Opinion article
21st-Century Alternatives to Classic Resurfacing Techniques
Nuevas técnicas alternativas al resurfacing clásico en el siglo xxi
B. Pérez-García
Servicio de Dermatología, Hospital Ramón y Cajal, Madrid, Spain
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A, Low-power magnification (x10). B, High-power magnification of neoplastic cells around the vascular lumen, with round monomorphous nuclei and scant cytoplasm (×400). C, The same sample studied immunohistochemically with α-SMA (smooth muscle actin) (×10). D, Detail of α-SMA-positive neoplastic cells (×400).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Fuertes, C. Santonja, H. Kutzner, L. Requena" "autores" => array:4 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Fuertes" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Santonja" ] 2 => array:2 [ "nombre" => "H." "apellidos" => "Kutzner" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Requena" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731012002773" "doi" => "10.1016/j.ad.2012.02.015" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731012002773?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219013000036?idApp=UINPBA000044" "url" => "/15782190/0000010400000002/v1_201304241618/S1578219013000036/v1_201304241618/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Opinion article</span>" "titulo" => "21st-Century Alternatives to Classic Resurfacing Techniques" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "96" "paginaFinal" => "98" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "B. Pérez-García" "autores" => array:1 [ 0 => array:3 [ "nombre" => "B." "apellidos" => "Pérez-García" "email" => array:1 [ 0 => "bibianapg@telefonica.net" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital Ramón y Cajal, Madrid, Spain" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nuevas técnicas alternativas al <span class="elsevierStyleItalic">resurfacing</span> clásico en el siglo <span class="elsevierStyleSmallCaps">xxi</span>" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Conventional resurfacing with carbon dioxide (CO<span class="elsevierStyleInf">2</span>) laser therapy is highly effective for reversing the signs of skin photoaging. Improvements can be appreciated and are often spectacular even after a single session. They are also long-lasting,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> as can be demonstrated on the basis of both clinical and histologic criteria.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, after the initial boom of the mid-1990s many dermatologists and plastic surgeons began to lose their enthusiasm for this technique as they became aware of the considerable associated morbidity, the long recovery times, need for meticulous postprocedural care, and non-negligible risk of adverse effects. Fewer and fewer patients are willing to accept prolonged periods away from work and social life or to assume the discomfort and risk that accompany CO<span class="elsevierStyleInf">2</span> laser therapy. As a result, other rejuvenation techniques have been developed. They sacrifice some degree of efficacy in the interest of safety and convenience but are at present generally better accepted by most patients. Grouped together under the heading of evolving approaches to therapies to reverse photoaging, these alternative treatments combine several techniques and are applied in a series of sessions for treatment and maintenance. Adverse effects are minimal and the improvements are more subtle, without sudden changes in the patient's appearance.</p><p id="par0010" class="elsevierStylePara elsevierViewall">These gentler approaches to treating the signs of aging—such as changes in coloring and texture or the formation of wrinkles—are based on 2 concepts.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The first is the use of nonablative mechanisms that act on the dermis without damaging the epidermis, thus lowering the risk of adverse effects and minimizing the time until the patient can resume normal activity. The second is the use of fractional therapy, through which microscopic treatment zones are distributed in columns separated from each other by intact tissue; this system encourages rapid recovery and lowers risk.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Experiments have shown that conventional nonablative lasers like those traditionally used to treat vascular lesions (pulsed dye, Nd:YAG [neodymium:yttrium aluminum garnet], and KTP [potassium-titanyl-phosphate] lasers) and infrared lasers with a wavelength of 1320 or 1450<span class="elsevierStyleHsp" style=""></span>nm are able to enhance collagen synthesis and decrease oxidative stress<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a>; however, their clinical rejuvenating effect is minimal and they are little used for this purpose. My opinion is that these tools could be useful to complement other antiaging treatments, such as the injection of botulinum toxin or fillers because they act on erythema and telangiectasia and attenuate color differences. Pulsed light therapy is particularly useful for such complementary purposes, especially when treating the neck and upper part of the chest, where it improves texture while also attenuating telangiectasis and pigmentation changes.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However, the effect on wrinkles is practically nil, so we cannot think of these techniques by themselves as true alternatives to classic resurfacing even when sessions are given in series.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Nonablative fractional laser therapy for photoaging is a step forward. The effect on wrinkles and changes in pigmentation and texture is moderate in this modality, in which the density of columns of thermal damage can be controlled and their depth adjusted according to the energy administered. Treatments are well tolerated and time away from work or social life is minimal. They are also safe, with minimal risk of adverse effects. Although appreciable results require several sessions (usually 3 to 6) and the improvement is not as great as that achieved with classic resurfacing, many patients prefer this alternative, which does not interfere with their routine and offers a high degree of safety. Another option that has proven useful is the combination of pulsed light and fractional nonablative laser at a wavelength of 1550<span class="elsevierStyleHsp" style=""></span>nm in the same session. When applied together, the effect of each treatment is enhanced, yet there is no increase in recovery time or adverse effects.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In 2007, reports of the results of fractional ablative laser treatment began to appear. Initially CO<span class="elsevierStyleInf">2</span> lasers were being used at a wavelength of 10 600<span class="elsevierStyleHsp" style=""></span>nm. Later, devices giving an Er:YAG (erbium-doped YAG) beam at a wavelength of 2940<span class="elsevierStyleHsp" style=""></span>nm were developed. The aim of these modalities was to approximate as closely as possible the response to traditional “confluent” ablative lasers (classic resurfacing) while significantly reducing recovery time, postprocedural discomfort, and the risk of adverse effects. In fractional techniques, a high percentage of skin remains intact, encouraging rapid recovery and lowering risk. Many studies have shown that the fractional ablative lasers are more effective than nonablative techniques,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in spite of higher associated morbidity. The new systems can probably be considered the true heirs of classic resurfacing, given that outcomes can even be equivalent to those achieved with traditional CO<span class="elsevierStyleInf">2</span> laser therapy and, for patients willing to take a certain amount of time off to recover, the fractional ablative approach offers a powerful tool for obtaining clearly appreciable results in a single session.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The tolerability and efficacy of other approaches to resurfacing have also recently come under study. These methods include minimally ablative resurfacing using Er:YSGG (erbium:yttrium, scandium, gallium, and garnet) laser light at a wavelength of 2790<span class="elsevierStyleHsp" style=""></span>nm. This modality has a water absorption coefficient of 5000/cm<span class="elsevierStyleSup">2</span>, which falls between the coefficients of the Er:YAG (12 500/cm<span class="elsevierStyleSup">2</span>) and CO<span class="elsevierStyleInf">2</span> (1000/cm<span class="elsevierStyleSup">2</span>) lasers. The ER:YSGG laser provides thermal stimulation and coagulation that cannot be achieved with the ER:YAG device without causing collateral damage and exudation—with the consequent need for a recovery time similar to that required after CO<span class="elsevierStyleInf">2</span> laser therapy.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Another approach that has been described is the combination of fractional and continuous laser treatments in the same session. This approach achieves complete vaporization of the superficial epidermis with coagulation of the deep epidermis and fractional coagulation of the deep dermis; improvement is evident within an average of 6 days, when make-up can again be applied and routine social life can be resumed.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Nonlaser modalities have also been used to rejuvenate photoaged skin. The latest radiofrequency devices not only encourage collagen contraction and remodelling—tightening the skin—but they also produce subtle improvements in texture. Some of these devices incorporate a laser beam or pulsed light to work more broadly on diverse effects of photoaging. More recently, the so-called fractional radiofrequency devices have begun to appear, offering both fractional ablative treatment and deep volumetric heat delivered to the dermis. Promising results have been reported for these devices in treating the effects of photoaging<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and in correcting acne scars.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The effect on collagen has been confirmed histologically. Fractional radiofrequency therapy has also been combined with ultrasound to enhance percutaneous penetration of the active principles in treatments for photoaging and other conditions. All these systems carry minimal risk of adverse effects and recovery is nearly immediate. As the beneficial effects are moderate, several sessions must be given before benefits become noticeable.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Laser and radiofrequency are not the only modalities used to apply thermal energy at doses that are sufficient for achieving collagen remodelling. Another option, plasma skin regeneration technology, is based on the ionization of nitrogen gas by means of radiofrequency stimulation. In this system the nitrogen gas is converted to plasma—the fourth state of matter, in which electrons have been separated from atoms to form an electromagnetically unstable ionized gas able to transmit energy directly to the skin in pulses. As the local heating by plasma bursts does not require a chromophore, energy is delivered uniformly to the skin. This technology is nonablative, recovery is rapid, and the effects have been compared favorably to those of classic rejuvenation therapy with ablative confluent lasers.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> Although this technique is little known and hardly used in Spain, it was approved by the US Food and Drug Administration for the treatment of facial wrinkles some years ago and the literature contains reports of beneficial effects on skin tone, texture, and coloring.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In spite of the vast literature on a great variety of skin rejuvenation techniques, it is not easy to draw conclusions as to the superiority of one over another. If we subscribe to the evidence-based practice of medicine, we must take note that few high-quality randomized controlled trials are available to help us decide which procedure is the safest and most effective. A 2009 Cochrane review on interventions for photodamaged skin found only limited evidence for the superiority of phenol peeling over CO<span class="elsevierStyleInf">2</span> laser treatment of photoaged skin of the upper lip, although postprocedural discomfort was greater with the phenol treatment.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> That review did not bring clear evidence to light to support the superiority of CO<span class="elsevierStyleInf">2</span> laser therapy over Er:YAG laser therapy; nor did it consider the new techniques discussed above. General review articles on the subject nonetheless express the opinion that ablative laser therapy achieves superior results, even though nonablative and fractional technologies have become much more popular because they give acceptable results with fewer adverse effects.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Practically speaking, our adoption of one type of treatment over another for routine use will be influenced by both the availability of the technology and the patient's expectations and willingness to undertake whatever skin rejuvenation option we might propose. Less aggressive techniques will be preferable for patients who cannot accept a recovery period of inactivity that can be fairly long and involve meticulous care of the treated skin. Patients who seek an easier recovery must be able to commit to multiple sessions at intervals of several weeks, however, as less aggressive approaches are delivered in series to achieve an effect that can be evaluated. The most useful therapies in these cases will probably be those that combine the application of light or radiofrequency energy along with neurotoxin treatment of expression wrinkles or fillers to replace loss of volume. Naturally, although such rejuvenating programs are highly effective and fairly well tolerated and safe, they are expensive. It will therefore be preferable to prioritize and treat only the aspect that concerns the patient most, in accordance with an acceptable risk of adverse effects.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In summary, we can conclude that fractional lasers (particularly ablative modalities), the new radiofrequency devices (combined or not with pulsed light or nonablative lasers), and the less-known plasma skin regeneration systems are techniques that offer effective and safe alternatives to confluent CO<span class="elsevierStyleInf">2</span> laser rejuvenation therapy. We should not forget, however, that classic resurfacing will continue to be the best choice for some patients. For classic resurfacing, the patient should be referred to one of the increasingly scarce specialists that still perform this procedure routinely, given that experience is the key to achieving an acceptable result.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Pérez García B. Nuevas técnicas alternativas al resurfacing clásico en el siglo XXI. Actas Dermo-sifiliogr. 2013;104:96–8.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term results of carbon dioxide laser resurfacing of the face" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.D. Ward" 1 => "S.R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 21 | 8 | 29 |
| 2024 October | 190 | 35 | 225 |
| 2024 September | 177 | 26 | 203 |
| 2024 August | 202 | 59 | 261 |
| 2024 July | 181 | 25 | 206 |
| 2024 June | 155 | 29 | 184 |
| 2024 May | 140 | 29 | 169 |
| 2024 April | 124 | 29 | 153 |
| 2024 March | 134 | 21 | 155 |
| 2024 February | 127 | 28 | 155 |
| 2024 January | 116 | 33 | 149 |
| 2023 December | 88 | 22 | 110 |
| 2023 November | 86 | 37 | 123 |
| 2023 October | 60 | 40 | 100 |
| 2023 September | 44 | 37 | 81 |
| 2023 August | 36 | 10 | 46 |
| 2023 July | 43 | 30 | 73 |
| 2023 June | 42 | 29 | 71 |
| 2023 May | 45 | 20 | 65 |
| 2023 April | 37 | 33 | 70 |
| 2023 March | 44 | 21 | 65 |
| 2023 February | 27 | 30 | 57 |
| 2023 January | 24 | 24 | 48 |
| 2022 December | 47 | 42 | 89 |
| 2022 November | 32 | 27 | 59 |
| 2022 October | 27 | 21 | 48 |
| 2022 September | 22 | 37 | 59 |
| 2022 August | 21 | 39 | 60 |
| 2022 July | 26 | 26 | 52 |
| 2022 June | 21 | 28 | 49 |
| 2022 May | 37 | 34 | 71 |
| 2022 April | 50 | 39 | 89 |
| 2022 March | 45 | 46 | 91 |
| 2022 February | 35 | 35 | 70 |
| 2022 January | 32 | 32 | 64 |
| 2021 December | 41 | 45 | 86 |
| 2021 November | 29 | 34 | 63 |
| 2021 October | 52 | 57 | 109 |
| 2021 September | 41 | 41 | 82 |
| 2021 August | 35 | 33 | 68 |
| 2021 July | 30 | 35 | 65 |
| 2021 June | 50 | 34 | 84 |
| 2021 May | 60 | 42 | 102 |
| 2021 April | 95 | 47 | 142 |
| 2021 March | 47 | 29 | 76 |
| 2021 February | 47 | 29 | 76 |
| 2021 January | 37 | 24 | 61 |
| 2020 December | 29 | 8 | 37 |
| 2020 November | 36 | 14 | 50 |
| 2020 October | 17 | 15 | 32 |
| 2020 September | 35 | 6 | 41 |
| 2020 August | 25 | 26 | 51 |
| 2020 July | 30 | 3 | 33 |
| 2020 June | 32 | 20 | 52 |
| 2020 May | 31 | 17 | 48 |
| 2020 April | 39 | 21 | 60 |
| 2020 March | 37 | 18 | 55 |
| 2020 February | 8 | 2 | 10 |
| 2020 January | 3 | 3 | 6 |
| 2019 December | 5 | 5 | 10 |
| 2019 November | 4 | 1 | 5 |
| 2019 October | 0 | 1 | 1 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 1 | 5 | 6 |
| 2019 June | 6 | 15 | 21 |
| 2019 May | 5 | 26 | 31 |
| 2019 April | 3 | 7 | 10 |
| 2019 March | 4 | 9 | 13 |
| 2019 February | 0 | 6 | 6 |
| 2019 January | 3 | 0 | 3 |
| 2018 December | 4 | 2 | 6 |
| 2018 November | 0 | 2 | 2 |
| 2018 October | 5 | 1 | 6 |
| 2018 September | 3 | 0 | 3 |
| 2018 May | 0 | 7 | 7 |
| 2018 April | 0 | 1 | 1 |
| 2018 March | 0 | 3 | 3 |
| 2018 February | 29 | 2 | 31 |
| 2018 January | 26 | 6 | 32 |
| 2017 December | 33 | 5 | 38 |
| 2017 November | 29 | 5 | 34 |
| 2017 October | 29 | 4 | 33 |
| 2017 September | 27 | 3 | 30 |
| 2017 August | 43 | 7 | 50 |
| 2017 July | 32 | 5 | 37 |
| 2017 June | 45 | 24 | 69 |
| 2017 May | 27 | 12 | 39 |
| 2017 April | 27 | 5 | 32 |
| 2017 March | 31 | 5 | 36 |
| 2017 February | 26 | 9 | 35 |
| 2017 January | 24 | 11 | 35 |
| 2016 December | 43 | 8 | 51 |
| 2016 November | 43 | 3 | 46 |
| 2016 October | 44 | 6 | 50 |
| 2016 September | 46 | 14 | 60 |
| 2016 August | 44 | 4 | 48 |
| 2016 July | 42 | 7 | 49 |
| 2016 June | 12 | 11 | 23 |
| 2016 May | 8 | 9 | 17 |
| 2016 April | 5 | 14 | 19 |
| 2016 March | 4 | 15 | 19 |
| 2016 February | 6 | 18 | 24 |
| 2016 January | 10 | 16 | 26 |
| 2015 December | 13 | 15 | 28 |
| 2015 November | 15 | 18 | 33 |
| 2015 October | 10 | 10 | 20 |
| 2015 September | 10 | 9 | 19 |
| 2015 August | 15 | 3 | 18 |
| 2015 July | 53 | 10 | 63 |
| 2015 June | 60 | 10 | 70 |
| 2015 May | 120 | 10 | 130 |
| 2015 April | 67 | 13 | 80 |
| 2015 March | 52 | 4 | 56 |
| 2015 February | 32 | 5 | 37 |
| 2015 January | 17 | 0 | 17 |
| 2014 December | 26 | 4 | 30 |
| 2014 November | 13 | 7 | 20 |
| 2014 October | 22 | 8 | 30 |
| 2014 September | 6 | 5 | 11 |
| 2014 August | 11 | 5 | 16 |
| 2014 July | 13 | 4 | 17 |
| 2014 June | 28 | 6 | 34 |
| 2014 May | 19 | 5 | 24 |
| 2014 April | 15 | 5 | 20 |
| 2014 March | 27 | 12 | 39 |
| 2014 February | 28 | 10 | 38 |
| 2014 January | 21 | 12 | 33 |
| 2013 December | 26 | 7 | 33 |
| 2013 November | 10 | 5 | 15 |
| 2013 October | 14 | 2 | 16 |
| 2013 September | 5 | 16 | 21 |
| 2013 August | 7 | 2 | 9 |
| 2013 July | 9 | 24 | 33 |
| 2013 June | 3 | 6 | 9 |
| 2013 May | 11 | 10 | 21 |
| 2013 April | 5 | 13 | 18 |
| 2013 March | 8 | 6 | 14 |
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