Expert survey on the efficacy, costs and healing of resurfacing procedures for facial static wrinkles

Received on: 10/12/2018
Approved on: 26/12/2018 This study was performed at the Yale Center for Clinical Investigation
Financial support: None
Conflict of interests: Carlos Gustavo Wambier is a speaker for Cynosure Inc.. Renato Soriani Paschoal is a speaker for DEKA Inc. and Laser Medical Group (LMG) lasers.

Abstract

A survey on the opinion of specialists regarding skin resurfacing was performed, with the objective of comparing costs and benefits between the techniques: totally ablative CO2 laser, fractional ablative lasers, fractional non-ablative lasers, ablative fractional radiofrequency, microneedling, dermabrasion, medium peels, phenol-croton oil peels. The most effective option for the treatment of static wrinkles was the phenol-croton oil peel, in first place by 71.4% of the experts, followed by totally ablative CO2 laser, by 28.6%. Regarding downtime, procedures ranked as fastest recovery were microneedling and fractional non-ablative lasers, with 42.9% each, followed by ablative fractional radiofrequency, with 14.3%. Complete recovery period for side and adverse effects was perceived as shorter with microneedling by 50% of the experts. Regarding operating costs. The less costly procedure was medium peels, according to the opinion of 71.4% of the experts. Such results point towards a better cost/benefit of procedures such as chemical peels and micro-needling, according to the opinion of 14 Brazilian specialists who answered the questionnaire.

Keywords: Chemexfoliation; Dermabrasion; Lasers; Needles; Phenol; Pulsed radiofrequency treatment

Dear Editors,

There are currently multiple resurfacing methods aiming at meeting the increasing demand for improvement of wrinkles that cannot be completely treated with injectable substances. A cost / benefit analysis can clarify the rationale for deciding for new treatment options at the practice and point to factors to be verified in controlled studies.

A expert survey was conducted of cosmetic dermatologists on facial resurfacing treatments for static wrinkles (Glogau III and IV). Fourteen resurfacing experts were selected. All dermatologists were practicing cosmetic dermatologists, board-certified by the Brazilian Society of Dermatology.

The cosmetic dermatologists received a list of factors linked to the resurfacing procedures (effectiveness, total cost, downtime or time for complete re-epithelization, and time for complete recovery with resolution of adverse effects such as prolonged erythema, postinflammatory hyperpigmentation, pruritus and dry skin). The physicians also received a random list of eight resurfacing methods (fully ablative CO₂ laser, ablative fractional lasers, non-ablative fractional lasers, ablative fractional radiofrequency, microneedling, dermabrasion, medium depth peelings, phenol-croton oil peels) that should be ranked regarding each factor.

Regarding the factor effectiveness, the top-ranked method for the treatment of static facial wrinkles was phenol-croton oil deep peels, having chosen as the first option by 71.4% of the experts, followed by the fully ablative CO₂ laser, which has been chosen by 28.6%. The least effective option was non-ablative fractional lasers, which were ranked 8^th by 42.9% of the experts. Regarding the factor downtime, the procedures with the fastest recovery were microneedling and non-ablative fractional lasers, ranked as the top choice by 42.9% of experts, followed by ablative fractional radiofrequency, with 14.3%. The method with the longest downtime was the deep chemical peel, ranked as such by 57.1% of the specialists. The method with the shortest time for complete recovery from adverse effects was the microneedling procedure by 50% of the experts, followed by non-ablative fractional lasers (chosen by 28.6%) and ablative fractional radiofrequency (21.4%). The procedure perceived as having the longest time for complete recovery was the fully ablative CO₂ laser (57.1%). Regarding the total cost of the procedure, chosen the most cost-effective method was the medium peels, ranked as such by 71.4% of the experts, followed by deep peels and dermabrasion, both chosen by 14.3% of the physicians. The fully ablative CO₂ laser was deemed as the most expensive method by 64.3% of the experts (Figure 1).

While the best method would ideally offer great effectiveness, rapid recovery and low cost, the present study consistently suggested a “no pain, no gain” rationale permeating the comparison among the resurfacing procedures. Despite the faster re-epithelization of the microscopic areas of damage, fractional treatments seem to have limited effectiveness as compared to treatments that cover the entire surface of the skin. Ablative fractional lasers and microneedling were considered more effective than ablative fractional radiofrequency and non-ablative fractional lasers. Microneedling has the advantage offering reduced costs, shorter downtimes and faster recoveries from adverse effects. The results of the present survey regarding various methods of cutaneous resurfacing in terms of effectiveness and downtime, is in line with a previous publication conveying the opinion of a panel of three expert physicians.¹

These data can provide validation for the adoption of more cost effective procedures in light of a greater effectiveness, according to the opinion of expert physicians. In this manner, it is possible to conclude that, for the purpose of improving static wrinkles, deep chemical peelings should be seen as the most successful option. For patients who cannot tolerate long down-times and the expected side effects, the dermatologic surgeon should consider microneedling as compared to more costly options, such as non-ablative fractional lasers or ablative fractional radiofrequency. Taking into account that deep peels offer the longest already verified permanence of benefits² and that this methods safety profile has improved with the use of Hetter formulas,³ including this procedure in the syllabus of dermatologic surgery Fellowships and residency programs would be of great importance for the Dermatology discipline.

DECLARATION OF PARTICIPATION:

Carlos Gustavo Wambier | ORCID 0000-0002-4636-4489

Statistical analysis; approval of the final version of the manuscript; study design and planning; preparation and drafting of the manuscript; collection, analysis and interpretation of data; effective participation in the research guidance; intellectual participation in the propaedeutic and / or therapeutic approach of studied cases; critical review of the literature; critical review of the manuscript.

Renato Soriani Paschoal | ORCID 0000-0003-0493-9966

Approval of the final version of the manuscript; study design and planning; preparation and drafting of the manuscript; obtaining; collection, analysis and interpretation of data; effective participation in the research guidance; critical review of the literature; critical review of the manuscript.

Taciana Dal’ Forno | ORCID 0000-0003-0848-9042

Approval of the final version of the manuscript; study design and planning; preparation and drafting of the manuscript; collection, analysis and interpretation of data; effective participation in the research guidance; critical review of the literature; critical review of the manuscript.

Kachiu Cecilia Lee | ORCID 0000-0003-2107-8985

Preparation and drafting of the manuscript; approval of the final version of the manuscript; analysis and interpretation of data; critical review of the literature; critical review of the manuscript.

REFERENCES

1. Cortez EA, Fedok FG, Mangat DS. Chemical peels: panel discussion. Facial Plast Surg Clin North Am. 2014;22(1):1-23.

2. Kligman AM, Baker TJ, Gordon HL. Long-term histologic follow-up of phenol face peels. Plast Reconstr Surg. 1985;75(5):652-59.

3. Hetter GP. An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil. Plast Reconstr Surg. 2000;105(3):1061-67.