Purpose:  Fractional resurfacing methods have improved safety and reduced side effects, but with reduced benefits and the need for multiple treatments when compared with traditional full-field laser resurfacing.  A new strategy to combine the coagulative damage from non-ablative fractional treatments with erbium:YAG fractional ablative treatment offers an opportunity to vary systematically both components and achieve very high single treatment coverage to maximize results.

Methods and Materials: Facial skin was treated using a 1540 nm and/or 1440 nm fractional nonablative laser followed by a 2940 nm erbium:YAG fractional ablative treatment (Palomar Medical Technologies, Burlington, MA).  The 1540 nm treatment utilized a prototype “XD” shaped optic which generates intense localized pressure at the skin surface co-located with each microbeam of light.  Total skin coverage was 20-30% each for the non-ablative and ablative components.  Healing time and adverse events were recorded.  Patient photographs were obtained for blinded scoring using the Fitzpatrick Wrinkle Scale (0-9), Fitzpatrick Dyschromia Scale (0-9) and quartile grading of wrinkle improvement. Skin biopsies were obtained to provide histological characterization of the fractional damage profile. 

Experience: Fourteen(14) patients with a minimum of 3 months follow-up were evaluated. 

Summary of Results:  Patient treatments were well tolerated with only topical anesthesia.  Occasional minimal bleeding and oozing was observed immediately post treatment.  Mean time to complete epithelialization was 5 days (range 3-6) compared with 3 days for the erbium:YAG treatment alone.  Mean duration of erythema was 7 days (range 5-21).  Combination high coverage (25% plus 25% ) treatments of more than 300 mcm depths produced a mean change in dyschromia score of 4.2+/- 1.9.  Combined high coverage deeper treatments from 600 mcm to 1.4 mm targeting deeper rhytids in the periorbital, perioral and cheek areas achieved greater than 50% (2 quartile) reduction in rhytids in 92 percent of patients with a notable reduction in skin laxity (see figures for representative patient before and 3 months after combined laser treatment.  Note improvement in rhytids and skin laxity).  Hematoxylin and eosin stained histologic sections of skin biopsies demonstrated deeper and wider columns of coagulated tissue at a given energy using the XD prototype handpiece compared to a conventional smooth fractional handpiece. 

Conclusions:  Combined fractional non-ablative and ablative treatment allowed substantial (>50%) single treatment coverage at substantial depth, producing increased efficacy compared to either modality alone.  Combining these modalities offers a new strategy for varying not only the combination of tissue coagulation and ablation produced in target skin but also the depth of energy distribution.  This approach holds promise for improving the consistency, efficacy and safety of laser treatments for photoaged skin.

Figure 1  Skin rejuvenation following a single treatment of combined fractional non-ablative then ablative treatment.  Subject was treated with Lux1440 at 600um depths for deep wrinkle areas and 300um depth for rest of face with 30 to 40% coverage followed by ablative treatment at depths over 500um in target areas and 300um depths on rest of face with additional coverage of 20 to 30%.