A 'bare bones' look at nonablative resurfacing

A basic premise of nonablative resurfacing is that it improves the texture and appearance of skin with minimal recovery time. But according to Roy C. Grekin, M.D., clinical professor of dermatologic surgery at the University of California, San Francisco, the initial over-hyped marketing of nonablative resurfacing procedures has led many patients to believe they can look 20 years younger at the speed of light with no side effects or downtime.

"The long and the short of it," Dr. Grekin says, "is that the technology doesn't exist right now. There are things out there that can improve the skin, but early mis-marketing of these procedures led people to think that nonablative resurfacing methods could replace the ablative, deeper and more aggressive surgical techniques. It's this kind of marketing that has plagued dermatologic surgeons and lasers for their entire existence."

Dr. Grekin's candid review of what's possible, what's available and what results patients can expect from nonablative resurfacing laser procedures helps put the issue into perspective.

The mechanisms behind nonablative resurfacing involve delivering repetitive, sub-clinical dermal injury, as well as injury to epidermal pigmented lesions. Depending on the device employed, the dermal injury occurs as a result of heating blood vessels, intradermal water or other dermal proteins. The action results in a wound repair response, fibroblast stimulation and collagen reformation, with no epidermal damage. Used mainly for improvement of telangiectasia, lentigos, solar bronzing and elastosis (texture change), all nonablative resurfacing methods (laser or non-laser) require multiple treatments administered at two to four week intervals.

"There really is very minimal change and no predictable effect on wrinkles or skin tightening of dermatochalasis," Dr. Grekin says. "These are effects you can get from more aggressive procedures."

NON-LASERS

Non-lasers, such as an intense pulsed light sources using wavelengths from 500 nm to 1,215 nm, are available from multiple manufacturers.

In a study conducted at the University of California, San Francisco, Quantum (Lumenis) intense pulsed light was administered to 15 patients (13 females, two males) with varying degrees of telangiectasia, dyspigmentation and solar elastosis. Each patient received five treatments at three-to four-week intervals. Results from 14 of the 15 patients at six months indicated that on a scale of 1 to 10 improvement, 11 of 14 patients rated 6 or better, with no change noted in wrinkling in any of the patients. There was one adverse reaction of hypopigmentation.

LASERS

Several types of lasers are used for nonablative resurfacing.

These include the pulsed dye lasers, 585 nm and 595 nm; long-pulsed Nd YAG, 1,064 and 1,319 nm; KTP lasers, 532 nm; and diode lasers, 1,450 nm. Due to the different wavelengths, each has different primary targets in the skin and their selection is based on the patient's primary lesions or concerns. It is not uncommon to use these lasers in combination.

As with many cosmetic procedures, it's not so much the device that's being used as it is how the physician is using the device, according to Dr. Grekin.

"Appropriate patient selection, matched with the appropriate device, is critical for success. Most importantly, patients need to be given reasonable and fair assessments of what they can expect."

Despite growing demand for nonablative laser procedures, Dr. Grekin offers some caveats on treading the path to what he calls 'The Holy Grail.'

"It's clear that we already see indications from these nonablative techniques that we are moving towards our goal," Dr. Grekin says. "However, we need more academic research and science behind the development of these machines before we can claim to have devices that replace the ablative techniques."