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Solta: Thermage & Fraxel > Fraxel limitations

I am 57 year old fair skinned woman. Never have received any plastic surgery or dermatological treatment. I am considering fraxel for sun damage, brown spots and eye wrinkles. Further, I am contemplating if I should pursue treatment for deeper wrinkles around my mouth area. I don't really have the desire or $ to invest in botox every 3-4 months, and wonder if there is another treatment that may be out there or is being developed that is safe produces longer term results.

02.10 | Unregistered Commentersg

I have used the fraxel on a few hundred patients in the past 2-3 years. The ones with your complaints are very pleased after 4 treatments or so. All of the issues may not clear 100%, but all will improve. If you are looking for a cleaner, fresher more youthful appearance, you should treat the whole face. The laser will thicken collagen on all areas treated, this additive effect gives a much better end result then spot treating.

A handful of new lasers use "fraxel like" technology. Is one better? I don't know, I have not used them all. The science the lasers are based on is the best currently used in practice.

If mild skin laxity is present it may tighten some.If laxity is moderate or severe the fraxel wont help. This may be a surgical issue

02.10 | Unregistered CommenterFlorida PA

SG:
I use Fraxel and Plasma Rhytec for skin resurfacing. Fraxel is good but won't be able to deal with your deeper wrinkles around your mouth. Your better bet would be Co2 laser or Plasma, the only 2 skin resurfacing platforms that are known to have good skin tightening effects. For Plasma, make sure to go to someone very experienced thu since operator's skills is very paramount. Make sure you take prophylactic Zorirax (antiviral) and Z-pak/Keflex/etc (antibacterial) for a week before. Good Luck.

02.10 | Unregistered Commenterpmdoc

pmdoc,

I get pretty good results on chin and upper lip for rhytids. Deep rhytid results are not consistent anywhere. What is your experience with fraxel for this?

02.10 | Unregistered CommenterFlorida PA

FloridaPA:
It is technically not possible to get so called "skin tightening" effects with Fraxel or Palomar 1550 or Pixel or Erbium 2970. In order for a skin resurfacing device to do this it must cause "thermal coagulation" (seen in Co2 laser and plasma Nitrogen gas with RF) resulting in collagen denaturation and thus neocollagenesis. Erbium cannot do this b/c it is so waterphillic that the heat quickly evaporates thus there is no time for heat to coagulate the tissues around it. Fractional resurfacing cannot do this in general b/c it is not ablative. This also proves the point that drilling a deeper hole (as in Fraxel, Palomar) than what co2 laser could does NOT necessarily have anything to do with affecting the collagen and its rejuvenating ability. I hope i did not confuse you.

02.11 | Unregistered Commenterpmdoc

Thank you for your help. Do you think the usse of co2 laser will become more refined over time to warrant waiting for treatment? I've heard some negative side effects regarding the pain associated with it and also some scarring.

02.11 | Unregistered Commentersg

pmdoc
I agree with you for the most part and understand Co2 thermal effect. Fraxel has a different mechanism of action because of depth penetration. Erbium beams pass through the epidermis into the reticular layer. Tissue is destroyed in the MTZ and becomes necrotic.This is why patients get a slight exfoliation. Histology shows collagen fibers are denser and depth increases as a result. Granted "tightening" is a misnomer but,mild and moderate rhytids improve and sometimes resolve.

Most age related changes are due to volume loss. There must be some, though limited neocollagenesis occurring or there would be NO results on rhytids, scars etc...

What I don't understand is why results are inconsistent with deep rhytids even though you have the ability to pass through to the subcutaneous layer.Depth with the fraxel is more then enough on the most common treated areas.

02.11 | Unregistered CommenterFlorida PA

Florida PA:
You brought up very interesting points. You made me think real hard in responding to them :-). I surmise that you must achieve 3 things for a "collagen tightening" phenomenon: depth of penetration (at least subdermal), bulk volumetric heating (in skin resurfacing: ABLATIVE. Not sure if fractional would do it) and duration of the heating (in skin resurfacing: THERMAL COAGULATION). An analogy I like to use would be like in fully cook a piece of meat; you need to know at what temperature, for how long and how well to circulate the heat evenly. This "duration" criteria also explains for why in using laser platform to eliminate telangectasia, you have to "extend" the pulse duration instead of shortening it as you do in LHR. This in combination of very high fluency exerts the "sclerosing effect" to the vessels. In Fraxel, you get MEND(s) but with only about 25% at a time and a long interval between treatments, you can see why it won't get you that "duration and completeness" criteria. You asked for why Fraxel seemed to sometimes (thu in more unpredictable way despite the depth of penetration should apparently have resulted in more predictable results) work in rhytids (fine type mostly) and scars, my possible explanation to this is to think of wrinkles as a global and dynamic accumulative sum of forces over time exerting on the skin by internal (collagen denaturation, genetics, diet) AND external (SUN and SUN and SUN UV exposure, pollutions, smoke) forces,e.g. wrinkles are almost NEVER seen upon smiling, frowning or whatsoever in that SAME person at age younger than 20 . With MEND(s), you were PARTIALLY fractioning off some of these pressures thus ending up with the "improvement" of the depth and "blurring out" of wrinkles WITHOUT any associated "lifting" effects seen in platforms such as RF or IR. This explanation probably also applies to Fraxel's effects on scars wherein you were simply extruding off partially the sum of scars' contracture forces.

SG:
With the micropulse technology, CO2 laser has become more acceptable. However I am not sure still if the fractional method (with minimal downtime) would get you the true tightening effects. According to Dr. Geronomus, he sees "collagen tightening effect" at 60-70 J with the Fraxel CO2!!!!!!!

02.14 | Unregistered Commenterpmdoc

pmdoc
Good point about contracture forces. The mechanism of action must be mechanical and physiologic. Thanks for your thoughts.

02.18 | Unregistered CommenterFlorida PA

hey guys,
I the fraxel re:store 70mj frequently for resurfacing. Average 8-10 cases per week. Mostly face and neck, but have treated just about everywhere for one reason or another

Started out conservative and got decent pt results. Increasingly aggressive in the past year with better results.

most common treated:
general resurfacing
dyschromia
rhytids
scars (hypertrophic and acne)
striae

I am interested in experienced users parameters, results or any pearls of wisdom you may have.

Here's one for you. Lower eye lids. 7mm tip,45mj, Level 10, 6 passes with about 1/3 overlap. 15-20 sec between passes to avoid bulk heating. After 3-4 treatments this will often completely resolve the "bags under my eyes" and "dark circles" complaints. Pulling down the lower lid, lasering on the proximal aspect on the orbital rim. This keeps you safely away from the orbit and allows you to get 1-2mm from the lash line
There will be immediate edema and erythema. I have pts ice 10 minutes per hour the day of. I have had no complications with this method, and results are excellent. Most pts swelling is resolved in 24hr. Pts prone to edema usually 24-48hr resolution

02.28 | Unregistered CommenterFlorida PA

Sorry
Its 15-20 sec between two passes (back and forth then break)

02.28 | Unregistered CommenterFlorida PA

I have had 3 Fraxel Laser Treatments for Melasma over the last 3 months. After 3 sessions and over $3000 I am very dissapointed with the results. I am Hispanic & Irish with a light olive skin tone. Since my 3rd Fraxel treatment I have developed a sensitivity to sunscreen. I break out in a red/itchy/bumpy rash. I am very frustrated. I have to wear SPF or I will get more brown spots but if I do I get a ugly/itchy rash. I have never had a problem with sunscreen before. I started using SOLAR 65 SPF today and I am hoping I won't get that horrible rash again! I was using Neutrogena 70 SPF with Helioplex when I started getting a rash a week after my 3rd Fraxel Treatment. Prior to that the Neutrogena was never a problem. I went to see my derm again today. It's been 3 weeks since my 3rd treatment which was at a level 25. My first Fraxel was at a level 10, my second was at a level 15 (whatever that means). I have actually gotten a few more brown spots since starting treatment and I don't know why. I tinted my car windows, I do not get direct sun exposure, I have my house basically blacked out and I feel like I live in a cave! Now my derm says he wants to put my 4th Fraxel session on hold and do an IPL/Micro Peel Combo instead. I'm afraid to do this based on all the possible side effects. I don't want to have scarring or develop more hyperpigmentation by aggrivating my skin even more. Any advice will be very appriciated. Feel free to e-mail me. I'm a 32 year old female and I really want to get rid of the sun spots/melasma/old acne discolorations. My derm also had me buy Tri-Luma which I haven't used yet. Thanks for any and all advice!

Cheshire4ever@yahoo.com

03.14 | Unregistered CommenterDiana

I wish i had never had Fraxel! i paid $900. the doctor said that it would take care of the dark spots on my cheeks and it would make the pores on my cheeks look just like the pristine skin on the sides of my face. i thought what he means was that the pores on my cheeks would go away and look like pristine skin, but just the opposite happened!!
the dark spots are still there, but it looks like a section of flesh has been removed over the dark spots and healed indented like that. i think she overdid it. Now where the dark spots were is now an obvious indentation of flesh.
and worse yet, my pores are still there, but my prevoiusly beautiful, clear, pristine skin i used to have on the rest of my face looks like there are small pores all over the place! it is like my face is now riddled with tiny little holes all over!
This has been four months since my treatment, and I am so depressed over what i allowed this doctor to do to me. I just ask people to please not rush into this. make sure you see before and after close ups of patients. And beware. the doctor ususally likes to take the "after" pic about a week or two after the patient's fraxel treatment while the face is still slightly plump from residual swelling. once the swelling goes down, you are left with horrific results.

07.16 | Unregistered CommenterKrystal

Diane and Krystal,

Did you have a "Fraxel" treatment with "The Fraxel" or did you have a Fractional Laser treatment with another Fraxional Laser?

When I send these posts to my Fraxel Rep, he keeps saying it was not THE FRAXEL, but another Fractional Laser.

Do you know what type of laser was used? This would help us help you.

07.16 | Unregistered CommenterMDR

Florida PA,

Excellent information. I have been searching for answers to dark circles under the eyes and bags under the eyes.

I few questions for clarification. The 7 mm tip is the small tip? Is it roller or blue dye?

How many rows do you do? How far down into the cheek (mm from lash line)? Do you do this in conjuction with treating the rest of the face or is this a stand alone procedure? How much do you charge per treatment if it is stand alone?

Are you treating dark circles under the eyes (pigment and vascular) AND infraorbital fat? or are you just treating pigment and vascular that makes people say "the bags under my eyes"?

Does this treat "fine lines under the eyes" - crepe skin?

Please clarify these points. I love your tip and plan to try it as soon as I know what to use it for. I will see if I have any tips to give in return (love the idea of exchanging tips - too bad Reliant does not help us with this).

Are you treating

Pigment?
Vascular?
Infraorbital Fat?
Fine lines from Crepe Skin? with this tip?

Thanks again.

ps. I have had some trouble with hyperpigmentation when I have tried to treat pigment under the eyes. Changes the brown color to a purple color. Not very nice. I was using the large tip (15 mm), 10 j/cm2; TL 5-6. Have you seen this? I will send pictures if you would like.

07.16 | Unregistered CommenterJEE

MDR

A lot of people will use Fraxel as a buzz word because of consumer recognition no matter what they have. If you see this tell Reliant and they will send them a cease and desist order.

I'm sure you and other users have heard Krystal's story. One Fraxel Tx is useless. I have seen multiple issues appear worse before getting better during a SERIES of Tx. In some pts this is part of collagen remodeling.

JEE

I have done this on type I-IV

I use 7mm roller tip.

For full face, three rows with 1/3 overlap. Use the 15mm tip up to about equal with orbital rim.

Just lower lids, four rows 1/3 overlap and feather the most distal row into proximal cheek. use only one pass here

I charge $1000 for full face and include this on all pts. Pts really get the "wow" improvement in the lower lids like this, and I can honestly say some are bleph-like results.

I charge $650 for Lower lids, crows feet and glabella. $350 for just lower lids. I am a little high in my area but I figure time for pre and post prep is almost the same. I also try to discourage spot treat on the face because the the appearance consists of the whole face. Another reason is why have nice skin next to crappy skin in the same area.

This technique treats "bags", puffy, dark circles, fine lines, and crepe skin. All are related to skin atrophy and decrease in collagen density and depth, unless the fat pad is large then it is a surgical issue or both. Average skin thickness on the face is 1500-2500u, lower lids is 500-1000u so any atrophy of collagen here looks bad.

Setting 45MJ, depth is 1176u. This goes through the reticular layer to where collagen is interwoven with SQ. I think there has to be some coagulation because you get a true tightening effect. Another reason I believe this is because about 50% of pts will have darker skin 2-3 wks after Tx which lasts a wk or so. This must be MTZ debris from SQ and is absorbed with a macrophage rxn.

Setting level 10 gives 29% coverage, a little more with 1/3 overlap.

I think people under treat with Fraxel. Since I have become more aggressive I get better results. I have even been able to fill some NLF with this technique

I have seen the purple skin you mentioned, looks almost like ecchymosis. At 10MJ you are at a depth of 555u. Level 5-6 is 14%-17% coverage. Maybe at lower settings Fraxel produces a wound healing effect and higher there is collagen remodeling effect. Of course this is relative to skin thickness as far as conservative to aggressive goes. The neck will also show some tightening at higher settings ( average thickness is 750-1500u)

Unfortunately Fraxel falls short in depth penetration for this to occur on the face. I think Profractional may achieve this depth. Anyone know?

Jee, I have never had any vascular success because the target is basically H2O.

07.17 | Unregistered CommenterFlorida PA

Florida PA,

Could I ask you a few more questions "off-line".
My email is Jeff4459@aol.com.

Thanks.

07.18 | Unregistered CommenterJEE

Sure JEE.

I have to clarify my last post for those who read it.

When I talked about density and % coverage per level (density), it is based on 8 Fraxel protocol passes. so the technique I described would be 1/4 of 29% (back and forth row) with 1/3 overlap.

07.18 | Unregistered CommenterFlorida PA

Florida PA,

I have a few clarifying questions, if you don't mind.

1. With Treatment Level 10 at 45 j/cm2, do you get much pain? How do you minimize the pain?
2. Do you think I got the purple discoloration because I was using 6-10 j/cm2 and this was too superficial?
3. Do you do 4 rows with the 7 mm tip if you are doing just under the eyes, the 4th row being the one pass feather?
4. Can you use the 15 mm tip if you are doing just under the eyes? How many passes would you do?
5. Is the 30% overlap important? Do you do 30% overlap when you treat the whole face?
6. How many patients have you done with your "under eye" protocol? How long have you been doing it this way? Are the results always good? Have you had any problems? How do you prevent these problems now and how did you handle the problems in the past?
7. How many treatments do you do? 5?
8. Have you gotten the "purplish" complication doing the treatment at 45 j/cm2?
9. Could you send me some before & after pictures?
10. How long have you had the Fraxel? Do you have any other fractional ablative or coagulative lasers?
11. I think that I undertreat with the Fraxel, but "the pain", the downtime, the PIH is all better if you use less j/cm2 and do less % skin coverage. How do you handle pain, downtime and PIH?
12. How do you take your photographs and when do you do your follow-up visits to demonstrate your results?
13. What is the difference between a wound healing effect and collagen remodeling effect? I thought you produced an injury and then you get wound healing which leads to collagen remodeling?
14. What parameters do you use to treat the neck?
15. Do you ever use IPL for dark circles under the eyes produced by pigment or vasc?

07.25 | Unregistered CommenterJEE

JEE,

Questions for you.

What settings do you use for general resurfacing? Type I-III? IV-VI?

Current anesthesia, topical? Injection? po?

1. Lower lid not a very painful area to pt. I usually use topical BLT 20% 8% 4% from CAP pharmacy in California. 20% lidocaine from Hopewell pharmacy in NJ is also good.

80% pts tolerate well with topical alone. They get up after and say “wow that burned”. I have them cool with ice packs and leave with sunscreen and 1% hydrocortisone bid for 3 days. Day of Tx ice for 10 minutes per hour.

20% pts depending on pain tolerance, topical, lortab 10/500 and 1mg xanax one hour before Tx. Once in a while Demerol po. I do 45mj and L 10 on cheeks at times for acne scars with just topical, it all depends on pt. I will say Fraxel final results are all about pain control to get needed energy/density laid down. I never do nerve blocks but will local inject area with 1-2% plain lido for spot treat (scars, cheeks for acne scars…)

2. I think it is possible, send me some pictures, and see 13.

3. Yes, for just under eyes 4th row is most distal with feather.

4. I have done it with the 15mm tip. Back and forth so, 2 passes. Results are much better with 7mm tip, more user friendly and accurate on this lower lid skin. 7mm tip lasts forever if used in small areas at a time. I got one a year ago and still have >50% left. I just use it for lids and small scars.

5. I think 30% overlap is important here on lower lids. Not any place else because you will throw off “Fraxel science” as far as MTZ per cm2.

6. I have done 50 plus pts with this protocol in the past year. Most results are very good, some are ok depends on pt, smoker, sun exposure……and of course what you have to start with (if skin is like an old saddle bag, well you know). Get best results overall on 35-55 y/o. No real problems, edema 24 hr. 48 hr rarely. Erythema 3-5 days. As I said before 50% will get darker skin 2-3wks post but it clears in 1-2wks. Leaves fresh tighter skin, 2-4 Tx depending on pt.

7. General resurface usually 4 Tx my standard is 25-35mj L 8 for type I-III. For IV-V 25-35mj L 6. I don’t treat many true type VI. Level 8 is 23% surface treated so in theory x4 = 92% of skin treated. 5 Tx for bad scars or acne scars. Melasma be careful with more than 3 Tx because it can go the other way and get worse, space them out and use Tri-Luma in between.

8. No purple skin with 45mj L 10

9. I will work on some pictures for you.

10. I have used the Fraxel for almost 3 yrs. Started with 750 model briefly then 1500 since. I estimate I have done 800-1000 procedures on about 250-300 pts. I am not a big fan of CO2, I am not convinced thermal denaturing of collagen is the best long term answer for skin tightening. So I am waiting for the jury on the fractional CO2 and may get one.

11. I disagree on a couple points, if you use 10mj L 6 you get 165 MTZ per pass or 1320 MTZ with 8 passes at depth of 555u. This is very painful for pts because 1320 points of nerve stimulation.

45mj L 10 = 1176u depth, 8 passes total density 528 MTZ or 66 MTZ per pass. Larger diameter MTZ, granted but less sensory nerve stimulation. Try the difference on staff or your arm. You will see a different more tolerable pain with 35mj/L8 or so.

Most Fraxel literature agrees Increase fluence = better aesthetic result, and increase density = PIH more likely.

So my settings of 35mj L8 even though more % coverage will disrupt less epidermal-dermal junction.

12. Nothing special with pictures. 8 pixel, same backdrop. I take before first picture then before each Tx. I have pt f/u 3 months after last Tx. Every pt started on Retin-A after last Tx, sometimes in between. Always stop 1 wk before procedure. Has synergistic effect, besides makes pt feel proactive.

13. No difference, poor wording on my part. What I mean is a few hundred large bore-deep MTZ leads to a better aesthetic outcome (remodeling). A few thousand small bore- shallow MTZ is unpredictable and may just “piss off” skin (wound healing). I have found these setting to work well with geographic melasma/dyschromia though.

14. Neck same settings for face (see #7). Thinner skin so more tightening effect.

15. I really do not use IPL for much. I don’t see any long tern result. Use KTP for linear facial vascular.

Let me know what you think

07.25 | Unregistered CommenterFlorida PA

I typically do 6-10 j/cm2 for pigment and 45-50 j/cm2 for acne scars, wrinkles etc.
For skin type 1-3, I do TL 5,6 and 7 and for Asian, Indian I do TL 4 or 5. For Italians, I do TL 5, 6, and maybe 7. For African Americans I do TL 3 and maybe 4.

Had problems with PIH, so reduced TL settings a lot. Patients also got lots of pain and swelling from high TL settings.

I am thinking about doing 25 - 50 j/cm2 for pigment rather than 6-10. I agree with your assessment of too many little irritations. Plus everyone wants some texture improvement.

I think 1.1 mm is deep enough with 45-50 j for acne scars and wrinkles, so I do not plan to go any higher in j/cm2.

07.25 | Unregistered CommenterJEE

Forida PA,

We use 7% lidocaine/7% tetracain for anesthesia plus zimmer cooler. We leave gel on for 1 hour. If patient has a ride home, we offer percocet and valium. I have not done blocks or lidocaine injections for Fraxel. I do the blocks and injections all the time for tattoo removal and fillers.

Are you using your Fraxel for Melasma? How is that working out? We are getting away from Fraxel for Melasma and getting more involved with Cosmelan (we are working on getting old formula from South America). We do a package of Fraxel and Cosmelan. Fraxel treatments are very weak (TL 4 and 5).

07.25 | Unregistered CommenterJEE

JEE,

I think 25-50j/cm2 is the sweet spot, works for pigment as well as age related change. Good selling point to pts also. I have gone to 70j with local injection for scars, no better than 50-55j as far as efficacy.

07.25 | Unregistered CommenterFlorida PA

I have also found that darker skin type patients respond more rebustly to the Fraxel. I can do 5 treatments at treatment levels 4 and 5 and get as good as or better results than treating treating 5 times at treatment level 7 with lighter skin types.

Therefore, I don't have to do more treatments if I reduce the treatment level in darker skin types.

This is for acne scars and wrinkles. Have you noticed this?

07.25 | Unregistered CommenterJEE

Your right. It seems Mediterranean, hispanic and such get better results. At 25-50j L 6-8, I don't have much PIH even with type IV. In fact in hispanics the color becomes very consistent on the face. Of course a few PIH, but a little HQ or tri-luma and problem solved, I think this goes back to what we were saying about fewer large diameter MTZ. Look back, were your PIH issues due to low fluence? Even at lower density there are still many more smaller MTZ.

Another thing I started doing in past 6 months is 6 passes. If you set the parameters to this the MTZ per pass, total, is within 3-5% of 8 passes. less discomfort for pts and less time for you. Efficacy is the same.

07.25 | Unregistered CommenterFlorida PA

I was BRIEFLY instructed by a rep recently hired by the company in my territory. She told me to do 8 passes everytime and to start essentially at 8 joules, level 8 ( 5-6 in type V or VI) and no overlaps. This is ALL I have used so far. Questions:
1) What is your protocol on the fundamentals of Fraxel?? passes?? overlaps??? direction of the optical tip?? I mostly treat type V and VI. at what joules?? passes?? level?? Thanks

07.25 | Unregistered Commenterpmdoc

In Asians, I start at level 4 and go to level 5 max. I am very conservative because I have had PIH with higher levels. Asians respond well to these levels. You may have to do more than 5 treatments at this low level but you will avoid PIH (you will also use less disposable tips per treatment). One doctor in Asia does 10 treatments with his acne scar patients.

I used to do 6-10 mj/cm2 for pigment, but I am going to start to do 25 mj for pigment. Perhaps with fewer and larger MTZs you will get less PIH.

07.25 | Unregistered CommenterJEE

I think 8mj L8 in not a very good place to start, especially on asians and darker skin types. It lays too many MTZ and would I assume PIH will be a frequent issue.

I think one of the important points in understanding Fraxel mechanism of action is DENSITY or surface area (%). Density by definition is what it is, but with Fraxel it is not just % surface area treated. The MJ setting is the deciding variable on prevalence of PIH.

When the treatment level is static a change in MJ setting (depth desired) will leave the % coverage the same, BUT there is a large variation in the number of times (MTZ) the integrity of the epidermal-dermal junction is compromised. In my experience the more MTZ per cm2 the less the aesthetic result (skin type I-III) and higher incidence of PIH (skin type IV-VI).

It makes sense to me. Did I describe this in a clear way?

07.25 | Unregistered CommenterFlorida PA

Just to be clear, this is what I would do for Asian Skin:

For pigmentation cases: 25 J/cm2, level 4-5 for Asian skin types, 6-8 passes; no overlap
For acne, texture: 45 j/cm2, level 4-5 for asians, 6-8 passes, no overlap

I would use the above settings for Asians.
Florida PA, what would you do?
Is 6 passes ok or should we use 8 passes? Does the number of passes matter?

07.25 | Unregistered CommenterJEE

I think the settings are reasonable for asians and darker skin types. 25 J/cm2 will treat pigment and also texture especially in younger pts. I start with level 6, 4-5 is ok while you get comfortable. Acne and rhytids, 35-45 J/cm2 level 6. Never a need for overlap unless doing special technique. Frequency is 3-4 wks apart with HQ between and after final Tx. Pigment may fade uniformly or geographically over treatments. texture takes months to get the final result. Pt will look better in a couple of wks and improves over time. I guess the new collagen formation begins within 24 hr but takes a while to change aesthetic appearance over months.

pmdoc brought up a very good point in the blog a while back about contraction forces. In types I-III when PIH is not an issue I have gone to 55J/cm2 level 10 and have seen very nice results on bad acne scars and resolved mild and moderate rhytids over the entire face. At this level pain control is difficult.

Contracture forces are released with large diameter/deep MTZ in scars and rhytids at this setting, all the while neocollogenesis is occurring. Extrapolate the Fraxels max potential settings of 1.35mm depth and 45% surface coverage. You should see significant tightening and resurfacing in less treatments at the higher levels. Longer down time for sure. I have heard anecdotally of Docs doing treatments like this under twilight or general anesthesia with fantastic results.

JEE, you talked about lower settings and more Tx. This will work for sure. In theory you can do Fraxel an infinite number of times as long as adequate time for dermal repair is given in between.

07.25 | Unregistered CommenterFlorida PA

Sorry there is more. If you want to be conservative 6 passes, 8 will be ok. At 6 passes with Fraxel set at 8 passes you will get 75% of total MTZ.
The number of passes does matter. With level and J/cm2 set, under the # of passes setting gives total MTZ per pass. Play with it and see how J/cm2, level and passes effects the # of MTZ per pass and total for passes setting, you will see what I mean. I find 200-400 MTZ per cm2 gives good results with 3-5 Tx. 500-1000 MTZ per cm2 is gray area and 1000-3000 MTZ is shallow and will increase PIH in darker skin types

07.25 | Unregistered CommenterFlorida PA

This email is my response to Florida PA from below. As someone who has been treating exclusively darker skin people, using IPL, Puslse Dye Laser, and thermage, etc. I has always employed the "weaker-fluency-with-less-contact (i.e. floating technique in IPL rather than contact one) and-to-"compensate" with-MORE-passes theory". Now that I started using Fraxel I found this theory being turned upside down. I also watched some webinar and articles posted on the Reliant website and found them to be quite informative. Florida PA, what is your take on the webinar on the treatment of scars??? vs. your method???
PS: Did you now that Thermage recently acquire Reliant for $95 millions and that Medicis bought Liposonix for $150mil?????? I believe that the future of non-invasive cosmetics will be thru guided ultrasound platform for skin tightening and fat reduction and possibly cellulite reduction. Liposonix and Ulthera are at the forefront. Comments????

07.25 | Unregistered Commenterpmdoc

Did Reliant ever publish a summary paper on their roundtable event at the 2008 ASLMS?

Their Director of Marketing and Sales told someone that I know (and trust) that these events were major ways they kept all of their users up to date and informed.

In fact they are so good and so important and so well distributed, that there is no need for e-blasts, newsletters, user groups or any other means of provider continuing education or clinical exchange.

Since there were only 200 users at the event and Reliant has over 2000 users, I assume they published a summary of this important information.

Did anyone see it? Was anyone notified that it existed? I never heard about it.

Does anyone know that they have promised a similar publication from this years "Controveries Conference".

Am I missing something? or Are all Fraxel Users missing something?

I am setting up a Fraxel Users Group. If you have the Fraxel Re:store 1550 Glass Erbium Laser and would like to be part of this group, please let me know.

Send your email to Jeff4459@aol.com.

I am going to put all the users on an email list (like this one) and we can send each other questions, comments, observations and thoughts about the Fraxel. I am interested in getting better results with fewer complications. I am interested in learning the best way to prevent complications and treat them if them occur. I am interested in discussing problems that I have had and discussing problems that I have read about on the blogs (www.realself.com and www.MedicalSpaMD.com).

If you want to be the best you can be with the Fraxel and you like helping others and being helped, just respond to this email and I will put you on the list.

I already have a very interesting discussion going with a provider in Florida who is getting great results under the eyes and other areas. He uses MTZ/cm2 as an important variable in his treatment settings. His ideas are different but they make sense and he is getting great results with fewer complications. I am no longer doing any treatments in the 8-10 mj range. I do my pigment treatments at 25 mj and above.

I tried to get Reliant to help me get this group together but they have other priorities and have not been very helpful (I can be very persistent and I think I have pissed them off). They think that I want to be told how to do treatments (I don’t think they are bright enough to understand what I want or they just don’t want to help me).

What I want is a discussion of how we do things, why we do them the way we do them and how we are doing with clinical outcomes and complications. It is my believe that someone out there is doing treatments differently then I am doing them and getting better results with fewer complications. I want to learn from this person. I hope you feel the same way. If you are getting zero complications and great results on all your patients, then I want to know what you are doing because this is not MY experience with my Fraxel and my patients.

Looking forward to a lively “clinical exchange” with you. Reliant will be looking to us as we start figuring this laser out and start getting better results with fewer complications then their other users. If you know anyone else who would like to join this group, please let me know.

Requirements: You have the Fraxel, You like to email, You like to help others, You like to discuss things and figure out the best way to do things.

Jeffrey E. Epstein, MD email: Jeff4459@aol.com

I have been a lurker on these boards for a while primarily because I'm trying to find the best treatment possible for my acne scarring. I've seen quite a few posts from people on this board and others complaining about "pock mark" like scarring CAUSED by fractionated lasers when, ironically, in many cases that is the exact problem that they are trying to treat -- and I find it disturbing that most of the time these posts go unanswered without any of the "experts" here "manning up" and helping these obviously mortified people understand why this may have happened to them and what they could do to avoid it in the future. I don't think any of these stories should be immediately written off as unfactual or fabrications, but rather, taken very seriously.

Many of you you have treated hundeds of patients with fractionated lasers and I'm sure a fair share of you have "scarred" patients in the past, perhaps sharing information about these failures would be beneficial to everyone who frequents this board -- fellow physicians and patients alike -- and I'm sure you could also be as vague as possible about who you treated as not to break any privacy laws -- the "who" in this case is not really even of any importance.

I've heard so many horror stories with fractional lasers, presumably damaging the deeper layers of the skin an causing atrophic-like reactions, that I'm almost more tempted to go the ablative route as most of the issues I see with these lasers usually comes in the way of long lasting red skin, pigmentation issues and other symptoms which seem a lot less scary, although they seem to appear a lot more often with this type of treatment.

Personally, I would like to know, how deep can you go around the different parts of the face without flirting with the potential of scarring -- so that if I decide to have a fractional treatment, I can tell whoever is performing my resurfacing procedure to adjust his energy settings accordingly. I don't want any overconfident doctor "pushing the envelope" on my face. Also, is it always the fault of the physician? Or is it that 1/100 people that you treat are going to wind up looking a hell of a lot worse than they did prior to the procedure simply because of the way their skin reacts?

How are you going to learn from eachother and prevent these "horror stories" from occuring in the future if you're not even going to adress the ones right infront of you in the present?

Sincerely,
Lurker.

09.17 | Unregistered CommenterLurker

Bravo, Lurker.

The biggest part of the problem is the laser companies who manufacture and don't support the physicians who use their lasers. I suggest that you send your email directly to the executives at Reliant, Lumenis and the other laser companies. You can find their contact information on their company websites.

The laser companies not only do not support "clinical exchange" they actively "shut it down" because they don't want the horror stories in the press. They are short sighted, stupid and greedy (just like AIG and Wall Street). Clinic problems are suppressed rather than openly discussed. New warnings are not propogated to the physician users. This is a big problem and it is 90% the fault of the laser companies.

09.18 | Unregistered CommenterMDR

I appreciate your honesty.

Lurker

09.18 | Unregistered CommenterLurker

Medical Aesthetic Practice Association (MAPA) Chat Room Event

MAPA is hosting a Fraxel 1500 Chat Session on December 16th at 9:00 pm Eastern Time.
Greg Sikorski, PA will be moderating the discussion along with Kevin Do, MD.
Greg and Kevin are very experienced users and get great results with their Fraxel Re:store Lasers.

This will be an advanced discussion, but all questions are welcome and all users are welcome.
We hope to share best techniques and share tips and pearls.

Go to the following links for more information:

Link to Chat Room: http://www.chlasermd.com/dynamicdata/chatroom.asp
Link to MAPA Home Page: http://www.chlasermd.com/dynamicdata/mapa.asp
Link to Discussion Topic Suggestions: http://www.chlasermd.com/dynamicdata/MAPAFraxelDiscussionTopics.asp

12.3 | Unregistered CommenterMAPA

Reminder as we go into the Weekend:
Medical Aesthetic Practice Association (MAPA) Chat Room Event
MAPA is hosting a Fraxel 1500 Chat Session on December 16th at 9:00 pm Eastern Time.

hank you very much for this useful article. I like it.
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01.27 | Unregistered CommenterSin

i had fraxal done. Im a guy. I did it to get rid of scarring on my face and some wrinkles on my head. My skin looks pretty much the same with a tan. So fraxal doesn't work. Not worth the money or pain you go through. The down time i would say is about 7 days its not 2 or 3 days. And im actually one of the faster healing patients. You will get small results but not worth the money i paid results. And i heard as you do more treatments you damage the skin and you start to develop spots so im just doing this one treatment and thats it and a few more v beams for redness and tahts it. I gave it a shot i honestly give it a thumbs down im not happy with the results but my skin got a little better maybe 5% better.

can someone please share your thoughts on treating the under eye area.
The P has some small micro scaring and fine lines.
* 35-7-8pass
*30- 8- 6pass.
Thank you will really appreciate your help.
September

11.27 | Unregistered Commenterseptember

hi all,

ive been reading this thread and site with great interest. i am hoping i could get advice on which treatment to go for.

unfortunately you could put me in the category "his hectic lifestyle and sometimes odd working hours are taking a toll"

in the past year ive seen a marked ageing of my face, in particular the peri-orbital region. dark circles, slight bags, fine lines.

All the usual culprits basically.

im 38, male, caucasian (fair skin, with a tendency to be oily).
im in good health and have no known allergies or sensitivities to medication
only relevant issue would be allergic conjunctivitis, which is extremely itchy and im sure has added to my woes with me rubbing my eyes often (before i was diagnosed and prescribed opatanol to ease the symptoms)

as is the case with so many looking for treatment, the array is bewildering, the pseudo-medical brochures can be misleading, and from reading the clinic sites i have, it seems all treatments are 100% ideal and effective for all people with all types of skin...

its only from being on places like this that you can get a more accurate picture of what is effective (or not) for which symptom/ailment/complaint or however you want to phrase it.

so - as it stands ive narrowed things down to Thermage or Fraxel. mainly due to availability (im in the UK).

looking at my stats above is there any treatment which sounds more suitable than others?

also - and i completely understand if no-one wants to answer tis (my email is included if you would prefer to contact me privately) - could someone give me recommendations for clinics or practitioners in the UK? i live pretty centrally, so its all within travelling distance for me.

thanks in advance for any advice you guys could furnish me

oh and i work from home so recovery time due to swelling or redness is not a problem.


again, thanks ,

Peter...

04.10 | Unregistered CommenterPeter

sorry my email is pete793r@gmail.com

04.10 | Unregistered CommenterPeter

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