Is full-field erbium laser (e.g. Sciton TRL) best combined with Profractional or CO2 fractional for the best acne scar results?

Question

I see a lot of doctors who combine the full-field erbium laser with fractional C02 (e.g. Sciton TRL with Deep/Active FX) and the results look great. Is combining Profractional with the full-field laser just as effective as with the C02? If not, please explain why the C02 is a better combination. Thanks!

Jason Emer, MD · Answer

A combination approach will give the most improvement. These types of scars need a combination of lasers, microneedling/prp, subcision, Cosmelan and fillers. Co2 is the best laser for scars, but Erbium is a great alternative. It may take a series of treatments and may need some treatments to maintain. I recommend getting a formal evaluation with an acne scarring expert. Best, Dr. Emer

Amiya Prasad, MD - Account Suspended · Answer

Thank you for your question. You’re asking, why are doctors often recommending a combination of full field Erbium laser treatment with a fractional CO2 laser treatment for acne scars.You’re trying to understand what the rationale is, and whether the CO2 laser is necessary.
I can certain share with you how I approach my patients with acne scars. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. I was very fortunate to be a part of lasers for skin resurfacing from the very beginning in the early 90s with the original, very aggressive, fully ablative CO2 lasers. Understanding the evolution of needs and outcomes are ultimately what resulted in types of combination strategies, which I’ll explain. 
With the original CO2 lasers, we were basically inducing a full facial second degree burn, then managing the patient like a burn patient in a hospital. It involved a long healing process, dressing changes, and other things, and also involved risks, challenges, and complications. The desirability of fully ablative CO2 laser dropped precipitously. Around 1998, the Erbium laser was introduced, and we decided it was better for faster healing time, and not deliver as much thermal energy to lower the risks of complications. Move the clock forward, and we have now fractionated forms of both Erbium laser and CO2 laser. 
If we are talking about using purely a laser strategy, you’re mostly dealing with a sub type of acne scar known as boxcar scars. The treatment tries to blend the transitions between the normal skin and the scarred skin. The intention with the Erbium laser is resurfacing a lot of the skin, without delivering thermal energy in a great amount. For deeper scars, you’re delivering CO2 thermal energy to induce a more robust collagen response. 
In addition I commonly also use microneedling, platelet-rich plasma, and subcision as there are a lot of different ways to maximize the outcome. The goal is to minimize healing time and the healing process. 
As of late, people with acne scars often don’t appreciate how much fat volume loss they have. Often, the most dramatic improvement for acne scars may be no laser at all, but rather the use of injectable fillers at a structural level. Very commonly, if you look at someone’s face, although people who have acne scars are bothered by the scars when they look at themselves, basically you’re looking at a triangle with the eyes at the top, and then the point of the bottom of the triangle is the chin. Within that area are the midface and the cheek. A lot of people who have depressed scars in that area and the cheeks get a really nice job with filler adding volume and softening the appearance of those scars. 
In addition, the strategy of improving these scars sometimes involve a slow approach where maybe a limited amount of fractional lasers, or a combination of subcision and PRP to try to condition the skin and improve its quality,  then do the lasers. People with acne scars are often very frustrated that they jump from one doctor to another, or one medispa to another trying to find the right laser and combination. The industry doesn’t help itself by constantly promoting the latest and greatest lasers. 
There’s a strategy your doctors you are consulting always have in mind, so it takes a certain amount of evaluation and understanding. One of the things that help people understand the significance of their acne scarring is through an examination technique with backlighting. We look at the scars with backlighting to get a sense of what the deepest layers are. When you think about laser, you’re dealing with just the skin at the thickest level around 2 millimeters. When you look with backlighting, you see a significant indentation, so there’s an opportunity to build under the skin where injectable fillers and PRP can also play a role. 
The goal is to maximize the outcome and minimize the downtime. Understand your doctor is trying to use probably that strategy to minimize the amount of significant thermal energy to get the best result, as well as minimize your downtime. I hope that was helpful, I wish you the best of luck, and thank you for your question.

Davin Lim, MBBS, FACD - Account Suspended · Answer

More info below but it really depends on the scar type of the patent. By doing hybrid erbium and fractional co2 enables and extra level of depth, with the added buffer of safety, especially in darker skin types. I have a few videos that show how I combine both. Adding fractional co2 enables me to improve the deeper scars, once I'm at my maximal depth of comfort. This goes for acne scars and for skin rejuvenation. Most specialist have been doing this for the past decade, we just don't talk about it much. Dr Davin Lim, Brisbane. Australia.

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