Walnut Creek Dermatologists

Fraxel Failed to Work on my Acne Scars

Hi. I have a question regarding Acne Scars. I have undergone six sessions of Fraxel Refine to minimize or make my scars disappear, which did not happen. The practitioner who did the procedure suggested Fraxel Repair but couldn't assure me that it'll work on my face. I was wondering how good of an improvement can you get out of Fraxel Repair. Will I see a huge difference? Thank you.

What concerns me is your use of the word "disappear".  No one should ever tell you that any procedure, no matter how many you do, will cause your scars to "disappear".

The problem with acne scars is that no matter what you do they will never be 100% gone.  You could do 20 Fraxel treatments and your scars wouldn't be 100% gone.  It's true that the more treatments you do, the better the results but there is a law of diminishing returns and for acne scars it's more a logarithmic curve--at some point, you do not get back as much as you put in and eventually the results just level out and don't keep getting significantly better.  The reason is that acne scars are holes or defects in the skin--the laser cannot remove the hole, the best it can do is to soften the shoulders of the hole so the drop-off isn't so apparent.  That's why fillers often work better than lasers on deep crater scars because they plump up the depression but it's very difficult to treat every scar on the face with fillers.  It's also very cost prohibitive to use temporary fillers because they have to constantly be redone to maintain the results.  A permanent filler such as Artefill might be appropriate for certain deep depressions or crater scars.  However, acne scarring has 4 types:  ice-pick, box car, rolling, and hypertrophic.  Each type of scar has to be addressed in a different way.  In addition, most people are more bothered by the discolorations than the actual depressions themselves.  

Now, if you're going to invest in a procedure, you need to know what to expect from all the different procedures and the options are wide and bewildering.  Noninvasive lasers such as KTP, Nd:YAG, pulsed dye, alexandrite, ruby, and IPL can address red and brown discolorations.  This can make the acne scars look significantly better without having to go thru the downtime and hassel of the invasive or ablative procedures.

In order to achieve textural improvement, one must turn to resurfacing procedures (which require some downtime, some less than others).  Dermabrasion and phenol peels are actually quite effective but have the downside of making the skin texture appear unnatural or waxy, and high risk of loss of pigmentation (hypopigmentation).

CO2 laser is the gold standard, most painful and invasive laser, but achieves the best results.  It is home-run for wrinkles but not so for acne scars.  At best, one may achieve on average 50-60% improvement after one CO2 laser.  That means there may be some scars (especially the deep pitted or ice-pick scars or box car or crater scars that do not respond at all).

Fractional CO2 laser has become a new gold standard for acne scarring but once again, not a home-run.  There are many different brands of fractional CO2 and they differ in the amount of energy, therefore effectiveness.  The Lumenis ActiveFX and DeepFX are the most powerful of the fractional CO2 lasers and capable of achieving the best results.  The Repair is less powerful than the ActiveFX and DeepFX.  The ActiveFX and DeepFX have the ability to be turned down to match the weakest of the fractional CO2 lasers--but the converse is not true--the other fractional CO2 lasers cannot be turned up to match the ActiveFX and DeepFX.  (ie: A Ferrari can be driven at the speed of a golf cart, but a golf cart cannot be driven at the speed of a Ferrari).  The CORE and Mixto lasers are also less powerful and less effective.

Having said that, even the best fractional CO2 laser only gives about 20-30% improvement per treatment if combining both ActiveFX and DeepFX together.  After 3 treatments of both, one can get about 50-60% improvement of their acne scars.  Doing more can give incrementally better results but at some point, one has to ask if it's really worth paying more money especially if doing even 6 more is not going to get you to 100%.

Fractionated Erbium lasers such as the Fraxel Restore or Refine or Pearl or Profractional or Affirm are even less effective than the fractional CO2 lasers so you would have to do many more treatments to even get decent results.  

Refine is the weakest of the fractional lasers--it was designed for use by nonskilled practitioners in order for them to not "get in trouble".  Unfortunately the lower power also makes the results from Refine almost not noticeable.  The Refine is MUCH weaker than the Repair so it's possible that you may get better results with the Repair...but not a lot better.  You will not see a "huge" difference.  

Most patients can be quite happy with any of these procedures as long as the physician properly helps to establish the right expectation level.  The question is always whether the results are worth the money and time you're investing.  There is no perfect procedure unfortunately that will make your acne scars completely gone. If someone asked me what the one best procedure to do is to get the best results for their acne scarring:  if discolorations are the primary issue, the best would be noninvasive lasers such as KTP and Nd:YAG, and IPL.  If the issue is textural irregularity such as depressions, I would say the one best laser is DeepFX, and if someone could afford it, to combine DeepFX with ActiveFX.  And then to follow up with fillers to the residual crater scars.

M. Christine Lee, MD

Walnut Creek Dermatologic Surgeon

ı Had Fractional Co2 Laser Done 2 Months Ago.it Healed Without Crustıng Peelıng or Wound but Now ı See Some Scratch Marks??

my face became quıte red lıke measles (red dots) after co2 fractional laser ,after two months now ı have dıscoloratıon on my face and ı see some scratches (naıl marks)on my face ı cant remember ıf they were there before ıs ıt possıble to have them after co2 fractıonal laser?? (by the way my face healed without crustıng peelıng or any wound)are scratches normal??

It's possible that you may have scratched yourself (even unknowingly during your sleep) after the fractional CO2 procedure.  It's common for the face to itch while healing and some patients accidentally scratch their face.  Also, any kind of resurfacing procedure may leave behind red discolorations or streaks or marks which may or may not go away on their own. This can be addressed with noninvasive lasers (such as KTP, Nd:YAG, pulsed dye, IPL). You should see the physician who performed the treatment and see if they can help you with this. If they can't and the scratch marks don't go away after 6 months or so, you should see another laser specialist who can help you with that.

M. Christine Lee, MD

Walnut Creek Dermatologic Surgeon

Will This Liposonix Work on the Top of the Hip Area Just Below Waist at Back?

I have square hips and would love to have the hour glass shape. Will Liposonix work this area?

Liposonix is the first FDA approved fat melting device (approved Nov 2011 for fat reduction of the abdomen and flanks--it can be used off-label to treat other body parts).  It uses high-intensity focused ultrasound (HIFU) to cause lysis or destruction of the fat cells.  There is no other device that can make this claim in the U.S.  It is nonsurgical liposuction, a revolutionary technologic breakthrough.  It is not a replacement for liposuction because you cannot remove the high volumes of fat possible thru liposuction but you can get about an inch reduction (2.5 cm) in fat per treatment per area.  You can get greater fat reduction in the area by doing multiple treatments.  UltraShape also uses HIFU but has not received FDA clearance and is not available in the U.S.  Clinical trials for both devices have shown impressive and consistent results.

You need to be able to pinch at least an inch of fat in the treatment area in order to be a good candidate for LIposonix. 

It is important to not get high-intensity focused ultrasound confused with unfocused ultrasound (ie: Vaser Shape).  Only high-intensity focused ultrasound (ie: Liposonix, UltraShape) causes destruction of fat cells, unfocused ultrasound does not.

M. Christine Lee, MD

Walnut Creek Dermatologic Surgeon