The CO(2) laser has been used extensively in dermatological surgery over the past 30 years and is now recognised as the gold standard for soft tissue vaporization. Considering that the continuous wave CO(2) laser delivery system and the newer "superpulsed" and scanned CO(2) systems have progressively changed our practice and patient satisfaction, a long range documentation can be useful. Our experience has demonstrated that the use of CO(2) laser involves a reduced healing time, an infrequent need for anaesthesia, reduced thermal damage, less bleeding, less inflammation, the possibility of intra-operative histologic and/or cytologic examination, and easy access to anatomically difficult areas. Immediate side effects have been pain, erythema, edema, typically see with older methods, using higher power. The percentage of after-treatment keloids and hypertrophic scars observed was very low (~1%) especially upon the usage of lower parameters. The recurrence of viral lesions (condylomas and warts) have been not more frequent than those due to other techniques. Tumor recurrence is minor compared with radiotherapy or surgery. This method is a valid alternative to surgery and/or diathermocoagulation for microsurgery of soft tissues. Our results are at times not consistent with those published in the literature, stressing the concept that multicentric studies that harmonization methodology and the patient selection are vital.

BACKGROUND As reported elsewhere, there are several drawbacks associated with traditional liposuction: increased blood loss, ecchymoses, long recovery times with increased postoperative discomfort, and skin laxity. Laser-assisted lipolysis (LAL) is an emerging technology, but the level of safety associated with this device has not been reported. In October 2006, a 1064-nm Nd:YAG laser was approved by the United States Food and Drug Administration for the surgical incision, excision, vaporization, ablation, and coagulation of all soft tissues and has been used for LAL as well as improvement of areas of flaccidity. The objective of this new device is to melt fat while also reducing the blood loss, ecchymoses, long recovery times and skin laxity. It achieves these improvements by destruction of adipocytes, coagulating small blood vessels and collagen, the end result being reduced adiposity, skin retraction and decreased flaccidity. OBJECTIVE To determine the number of adverse events associated with LAL and the frequency with which secondary procedures had to be performed after the primary one to correct defects (touch-up rate). METHODS A total of 537 consecutive LAL cases were performed with tumescent anesthesia between January 2006 and November 2007 at one center. These 537 cases were reviewed retrospectively to determine the number of adverse events associated with the LAL procedure and the number of touch-up procedures performed. RESULTS No systemic complications were identified and only five local complications were found. These complications included one local infection and four skin burns. This represents a complication rate of 0.93%. Nineteen touch-up procedures were necessary: a rate of 3.5%. CONCLUSION Laser-assisted lipolysis (LAL) is a safe adjunct to traditional tumescent liposuction which assists in melting fat and tightening the skin. LAL may serve as a useful tool for the surgeon performing liposuction.

The age-old spa concept is no less valuable today than it was during the time of Julius Caesar. Over the centuries, there have been many iterations of the concept of the spa. The most recent is the medical spa, which has become the fastest-growing segment of the spa industry. Many physicians including dermatologists wish to incorporate a medical spa into their practices. This article discusses the key elements that should be considered to make this venture successful.

Laser-assisted lipolysis with a medium-pulsed 1064-nanometer neodymium-doped yttrium aluminum garnet (Nd:YAG) system is a new FDA-approved method of removing localized areas of fat with the added benefit of skin tightening. This new method is particularly useful in treating the lower abdomen and submental areas where skin laxity may occur after the removal of adipose tissue. In addition, decreased bruising and scrotal edema after treating men is possible with use of the tumescent technique and the added benefit of coagulation produced by the laser. Experience in treating men with this modality is reviewed.

We report a case of a 45-year-old woman who presented with facial erythema, papules, pustules, and severe flushing consistent with rosacea. The patient had failed standard pharmacologic treatments. The patient's flushing was so severe that she had undergone an elective sympathectomy. She received 6 sessions of photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA as Levulan Kerastick, Dusa Pharmaceuticals) given at 2-week intervals. Improvement was evident after the second treatment and was considered "excellent" after the sixth treatment. Improvement continued and no flares were observed 1 month after the final treatment.

Abstract Background: Fractional ablative CO(2) laser therapy is based on the theory of fractional photothermolysis. It can be effective in treating acne scars in a less invasive fashion than conventional ablative CO(2) laser therapy. Objective: In this clinical study, the safety and efficacy of a novel CO(2) fractional ablative laser was investigated for the treatment of facial atrophic acne scarring in Chinese individuals. Materials and methods: A total of 31 patients (11 females, 20 males, Fitzpatrick skin phototypes III-IV) with facial acne scarring received three sequential fractional treatments over a 6-month period. Outcome measurements included blinded evaluations of before and after photographs by two physicians at 3 and 12 months after the final treatment. Global improvement was noted as well as any untoward events. Results: At the 12 months follow-up time period, 12.9% of the patients showed excellent improvement in their acne scars, while 38.71% noted good to fair results. The clinical response at the 12-month follow-up visit tended to be better than at the 3-month follow-up visit, but was not statistically significant. Four patients experienced post-treatment and transient PIH but three patients were noted to have prolonged erythema. There was no evidence hypopigmentation or worsening of the scarring in any of the study patients. Conclusion: This high-energy pulsed and cool-scanned fractional ablative CO(2) laser system is safe and effective for facial atrophic acne scarring. Improvement in scarring was noted in the majority of patients with minimal discomfort and minimal downtime. Continued improvement over time is also an important clinical finding.

Abstract Background/Objective: A variety of modalities are available for the treatment of acne scars. This prospective, IRB-approved study evaluates the efficacy and tolerance of fractional bipolar RF energy in the treatment of facial acne scars. Methods: Healthy subjects (n = 15, 13 females, aged 35.7 ± 5.6 years [mean ± SD], skin types I-V) with mild to moderate acne scars received three monthly treatments with a fractional bipolar RF device. Improvement and tolerance were evaluated at each visit, including a 1-month and 3-month follow-up visit. Results: Ten subjects completed the study. Physician-assessed acne scar severity was significantly reduced at 1 month and 3 months. Adverse effects were limited to transient erythema. Dryness, bruising and crusting erosion were limited. Subject-assessed stinging/burning, stinging (alone), tingling, itching and burning were also limited and consistent with each treatment. Subject-assessed fine lines and wrinkles, brightness, tightness, acne scar texture, pigmentation were all improved significantly. Satisfaction was high in 67-92% of subjects. Conclusion: Fractional bipolar RF energy is a safe and effective modality for the treatment of acne scars.

BACKGROUND Hypopigmented scarring is a challenging condition to treat, with current treatments showing limited efficacy and temporary results. Nonablative fractional resurfacing has been demonstrated to be an effective and safe modality in the treatment of hypopigmented scars. OBJECTIVES To demonstrate the efficacy and safety of combining fractional resurfacing with topical bimatoprost and topical tretinoin or pimecrolimus for the treatment of hypopigmented scars. MATERIALS AND METHODS Fourteen patients with hypopigmented scars were treated with a mean of 4.5 sessions of a fractionated 1,550-nm erbium-doped laser at 4- to 8-week intervals and subsequently started topical bimatoprost and tretinoin or pimecrolimus. An independent physician evaluated digital photographs taken before and 4 weeks after the last laser treatment using a quartile grading scale (grade 1, ≤25% improvement; grade 2, 26-50% improvement; grade 3, 51-75% improvement; grade 4,>75% improvement). RESULTS Five patients had >75% improvement in hypopigmentation, and 12 had >50% improvement. After a mean follow-up of 20.1 months, all patients demonstrated prolonged results. Side effects were limited to transitory post-treatment edema and erythema. CONCLUSION The combination of fractional resurfacing, topical bimatoprost, and tretinoin or pimecrolimus is a potential effective resource for the treatment of hypopigmented scars, with long-lasting results.

The main use of non-ablative fractional photothermolysis today is for the improvement of wrinkles and scars. The purpose of this work was to evaluate the effect of a "classic" non-ablative fractional 1540nm on facial photodamaged skin and actinic keratoses. Seventeen patients with facial actinic keratoses (AKs) and photodamage underwent two or three laser treatments with fractional 1540-nm erbium glass laser at fluences of 75 mJ, 15 ms pulse duration, and 10-mm spot size in non-contact mode. Two blinded assessors and participants evaluated clinical improvement of treatment areas after 3 months, using a quartile grading scale (no improvement = 0, 1-25% improvement = 1, 26-50%= 2, 51-75%= 3, and 76-100%= 4). Three months after the last treatment, the mean level of improvement was 3.4 ± 0.72 for AK and 3.3 ± 0.54 for skin appearance. Adverse events observed after each treatment were moderate erythema, mild edema, erosions (two cases), and mild desquamation. No scarring or post-inflammatory pigmentary changes were observed. The clinical results were supported by histological changes observed in Yucatan pig studies in vivo and ex vivo. The 1540-nm fractional erbium glass laser in the non-contact mode is a safe and effective treatment for facial photodamage and AKs.

Aging and sun damage of the skin results in skin laxity, rhytides, texture irregularities, dyspigmentation, and vascular changes. Many different laser devices are frequently used to correct these changes from age and photodamage. This article describes the author's experience in combining laser technologies (different wavelengths and applications) in one treatment session to achieve better outcomes with fewer visits for the patient.

Since its approval for use in 2007, many surgeons have been using the laser for subcutaneous use, primarily for lipolysis, facial neck and body contouring, and skin tightening. Techniques have recently evolved to enable use of the subcutaneous laser with concurrent skin resurfacing techniques for improvement of photoaging and acne or facial scarring. The technique shows great promise in patients with facial aging and photodamage who are not deemed candidates for rhytidectomy surgery. With strict patient-selection criteria of mild to moderate facial laxity and mild to moderate photoaging, the procedure can be gratifying for the surgeon and patient alike.

BACKGROUND Fractional technology overcomes the problems of ablative lasers, such as inaccurate depth control and damage to the epidermis. Minimally invasive fractional radiofrequency microneedle devices allow for more-selective heating of the dermis. OBJECTIVE To evaluate the clinical efficacy of fractional radiofrequency microneedle (ERM) treatment in acne scars and large facial pores. MATERIALS AND METHODS Thirty patients with acne scars and large facial pores were enrolled. Bipolar radiofrequency energy was delivered to the skin through the electrodes of the FRM device. Skin lesions were evaluated according to grade of acne scars, Investigator Global Assessment of large pores, skin surface roughness, transepidermal water loss (TEWL), dermal density, microscopic and composite image, sebum measurement, and questionnaires regarding patient satisfaction. RESULTS The grade of acne scars and Investigator Global Assessment of large pores improved in more than 70% of all patients. Skin surface roughness, dermal density, and microscopic and composite images also improved, whereas TEWL and sebum measurement did not change. CONCLUSION Clinical improvement from FRM treatment appeared to be related to dermal matrix regeneration. FRM treatment may be effective in improving acne scars and facial pores.

BACKGROUND As the demand for noninvasive procedures for skin rejuvenation is increasing, combined diode laser and radiofrequency and combined infrared and radiofrequency devices have recently emerged. AIM To compare Polaris WRA(TM), a combination device of diode light and RF, and ReFirme ST(TM), a combination device of infrared and bipolar RF, in terms of safety and efficacy on skin rejuvenation. METHODS Fourteen Korean volunteers of skin type II-IV, with facial laxity and periorbital rhytids, received three treatments at 3-week intervals with combined diode laser and bipolar radiofrequency (laser fluence 30 J/cm2, RF fluence 90 J/cm3) on the right half of their faces and combined infrared light and bipolar radiofrequency (RF fluence 120 J/cm3) on the left half of their faces. Clinical photos of front and bilateral sides of the subjects' faces were taken at baseline and at 6, 9, 12 weeks after the treatment initiation. The investigators' and the subjects' global assessments were performed. RESULTS There is no statistically significant difference in the overall outcome between Polaris WRA(TM) and Refirme ST(TM) based on pre- and post-treatment objective measurements. Polaris WRA(TM) was more effective than Refirme ST(TM) at reducing wrinkles when therapeutic results of the two appliances were compared based on the patient satisfaction measurements. After the treatment with both instruments, histological increase in the production and rearrangement of collagen fibers at the dermal layer was observed. The density of the collagen fibers was more increased with the Polaris WRA(TM)-treated facial area than that of Refirme ST(TM). Treatment was generally well tolerated, and there was no serious complication. CONCLUSION In this study, both the lasers appeared to be safe, and effective methods for treating skin laxity and facial wrinkles. Combined diode laser and radiofrequency was more effective than combined infrared and radiofrequency at reducing wrinkles and pores when the therapeutic results of both the appliances were compared.

BACKGROUND The 2,790 nm Er:YSGG wavelength has a lower water absorption coefficient than the 2,940 nm Er:YAG, but a higher coefficient than the 10,600 nm CO(2) laser. This allows ablative resurfacing with mild thermal coagulation, which may increase clinical efficacy while reducing patient downtime. OBJECTIVES To evaluate the efficacy and safety of the confluent 2,790 nm Erbium:YSGG (Pearl™, Cutera) laser for facial rejuvenation. STUDY DESIGN/MATERIALS AND METHODS Eleven subjects (mean age 50, skin types I-III) with mild to moderate photodamage and wrinkles had two facial treatments with the 2,790 nm Er:YSGG laser using a fluence of 3.5 J/cm(2), pulse duration of 0.4 msecond, and 20% overlap. Treatments were performed 6 weeks apart. Pre-auricular biopsies from five subjects were evaluated at baseline and 6 weeks after the final treatment. Data from blinded photo assessments and subjects' self-assessment of improvement were analyzed 6 weeks after the final treatment. Additionally, long-term safety and efficacy were evaluated 2 years after the final treatment. RESULTS Histologically, 80% of subjects had new collagen formation in the dermal grenz zone, and 60% had increased epidermal thickness. Almost all subjects (91%) showed improvement in tone/texture, 82% of subjects showed improvement in dyschromia and fine lines, and 54% showed improvement in wrinkles 6 weeks after the final treatment. Subjects' self assessment indicated "significant" to "dramatic" improvement in dyschromia (91% of subjects) and tone/texture (82%) 6 weeks after the final treatment. All subjects saw "mild" to "significant" improvement in fine lines and wrinkles. At the 2-year follow-up visit, 57% of the overall improvement achieved at 6 weeks was maintained. No adverse events were reported throughout the study. CONCLUSION Ablative resurfacing with the 2,790 nm Er:YSGG laser demonstrated visible improvement in photodamage with good tolerability and minimal downtime. Subjects were highly satisfied, especially with respect to dyschromia, skin tone, and texture.

This review investigates the effectiveness of ablative and nonablative fractional photothermolysis (FP) lasers for treating facial acne scars. Twenty-six studies (13 ablative FP, 13 nonablative FP) published between 2003 and January 2011 were reviewed. Quantitative and qualitative data from each article were examined and analysed. Four studies were split-face randomized controlled studies. While the data analysed were all clinically relevant and significant, there were some methodological differences between the studies. Outcomes included subjective and objective assessment of scar appearance, pre- and postoperative treatment, side-effects and pain scores. A small number of studies used three-dimensional optical imaging profiling and histology for objective assessment. Even allowing for methodological variability, ablative FP had an improvement range of 26-83% whereas nonablative FP had an improvement range of 26-50%. Patients who underwent treatment with an ablative FP laser experienced erythema for 3-14 days which resolved by 12 weeks, whereas patients who opted for the nonablative FP laser experienced erythema for between 1 and 3 days and this resolved within a week. A higher proportion of patients (up to 92·3%) who underwent ablative FP experienced postinflammatory hyperpigmentation (PIH) than those who had nonablative FP (up to 13%). The maximum duration of PIH in ablative FP was up to 6 months whereas in nonablative FP it lasted for up to 1 week. The procedure with ablative FP was relatively uncomfortable compared with nonablative FP. The pain score with ablative FP ranged from 5·90 to 8·10 (scale 1-10) and with nonablative FP from 3·90 to 5·66 (scale 1-10).