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Years of damaging ultraviolet light exposure manifest clinically as a sallow complexion with roughened skin surface texture and variable degrees of dyspigmentation, wrinkling, and laxity.1,2 Other cutaneous insults such as scars from acne, trauma, or surgery also affect the appearance of the skin. Histologically, these extrinsic aging and traumatic effects are usually limited to the epidermis and upper papillary dermis and, thus, amenable to treatment with a variety of ablative and nonablative lasers, chemical peeling agents, and dermabrasion. The armamentarium of lasers and chemical peeling agents available to treat cutaneous photodamage, and textural irregularities is larger than ever. The most appropriate treatment technique is dependent on the severity of the photodamage or scarring, the expertise of the dermasurgeon, and the expectations and lifestyle of the individual patient.
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For years, fully ablative laser skin resurfacing (LSR) with the carbon dioxide laser (CO2) was the gold standard in skin resurfacing. Developed in the mid-1990s, traditional multipass ablative LSR with a CO2 laser demonstrated excellent efficacy for the treatment of rhytides, photodamage, and scars.3–6 However, popularity of the procedure waned due to the extended postoperative recovery required, the inability to treat nonracial areas, and the significant risk of side effects and complications including persistent erythema, permanent hypopigmentation, and scarring.7,8
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To mitigate the problems associated with traditional ablative LSR, nonablative laser devices were subsequently introduced.9–30 The 532-nm-potassium titanyl phosphate (KTP),18,19 585- to 595-nm pulsed dye,11,12 1,064- and 1,320-nm Neodymium:yttrium-aluminum-garnet (Nd:YAG),17–21 and 1,450-nm diode lasers,9,10,25,26 and a 550- to 1,200-nm intense pulsed light device (IPL)12–15 were developed to stimulate dermal neocollagenesis without epidermal injury or significant recovery. Each of these systems demonstrated histologic changes in dermal collagen, a series of treatments often yielded limited clinical improvement. Nonablative LSR is described in detail in Chapter 252.
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A novel concept in skin resurfacing, termed fractional photothermolysis, was developed by Manstein and colleagues in 2004.31 Fractional photothermolysis involves the creation of microscopic thermal wounds regularly interspersed within areas of nontreated skin. The intact nontreated skin forms bridges between the microscopic treatment zones (MTZ), thereby leading to rapid healing. The wound healing response differs from fully ablative techniques because the epidermal tissue that is spared between the thermal zones contains viable transient amplifying cells that are capable of rapid re-epithelialization.
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Fractional photothermolysis devices include a 1,550-nm erbium-doped fiber, 1,540-nm erbium glass, and 1,320-nm or 1,440-nm Nd:YAG laser.32–...