 645-nm cutoff filter. This technique leads to an emission of light with wavelengths of 645-1100 nm. Light was delivered through a bracketed cooling device in triple 7-msec pulses with a 50-msec interpulse delay between the pulses. Delivered fluences were between 40-50 J/cm2. The author evaluated the degree of improvement 6 months after the last treatment. Complications were also evaluated at this time. Clinical improvement was divided into the following 4 quartiles: no improvement, some improvement, substantial improvement, and total improvement.

Six months after the final treatment, 5 research subjects were noted to have no improvement. Similarly, no research subjects were noted to have total improvement. Sixteen research subjects showed some improvement, while 9 showed substantial improvement. All research subjects were evaluated for pigmentary changes, posttreatment blistering, erythema, and scarring. Three of the 30 research subjects were noted to have blistering immediately after treatment. All 30 research subjects had posttreatment erythema. Six months after treatment, no pigmentary changes, erythema, or scarring was noted. The author concluded that intense pulsed light could improve some rhytides, as demonstrated in the images below.

Periorbital rhytides before treatment with an inte Periorbital rhytides before treatment with an intense pulsed light source.
Improvement in rhytides after treatment with an in Improvement in rhytides after treatment with an intense pulsed light source.

New collagen formation and improvement of age-related vascular and pigmented lesions can follow treatment with this nonlaser technology. However, the changes appear to be subtler than those seen with ablative techniques.

The first specifically nonablative laser to be solely marketed to the physician community is a 1320-nm Nd:YAG laser. The goal of this system, similar to that of the previously described systems, is improvement of rhytides without the creation of a wound. The 1320-nm wavelength is advantageous in its high scattering coefficient. Thus, the laser irradiation scatters throughout the treated dermis after nonspecific absorption by dermal water.

In 2001, Pham [36] reported that the CoolTouch (Roseville, Calif) laser that blends an Nd:YAG, 1320-nm wavelength beam and thermal-sensing cryogenic spray was an effective nonablative treatment modality.

In 2004, Fulchiero et al [37] reported tandem treatment with needle subcision of acne scars and 1320-nm Nd:YAG nonablative laser resurfacing. They deemed this double-pronged treatment modality to be a well-tolerated and highly effective regimen compared with either modality alone.

In 2005, Bellew et al [38] reported on 29 patients treated with nonablative laser skin resurfacing with a 1320-nm Nd:YAG laser. They demonstrated significant positive changes in the appearance of facial acne scars and reported no adverse effects.

In August 2004, Sadick and Schecter [39] reported on 7 persons with photoaged hands. These patients underwent 6 monthly treatments with a 1320-nm Nd:YAG laser. They assessed skin smoothness improvement objectively, and patients also evaluated the results. The scale used was a 6-point improvement scale with 1 point for no improvement, 2 points for 20% improvement, 3 points for 40% improvement, 4 points for 60% improvement, 5 points for 80% improvement, and 6 points for 100% improvement. The mean improvement by objective assessment was 2.4 points. They noted objective improvement in 4 of 7 patients. In these 4 patients, a mean improvement score of 3.5 points was recorded. The mean improvement reported by the patients was 3.1 points.

In July 2004, Sadick and Schecter [40] exposed 8 persons with facial acne scars to 6 monthly treatments with a 1320-nm Nd:YAG laser with built-in cryogen cooling. They assessed acne scar improvement after treatment with the 1340-nm laser. They assessed the improvement objectively, and, again, the patients also evaluated the results. The 6-point improvement scale was also used again, with 1 point for no improvement, 2 points for 20% improvement, 3 points for 40% improvement, 4 points for 60% improvement, 5 points for 80% improvement, and 6 points for 100% improvement. They noted the mean improvement by objective assessment was 3.9 points (P = .002) at 5 months and 4.3 points (P = .011) at 1 year. The patient evaluations yielded similar scores of 3.6 points (P = .002) at 5 months. These researchers stated that acne scar improvement achieved statistical significance at the 5-month and 1-year milestone evaluation points.

In 2003, Rogachefsky et al [41] studied 12 patients with atrophic facial acne scars (N = 6) or a combination of atrophic and pitted, sclerotic, or boxcar scars (N = 6). These patients received 3 laser exposures with a 1320-nm laser. Both the researchers and the patients evaluated the scars before the initiation of treatment and at 6 months subsequent to the final laser exposure. A 10-point rating scale was used. Rogachefsky et al [41] found an average acne scar enhancement of 1.5 points (P = .002). The patient enhancement evaluations scored 2.2 points (P = .01). Patients rated the acne scars as worse compared with the ratings of Rogachefsky et al. [41] The researchers concluded that the 1320-nm was a useful and effective modality for ameliorating acne scars, and no adverse effects were reported at 6 months.

In 2002, Fatemi et al [42] used a 1320-nm laser on 10 patients and then performed biopsies. They stated that their data indicated that in addition to dermal collagen heating with subsequent collagen healing, nonablative resurfacing can engender subclinical epidermal injury that somehow improves appearance. Fatemi et al [42] speculated that acute alterations of superficial blood vessel injury somehow linked to cytokine release are also important factors. They concluded based on histologic findings that 3 passes with fluence and cooling adjusted a maximum temperature of 45-48°C yields optimal clinical improvements.

In the study by Nelson et al, [43] one or more passes of a 1320-nm Nd:YAG laser were used on photoaged skin. The waveform consisted of 3200-µsec laser pulses at a 100-Hz repetition rate. Laser energy was delivered through a 5-mm spot size with fluences up to 10 J/cm2. A dynamic cryogen cooling technique was applied immediately prior to laser treatment to produce selective subsurface skin heating without epidermal damage. Immediately after treatment, mild edema and erythema appeared in the treated skin. These adverse effects resolved within 2 days. At 2 months after treatment, facial rhytides improved notably. No persistent erythema or pigmentary changes were observed.

The currently available model of this 1320-nm Nd:YAG laser is accompanied by a unique handpiece with 3 portals. One portal contains the cryogen spray that cools the epidermis prior to and during treatment, another portal emits the 1320-nm Nd:YAG laser irradiation, and the third portal contains a thermal sensor. Fluences that are used with the currently available models vary from 30-40 J/cm2. Such fluences lead to peak measured temperatures of 42-48°C. Patients are usually treated at 2- to 4-week intervals and can be expected to show the degree of improvement expected from a nonablative approach.

Consistent with the noted clinical improvement is the histologic replacement of the irregular collagen bands with organized new collagen fibrils, as demonstrated in the images below.

Histologic findings consistent with solar elastosi Histologic findings consistent with solar elastosis.
Histologic findings 6 months after 4 treatments wi Histologic findings 6 months after 4 treatments with a 1320-nm Nd:YAG laser. Note the upper papillary dermal fibrosis.

This laser has also been used as part of a full-face antiaging approach because it produces new collagen formation, as demonstrated in the images below. Eyelid tightening and improved aperture through nonablative fractional resurfacing has also been reported.

Patient with almost no rhytides seeking full-face Patient with almost no rhytides seeking full-face 1320-nm Nd:YAG laser antiaging treatment.
Nonablative resurfacing. Six months after 1320-nm Nonablative resurfacing. Six months after 1320-nm Nd:YAG laser treatment.

The newest version of this laser leads to extremely safe and fast nonablative treatment through the use of either pretreatment cryogen cooling or posttreatment cryogen cooling and delivery of laser energy through a 10-mm spot size.

A 1450-nm diode laser has also been shown to be effective for the nonablative treatment of photoaged skin. The 1450-nm wavelength is extremely well absorbed by water. The laser also uses cryogen cooling to protect the epidermis before, during, and after treatment, as demonstrated in the images below.

Periorbital rhytides before treatment with a 1450- Periorbital rhytides before treatment with a 1450-nm diode laser.
Improvement in rhytides after treatment with a 145 Improvement in rhytides after treatment with a 1450-nm diode laser.

In 2005, Hohenleutner et al [44] reported on treatment of 30 facial areas with a 1450-nm diode laser. The treating laser surgeon and 2 blinded observers reviewed prelaser and postlaser exposure photographs. While as much as 35% enhancement seemed to occur in some patients, little concordance was achieved between the 3 reviewers. Thus, objective data did not demonstrate the efficacy of nonablative treatment of rhytides with the 1450-nm diode laser.

In 2004, Tan et al [45] reported a series of patient treated with the 532-nm laser on one side of the face and with the 532- and 1064-nm lasers to the other side of the face, followed by 3 treatments with the 1064-nm laser to both the right and left cheeks. They assessed skin quality (ie, visual dryness, roughness, uneven pigmentation) before, during, and up to 4 months after laser exposure. They noted greater than 25% improvement in overall skin quality for more than 30% of patients at the 1-month follow-up and for more than 40% of subjects at 4-month follow-up. The skin qualities most enhanced were visual dryness, roughness, and uneven pigmentation. Tan et al did not report adverse effects, and they stated that persons who receive more treatments with the 1064-nm would have greater improvement, but this outcome did not achieve statistical significance.

Dayan et al [46] in 2003 in a study of 1064-nm laser treatment in 51 patients found that it reduced coarse wrinkles and skin laxity and induced an overall improvement in the appearance of skin. Most patients received 7 treatments. Adverse effects were minimal.

In 2004, Tanzi and Alster [47] reported their important study involving 20 people with Fitzpatrick skin types demonstrating mild-to-moderate atrophic facial acne scars. These 20 persons were randomly exposed to 3 successive monthly laser exposures with the nonablative long-pulsed 1320-nm Nd:YAG and 1450-nm diode lasers. Tanzi and Alster [47] found that the 1320-nm and 1450-nm lasers provided enhancement with minimal untoward changes. However, the 1450-nm diode laser provided greater clinical scar amelioration when used by at the settings Tanzi and Alster [47] used.

In 2002, Lupton et al [23] reported on a study of the 1540-nm Er-doped phosphate glass laser operated by one laser surgeon. They found that the 1540-nm Er-doped phosphate glass laser was effective. Interestingly, histologic dermal alteration did not appear immediately; instead, several months after exposure to the 1540-nm laser, a dermatopathologist was able to report that a greater quantity of dermal collagen was present. Lupton et al [23] noted slow, progressive clinical and sustained improvement of rhytides in most patients.

In 2001, Fournier et al [48] reported on their study of 60 patients (mean age 47 y) who had skin phototypes ranging from I-IV and who were exposed for 4 treatments over 6-week periods to the 1540-nm Er:glass laser with contact cooling for nonablative skin remodeling. The focus was perioral and periorbital rhytides. All patients experienced subjective improvement. Ultrasound imaging data showed a 17% increase of dermis thickness (P< .005), and histologic data demonstrated new collagen formation. Thus, Fournier et al [48] concluded that the 1540-nm was a useful nonablative modality.

Fractional resurfacing has been used to decrease the size and extent of atrophic facial acne scars in various skin types, including Asian skin. [49, 50] Fractional resurfacing has also been noted to improve and tighten eyelid skin. [51]

The low-density, low-energy, nonablative, 1440-nm fractional laser can produce a slight improvement after four treatments on certain aspects of photodamage, without long-term adverse effects. [52]

A 1927-nm wavelength laser can be used effectively for nonablative skin resurfacing. [53]

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Postoperative Details

Graber et al [54] studied the use of the fractionated 1550-nm laser retrospectively from 961 treatments. Of these treatments, 7.6% of patients developed complications. The most common adverse effects were acneiform eruptions (1.87%) and herpes simplex virus eruptions (1.77%). Of note, darker-skinned patients experienced more pigmentary alteration.

After ablative fractional carbon dioxide laser resurfacing, reduced erythema and rapid healing was achieved with autologous platelet-rich plasma application. [55]

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Complications

Erythema and edema may be seen after treatment. Scarring, although extraordinarily rare, can be seen with any modality. Complications related to herpes simplex virus infection have been reported. [56]

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Outcome and Prognosis

All treated patients should note improvement in the quality, the tone, and the texture of their skin. Mild improvement in early rhytides may also occur. The outcome is maximized when other adjunctive agents, such as fillers, botulinum toxin, and microdermabrasion, are used. Ongoing treatment is to be expected. In a 2010 literature review, Tierney and Hanke found 10 studies that reported histologic evidence of cutaneous repair of photodamaged skin with the use of combination treatments to treat photoaging; reported treatments included nonablative and ablative laser resurfacing, topical retinoids, and topical photosensizers with lasers and light sources. [29]

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Future and Controversies

Nonablative or subsurface remodeling represents the newest approach to improving photodamaged skin. The degree of collagen remodeling is not expected to be as great as that seen with other, more destructive ablative approaches; therefore, the nonablative technique is meant for individuals who do not wish to take time away from their daily activities to improve the quality of their sun-damaged skin through laser techniques. The technique is also not meant for individuals with extensive solar-induced epidermal pigmentary changes. Those individuals are best treated with either an ablative laser or a specific pigmented lesion laser. The histology of nonablative resurfacing has been further defined in 2014. [57]

Combinations of nonablative laser treatment with medical treatment present an interesting new treatment modality. [58] Repigmentation of scars that are hypopigmented using an erbium-doped 1,550-nm fractionated laser in combination with topical bimatoprost works better than either treatment alone. Other combination of fractionated laser with topical medications are being explored.

Present studies are examining comparisons between the currently available systems. In the future, lasers or nonlaser radiofrequency devices may be created that can cause the same degree of improvement as ablative systems without the potential complications and down time.

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