Glossary of Skin Resurfacing Terms

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John Q. Cook, M.D.

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I have put together this glossary to help you understand the often-confusing terms used to define various skin resurfacing techniques.

Skin Resurfacing – Any method that has as its goal a restoration of youthful structure to the skin. This includes a well-organized structure to the epidermis, the outer layer of the skin, and to the dermis, the deeper springy layer of the skin, which thins out as we age.

Chemical Peel – Application of a substance to the skin to freshen the appearance of the skin. The effects of chemical peels vary with the strength of the solution and the material used in the peeling solution. The mildest chemical peels simply clean off the outer layer of the skin to impart a fresher appearance. The deepest peels can be much more powerful and produce changes in the epidermis and the dermis that in many ways revert to the structure of youthful skin. This is done at a price, since the outer layer of the skin is removed and a prolonged healing time is required. Intermediate level peels can produce many benefits with a milder healing process.

TCA Peel – A widely used peel technique than can be used to freshen the outer layer of the skin or reach the deeper layers depending on concentration and amount of application. This peel, which uses a chemical of very simple structure, works very well around the eyelids and mouth but can also be used for the entire face. Before the advent of laser skin resurfacing TCA peels were the workhorse of skin resurfacing. TCA forms the basis of the popular Obagi® peel, which simply combines TCA with an indicator that tells the person applying the peel when to stop.

Phenol/Croton Oil Peel – In many ways the gold standard for results, a precisely designed phenol/croton oil peel can produce remarkable changes in the skin. It does not depend upon expensive technology. The peel suffers from two downsides. First it requires a great degree of skill in its use. Second, there is a prolonged period of recovery. For these reasons it is used less commonly than other methods.

Deep Dermabrasion – One of the first methods of skin resurfacing that has been around for decades, dermabrasion employs a rotating diamond-covered wheel or metal brush to sand down the outer layer of the skin and reach areas of irregularities in the dermis. Dermatologists and plastic surgeons use dermabrasion most commonly to smooth out areas of acne scarring and to soften the wrinkles (smokers’ lines) that occur around the mouth. To reach these deeper areas, the physician must remove the epidermis, so a relatively long healing time is required.

Microdermabrasion – A newer version of dermabrasion in which a fine stream of crystals is carried by an air jet to abrade the surface of the skin. There are also versions, such as the silk peel®, which avoid the use of crystals. Microdermabrasion can help to refine the quality of the skin and in the hands of a skilled practitioner soften fine lines and scars and remove brown patches from the skin. The technique is often combined with other methods of skin therapy, such as the application of beneficial compounds to the skin. There is a wide range of power and efficacy with these techniques. Spa grade machines work at relatively modest settings and produce modest but pleasant results. More powerful results can occur when medical grade equipment is used, but a skilled operator and medical environment provides the best outcome.

DermaPlaning – A non-surgical treatment performed with a special blade and held at 45 degree angle to remove rough, dry and dead skin cells from the epidermis, which is the surface of your skin. The procedure can be performed in small, precise areas or applied to the full facial area. DermaPlaning does not use the application of chemicals so it is an ideal exfoliation treatment for sensitive skin.

Laser Skin Resurfacing – Laser energy has many useful medical applications. By definition, a laser is an amplified beam of light of a single wavelength that follows a straight line path. Although there is a good deal of obfuscation about this technology, the concept is simple. Deep dermabrasion uses a mechanical surface to rub through the surface of the skin and reach the deeper layers to smooth them and stimulate the healing process. A deep chemical peel does exactly the same thing, but it does so by chemically dissolving the epidermis in order to reach the dermis. With laser resurfacing the fundamental process is the same. Laser energy targets the water in the skin and denatures the protein of the surface protective layer (the epidermis) and heats the dermis to stimulate the healing response. Like the other two methods, first generation CO2 laser machines produced powerful results with light at a 1064nm wavelength but required a prolonged down time for the healing patient. There were also problems in some patient with changes in skin pigment quality, so that the treated area might be left lighter or darker than adjacent areas. To diminish these problems, companies developed the Erbium laser (2940nm wavelength), which was designed to deliver short bursts of energy and limit collateral damage. Early erbium machines produced excessive bleeding and didn’t stimulate the dermis as well as expected, so combined short and long pulse machines were developed.

Fractional Skin Resurfacing – For decades doctors involved in skin resurfacing were frustrated by the fact that it really wasn’t necessary or even desirable to destroy the epidermis in order to reach the dermis in order to stimulate the healing response, but there wasn’t a way to avoid this collateral damage. Some very bright people came up with the idea of fractional laser skin resurfacing. Fractional resurfacing uses advanced technology to make tiny holes in the skin with the laser beam in a precise pattern. The energy passes through these holes to heat the dermis and stimulate the healing response, but it leaves the spaces between the holes intact, so there is much less damage to the epidermis. The result is a much quicker healing time than with first generation laser resurfacing.

Ablative, Nonablative, and Microablative Skin Resurfacing – These off-putting terms seem designed by the laser companies to mystify a straightforward concept. These terms simply refer to whether you remove (ablative), keep intact (nonablative), or partially remove (micoablative) the skin surface when you stimulate the healing response in the dermis.

Ablative Skin Resurfacing includes all forms of traditional CO2 and erbium lasers, deep chemical peels, and deep dermabrasion.

Nonablative Skin Resurfacing includes a wide variety of technologies, which can be laser-based, radiofrequency-based, or use other energy sources. The point is that they leave the skin intact or just with tiny holes so that healing time after treatment is very short. The earliest nonablative skin resurfacing systems produced moderate but not spectacular improvement with essentially no recovery time. In order to boost the power, several of the companies have developed fractional nonablative technologies, which prick tiny holes in the skin and allow a greater amount of energy to be delivered to deeper structures. One nice example of non-ablative skin resurfacing is the Palomar Lux 1540® laser, a nonablative fractional laser that has produced a high level of satisfaction in our patients.

Microablative Skin Resurfacing seeks a middle ground between the power of fully ablative skin resurfacing (i.e. traditional CO2 laser resurfacing with powerful results but weeks of downtime) and the diminished power of nonablative fractional resurfacing (with more limited results and very little downtime). In this approach, which typically employs fractional technology, a greater amount of the skin surface is damaged and a bigger dose of energy is sent to the dermis. In other words, a greater amount of injury is inflicted with a proportionately greater healing response. The tradeoff is that the patient has to experience several days at least where the skin is raw and irritated, but the recovery is not as severe as with traditional ablative methods. The overall results can be lovely, but still don’t approach the power of fully ablative methods that have been used for decades.

Just when you thought this was all making sense the laser companies have added more jargon. Right now some companies market what they describe as Ablative Fractional Laser Systems.

From my perspective, this is an inaccuracy that just confuses patients (and many physicians). The whole purpose of fractional resurfacing is that it is not fully ablative! If it were, this would mean that the entire surface of the skin has been removed, in which case we would have come full circle to the methods of 20 years ago where we got big results, but we inflicted big damage.

Ablative Fractional Resurfacing – A nonsense term commonly used by laser companies to describe microablative fractional resurfacing. The idea is the same as I have described above for microablative fractional resurfacing.

Nonablative Fractional Resurfacing – The use of fractional technology usually coupled with a laser energy source to make tiny holes in the skin in a computer-generated pattern to stimulate the healing process in the dermis and the deeper layers of the skin.

Micoablative Fractional Resurfacing – This is similar to nonablative fractional resurfacing, but a greater amount of the skin surface is damaged and greater energy is delivered to the deeper layers. This leads to a more powerful result, but with a longer recovery period than experienced with nonablative fractional resurfacing.

Radio-Frequency Resurfacing – The use of radio-frequency energy to stimulate the repair mechanism of the skin. Radio-frequency energy is in the part of the electromagnetic spectrum that includes radio waves. Radio-frequency energy has a longer wavelength than visible light (which includes laser energy). RF has been used in medical applications for decades, but this energy form has become increasingly popular for skin applications in the last few years.

Unipolar Radio-Frequency Resurfacing – Radio-frequency energy is directed into the skin to heat the deeper tissues and initiate the healing response and skin tightening.

Bipolar Radio-Frequency Resurfacing – Radio-frequency energy can be designed to flow between positive and negative electrodes, so that it follows a path through the skin.

Fractional bipolar Radio-Frequency Resurfacing – This is the design of the Fractora™ system.

Fractora Delivering Radio-Frequency Energy

Since it is a bipolar system, Fractora allows energy to flow between pins in the center of the hand-piece and plates on the sides of the hand-piece. The farther the pin is from the plate, the deeper the energy goes. This provides a very uniform distribution of energy through the dermis.

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