Efficacy and safety of CO2 fractional laser versus Er:YAG fractional laser in the treatment of atrophic acne scar: A meta-analysis and systematic review

BACKGROUND

To date, a consensus on the relative efficacy and safety of CO2 fractional laser versus erbium-doped yttrium aluminum garnet (Er:YAG) fractional laser treatments for atrophic acne scars has not been reached. This meta-analysis aims to systematically assess and compare their effectiveness and safety in clinical practice.

METHODS

For this meta-analysis, we conducted comprehensive searches in Pubmed, Embase, and Cochrane databases, covering publications from their inception up to August 2023. Our focus was on studies comparing fractional CO2 laser with Er:YAG fractional laser treatments for atrophic acne scars. We excluded duplicate publications, research lacking full-text access, incomplete data, or cases where data extraction was not feasible. Additionally, animal experiments, reviews, and systematic reviews were not considered. Data analysis was performed using STATA 15.1.

RESULTS

Eight studies (seven randomized controlled trials (RCTs) and a retrospective study) were included in this meta-analysis. The sample size ranged from 28 to 106 with a total of 418 patients, including 210 in the CO2 fractional group and 208 in Er:YAG fractional group. The pooled results showed that the effective rate of CO2 fractional laser in treating atrophic acne scar was significantly higher than that of Er:YAG fractional laser (OR = 1.81, 95% CI: 1.08-3.01) and the downtime of CO2 fractional laser in treating atrophic acne scar was significantly shorter than that of Er:YAG fractional laser (Weighted Mean Difference (WMD) = -2.11, 95% CI: -3.11 to -1.10). In addition, VAS of CO2 fractional laser in treating atrophic acne scar was significantly higher than that of Er:YAG fractional laser (WMD = 1.77, 95% CI: 1.32-2.21) and the duration of erythema of CO2 fractional laser in treating atrophic acne scar was significantly longer than that of Er:YAG fractional laser (WMD = 1.85, 95% CI: 1.63-2.07). However, there was no significant difference in the duration of pain and incidence of PIHbetween CO2 fractional laser and of Er:YAG fractional laser.

CONCLUSION

When it comes to treating atrophic acne scars, CO2 fractional laser demonstrates superior efficacy and leads to shorter downtime. However, it is important to note that CO2 fractional laser treatments tend to result in higher pain intensity and may carry a higher risk of post-treatment pigmentation compared to Er:YAG fractional laser procedures.

Clinical evaluation of a new fractional ablative 2910 nm erbium laser on photodamaged skin: A pilot study

OBJECTIVE

To examine the efficacy and safety of a new fractional, ablative erbium:glass fiber (Er:glass) laser (2910 nm) at improving clinical signs of photodamaged skin.

MATERIALS AND METHODS

Thirty-seven healthy participants aged 38-75 years with photodamaged skin were enrolled into two treatment groups. Group A (n = 14) received up to four laser treatments with mild settings, and focal facial subunits were treated with deeper settings. Group B (n = 23) received a single treatment using deeper settings. Following treatment, pain scores and severity and duration of skin responses (erythema, edema, and pinpoint bleeding) were assessed. Primary outcome was the improvement in participant and investigator Global Aesthetic Improvement Scale (GAIS) at 3-month follow-up. Secondary outcomes were participant satisfaction with treatment and whether they would repeat treatment.

RESULTS

Thirty-five participants completed the study (n = 1 lost to follow up in each group). Both groups had similar mean participant and investigator GAIS scores of 3/5 corresponding to "Improvement." All but two patients (both from Group A) reported improvement, satisfaction with treatment, and would repeat treatment. Posttreatment skin responses were mild-to-moderate, lasting up to 5 days. There was no scarring or dyspigmentation.

CONCLUSION

The 2910 nm Er:glass laser provided improvement in photoaging with high patient satisfaction.

Periorbital rejuvenation in the clinic: A state-of-the-art review

Objective

To provide an overview of the various treatment options available in the clinic to achieve periorbital rejuvenation.

Data Sources

Literature review and expert opinion.

Conclusions

Periorbital rejuvenation in the clinic can be accomplished through a variety of treatment modalities, including topical therapies, skin resurfacing, and fillers and injectables. Furthermore, some surgical approaches, such as upper blepharoplasties, ptosis, and brow lifts, can be performed in the clinic under local anesthesia with only mild oral sedation. However, the successful execution of such procedures depends on proper patient selection and maximizing patient comfort.

Prospective study of efficacy and safety of non-ablative 1927 nm fractional thulium fiber laser in Asian skin photoaging

Background and Objective

Photoaging manifests as deeper wrinkles and larger pores. It has been tried to rejuvenate photoaging skin using a variety of lasers, including fractionated lasers, which are a popular photorejuvenation treatment. A new breakthrough for skin rejuvenation is the 1927 nm fractional thulium fiber laser (FTL), a laser and light-based treatment option. Clinical data regarding the FTL for treating photoaging are limited despite its effectiveness and safety. This study is aim to evaluate FTL' clinical effectiveness and safety.

Methods

Fitzpatrick skin types II-IV subjects with mild to moderate photoaging signs were enrolled in this prospective study. At intervals of one month, patients received three full face treatments. Wrinkles, spots, texture, pores, melanin index, erythema index (MI and EI), skin elasticity and hydration were measured with non-invasive tool. The epidermal thickness and dermal density on ultrasonography were compared between baseline and one month after all treatment sessions. The Global Score for Photoaging scale (GSP) was rated by two independent evaluators at the baseline and final follow-up visit. Secondary outcomes included patient-rated pain on a 10-point visual analog scale (VAS), as well as overall satisfaction. Following each treatment, adverse events were noted.

Results

Totally 27 subjects (24 females and 3 males) with Fitzpatrick skin types II to IV and a mean age of 44.41 (range33-64) were enrolled. Results suggests that the epidermal thickness has significantly improved after treatment. Statistically significant improvements in melanin index, skin elasticity and wrinkles were noted. An analysis of 12 subjects' reports (44%) suggested their skin felt brighter. No post-inflammatory hyperpigmentation changes or adverse events were observed. 70% patients reporting "satisfied" or "extremely satisfied".

Conclusions

In this study, FTL was found to be a safe and effective treatment option for treating photoaging.

Wounding Therapies for Prevention of Photocarcinogenesis

The occurrence of non-melanoma skin cancer (NMSC) is closely linked with advanced age and ultraviolet-B (UVB) exposure. More specifically, the development of NMSC is linked to diminished insulin-like growth factor-1 (IGF-1) signaling from senescent dermal fibroblasts in geriatric skin. Consequently, keratinocyte IGF-1 receptor (IGF-1R) remains inactive, resulting in failure to induce appropriate protective responses including DNA repair and cell cycle checkpoint signaling. This allows UVB-induced DNA damage to proliferate unchecked, which increases the likelihood of malignant transformation. NMSC is estimated to occur in 3.3 million individuals annually. The rising incidence results in increased morbidity and significant healthcare costs, which necessitate identification of effective treatment modalities. In this review, we highlight the pathogenesis of NMSC and discuss the potential of novel preventative therapies. In particular, wounding therapies such as dermabrasion, microneedling, chemical peeling, and fractionated laser resurfacing have been shown to restore IGF-1/IGF-1R signaling in geriatric skin and suppress the propagation of UVB-damaged keratinocytes. This wounding response effectively rejuvenates geriatric skin and decreases the incidence of age-associated NMSC.

Comparative appraisal with meta-analysis of erbium vs. CO2 lasers for atrophic acne scars

Recent advances in laser technology allowed the development of systems that improve texture, appearance and pliability of skin in acne scars (AS). Currently, comprehensive comparative studies on the efficacy of the most commonly used fractional systems in AS are lacking. Thus, the aim of this work was to appraise and compare the clinical response to erbium versus CO₂ lasers in AS in the form of a meta-analysis. The databases MEDLINE, EMBASE, Cochrane library were searched. Main clinical outcomes were investigator-reported scar improvement and participant-reported scar improvement. Five studies were included in this meta-analysis. Scar improvement was similar for both types of laser in terms of investigator-reported scar improvement (RR: 0.60 95 % CI: 0.35-1.02) and participant-reported scar improvement (RR: 0.99 95 % CI: 0.79-1.25). A sensitivity analysis that excluded studies with high risk of bias found the CO₂ lasers to be superior to the erbium lasers (RR: 0.47 95 % CI: 0.24-0.93): However, the subgroup analysis showed the CO₂ laser not to be significantly different from either the non-ablative erbium (RR: 0.65 95 % CI: 0.34-1.24) or the ablative erbium laser (RR: 0.60 95 % CI: 0.35-1.02). The CO₂ laser produced a slightly greater clinical response compared to the erbium lasers based on the physician's assessment. Overall, the two devices do not differ largely in terms of efficacy but may be complementary, with each resurfacing laser better suited for different clinical tasks.

Microneedle based adipose derived stem cells-derived extracellular vesicles therapy ameliorates UV-induced photoaging in SKH-1 mice

Extracellular vesicles from adipose derived stem cells (ADSCs-EVs) have shown immunomodulation and anti-photoaging effects; however, the skin barrier prevents their absorption via skin. Meanwhile, microneedle (MN) is a widely used and minimally invasive tool for dermal delivery of drugs, it also has neocollagenesis effect by creating tiny injuries and initiating wound healing process. To investigate the effect of MN combined with ADSCs-EVs on skin aging, photoaging in SKH-1 mice was induced by chronic exposure to ultraviolet radiation. Then the mice were treated following a split-dorsal scheme, in which one side had MN alone or MN + EVs treatment and the other side was left untreated. For the side treated with MN alone or MN + EVs, the epidermal thickness was decreased and the skin barrier function was enhanced compared with the untreated side. However, MN + EVs group showed the least wrinkles, the highest collagen density and the most organized collagen fibers among the three groups. The level of CD11b + cell infiltration was lower in MN + EVs group than that in the MN group at 3 day after the treatment. These results indicated that MN treatment alone could improve epidermal structure and function of photoaging skin, and a combination with ADSCs-EVs would accelerate the restoration of inflammation caused by MN and improve the content of collagen. In all, this study indicated that a combination of MN and topical applied ADSCs-EVs was a feasible and safe strategy to ameliorate photoaging, providing a new avenue for safe administration of EVs.

Nonsurgical Light and Energy-Based Devices: Utility in Eyelid and Periorbital Surgery

Periorbital rejuvenation is a common reason for patients to seek cosmetic treatment. There are several nonsurgical light and energy-based devices available to treat various aspects of periorbital rejuvenation without risks of an invasive, surgical procedure. Although ablative laser resurfacing appears to offer the most impressive clinical improvements, nonablative devices result in noticeable cosmetic improvement with more favorable side-effect profiles and shorter recovery times. The specific modality selected for periorbital rejuvenation should be tailored to patients' individual characteristics, preferences, and aesthetic goals. With continued advancements, additional nonsurgical light and energy-based devices will become available in the future for periorbital rejuvenation.

1540-nm fractional erbium: Glass laser is a safe and effective modality for nonablative facial rejuvenation

BACKGROUND

Laser treatments for facial rejuvenation are common, with ablative modalities being of more common use for this indication. Efficient nonablative modalities are of rising demand.

AIM

Our aim was to determine the safety and efficacy of high-fluence, nonablative 1540-nm fractional Erbium:glass laser for facial rejuvenation.

PATIENTS AND METHODS

A retrospective study of patients treated with 3-4 treatments using the 1540-nm fractional Erbium:glass laser for facial rejuvenation, using 2500-3000 mJ/stacked pulses (51-61 mJ per pixel). Patients were followed-up for 3 months following their last treatment. Before and after photos were independently blindly evaluated by 2 dermatologists, who graded them using a scale from 0 (exacerbation) to 4 (76%-100% improvement) for 2 different facial regions (frontal face region and lateral canthal region). Pain perception and adverse effects as well as patient satisfaction were documented throughout the study.

RESULTS

Sixteen patients completed both treatment and follow-up period. At the 3-months posttreatment follow-up visit, moderate-to-significant improvement in rhytids appearance (mean grade of improvement: 2.93 for frontal face and 3 for lateral canthal region) was observed. Patients' satisfaction was high (4.25). Patients reported mild and transient erythema posttreatment with no other adverse effects.

CONCLUSION

The high-fluence 1540-nm fractional Erbium:glass laser is a safe and effective nonablative modality for facial rejuvenation.

Practical Considerations in Adopting New Technology for Facial Cosmetic Procedures

The field of facial plastic and reconstructive surgery encompasses both surgical and nonsurgical facets, creating a supplemental level of care and an additional layer of complexity. Determining the "best course of care" can be very difficult in experienced situations, but even more so when considering adopting an emerging technology. A basic and practical method of analyzing a new technology requires investigating the risk-to-benefit assessment, the utility and clinical outcomes compared with other treatment options, and an introspective ethical appraisal of whether the technology is foremost for patient care purposes. Even after employing a new technology, constant monitoring and reevaluation of the results is necessary to determine if it should be continued or altered.

When Wounds Are Good for You: The Regenerative Capacity of Fractional Resurfacing and Potential Utility in Chronic Wound Prevention

Significance: Fractional resurfacing involves producing arrays of microinjuries on the skin, by thermal or mechanical means, to trigger tissue regeneration. Originally developed for cosmetic enhancement, fractional resurfacing induces a broad array of improvements in the structural and functional qualities of the treated skin and is especially effective at returning defective skin to a more normal state. In addition to fascinating questions about the nature of this remarkable regenerative capacity, there may be potential utility in ulcer prevention by halting or even reversing the progressive decline in overall skin quality that usually precedes chronic wound development. Recent Advances: Photoaging and scarring are the two skin defects most commonly treated by fractional resurfacing, and the treatment produces profound and long-lasting improvements in skin quality, both clinically and at the cellular/histologic level. Chronic wounds usually occur in skin that is compromised by various pathologic factors, and many of the defects found in this ulcer-prone skin are similar to those that have seen improvements after fractional resurfacing. Critical Issues: The mechanisms responsible for the regenerative capacity of fractional resurfacing are mostly unknown, as is how ulcer-prone skin, which is usually afflicted by stressors external to the skin tissue itself, would respond to fractional resurfacing. Future Directions: Better understanding of the cellular and molecular mechanisms underlying the unique healing response to fractional resurfacing could reveal fundamental information about adult tissue regeneration, lead to improvements in current applications, as well as new therapies in other pathologic conditions.

Topical 5 fluorouracil cream vs combined 5 fluorouracil and fractional erbium YAG laser for treatment of severe hypertrophic scars

Background

Topical 5 fluorouracil (5-FU) has been reported as one of the standard treatments for hypertrophic scars (HTS). Ablative fractional laser was found to have promising results in the delivery of topical drugs into the skin by creating vertical channels through which the drugs can penetrate the skin. So far there have been no comparative studies performed to compare both modalities in the same patient and same anatomical region, especially in severe HTS.

Objective

The aim of this study was to compare the effectiveness of topical 5-FU and combined topical 5-FU and laser in treating severe HTS.

Patients and methods

Twenty-four severe HTS lesions were treated by 5-FU monotherapy and 5-FU combined with ablative fractional erbium YAG laser. Each lesion was divided into two parts. One part was treated with topical 5-FU twice weekly for 8 months. The other part was treated with combined topical 5-FU and ablative fractional erbium YAG laser once per month for 8 months. The scars’ improvement was evaluated by Vancouver scar scale (VSS) and skin analysis camera.

Results

The assessment by VSS showed a significant reduction in the mean height, pliability, and vascularity of the lesions which were treated with combined approaches compared to 5-FU monotherapy. Pain and ulceration occurred at a higher rate in the combination therapy group.

Conclusion

Treatment of severe HTS with combined 5-FU and ablative fractional erbium YAG laser is more effective than 5-FU alone.

Implications of Aging in Plastic Surgery

Given the rapidly aging population, investigating the effect of age on plastic surgery outcomes is imperative. Despite this, the topic has received relatively little attention. Furthermore, there appears to be little integration between the basic scientists investigating the mechanisms of aging and the plastic surgeons providing the majority of "antiaging" therapies. This review first provides a description of the effects and mechanisms of aging in 5 types of tissue: skin, adipose tissue, muscles, bones and tendons, and nervous tissue followed by an overview of the basic mechanisms underlying aging, presenting the currently proposed cellular and molecular theories. Finally, the impact of aging, as well as frailty, on plastic surgery outcomes is explored by focusing on 5 different topics: general wound healing and repair of cutaneous tissue, reconstruction of soft tissue, healing of bones and tendons, healing of peripheral nerves, and microsurgical reconstruction. We find mixed reports on the effect of aging or frailty on outcomes in plastic surgery, which we hypothesize to be due to exclusion of aged and frail patients from surgery as well as due to outcomes that reported no postsurgical issues with aged patients. As plastic surgeons continue to interact more with the growing elderly population, a better appreciation of the underlying mechanisms and outcomes related to aging and a clear distinction between chronological age and frailty can promote better selection of patients, offering appropriate patients surgery to improve an aged appearance, and declining interventions in inappropriate patients.

A randomized, single-blind, study evaluating a 755-nm picosecond pulsed Alexandrite laser vs. a non-ablative 1927-nm fractionated thulium laser for the treatment of facial photopigmentation and aging

Background: Laser toning is one of the most popular strategies to treat facial photopigmentation and aging. Several laser modalities, including fractional non-ablative, Q-switched (QS) lasers and new generation picosecond lasers have been used for this indication. However, there is paucity of head to head comparisons of older generation of lasers with new ones. Objective: To compare a 755 nm picosecond pulsed alexandrite laser with a non-ablative 1927 nm fractionated thulium laser for the treatment of facial photopigmentation and aging through a randomized, single-blind study. Materials and methods: 20 subjects (skin types I-IV) were randomized to receive either four 755-nm picosecond alexandrite laser treatments, spaced 3 weeks apart, or two dual wavelength thulium fiber fractionated 1550/1927 nm laser treatments, spaced 6 weeks apart. Follow-up assessment visits occurred 4 and 12 weeks after the last study treatment. Results: At the 4- and 12-week follow-up, both groups showed significant improvement of photoaging, pigmentation, skin quality according to the investigator and subjects assessments. When comparing the two groups, subjects in 755 nm group had statistically significant greater improvement in investigator assessments of photoaging/skin quality and subject satisfaction than those in the 1927 nm group. Conclusion: Both the non-ablative 1927 and 755 nm picosecond laser can improve facial photopigmentation, but the latter can yield superior results with less pain and side effects according to patient and investigator assessments.

Unique Clinical Aspects of Nasal Scarring

Various methods are available for refining scars of the external nose and optimal scar revision frequently requires the utilization of multiple techniques. Differing anatomy of nasal subunits and their underlying structural framework limit surgical options in nasal scar revision compared with other areas of the face. An understanding of a variety of laser technologies and their specific applications can vastly aid in fine, controlled scar revision. Achieving optimal scar reduction regularly requires multiple stages of intervention, close follow-up, and repeat procedures.

A Combination Approach to Surgical Scars

BACKGROUND

Scar formation from surgical procedures is an unavoidable risk. Despite measures taken by both the surgeon and patient during the perioperative and postoperative periods to maximize cosmesis, some patients will wish to pursue surgical or laser scar revision.

OBJECTIVE

The authors propose a treatment algorithm to assist in approaching surgical scar revision with combination treatments.

MATERIALS AND METHODS

A PubMed search was performed on various surgical scar revision techniques. The authors augment these findings with their own personal experiences.

RESULTS

Reports of surgical excision, intralesional corticosteroid injection, intralesional 5-fluorouracil injection, pulse dye laser treatment, nonablative fractional laser resurfacing, ablative fractional laser resurfacing, and microneedling and fractional needle radiofrequency, used in isolation or combination, were found. The authors also provide clinical photographs documenting improvement in appearance of surgical scars using these treatments.

CONCLUSION

Surgical scars are best treated with a combination approach to address various features of the scar. The authors propose a treatment algorithm with multiple treatment options and how to combine them safely and effectively.