N.I.C.E IMPROVEMENT

Newport Beach, Calif. - Skin softening and facial rejuvenation can be obtained without resorting to the CO2 laser and its associated risks, W. Gregory Chernoff, M.D., said at the annual symposium of the Foundation for Facial Plastic Surgery.

It is fashionable now not to wear much makeup, so the surgeon must avoid over-treatment and the risk of permanent hypopigmentation, typically around the mouth or eyes, that forces the patient to wear lots of makeup.

Dr. Chernoff's interest in long-pulse YAG laser systems followed a critical com­parison of the laser-based and chemical-based exfoliating systems to the nonexfoliating systems. For a given effect, the poten­tial for complications, cost to the patient, and time off for healing is high with exfoli­ating systems, he said. "We know we can exfoliate as lightly or deeply as we want with any of these systems, and we're finding that deep exfoliation is necessary less often."

Not a quick fix
Certainly, a deep C02 laser exfoliation pro­duces extensive new collagen synthesis with­in the papillary dermis, affects basal polari­ty, reorganizes collagen fibers, and compacts elastin fibers, he said. The results are often dramatic for patients with rhytides. Scars are also effectively treated with the C02 laser, and improving a heavily scarred patient is very gratifying for the doctor. Furthermore, the effects of CO2 resurfacing are seen soon after the procedure. "So over the years of using the CO2 laser, we've gotten used to having patients end up very happy in one 'shot'," he said.

Today nonablative ways of activating fibroblasts to stimulate new collagen forma­tion are available, but repeat visits are neces­sary. "This really involves a change in our mentality," he said. "We surgeons are used to delivering our patients a dramatic result in one treatment and getting paid for it all at once. But with [nonablative systems], you have think about patients paying you over a long period of time."

The first system was the 1320 YAG laser (Laser Aesthetics), followed by different wavelength systems from different compa­nies. Contraction and new collagen forma­tion do occur after YAG laser treatment, but the wavelength must be appropriate to obtain the effect, he said. The waveform and radiant exposure to tissue must be appro­priate to activate the long-term wound heal­ing response so fibroblasts are activated to produce collagen.

Dr. Chernoff finds patients are much happier than the doctors are with nonexfoliating procedures because "we doctors have a mindset of having to get that 'grand slam,' and are not as happy if we get a 'walk' or get on first base. The patients are very happy. They compare their preop and postop pho­tographs and say,'Look, for $250 I really did get a new self.'"

Built-in safety
The safety of the CoolTouch YAG laser comes from thermal sensor built into the handpiece. If the epidermal temperature exceeds 40 degrees C, the laser stops firing. Pressing the foot pedal delivers a pulse of tetrafluoroethylene coolant to the skin, which decreases the surface temperature, and microseconds later a triple pulse of the YAG is fired that increases the temperature within the deep dermis to approximately 80 degrees C.

"In our dynamic cooling study, we determined the surface epidermal temperature and the depth that correlates with fibroblast stimulation sufficient to start the production of new collagen," Dr. Chernoll said. The effect was demonstrated in histologic studies. Electron microscopy photographs also showed neocollagen formation, similar to that seen following Er:YAG laser treatment. Without the cooling pulses, the increase in epidermal temperature would produce epidermolysis and tissue necrosis. "So this laser has a built-in safety device which makes it very difficult for you to hurt the patient," he said.


"Nonablative ways of activating fibroblasts to stim­ulate new collagen formation are available, but repeated visits are necessary."
W. Gregory Chernoff, M.D.

Patient selection
Treatment with the CoolTouch laser is not for everyone. Patients who ask for maxi­mum benefit in one sitting would  more appropriately be treated with a chemical peel or a deeper exfoliating laser treatment. But Dr. Chernoff is seeing an increasing number of patients saying, "I don't want to take a week off, I don't want to lake 10 days off, so is there something you can do for me that has some benefits?"


"We are seeing pretty dramatic softening in pitted acne scars."


Most patients have the treatment every couple of months for about one year. From a doctor's standpoint, the results are conserva­tive "because we are used to seeing much more dramatic results" with the CO2 laser or chemical peel, he said. "But our patients are more satisfied than the doctors."