Sculptra and Fraxel repair. Which should I get first?

Sculptra and Fraxel combination is very popular in practices in the "para-plastics" fields.  I don't know of many true plastic surgeons that run ethical practices that would offer you these treatments.  Both treatments have incredible marketing dollars behind them and have patients like you convinced that this is what they need before you even have a consultation.So what's wrong with Fraxel?Fraxel is based on a great concept but uses what many consider an antiquated laser beam.  The CO2 laser is what really got laser resurfacing going, but it was poorly tolerated when used effectively.  To get good results from a CO2 laser patients had to endure weeks of redness and many suffered horrible pigmentation complications such as hypo and hyper pigmentation, shiny tight unnatural appearing skin, full thickness loss and others.  Fraxel was the first fractionate beam to the market and was a brilliant business plan.  It is sold as delivering an effective treatment with low recovery because it treats a fraction of the skin, allowing a large percentage of healthy untreated tissue to remain and speed recovery.  The truth however is that the CO2 beam causes a very large component of what we call "coagulative damage" this is damage from extreme tissue temperature that causes coagulation, tissue destruction and apoptosis well outside the impact of the laser's beam and is also the cause of the high rate of complications from CO2 beams.  Fraxel does indeed deliver separated fractionated beams but because of the wide zone of coagulation, the effect of the laser is not changed much from previous generations of full field treatment.  What is very different about Fraxel is that the treatment is reduced by 80-90% of the energy used.  This is what is responsible for the reduced downtime and tolerability.  It is an absolutely genius business model- the practitioner delivers 10-20% of the treatment to the patient and charges 3-400% more.  Most knowledgable plastic surgeons recognize Fraxel as a clever marketing of an outdated technology.Thus is there really a fractional resurfacing laser?Yes, the Erbium beam laser is what most consider state of the art today and is tunable to deliver selected percentages of tissue ablation and coagulation.  Tissue ablation is essentially instantaneous vaporization of tissue without heat of coagulative damage.  The Erbium beam is actually able to deliver what Fraxel claims to.  When I perform a fractional resurfacing I use pure or near pure ablation and treat less than 20% of the surface area of the skin, but actually treat FULL THICKNESS, something that is not possible to perform safely with ANY CO2 based system.  The down side is that you do not get as much tissue contraction or what is referred to as "tightening."  Tightening is, just like the severe compilations of CO2 lasers, the result of the coagulative component.  The tunable Erbium beam allows the surgeon to actually add as much or as little coagulative component as desired to deliver this tightening, but the more you add, the more it becomes similar to Fraxel or CO2.  In my opinion this is not the safest or most effective way to tighten skin and I simply do not use the coagulative technique in my practice.  There are much better non ablative ways to achieve tightening that do not thin the skin, alter skin moisture and set up pigment problems.What about Sculptra?  Doesn't it build native collagen?Sculptra is an interesting product and again, a very clever business strategy.  Sculptra is made of Poly-L-Lactic acid, a material surgeons are very familiar with and have been using inside the body for a long time.  Plastic surgeons have a love-hate relationship with this material.  It is used to make a long lasting absorbable suture most popularly brand named Vicryl.  Plastic surgeons love Vicryl sutures as they are very strong and hold a knot exceptionally well.  We hate them because they cause a local inflammatory response that is responsible for their absorption.  Thus we try our best to use the minimum amount necessary, throw the minimum amount of knts required and keep them deep far away from the skin.  Even with these precautions none of us are surprised when they "spit" or create a "sterile abscess."  This is a nasty material that the body does not like having around- thus it goes away with good timing in the healing of incisions.  Ask any plastic surgeon if they are surprised when there are several spitting sutures in an abdominoplasty incision or body lift- they will tell you it happens.Thus along comes Sculptra- a brilliant way to market a known FDA approved implantable material with an acceptable safety profile for a new indication in the aesthetics market.  Sculptra is essentially micro particles of Vicryl suture injected in amounts that far exceed that body's local exposure of a suture.  What is the secret for success? - product direction to inject deep.  Just like plastic surgeons closing an incision, we want to keep the inflammation away from the surface where it can really cause problems.  Nevertheless, down deep in the face of every Sculptra patient is a robust inflammatory response that can causes strange swelling, tenderness, granulomas and tissue destruction, yes, tissue destruction.  The amazing this is that this robust inflammatory response and scarring is marketed as "generating your body's own natural collagen."  The sad truth is that is creates a scar ball that combined with prolonged inflammation can actually cause facial fat atrophy which is essentially accelerated facial aging.  Do you really want to pay to have your face aged?So why are practitioners injection it?Most patients do not return to the injector when they have problems.  Instead they find a true plastic surgeon with aesthetic and reconstructive experience.  Adverse results usually take time to show, and patients can be happy for months to years before having problems.  Look at the reviews on this website and the time after the procedure that they were posted and this will become very evident.  I have seen a tremendous amount of complications from Sculptra, Radiesse, Silicone and other fillers with great marketing promise.The only safe off the shelf fillers are the relatively unadulterated hyaluronic acid products( Perlane and Juvederm Ultra) and believe it or not if used with appropriate technique (off label) these products can deliver much longer lasting results and actually induce the healthy rejuvenating process of angiogenisis instead of inflammation and scarring.  I personally treated my own face with hyaluronic acid and a technique I call "Aesthetic Facial Balancing" and have results that have been stable for three years.  DO NOT FALL INTO THE TRAP OF SO MANY OTHERSI hope this helps!All the best,Rian A. Maercks M.D.

Hi Donva,In general it is preferred to tighten the skin prior to filling it.  With Sculptra, it may take 6 to 12 weeks before you can visualize the results.  Therefore, we will often treat patients with their first Sculptra treatment at the same time as their Fraxel repair, or even a week or two before. After 6 to 8 weeks, the great majority of swelling from Fraxel repair has resolved, and our patients can have their second session of Sculptra injections.  Most importantly choose your treating physician most carefully based on their artistic vision, skill, and expertise.  Good luck and be well.Dr. P