PROFRACTIONAL™ FOR ACNE SCARRING B. KENT REMINGTON, M.D., F.A.C., F.R.C.P., Calgary, Canada R. JAMES KOCH, M.D., Palo Alto, California INTRODUCTION/BACKGROUND ProFractional capability that allows users to adjust a scanned pattern size from 6 x 6 mm to The successful treatment of scarring secondary 20 x 20 mm and a precise penetration depth of to active acne vulgaris is a major challenge 25–1000 µm. This allows the physician to treat to practitioners of aesthetic medicine. To different types of scars gently or assertively, as the patient, acne scarring is as physically and the patient requires. There is still a little down- emotionally traumatic as active acne. The time—patients look like they have a sunburn number of patients requesting cosmetic for a short time. The economics of the improvement of acne scars is rising rapidly, ProFractional are advantageous since there are and armed with knowledge about emerging no consumable components. technology, so are their expectations. But even with new therapies, the issue is still a complex PROFRACTIONAL VS. one. Many available treatment options do not TRADITIONAL FRACTIONAL seem to satisfy patients, and as such, 50% TECHNOLOGY improvement is considered a success. The advent of fractional technology came Patients come into our clinics daily looking to with the promise of better results with less improve their appearance by reducing acne downtime, even with acne scarring. The scarring. Until recently all we had to offer them ProFractional device ablates narrow, precise were ablative modalities such as dermabrasion, channels into the dermis with no collateral chemical peels, or CO2 laser resurfacing, all of thermal necrosis, stimulating neocollagenesis which require the patient to accept a significant and wound healing in the dermis to create amount of downtime in one form or another. smoother, softer skin that feels better to the Technology has since evolved for improvement touch. The untreated surrounding tissue of the different phases of scars. Intense pulsed promotes rapid, uniform healing. With light (IPL), vascular lasers, and fractional ProFractional, precise depths can be selected systems that started with Fraxel™ (Reliant as can the pitch or distance between the spots. Technologies, Palo Alto, CA), offer the same In comparison, Fraxel creates necrotic micro- level of improvement as previous modes with- thermal zones to a depth of 90 microns; Pro- out the downtime and hassle. Fraxel, however, al Fra c t i on can ablate from 25 µm to 1.5 mm. had the difficult-to-remove blue dye, signifi- ProFractional can be as effective as other cant discomfort and required a long treatment fractional devices but offers the physician series. Even the new generation of Fraxel does more treatment flexibility. This leads to not provide adequate control over the device positive results that can be seen in fewer according to some. treatments and less overall downtime. The new ProFractional™ (Sciton, Inc. Palo More importantly, ProFractional users can treat Alto, CA) softens and blends scars, and individual scars as minimally or as aggressively patients can feel the difference. Building up as necessary to create an overall evenness to the on the Contour™ 2940 Er:YAG laser (used to skin. Deeper scars that require more aggressive perform MicroLaserPeel®), Sciton added the treatments can be treated accordingly, while more shallow scars on the same patient can Patients with skin types I to IV have been be treated at a different setting. Though treated more often than V and VI, but the evi- ProFractional can spot treat, treating the whole dence so far suggests that ProFractional can face at varying intensities creates a uniform treat even darker skin types without unwanted color, texture, and tone. pigmentation changes. TREATMENT PROTOCOL PROFRACTIONAL COMBINED WITH MICROLASERPEEL ProFractional protocols will vary according to each patient’s individual needs and we continue ProFractional is also being used in combination to improve techniques and outcomes. Factors with Sciton’s MicroLaserPeel® (MLP) that affect treatment include the number of procedure to treat acne scars. Acne scars cause treatments required; location, type, depth, and uneven texture, and often uneven color and severity of the scar; and age of the patient. tone in the skin as well. This uneven appear- ance is accentuated with accumulated sun The nice thing about the ProFractional is that damage. The one-two punch of superficial it’s easy to precisely regulate treatment depth, resurfacing and deep penetration collagen which is shallower for the forehead and nose remodeling helps blend these textures, tone and deeper on the cheeks. A single pass is all and color. that is required for most patients. Patients don’t require dressings, pain killers or wound care. The ProFractional creates small channels that Acne scars require four or five treatments about stimulate collagen remodeling, giving the a month apart using conservative protocols. benefits of deep resurfacing without creating The interval is approximate; four weeks gives excess necrotic debris that hinders wound heal- the patient time to heal, and allows time for ing. The adjustability of ProFractional is useful collagen remodeling. Three weeks is sufficient, for different areas of the face where scarring is as would be six. This flexibility of intervals is more or less severe. The user can selectively nice for both the patients and clinics. deposit different amounts of energy. Depth and density of spots can be customized to provide For areas of mild acne, a shallow depth of uniform color, texture and tone to the face— approximately 100 µm at 4% coverage is and can do so without heavy ablation, scabs, effective. For more aggressive treatment, depth crusting, and long downtime. The MLP treats settings can be increased to 400 µm or even the surface of the skin to put on a finishing 800 µm. touch, especially around sensitive areas such as Pre- and post-treatment care with Pro- the eyelid. Fractional is relatively universal. The procedure RESULTS is only slightly uncomfortable depending on density settings used, and topical anesthetics Acne scars have always been a treatment chal- can make the patient more comfortable with lenge, so managing expectations plays a key aggressive treatment. Side effects at any setting part in patient satisfaction. Whether for the are minimal. No blisters or scabs have been treatment of acne scars or traumatic scars, 50% observed by us. Pinpoint bleeding may occur, improvement in texture, tone, color, depth and but chemical cautery swabs such as aluminum size is the accepted standard with any treat- hexahydrate will seal the tiny wounds. For ment option. Photography is helpful in that posttreatment care, any simple, water-based both patients and clinicians can see improve- moisturizers will effectively promote healing ment by comparison. And happy patients will and make the patient comfortable after treat- come back for more treatments. ment. Thermal mist sprays also help cool and comfort the skin as the moisture evaporates. Before Treatment Four weeks after 1 treatment Photos courtesy of • Improved Tex t u re Tone – Radiance B. Kent Remington, M.D., F.A.C., F.R.C.P. • Acne Sca rs , Pits and Icepick A reas Calgary, Canada Softened-Flattened Before Treatment Four weeks after 1 treatment Photos courtesy of • Improved Tex t u re Tone – Radiance B. Kent Remington, M.D., F.A.C., F.R.C.P. • Acne Sca rs , Pits and Icepick A reas Calgary, Canada Softened-Flattened Patient satisfaction has been very high because their skin’s texture, tone and color. Dermal both visible and tactile improvement is obvi- fillers are being used after the third treatment ous. Acne scars make the skin dull; after by one author to help elevate the scars and ProFractional treatment patients’ skin looks bring more dramatic results on the face. fresh, and they have the glow of a more youth- Inflexible scars such as depressed pox scars ful person. This device really improves the require that the filler not be injected until after overall quality of the skin. the third ProFractional treatment due to the effects of collagen remodeling. But acne is a CONCLUSION/FUTURE management project, and such a combination is Much of the focus with ProFractional has been proving beneficial. Combination treatments, for facial acne scarring, but successful treatment such as with MLP or dermal fillers and others of the neck and chest is also possible and has involving laser- and light-based modalities, been done in our clinics. Overall, patients mean that the future for ProFractional looks report satisfaction with the improvement in bright.