Dr. Patrick Treacy trials the advantages and disadvantages of ActiveFx and SmartXide Co2 fractionalised lasers

1. 28 KNOWLEDGE CASE STUDY
ON thE sURFacE
DR PatRicK tREacy on frACTionAliSED Co2 lASEr Skin rESUrfACing
As patients continue the trend of seeking less velopment of high-energy pulsed lasers made largely considered the best option for treat-
invasive procedures with lower downtime and it possible to safely apply higher energy densi- ment of this type of photo-aged facial skin, it
associated risks, fractionalised carbon dioxide ties with exposure times that were shorter than also had certain post-procedural problems,
(CO2) laser skin resurfacing with newer genera- the thermal relaxation time of water-containing including prolonged post-operative recovery,
tion lasers such as the Lumenis ActiveFx or the tissue, which lowered the risk of thermal injury pigmentary changes and a high incidence of
Deka SmartXide DOT has become an important to surrounding non-targeted tissue. Two of infective adverse side effects, including acne
component of facial rejuvenation surgery. the first of these devices were the UltraPulse flares and herpes simplex virus (HSV) infection.
This recent behavioural change in patient 5000 and Silk-Touch lasers (Lumenis Corp). Many patients also complained of oedema,
attitude has largely been prompted by a reali- The UltraPulse emitted individual CO2 pulses burning, and erythema that sometimes lasted
sation, by both doctors and patients, that the with variable dwell time and a peak energy for many months. The delayed healing, the
much hyped radiofrequency type non-ablative density 500mJ, whereas the SilkTouch was a implied risks and long downtime made many
methods are not comparable with ablative skin continuous-wave CO2 system with a micro- patients reluctant to accept this method.
resurfacing and are often subject to extrava- processor scanner that continuously moved
gant claims in terms of efficacy. the laser beam so that light does not dwell on sEEKiNG saFEty
For the past 10 years, CO2 laser resurfac- any one area for more than one millisecond. The short-pulsed Er:YAG laser was introduced
ing was considered the ‘gold standard’ for the Many proceduralists of this period stated the as an alternative to the CO2 laser for skin
treatment of wrinkles and photo-damaged fa- ultrapulsed CO2 laser was the most effective resurfacing in an attempt to minimise the
cial skin. The first system CO2 laser developed modality for repairing years of skin exposure recovery period and limit side effects while
for cutaneous laser resurfacing was approved to harmful ultraviolet light and photo-damaged maintaining clinical benefit. It was approved by
by the US Food and Drug Administration (FDA) skin. This photo-ageing effect is demonstrated the FDA in 1996 for use in cutaneous resurfac-
in 1996. The earliest systems were continuous- clinically as a gradual deterioration of cutane- ing. It emitted 2940nm light that corresponded
wave CO2 lasers, which were effective for gross ous structure and function. It manifests itself to the 3000-nm absorption peak of water mak-
lesional destruction. However, these systems in the epidermis and upper papillary dermis by ing it 12 to 18 times more efficiently absorbed
could not reliably ablate fine layers of tissue giving skin a roughened surface texture as well by H2O-containing tissue than the light of the
because of their prolonged tissue-dwell times, as laxity, telangectasias, wrinkles and vari- CO2 laser. It was also a more precise ablative
and they produced unacceptably high rates of able degrees of skin pigmentation. Although, tool than the CO2 laser, although its shorter
scarring and dyspigmentation. Subsequent de- ultrapulsed CO2 laser skin resurfacing was pulse duration resulted in decreased thermal
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2. KNOWLEDGE CASE STUDY 29
casE 1
diffusion and less effective haemostasis. This
in turn increased intra-operative bleeding,
which was favoured by neither doctor nor
patient. The new safer Er:YAG laser eventu-
ally proved less favourable for deeper dermal
treatment and this, in turn, led to the develop-
ment of many non-ablative treatments such
as the Thermage®, Polaris® and the Titan®.
These devices quickly fell into disfavour as they
created a high level of non-responders after
quite expensive treatments that often required
multiple painful sessions.
Although non sequential fractionalised
technology is relatively new, its benefits of LEFt: PoST rESUrfACing
faster recovery time, more precise control of
ablation depth and reduced risk of post-proce-
dural problems are already clear. The obvious
benefits of these lasers has led to many new
fractional resurfacing lasers reaching the
market at the same time. The recent adoption
of the newer fractionalised CO2 lasers by many
physicians also appears to have reduced the
morbidity associated with this type of laser
treatment. Damage to the epithelium is less
apparent because, unlike in conventional abla-
tion, some of the stratum corneum remains
intact during treatment and acts as a natural
DAY 2 lASEr rESUrfACing DAY 7 PoST rESUrfACing
bandage. This allows the skin to heal much
faster than if the whole area was treated, as
the ‘healthy’ untreated tissue surrounding the size (1300mm instead of 2500mm) resulting in Before treatment
treated zones helps to fill in the damaged area less post procedure erythema due to reduced One hour before, the patient applies a thin layer
with new cells. Downtime is also reduced and heat build up in these tissues. Lastly, the CPG of Anestop® : (Amethocaine; Propitocaine;
erythema is moderate, permitting patients to lays down a random series of spots rather than Lignocaine) topical anaesthetic to the entire
apply cosmetics five days after treatment. a sequential sequence resulting in greater facial area. This is used with particular care in
thermal relaxation time and less overheating the periorbital areas and other lateral facial
FRactiONaLisED cO2 LasERs: of the treated tissue. The application of random regions not easily covered by a regional block. A
cURRENt DEvicEs rather than sequential beams is termed ‘Cool plastic wrap is not used during this procedure.
Fractionalised CO2 lasers are extremely versa- Scan’ and this feature was used with every
tile, in that they can be used for the treatment patient in the study. For anxiety and analgesia
of facial rhytides, acne scars, surgical scars, Valium (Diazepam5-10mg po), Tylex (Paracete-
melasma and photo-damaged skin. There are smartXide DOt mol Codeine) to be given 45 minutes prior to
presently several high-energy, fractionalised The SmartXide DOT (Dermal Optical Thermo- the procedure.
CO2 lasers currently available for cutaneous lysis) laser is a 30W fractionalised CO2 laser
resurfacing. with computerised scanner which enables For herpetic infection
Although each laser system adheres to the the user to deliver a customised scanned If the patient has a strong history of HSV,
same basic principles there are significant pattern with adjustable power, pattern den- Famvir (Famciclovir) 750mgs daily for 10 days
differences between lasers with respect to tis- sity and dwell times. With DOT technology or Valtrex (valcyclovir) 500 mg bd for 10 days
sue dwell time, energy output, and laser beam the physician is able to deliver a superfi- starting five days before surgery. I routinely
profile. These differences may result in variable cial ‘soft’ treatment with no downtime, a prescribe Famvir (Famciclovir) 750mgs daily or
clinical and histological tissue effects. moderate treatment requiring a few days of Valtrex (valcyclovir) 500mg bd for seven days
downtime, or a fully ablative traditional laser starting three days before surgery to every pa-
activeFx resurfacing treatment. The SmartXide DOT tient. (I found a 10% viral outbreak from more
The ActiveFx (although technically the name of adopts lightweight titanium articulated arm than 450 patients treated by this method)
a set of parameters) is an upgrade of the Ultra- in conjunction with a user friendly colour
pulse Encore with smaller spot size and a new touch-screen control panel to display the For bacterial infection
Computerised Pattern Generator (CPG), giving settings. The SmartXide DOT requires an If the patient has a strong history of acne, Ke-
a random pattern and reducing the possibility external plume device. flex (Cephalexin 500 mg bd), ByMycin (Doxycy-
of having several adjacent spots with resultant cline 100mgs daily) or Augmentin Duo, (Amoxil
heat accumulation. Other technical differences tREatmENts Clavulinic Acid) for seven days, starting the day
include the device leaving intact tissue bridges Pre laser procedure of surgery).
between spots, which results in faster healing For full-face resurfacing, I prescribe the follow-
time and less thermal damage to the basal cell ing analgesic type medications to be started on For yeast infection
membrane. The device also has a smaller spot the day of treatment: If the patient has a strong history of fre-
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3. 30 KNOWLEDGE CASE STUDY
quent yeast infections, Diflucan (Fluconazole casE 2
150mgs), starting on the fourth post-operative
day and taken once orally every other day.
I do not routinely prescribe antibiotic and
antifungal medication. Prior to resurfacing, the
nurse washes the patient’s entire face and neck
to remove the topical anaesthetic.
Procedural treatment
As a dermasurgeon, I normally prefer a deeper
form of anaesthesia for full-face ablative laser
procedures and use regional nerve blockade
and sometimes IV sedation, to provide more
complete anxiolysis, amnesia, and sedation. PrE rESUrfACing of CongEniTAl nEvUS PoST AfX rESUrfACing
Since the advent of fractionalised CO2 lasers
this is not required but I still feel more com-
fortable providing regional anaesthesia in the erythema can remain for a period of 14 days
supraorbital, perioral and marionette areas. I but this is rather unusual at the lower settings.
“
usually treat the cheek area and perioral area Most patients can use camouflage make-up
(which are under regional anaesthesia) first in to cover up the erythema on day four to five.
order to get the patient used to the laser with No significant sex differences are noted in the
the periorbital area next and finally extend duration of reepithelialisation, erythema or in
down into the neck area. When treating the
neck area, the parameters were modified to
the histopathologic changes. It should be noted
that most patients do not really feel pain with
use the lowest energy density possible (Ac- these devices until the proceduralists moves
tiveFx density 1).
I always use the Cool Scan. Care is taken in
both CO2 lasers them into higher energies.
The adoption of the single-pass technique,
the inferior regions of the neck with a tendency appear to produce which was widely adopted with earlier non-
to feather in the posterior border. The patients
are then placed under a 633nm Omnilux Revive equivalent clinical fractionalised devices in order to reduce the
morbidity associated with CO2 laser treatment,
to try and biomodulate fibroblast activity,
thereby leading to faster and more efficient
improvement of is not as necessary with these devices. Single
pass techniques tended to limit the depth of
collagen synthesis. lesions and rhytides penetration thereby decreasing the risk of
scarring and permanent pigmentary alteration.
Regional anaesthesia Post laser procedure care Post-inflammatory hyperpigmentation is
Normally, I give patients this regional anaes- If the patient has pain I resolve this with ice also unusual with proper patient selection
thesia during the procedure: packs. The patients’ face is covered with Vase- with these newer devices. Histological studies
line (petrolatum gel) using a tongue depressor demonstrate that 50 to 150µm of skin may be
supraorbital and supratrochlear and they are asked to continue doing this every ablated with a single pass of a CO2 laser. In my
nerve block few hours. I used to use dilute vinegar soaks own experience, skin biopsies (as shown) show
Locate the supraorbital foramen and insert (one teaspoon of distilled white vinegar to two effect of thermal treatment with thermal co-
the needle lateral to supraorbital foramen. cups of water) applied over the layer of Vaseline agulation of epidermis and superficial dermis
Direct the needle medially, parallel to the brow, petrolatum every few hours post-operatively, in a depth ranging from 85 to 113 microns. This
towards the nose. Infiltrate mid-two thirds of but not with the newer fractionalised devices. was similar in both lasers with the SmartXide
lower edge of eyebrow. Use 1cc of 1-2% Lido- The patients are reviewed at seven to 10 consistently getting below 100µm.
caine and inject just above bone level. days post-operatively, during which time the If fractionalised laser skin resurfacing
treated areas of the face have mostly returned with minimal downtime is now considered the
infraorbital nerve block to normal. latest method of ‘softly’ treating patients for
Locate the infraorbital foramen. Insert the Outbreaks of herpetic infection are reviewed skin conditions such photo-ageing then the
needle inferior to the foramen by 1cm (slightly on an almost daily basis and the patients are SmartXide DOT has certain cost advantages to
medial). Direct the needle towards the su- either admitted or commenced on Famvir the operator. However, the lack of an internal
praorbital foramen (avoid approaching orbit) In- 750mgs tid during this period. Topical steroids exhaust device to remove the laser plume is a
filtrate at infraorbital foramen. Use 1cc of 1-2% (1% Hydrocortisone) can be applied for a short distinct disadvantage. I feel the SmartXide also
Lidocaine and inject just above bone level. period to patients for continual itch but balance works faster, covers a greater area and has a
this against potential problems such as stop- more sophisticated CPG effect. It has yet to be
mental nerve block ping new collagen formation. established whether this device will continue
Locate the mental foramen. Insert the needle My own evaluation shows both CO2 lasers to require multiple treatment sessions or not.
1.5cm posterolateral to the mental foramen. (Lumenis ActiveFx and Deka SmartXide) appear However, if the physician is treating patients
Direct the needle towards the mental foramen to produce equivalent clinical improvement with deeper facial rhytides or other pathology
(avoid approaching orbit). Infiltrate at the men- of lesions and rhytides. It is also noted that such as deeper congenital nevi in a one off ses-
tal foramen. Use 1cc of 1-2% Lidocaine and re-epithelialisation occurs in all laser treated sion, then the variable settings of the ActiveFx
inject just above bone level. areas by both devices by day seven. Residual appears to have the advantage.
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