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Novel Use of Erbium:YAG (2,940-nm) Laser for FractionalAblative Photothermolysis in the Treatment of PhotodamagedFacial Skin: A Pilot Study MOSHE LAPIDOTH, MD, MPH,y MARINA EMIKO YAGIMA ODO, MD,z AND LILIAN MAYUMI ODO, MDz The use of CO2 or conventional erbium laser ablation or more recent nonablative laser photothermolysis for skin rejuvenation is associated with significant disadvantages.
The objective was to assess the efficacy of the erbium:YAG laser (2,940 nm) using the ‘‘ablative'' fractional resurfacing mode to improve photodamaged skin.
A total of 28 patients, 27 women and 1 man, aged 28 to 72 years (mean age, 54.2 years), with Fitzpatrick Skin Types II to IV, were treated for mild to moderate actinic damage using fractional er-bium:YAG laser (2,940 nm) combined with Pixel technology. Sessions were scheduled at 4-week inter-vals. Response to treatment was evaluated by two physicians on a five-tiered scale.
Patients underwent one to four treatment sessions (mean, 3.2). The initial reaction consisted of erythema and minimal swelling. On clinical assessment 2 months after the final treatment, the resultswere rated excellent by 21 patients (75%) and good by 7 (25%). Nineteen of the 21 were also evaluated 6to 9 months after final treatment without any significant change in the results.
Fractional ablative photothermolysis using erbium:YAG laser (2,940 nm) is a promising option for skin resurfacing with reduced risk and downtime compared to existing laser methods.
The equipment used in the Israel group only was loaned by Alma Lasers, Ltd. Fractional photothermolysis is a new technique on the skin surface that are rapidly reepithelialized for the treatment of skin lesions1 in which an by the surrounding, undamaged tissue, sparing the array of microscopic thermal wounds (microscopic epidermis. The aim of this pilot study was to describe treatment zones) is induced into the skin to stimulate our clinical experience with this emerging technique.
a therapeutic response deep in the dermis. Nonab-lative fractional photothermolysis at a wavelength of Subjects and Methods
1,550 nm has been found to be effective for thetreatment of melasma,2 mild to moderate rhytides,3 The study group consisted of 18 women, who were acne scars,4 surgical scars,5 and even poikiloderma treated in Israel, and 9 women and 1 man, who were of Civatte.6 However, this ‘‘coagulative'' approach is treated in Brazil. Patients ranged in age from 28 to time-consuming and painful, and the results are not 72 years (mean, 54.2 years). All patients presented always predictable. Recently, ‘‘ablative'' fractional with mild to moderate actinic damage (solar lenti- photothermolysis using the erbium:YAG laser ginosis, actinic keratosis, flat seborrheic keratosis, (2,940 nm) has been introduced as a novel means of and fine wrinkles). Eight patients had Fitzpatrick providing treatment that would be as effective as Skin Type II, 12 had Type III, and 8 had Type IV.
traditional ablative approaches while avoiding their None of the patients had undergone skin resurfacing high downtime and risks. The laser produces thou- in the past. Exclusion criteria were photosensitivity, sands of microscopic, clinically inapparent wounds use of photosensitive medications, history of scarring, Department of Dermatology, Rabin Medical Center, Petah Tiqwa, Israel; ySackler Faculty of Medicine,Tel Aviv University, Tel Aviv, Israel; zDepartment of Dermatology, School of Medicine, University of Santo Amaro,San Paulo, Brazil & 2008 by the American Society for Dermatologic Surgery, Inc.
Published by Blackwell Publishing
ISSN: 1076-0512
Dermatol Surg 2008;34:1–6
DOI: 10.1111/j.1524-4725.2008.34204.x and use of isotretinoin in the previous year. Patients diately after treatment; and 3, 7, and 60 days fol- were provided with a detailed description of the pur- lowing the end of treatment.
pose and possible outcomes of treatment and signedinformed consent forms to participate in the study and to concede their permission for clinical photographs to Immediate follow-up examinations were performed be taken. All subjects signed the informed consent after each session. Further follow-up was performed form before being enrolled to the study.
2, 5, 7, 30, and 60 days posttreatment to monitorrecovery, improvement, and any subsequent sequel-ae. Each patient was evaluated by the physician with respect to the severity of photodamage and wrinkles(wrinkle severity: no wrinkles = 1, completely wrin- Patients were treated in the offices of the principal kled = 9) before treatment and at the 60-day follow- investigators using their existing treatment facilities.
up. Textural irregularity was also evaluated by the In 50% of the patients, according to patient's physician at these time points. Side effects and decision, treatment was carried out using a topical complications were recorded. To evaluate skin im- anesthetic cream (EMLA [eutectic mixture of lido- provement, photographs were taken with a digital caine and prilocaine], AstraZeneca, London, UK) camera (Sony T7, 5.1-megapixel resolution, Sony, applied to the face under occlusion 2 hours beforetreatment. Fractional ablative photothermolysistreatment is carried out using a 2,940-nm Er:YAGlaser (Pixel, Alma Lasers Ltd, Caesarea, Israel) thatincorporates a microlens aligned in a matrix of either9  9 (81) dots (pixels), which emits 17 mJ/P perpixel, or 7  7 (49) dots (pixels), which emits 28 mJ/P per pixel, with the maximum pulse energy outputbeing 1,400 mJ/P. The single-pass ablation micro-zone of each pixel measures approximately 150 mmin diameter and 120–140 mm in depth. The lasermicrobeam passes through the matrixed microlens tointeract with the skin surface without affecting theskin in the nonpixel zones. The total collateral mi-crodamage depends on the number of passes, matrixsize, and the level of energy used.
For this study, an Er:YAG laser device (Pixel, AlmaLasers Ltd) with 7  7 (49-dot) alignment was used.
Two to four stacked laser passes were performed fora penetration of 20m (evaporative) 30m (thermal) (1stpass), 35m 1 40m (2nd pass), 50m 1 45m (3rd pass),60m 1 50m and (4th pass; unpublished manufac-turer's data) and a microzone diameter of 150 mm.
Treatment was given at 4-week intervals and con-tinued until an acceptable end point was achieved.
Figure 1. Immediately after treatment, ‘‘netlike'' ablation
Biopsies were taken from the preauricular area in the with background erythema (A); 3 days after, darkening of Brazilian group before initiation of therapy; imme- the skin by exfoliated epidermis, in a ‘‘net'' pattern (B).
Figure 2. Before treatment (A); 7 days posttreatment (B); 60 days posttreatment (C); 9 months posttreatment (D).
Tokyo, Japan) before treatment and at each follow- provement; poor, o25% improvement; or worse, up visit. The photographs taken before initiation of final results were worse than the pretreatment find- treatment and 60 days following the end of treat- ings. Nineteen of the 21 were also evaluated 6 to 9 ment were independently evaluated and compared months after final treatment.
by a plastic surgeon and a dermatologist or twodermatologists, who graded the results on a five- tiered scale, as follows: excellent, 75% to 100%lesion clearance and textural improvement; good, All 28 patients completed the study. The number of 50% to 75% improvement; fair, 25% to 50% im- treatment sessions ranged from 1 to 4 (mean, 3.2).
Figure 3. Normal skin before treatment (A); immediately after, coagulation of epidermis and top of superior dermis (B); 3
days after, crust of coagulated epidermis is being eliminated and epidermis restored (C); 7 days after, normal epidermis and
inflammatory infiltrate in the dermis (D). Original magnification,  100.
At the clinical assessment carried out 2 months after that were evaluated also 6 to 9 months after final the last treatment session, outcome was rated ex- treatment, there was not any significant change in cellent in 21 patients (75%) and good in 7 (25%).
the results.
No cases were graded as fair, poor, or worse. In allpatients, the initial reactions to treatment consisted of erythema and minimal swelling in the treated ar-eas; the patients reported a burning sensation but no This study reports the outcome of 28 patients treated significant pain. The erythema lasted between 2 and with ablative fractional laser photothermolysis 10 days (mean, 3.6 days), and its severity was cor- (2,490 nm) for photodamaged skin. Although abla- related with the number of laser passes. Overall, tive resurfacing with the CO2 or Er:YAG laser re- erythema was mild without any downtime. No per- mains the gold standard in skin rejuvenation,7 it is manent side effects were noted. (A typical patient's associated with considerable downtime and a risk of follow-up is illustrated in Figures 1 and 2). The bi- prolonged erythema, infection, scarring, and delayed opsy samples clearly showed the epidermal and up- hypopigmentation.8,9 Moreover, it is painful and per dermal ablation and healing process with usually requires general anesthesia. In the search for collagen regrowth as highlighted by Masson's tri- alternatives that would also promote some collagen chrome stain (Figures 3 and 4). In the 19 of the 21 regrowth,8 researchers first turned to nonablative and therefore led to fewer clinically evident pig-mentary changes. Nevertheless, hyperpigmentationis a long-term sequela of laser treatment, and ex-tended follow-up is required before it can be com-pletely ruled out. Further comparative studies with1,550-nm fractional photothermolysis are alsoneeded to confirm the efficacy and safety of this newtechnique. It should be emphasized that the systempresented in this study is a ‘‘stamped'' fractionalphotothermolysis technique compared to scanningfractional photothermolysis that requires a scanner Figure 4. 2 months after treatment: the collagen Masson's
trichrome stain demonstrates new bands of collagen in the
and, in some systems, expensive consumables.
superior dermis.
In conclusion, Er:YAG laser fractional photocoagu- and intense pulsed light lasers. These were found to lation is a promising option for the treatment of be safe but limited in efficacy, and the results were various dermatologic conditions, avoiding the ad- not comparable to ablative resurfacing.9–12 verse effects of ablative laser procedures while im-proving the limited efficacy of the nonablative ones.
In 2003, Manstein and colleagues1 introduced theconcept of fractional photothermolysis to bridge the We thank Gloria Ginzach for gap between ablative and nonablative resurfacing.
her editorial and secretarial assistance.
Local resurfacing with a 1,550-nm nonablative laserusing an array of microscopic thermal woundsproved effective, and downtime and morbidity wereminimal. However, the procedure required multiple sessions and local anesthesia, and the results were 1. Manstein D, Herron GS, Sink RK, et al. Fractional photo- sometimes variable.13–16 This article describes a thermolysis: a new concept for cutaneous remodeling using mi- novel modification of the fractional photothermoly- croscopic patterns of thermal injury. Lasers Surg Med2004;34:426–38.
sis technique, from ‘‘bulk ablation'' to ‘‘localized 2. Geronemus RG. Fractional photothermolysis: current and future ablation,'' wherein only a small fraction of the skin is applications. Lasers Surg Med 2006;38:169–76.
treated. The laser is used to produce thousands of 3. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with microscopic, clinically inapparent, thermal wounds fractional photothermolysis: a pilot study. Dermatol Surg in the skin, while the intact, undamaged skin around each wound acts as a reservoir, allowing relatively 4. Hasegawa T, Matsukura T, Mizuno Y, et al. Clinical trial of a laser device called fractional photothermolysis system for acne scars.
rapid reepithelialization of the treatment zone with, J Dermatol 2006;33:623–7.
consequently, little risk of infection and scarring. On 5. Behroozan DS, Goldberg LH, Dai T, et al. Fractional photo- the basis of the present results, fractional ablative thermolysis for the treatment of surgical scars: a case report.
photothermolysis appears to be at least as effective J Cosmet Laser Ther 2006;8:35–8.
as nonablative procedures, and the outcome is pre- 6. Behroozan DS, Goldberg LH, Glaich AS, et al. Fractional pho- tothermolysis for treatment of poikiloderma of Civatte. Dermatol dictable. It is noteworthy that hyperpigmentation, a particularly troublesome side effect of ablative laser 7. Ross EV, Miller C, Meehan K, et al. One-pass CO2 versus resurfacing, was not noted in our patients, although multiple-pass Er:YAG laser resurfacing in the treatment ofrhytides: a comparison side-by-side study of pulsed CO the follow-up was relatively short. We speculate that Er:YAG lasers. Dermatol Surg 2001;27:709–15.
the microscopic pattern of injury induced by the 8. Hruza GJ, Dover JS. Laser skin resurfacing. Arch Dermatol 2,490-nm laser caused only minimal inflammation 9. Rostan EF. Laser treatment of photodamaged skin. Facial Plast during fractional photothermolysis. Dermatol Surg 2005;31(9 Pt 2):1242–3; discussion 1244.
10. Goldberg DJ, Whitworth J. Laser skin resurfacing with the 15. Fisher GH, Geronemus RG. Short-term side effects of fractional Q-switched Nd:YAG laser. Dermatol Surg 1997;23:903–6.
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13. Marra DE, Yip D, Fincher EF, et al. Systemic toxicity from top- ically applied lidocaine in conjunction with fractional photo- Address correspondence and reprint requests to: Moshe thermolysis. Arch Dermatol 2006;142:1024–6.
Lapidoth, MD, Head, Laser Unit, Department of Derma- 14. Fisher GH, Kim KH, Bernstein LJ, et al. Concurrent use of a tology, Rabin Medical Center, Golda Campus, Petah handheld forced cold air device minimizes patient discomfort Tiqwa 49372, Israel, or e-mail: [email protected]

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