Dr. TroellIn his quest to find the optimal skin resurfacing device and post-treatment regimen for patients, Las Vegas, Nev., facial plastic and cosmetic surgeon Robert J. Troell, M.D., studied more than 250 patients over 10 years. He shared some of his findings yesterday at the American Academy of Cosmetic Surgery’s (AACS’s) 2017 annual scientific meeting in San Diego, Calif.
During his presentation, “Fractional CO2 Laser Skin Resurfacing: Treatment Results Comparing Platelet Rich Plasma and Alastin to Standard Post-Treatment," Dr. Troell compared devices and tested posttreatments to answer burning questions about what works best. These are the questions he asked and answered. Also, don't miss the Laser Skin Resurfacting Treatment Protocol he provided.
Q: What energy-based system is best in treating facial wrinkles and acne scarring?
A: CO2 laser
“I have compared radiofrequency devices, fractional erbium-YAG lasers and carbon dioxide (CO2) lasers for wrinkle and acne scarring treatment. These procedures were performed alone or adding topical platelet-rich plasma (also adding dermal needling with radiofrequency),” he says. “The carbon dioxide laser outcomes were superior for wrinkle and acne scarring indications.”
Dr. Troell cites this study, published 2009 in the Journal of Drugs in Dermatology (JDD), which helps to confirm the superior results with the CO2 laser.
“[Waibel J, Beer K, Naruker V, Alster T] showed that an Erbium:YAG laser (2940 nm wavelength) is superior for improving hyperpigmentation and revealed that the Erbium:YAG and carbon dioxide lasers are comparable regarding improving texture and skin tightening,” he says.
However, Dr. Troell says, he has found that in patients with Fitzpatrick classification V and VII skin types, the preferred options were radiofrequency devices, such a Venus Viva [Venus Concept], Matrix RF [Syneron] or Fractora [Invasix], to minimize the risk of post-treatment hyperpigmentation.
Q: Does the specific CO2 laser produced by different manufacturers make a difference?
A: Yes
“DEKA [Implant Direct], Equinox [Eclipse Aesthetics] and Lutronic [Lutronic Aesthetics] CO2 lasers were compared concerning aesthetic outcome, length and severity of recovery and discomfort during treatment,” Dr. Troell says. “The DEKA laser revealed less discomfort during the treatment, more rapid recovery and better aesthetic overall results. All these study variables were followed by the Equinox and lastly the Lutronic CO2 laser.”
The JDD study confirms the DEKA laser’s superiority for texture, rhytid improvement and overall appearance, over the other studied CO2 and Erbium:YAG lasers, according to Dr. Troell.
Q: Does topical PRP application immediately post-laser treatment alter the studied variables?
A: Yes
PRP post-laser treatment shortened the duration and severity of erythema during recovery, resulted in less (observed) hyperpigmentation and improved subjective and objective aesthetic outcomes, according to Dr. Troell.
“The objective outcomes were assessed by using Enhanced Image Pro system. It revealed 10% to 15% less wrinkles, compared to conventional post-treatment occlusive treatments and moisturizers alone,” Dr. Troell says.
He cites this study published in April 2011 in Dermatologic Surgery, which showed PRP applied on one arm but not the other after carbon dioxide lase treatment resulted in faster recovery, less erythema index, less melanin index (hyperpigmentation), as well as induced angiogenesis and increased collagen production by biopsies.
Q: Is there any benefit to adding Alastin (Alastin Skincare), as an extracellular matrix modulator, to the PRP and post-treatment skincare regimen after CO2 laser skin resurfacing?
A: Yes
“The addition of autologous platelet rich plasma (PRP) along with the Alastin tripeptide and hexapeptide extracellular matrix modulator system shortens the severity and length of the recovery period, lowers the incidence of hyperpigmentation, and improves the overall post-treatment result, Dr. Troell says. “The Alastin Skin Nectar is a unique product of an anhydrous formulation of a tripeptide and hexapeptide, with histological demonstration of [extracellular matrix] recycling with increased production of elastin and collagen.”
The addition of human stem cell protein cytokines (Stemulation Facial Serum by Stemulation or Regenica Dual Serum by Suneva Medical) appears to further hasten healing and yield improved aesthetic outcomes, he says, but further testing is needed.
“…we do not currently have enough patient numbers, length of time post-treatment, and objective testing to determine the amount and type of improvement using human stem cell protein cytokines topically after energy-based systems treatment,” he says.
NEXT: Dr. Troell’s Laser Skin Resurfacing Treatment Protocol
Dr. Troell’s Laser Skin Resurfacing Treatment Protocol
“This is my current validated clinical treatment protocol that practicing aesthetic physicians may find useful in their own practice,” Dr. Troell says.
Pre-Treatment
- Timing of laser treatment is best between September 15th and April 15th to avoid summer sun.
- Four to six weeks prior to treatment, if Fitzpatrick skin classification IV or V (VI is not treated by CO2 laser), test patches are performed at four different energy settings (two behind each ear).
- One week prior: Cleansing facial with extractions and either a combination of chemical peels (usually mandelic and salicylic), dermal planning, and/or microdermabrasion (in that order if multiple esthetician treatments).
- Two days before treatment: Acyclovir 800 mg twice daily.
Day of Treatment
- Patient does not wear makeup.
- Gentle facial cleansing in office.
- Confirmed laser treatment anatomical areas (face, neck, décolletage).
- Review home skin treatment regimen (written instructions included).
- Look at laser test patch areas (if performed) to assess the absence or presence of hyperpigmentation to guide laser treatment settings.
- Application of topical anesthetic cream for two hours (7% tetracaine/7% lidocaine). (Use of Pliaglis (Galderma) topical anesthetic cream appeared to achieve better anesthesia and is easier to remove, since it hardens to a thin film.)
- Blood draw for platelet rich plasma (PRP) centrifugation.
- Administration of oral sedation and analgesic medications (hydrocodone 5-10 mg and lorazepam 1-2 mg) 30 minutes prior to treatment.
- Topical anesthesia is removed.
- Trigeminal sensory nerve blocks are performed. 1-2 cc of local anesthesia is injected into each nerve (supra-trochlear, supra-orbital, zygomatico-facial, zygomatico-temporal, infra-orbital, anterior superior alveolar and mental nerves bilaterally). Local anesthetic (10 cc) is composed of 4 cc 1% lidocaine with epinephrine, 5 cc 0.25% bupivacaine with epinephrine and 1 cc of 8.4% sodium bicarbonate.
- CO2 laser settings decided. This is the most important aspect to optimize treatment outcome. Per physician experience with the specific type of CO2 laser, the maximum energy settings are chosen given the underlying skin pathology (wrinkle severity/acne scarring) and Fitzpatrick skin classification. Laser energy levels are lower in darker skin patients to minimize risk of hyperpigmentation. Laser energy levels are higher in severe wrinkle or acne scarring patients to optimize outcomes.
Immediate Posttreatment
- Apply iced moist cold towels (towels soaked in water and placed in freezer for about ten minutes) topically for about five minutes.
- PRP (6-7 cc) is mixed with 2 cc of calcium gluconate for activation (not required if injecting).
- Topical PRP is placed on the treated area and massaged into the skin.
- Moisturizer is placed topically.
- Patient is discharged home.
Posttreatment Skin Care Regimen
- Acyclovir 800 mg twice daily for eight days posttreatment
- Sun avoidance (as much as possible)
DAY 1 to 3
- Gentle skin cleanser: Use twice daily.
- Alastin Skin Nectar
- Alastin Occlusive Moisturizer (Vaseline or Aquaphor alternatives)
DAY 4 to 14
- Gentle skin cleanser: Use twice daily.
- Alastin Skin Nectar
- Alastin Moisturizer (non-occlusive moisturizer alternatives)
- Alastin Broad Spectrum Sunscreen (SPF 30+ sunscreen alternative)
Day 14 to 6 weeks
- Human Stem Cell cytokine cream (Stemulation or Regenica, Suneva Medical), if chosen by patient in the treatment regimen. Cost sometimes limits addition.
- Alastin Moisturizer (non-occlusive moisturizer alternatives)
- Alastin Broad Spectrum Sunscreen (SPF 30+ sunscreen alternative)
Weeks 3 to 8
- If observed hyperpigmentation occurs (most common time to observe start of hyperpigmentation) or for at-risk patients Fitzpatrick type III, IV or V), add IS Clinical White Lightening cream [Innovative Skin Care] at night to resolve or prevent hyperpigmentation.
Disclosure: Dr. Troell has relevant financial relationships with Venus Concept, Eclipse Aesthetics and Sound Surgical Technologies (Valeant). He’s on the speakers’ bureau for Alastin Skincare.
