Introduction

Treatment approaches are constantly being developed and refined in the field of skin rejuvenation. Since its original introduction in 2004, fractional photothermolysis has provided rejuvenation treatment approaches that are both effective and safe. Developed by Anderson & Manstein, fractional photothermolysis generates targeted microthermal treatment zones (MTZs), columns of thermally denatured skin of controlled width and depth, in the dermis. Their original device utilizing this technology induced necrosis within the epidermis and dermis while leaving the stratum corneum histologically intact and was thus termed non-ablative fractional photothermolysis (NAFR).

One of the main advantages of NAFR is limited discomfort and the minimal recovery that is required after the procedure. In contrast to conventional resurfacing devices, fractional photothermolysis treats only a fraction of this skin, allowing for rapid epidermal repair from undamaged areas. Although multiple treatment sessions are required to achieve the desired outcome, downtime is limited to an average of 3 days of redness and swelling as opposed to an average of 7–10 days of an open wound after aggressive non-fractional ablative resurfacing. Combined with an excellent safety profile, NAFR has become the cornerstone of laser skin rejuvenation for the treatment of photoaging and acne scarring and a variety of other clinical applications.

Pathophysiology

In fractional photothermolysis, a regular array of pixelated light energy creates focal areas of epidermal and dermal tissue damage or microthermal treatment zones (MTZ) (Fig. 6.1). Since its inception, several different lasers have been developed to take advantage of this technological advance. Each laser has parameters that can modify the density, depth, and size of the vertical columns of MTZs. The individual wounds created by FP are surrounded by healthy tissue resulting in a much quicker healing process when compared with traditional ablative skin resurfacing. This targeted damage with MTZ is hypothesized to stimulate neocollagenesis and collagen remodeling leading to the clinical improvements seen in scarring and photoaging. In the original study by Manstein et al., the histologic changes seen after NAFR were elegantly described. Immediately following treatment, lactate dehydrogenase (LDH) viability staining showed both epidermal and dermal cell necrosis within a sharply defined column correlating with the MTZ. There was continued loss of dermal cell viability 24 hours after treatment, but via a mechanism of keratinocyte migration, the epidermal defect had been repaired. One week after treatment, individual MTZs were still evident by LDH staining, but after 3 months there was no histologic evidence of loss of cell viability. Water serves as the target chromophore allowing for thermal damage to epidermal keratinocytes and collagen.

Figure 6.1 Diagram showing the differences between traditional ablative, non-ablative fractional, and ablative fractional resurfacing. With the fractional laser technology, microthermal treatment zones are created with intervening islands of unaffected tissue. Healing time is significantly less, and the energy can safely reach deeper into the dermis.

Hantash and colleagues demonstrated a unique mechanism of tissue repair with fractional photothermolysis. In 2006, they demonstrated, using an elastin antibody, that damaged dermal content was incorporated into columns of microscopic epidermal necrotic debris (MEND) and shuttled up through the epidermis and extruded in a process of transepidermal elimination. This mechanism, which had not been described with previous laser technologies, explains the elimination of altered collagen in photoaging and scars and was also hypothesized to provide novel treatment strategies for pigmentary disorders like melasma as well as depositional diseases like amyloid and mucinoses.

Epidemiology

According to the American Society for Plastic Surgery statistics, which provides a comprehensive estimate on the total number of cosmetic procedures performed in the United States, minimally invasive cosmetic procedures have increased by more than 100% since 2000. In 2010, over 300 000 non-ablative laser skin resurfacing procedures were performed with the majority done on females.

Equipment

As the technology of fractional photothermolysis continues to evolve, new devices continually come to market. A list of currently available NAFR systems is given in Table 6.1. The table is not comprehensive and, as one can imagine, the devices will change constantly. This section will provide a brief description of a few of the more commonly used devices.

The original non-ablative fractional resurfacing system described by Manstein featured a scanning handpiece with a 1500 nm wavelength. The updated, currently available model, the Fraxel re:store (Solta Medical, Hayward, CA), employs a 1550 nm erbium glass laser. The device has tunable settings to adjust the density of the MTZs and energy depending on the treatment. Density can be varied to treat anywhere from 5 to 48% while energy settings can be adjusted to control depth of penetration from 300 to 1400 µm. Most of the studies available on non-ablative fractionated lasers are based on this device.

Solta Medical’s newest addition, the Fraxel Dual, couples the 1550 nm erbium laser with a 1927 nm thulium fiber laser in one platform. The thulium laser provides a more superficial treatment option and better addresses dyspigmentation while the 1550 nm penetrates deeper to stimulate collagen remodeling. The system increases flexibility, allowing the practitioner to switch between the two lasers to tailor treatment accordingly. Parameters can be adjusted similarly to the Fraxel re:store. Cooling is also built in with the Fraxel Dual.

Palomar Medical Technologies (Burlington, MA) offers an intense pulsed light platform with individual handpieces that attach to a single unit to cover a wide range of uses. The Lux1440 and Lux1540 handpieces provide two wavelength options (1440 and 1550 nm) for fractional non-ablative photothermolysis. In addition, the company has developed a new XD Microlens for their non-ablative laser handpieces. In their study, the company claims that, as the dermis is compressed by the optical pins on the handpiece, the pins are brought closer to deeper targets and the interstitial water is displaced from the dermal–epidermal junction into the surrounding spaces. With less water to absorb, scattering of the laser light is reduced enabling increased absorption of the light by deeper targets.

The Affirm (Cynosure, Inc., Westford, MA) is a 1440 nm Nd : YAG laser device that utilizes a proprietary Combined Apex Pulse (CAP) technology. The technology creates columns of coagulated tissue surrounded by uncoagulated tissue columns, which purportedly improves treatment efficacy. The Affirm uses a stamping handpiece with two spot sizes and energies that penetrate up to 300 µm in depth. A recent advance has been the addition of their multiplex technology, which stacks a 1320 nm wavelength with the 1440 nm system, allowing for penetration down to 1000–3000 µm.

Applications

While NAFR is currently approved by the US Food and Drug Administration for the treatment of benign epidermal pigmented lesions, periorbital rhytides, skin resurfacing, melasma, acne and surgical scars, actinic keratoses, and striae, it has been reported to be used in many other clinical settings (Box 6.1).

Photoaging

With their seminal study in 2004 using a prototype non-ablative fractional resurfacing device, Manstein and colleagues first demonstrated the clinical effectiveness of fractional photothermolysis by showing improvement in periorbital rhytides. Three months after four treatments with the fractionated device, 34% of patients had moderate to significant improvements and 47% had improvement in texture as rated by blinded investigators. Overall, 96% were noted to be ‘better’ post-treatment. The skin tightening seen after non-ablative fractional resurfacing is similar to ablative resurfacing with tightening within the first week after treatment, apparent relaxation at 1 month, and retightening at 3 months (Case study 1).

Case Study 1

The right patient

A 58-year-old Caucasian male with mild rhytides and mild to moderate photodamage with scattered facial lentigines presents for consultation. You recommend a series of non-ablative fractional resurfacing laser procedures. Six months after the sixth laser procedure, you see the patient back in follow-up. He is delighted with his improvement in both texture and skin tone and subsequently refers a couple of his friends to see you.

The above patient is the ideal patient for non-ablative fractional resurfacing. These results are typical of the improvement we see in our patients when selected appropriately.

Subsequent reports have confirmed the efficacy of NAFR beyond just periorbital lines. Wanner and colleagues showed statistically significant improvement in photodamage of both facial and non-facial sites with 73% of patients improving at least 50%. In 2006, Geronemus also reported his experience with fractional photothermolysis, finding it to be effective in treating mild to moderate rhytides. Figures 6.2 and 6.3 show typical improvement in rhytides and pigmentation after treatment with non-ablative fractional resurfacing. For deeper rhytides, such as the vertical lines of the upper lip, improvement is also seen but not nearly to the same degree as in ablative approaches.

Figure 6.2 Improvement in moderate rhytides 1 month after two treatments with Fraxel 1927 nm.

(Photo courtesy of Solta Medical.)

Figure 6.3 Improvement in rhytides and dyspigmentation 1 month after three treatments with Fraxel re:store.

(Photo courtesy of Solta Medical.)

NAFR is also considered to be an effective and safe treatment modality for photoaging off the face including the neck, chest, arms, hands (Fig. 6.4), legs, and feet. These body sites are typically very challenging to treat with other treatment modalities given either increased risks of complications (e.g. scarring) associated with ablative technologies or lack of efficacy that has been previously observed with other non-ablative devices. Jih et al reported statistically significant improvement in pigmentation, roughness, and wrinkling of the hands in ten patients treated with non-ablative fractional resurfacing. In our experience, we have found NAFR to be very safe when settings are adjusted accordingly.

Figure 6.4 Improvement in rhytides and dyspigmentation of the hands 1 month after two treatments with Fraxel re:store.

(Photo courtesy of Solta Medical.)

Scarring

Scarring can induce a tremendous psychological, physical, and cosmetic impact on individuals. Previous therapeutic modalities in scar treatment include surgical punch grafting, subcision, dermabrasion, chemical peeling, dermal fillers, as well as laser resurfacing with ablative and non-ablative devices. Published studies have demonstrated that NAFR can be successfully utilized in the treatment of various forms of scarring, including acne scarring, with a very favorable safety profile (Fig. 6.5). Mechanistically, fractional photothermolysis allows controlled amounts of high energy to be delivered deep within the dermis resulting in collagenolysis and neocollagenesis, which smoothes the textural abnormalities of acne scarring. In a large clinical study, Weiss showed a median 50–75% improvement of acne scars using a 1540 nm fractionated laser system after three treatments at 4-week intervals with 85% of patients rating their skin as improved. Alster showed similarly impressive results in a study of 53 patients with mild to moderate acne scarring; 87% of patients who received three treatments at 4-week intervals showed at least 51–75% improvement in the appearance of their acne scars. Non-ablative fractional resurfacing, in our estimation, is the treatment of choice for facial acne scarring.

Figure 6.5 Significant improvement in texture and rolling acne scars 2 months after four treatments with Fraxel re:store.

Pearl 1

Patients with deep acne scarring or severe rhytides often require high-energy settings, which correlates with deeper penetration of the laser and subsequent remodeling of collagen deeper in the cutis.

NAFR can also be safely used to treat acne scarring in darker-pigmented patients (Fig. 6.6). A study of 27 Korean patients with skin types IV or V that were treated with three to five non-ablative fractional resurfacing treatments revealed no significant adverse effects, specifically pigmentary alterations. Furthermore, all forms of acne scarring including ice-pick, boxcar, and rolling scars improved with eight patients (30%) reporting excellent improvement, 16 patients (59%) significant improvement, and three patients (11%) moderate improvement. With such a good efficacy and safety profile, many clinicians prefer NAFR to ablative fractional photothermolysis when it comes to treating acne scarring.

Figure 6.6 1 month after five treatments with Fraxel re:store showing significant improvement in acne scarring in a darkly pigmented patient.

(Photo courtesy of Solta Medical.)

NAFR can also be used in the treatment of other types of scars, including hypertrophic and hypopigmented scars. In a study of eight patients with hypertrophic scarring, all patients had improvement in their scars based on the physician’s clinical assessment, with a mean improvement of 25–50%. While the flashlamp-pumped pulsed dye laser (PDL) had long been considered the laser of choice for treating hypertrophic scars, NAFR has showed tremendous promise when compared with PDL. In a study of 15 surgical scars in 12 patients, NAFR outperformed PDL in the improvement of surface pigmentation, texture change, and overall scar thickness. While more studies are needed, NAFR should be considered as a therapeutic option to be used in conjunction with or as an alternative to PDL.

Traditionally, treatment of hypopigmented scars has shown variable efficacy, but current evidence suggests that NAFR may be particularly useful. A pilot study of NAFR laser treatment showed a 51–75% improvement in hypopigmented scars in 6 of 7 patients treated. The mechanism of action for this repigmentation has been hypothesized to be secondary to migration of melanocytes from the pigmented, normal skin into the scar, resulting in blending of the border (Fig. 6.7).

Figure 6.7 Improvement of hypopigmented scars 1 month after three treatments with Fraxel 1927 nm.

Patient selection

The preoperative consultation is crucial to maximize outcomes while minimizing complications. The clinician should assess the patient expectations and goals for treatment during this encounter. Showing patients before and after photos of a typical result can help set patient expectations regarding the efficacy of treatment. Even so, the patient must also understand that individual responses can vary.

To achieve satisfactory results with NAFR, a series of four to six treatments is required. Typically these procedures are spaced out every 4 weeks and thus, an entire treatment regimen may take 6 months or more to complete (Case study 2). Those patients who prefer to have dramatic results after only one session are not the right candidates for non-ablative fractional resurfacing. Instead, these patients may benefit from fractional ablative resurfacing, which typically requires fewer treatment sessions, but has a much longer recovery. The procedure is painful, but topical anesthesia and forced-air cooling make the procedure tolerable in most. Redness and swelling last an average of 3 days.

NAFR can be performed safely on patients with all Fitzpatrick skin types, but patients with darker skin types should be treated with caution. A study of fractional lasers in the treatment of acne scars by Alajlan & Alsuwaidan showed a high safety profile in those of ethnic skin. Although hyperpigmentation was noticed more commonly in darker skin patients, particularly when higher fluences were used, this effect was usually transient. To minimize complications in darker-skinned patients, bleaching creams along with lower treatment settings are recommended.

It is important to gather a history of prior laser procedures and responses, history of keloids, history of herpes simplex infection, skin phototype, history of postinflammatory hyperpigmentation (PIH), current medications including previous isotretinoin use, lidocaine allergy, pain tolerance, and anxiety level.

Patients who should not be treated with fractional resurfacing are women who are pregnant or lactating, those with active infection, particularly herpes simplex, and patients with a history of isotretinoin use in the past 6 months (Box 6.2). Furthermore, individuals with unrealistic expectations should not be treated.

The ideal patient for treatment is a fair skin (Fitzpatrick types I–III), motivated patient who desires attainable results with a few days downtime and has realistic expectations (Case study 3).

Pretreatment

All patients should wear a broad-spectrum sunscreen (SPF >30) and should avoid sun exposure before, during and immediately after their treatments. There is no evidence that treating with topical hydroquinone for 1–2 months prior to non-ablative fractional resurfacing decreases the risk of postinflammatory pigmentation in individuals with darker skin types (type IV–VI). Nor is there any scientific proof that topical retinoids need to be discontinued prior to treatment in those with sensitive skin. In spite of this many physicians recommend using hydroquinone, and ask patients to discontinue retinoids, prior to non-ablative fractional resurfacing.

Pre-treatment with oral antiviral medications is recommended in those with a history of herpes simplex virus (HSV) infection (Box 6.3). Although some practitioners advocate the routine use of HSV prophylaxis regardless of previous infection, we do not feel that this is necessary. Firoz et al recently reported the first three cases of herpes zoster within the distribution of the trigeminal nerve after NAFR. The patients all had a history of chicken pox and none had received prophylaxis prior to treatment. Patients with a family history of herpes zoster and who have not had shingles themselves may thus benefit from the use antiviral treatment prior to treatment. Prophylactic antibiotics are not needed for non-ablative fractional resurfacing.

On the day of the first procedure, serial standardized photographs should be taken to allow patients to observe their treatment progress. Topical anesthesia should be applied 1 hour prior to starting the treatment. Several different anesthetic agents are currently available including 5% lidocaine, 7% lidocaine/7% tetracaine, 23% lidocaine/7% tetracaine, and 30% lidocaine. In our experience, anesthetic agents with tetracaine induce significant erythema leading to patient dissatisfaction. We use 30% lidocaine in our practice as it provides the most comfort with the least erythema. To minimize the risk of systemic toxicity from the topical anesthetics, areas no greater than 300–400 cm² should be treated during each session. Before the treatment, all of the anesthetic should be thoroughly washed off (Case study 4). Oral anxiolytics and analgesics may be required in a small fraction of patients who cannot tolerate the procedure with topical anesthesia alone. In those who find the procedure too uncomfortable with topical anesthesia, we first add ketorolac (Toradol^®). In more anxious or intolerant individuals we have had success with diazepam and IM meperidine (Demerol^®). IV sedation is not needed for this procedure. Metal eye protection is advised for the patient. All individuals in the treatment room should also wear eye protection. When it comes to selection of treatment parameters, a number of factors need to be considered including clinical indication, anatomical site, as well as skin phototype of the patients. In general, studies demonstrate that post-inflammatory pigmentation is less common when fractional resurfacing of darker skin is performed using lower density settings, fewer passes, and longer treatment intervals. Treatment of non-facial sites should be done with slightly lower density and fluence settings.

General technique

We find the supine position most comfortable for the patient and practitioner. In this position, the practitioner can be seated comfortably with elbows close to 90° to alleviate fatigue and repetitive stress injury. During treatment, patient positioning is crucial to ensure perpendicular application of the laser handpiece. For example, when treating the neck, especially in the submandibular area, it is often helpful to have the chin tilted upward to allow for better exposure.

With the scanning handpiece of the Fraxel systems (Solta Medical, Hayward, CA), we deliver eight passes when treating acne scars, rhytides, and photoaging of the face. We use a double-pass, 50% overlap technique. One linear pass is delivered, the handpiece is brought to a complete stop, lifted, repositioned, and then returned along the same path for a second pass. The handpiece is then moved laterally by 50% and the technique is repeated until the treatment area is completed. As a result, each area is treated with four passes. For the next four passes, we direct the passes perpendicular to the first treatment to ensure complete and even laser coverage. Dividing the face into four quadrants also helps manage the treatment area and reduce the risk of overlap or missing a section.

For facial resurfacing, our settings are individualized according to patients’ needs and tolerability. We often start with energy levels between 40–50 mJ and a treatment level of 6–8 (Table 6.2). The settings are often increased during subsequent visits if tolerated.

For stamping handpieces, the fractionated energy is delivered according to the tip size. For example with the StarLux system (Palomar Medical Technologies Inc., Burlington, MA) and the 15 mm Lux1540 handpiece, three to four passes are generally delivered with a 50% overlap in both directions. The handpiece should be lifted off the skin between each pulse, and pulse-stacking is not recommended. For facial resurfacing with the Lux1540 15 mm tip, we recommend using 10–15 mJ per microbeam with a pulse width of 10–15 ms. With the Affirm (Cynosure, Westford, MA) 1440 nm device, we use 3–5 mJ, depending on the tip size, and perform two passes for facial resurfacing, The number of passes and treatment parameters vary with the different machines and is beyond the scope of this chapter.

Cooling

A cooling device used in conjunction with the NAFR laser device should be standard for all treatments. A popular forced-air cooling device, the Zimmer Cryo (Zimmer Medizin Systems, Irvine, CA) increases patient comfort significantly. Some laser systems now also come with a built-in cooling device. In a study of 20 patients, 19 noted reduced pain with the addition of a cooling device.

Post-treatment

Upon completion of the treatment, patients are advised to ice their skin for several minutes and then periodically over the next few hours. Not only does this help with patient comfort, but it also reduces post-procedure swelling. Erythema develops immediately afterwards in all treated patients (Fig. 6.8) and typically resolves in 3 days. Use of non-comedogenic moisturizers is also recommended. Patients are advised to wear sun protection for several weeks after their treatment to reduce the risk of hyperpigmentation. In those with an increased risk of hyperpigmentation, hydroquinone may be started immediately after the procedure. We routinely wait to start lightening agents until we see the first signs of post-inflammatory pigmentation, which is usually around day 21 post-treatment. In a recent prospective study by Alster et al, a light emitting-diode device (Gentlewaves, Light BioSciences, Virginia Beach, VA) has been shown to decrease erythema intensity and duration following treatment, although the precise mechanism of action is unclear.

Figure 6.8 Prior to treatment (A) and immediately after non-ablative fractional resurfacing (B) demonstrating erythema.

Safety and complications

NAFR is a well-tolerated procedure with an excellent safety profile. Fisher and Geronemus studied the immediate and short-term side effects showing a favorable side effect profile. In their study of 60 patients with skin types I–IV, all patients expectedly developed erythema immediately post-treatment, which in most patients resolved in 3 days. Xerosis occurred in 86.6% of patients, usually presenting 2 days after treatment and resolving by day 5 or 6. This was minimally bothersome and responded well to moisturization. Other frequently reported post-treatment side effects were transient and included facial edema (82%) and flaking (60%). Small, superficial scratches were also reported in 46.6% of patients. These scratches, which all resolve without sequelae, are thought to be related to tangential application of the hand piece or pulse stacking by inexperienced users. Pruritus (37%) and bronzing (26.6%) are also common side effects of treatment.

Perhaps the most valuable finding from this short-term study was the impact on the patient’s quality of life; 72% reported limiting social activities by an average time of only 2.1 days, which is in stark contrast to the downtime seen with the conventional resurfacing laser. The most commonly attributed reasons were erythema and edema. The treatments were well tolerated with an average pain score of 4.6 on a scale of 1 to 10.

Given that NAFR was specifically developed to minimize the extent of complications, long-term complications are also extremely rare. Graber and colleagues recently performed the first large-scale study looking at the complications and long-term side effects of NAFR. Consistent with Fisher & Geronemus’s study, they also reported a low short-term complication rate. In their study of 422 patients with a total of 961 treatments, the most common complications were acne eruptions (1.87%), HSV outbreaks (1.77%), and erosions (1.35%), all of which occurred with lower frequency than after ablative procedures. Acne outbreaks were more likely to occur in patients who were acne-prone and thus oral antibiotic prophylaxis may be considered in some patients. Other uncommon complications included prolonged erythema and edema.

When similar treatment parameters were used across different skin phototypes, complications were more likely to occur in those that were more darkly pigmented, especially with regards to postinflammatory hyperpigmentation. While an uncommon complication (0.73%), postinflammatory hyperpigmentation (PIH) lasted an average of 51 days, significantly longer than any other complication. Recent studies have shown that, with proper titration of settings, darker-pigmented patients can be treated more safely. While both energy and MTX density determine treatment level, Chan et al provided the first evidence that density of MTZs may specifically increase the risk for PIH. By reducing the density and lengthening the treatment interval, the risk of PIH in darker-skinned patients can be significantly reduced. Sunscreen and hydroquinone use should be implemented both before and after treatment to minimize this risk even further.

While complications, especially long-term ones, are extremely rare, patients should be educated to expect typical side effects including post-treatment erythema, edema, dry skin, and desquamation (Box 6.4).

Advances in technology

The field of fractional resurfacing is relatively new with advances in treatment parameters and new applications for the technology evolving seemingly every month. Since the first fractional resurfacing device was used in 2004, laser systems have continued to be refined and updated. The Fraxel re:store (Solta Medical, Hayward, CA), for example, provides deeper penetration, greater percentage of skin covered, and a variable spot size over the original SR750 model. Non-ablative laser wavelengths have also been broadened significantly with systems utilizing infrared (LuxIR fractional, Palomar Medical Technologies Inc., Burlington, MA), and now even radiofrequency. The eMatrix system (Syneron, Irvine, CA), a fractionated bipolar radiofrequency device, utilizes a new concept of sublative rejuvenation. The technology is purported to cause limited epidermal disruption while creating a wider, conical injury zone within the dermis. Although few clinical studies have been done with this newer technology, it is clear that technological advances in fractional photothermolysis will continue to be made as the field evolves even further.

Over-the-counter devices – the future?

Given the tremendous success of in-office devices, several companies are in the process of developing their over-the-counter non-ablative fractional counterparts that are designed for photorejuvenation. PaloVia Skin Renewing Laser (Palomar Medical Technologies, Burlington, MA) was the first handheld, fractional, non-ablative diode laser (1410 nm, 15 mJ, 10 ms pulse duration) to be FDA cleared for the reduction of fine lines and wrinkles around the eyes. With a demonstrated depth penetration of approximately 250 µm, this device has been shown in two pivotal studies to improve facial wrinkle score by at least one grade among 90% of patients after 4 weeks of daily use. On self-assessment in the pivotal phase study, 87% of patients felt they had reduction in the degree of their wrinkles.

Another home-based photorejuvenation device, RéAura (a collaborative effort between Solta Medical, Hayward, CA and Philips, Einthoven, Holland) is currently undergoing further studies and at the time of writing was pending approval by the FDA. This home version of the original Fraxel re:store (Solta Medical, Hayward, CA) is a 1435 nm laser that uses a high-speed scanner and produces fractionated microscopic skin injury at approximately 200 µm. A study of 80 patients who received twice-weekly treatments to face, neck, chest, and arms for 8–12 weeks revealed statistically significant improvement in overall appearance, fine lines, pigmentation, age / sun spots, texture, firmness, and radiance at 1 and 4 weeks after completion of the course of treatment.

Despite the advances made in home fractionated technologies, home devices simply cannot and will not replace office-based non-ablative fractionated devices. Although modest improvement in wrinkles and texture may be observed, the degree of dermal injury cannot match office-based more aggressive devices. Home fractionated devices also carry a significant risk of potential misuse, but the companies that make these devices make every effort to prevent that possibility.

Advanced topics: treatment tips for experienced practitioners

Many patients have both the pigmentary changes and rhytides associated with photoaging. A hybrid approach combining two non-ablative fractional resurfacing wavelengths optimizes outcomes. Alternating 1927 nm with 1550 nm treatments addresses both concerns (Case study 5). An alternative approach uses intense pulsed light (IPL) to address the dyschromia and uneven pigmentation of photoaging while 1550, 1540, or 1440 nm NAFR devices address wrinkling. In a yet unpublished study that we recently performed, the addition of a MaxG IPL (Palomar Medical Technologies, Burlington, MA) treatment immediately prior to the Lux1540 non-ablative resurfacing device yielded significant improvement in photoaging scores when rated by blinded physicians.

Conclusion

The science of NAFR has revolutionized our treatment strategies for a host of dermatologic conditions. Coupled with a very favorable side effect profile and minimal downtime, this relatively new technology will continue to gain in popularity. With new devices and modifications to current systems emerging constantly, its applications will also continue to evolve and broaden. Clinical studies demonstrating efficacy and further scientific scrutiny will help continue to advance this technology.