Sciton Erbium:YAG Laser
I have been using an erbium:YAG device by Sciton (Palo Alto, CA) for 11 years and have treated thousands of patients with it. This device can be used in full-field or fractional mode and in both modes may be used with a short ablative pulse or with a variable or long pulse (Fig. 6). Sciton calls this the Contour TRL (Tunable Resurfacing Laser). The theory behind the variable pulse mode is that, by lengthening the pulse width, it mimics the thermal damage created by CO2 lasers. The Contour TRL achieves this when on its coagulation setting by applying a train of subablative pulses that lead to increased thermal damage. The advantage of this laser is that thermal damage can be applied where needed to tighten skin, but not at the amounts produced by CO2 lasers, which can lead to complications of hypopigmentation, prolonged redness, and even scarring.
I use the laser in full-field mode to perform deep resurfacing in patients who have significant rhytids or photodamage and a fair amount of downtime available. The depth of resurfacing depends on the anatomic area treated, the degree of pathology, and the patient's available recovery time. In general, recovery time with the Sciton device in this mode is less than with full-field CO2 laser resurfacing, and complications are far fewer. I have had one case of hypertrophic scarring and no cases of hypopigmentation. For patients with limited recovery time available, I may perform a combination treatment of pulsed light, superficial erbium:YAG laser peel, and fractional resurfacing (discussed in the following section). Reepithelialization of skin following full-field resurfacing occurs from sebaceous glands and hair follicles. Abnormalities of these structures caused by isotretinoin (Accutane) use, skin grafts, or extensive electrolysis may lead to scarring after resurfacing. The neck has a lack of appendageal structures needed for skin repair, and mild resurfacing is indicated in this area to prevent scar formation.
The Sciton Contour TRL system also allows fractional resurfacing. The handpiece on the device is different than the one used in full-field mode, and the appropriate software must be activated. The fractional spot size is fixed at 430 microns, and the spot density for treatment is adjustable to 5.5%, 11%, or 22% (Fig. 7). Multiple passes may be performed for different densities. The operator can also vary the thermal damage created, much like with full-field resurfacing, with no additional thermal damage laterally and deep to the hole created (subablative pulse), or with three levels of increasing thermal damage.
I typically use the fractional mode alone to treat acne scars or surgical scars. My usual treatment for patients with limited recovery time available is to combine superficial erbium:YAG laser peeling (intraepidermal) with fractional erbium:YAG laser resurfacing under topical anesthesia. I have had a lot of experience with fractional erbium:YAG laser resurfacing and have found clinically that, when combined with superficial erbium:YAG laser resurfacing, and sometimes with pulsed light, I achieve better results than are possible with fractional resurfacing alone.