Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology


ISSN-e 1984-8773

Volume 2 Number 3

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Case reports

Fractional non-ablative lasers in rejuvenation

Análise clínica de 16 pacientes consecutivos tratados com LUX 1540® para rejuvenescimento

Ana Beatriz Palazzo Carpena El Ammar1, Valéria Barreto Campos1, Rodrigo Pereira Duquia1



Introduction:The treatment of cutaneous aging with fractional non-ablative lasers has been intensely studied in the last few years, yet the number of publications describing specific equipments is limited.
Objective: To describe patient and dermatologist satisfaction after treatment with the Lux 1540®laser.
Methods: Retrospective study of patients (n=16) who have undergone facial rejuvenation therapy with Lux 1540® laser. Photographic assessments were performed by a dermatologist not involved in the treatments. Patient satisfaction was analyzed before treatment and after three sessions. The study variables were spots, sagging, wrinkles, enlarged pores, telangiectasias, and general satisfaction.
Results: In the dermatologist's evaluation, good or excellent improvement was found in the majority of the patients, for all studied variables. Regarding the improvement in the patients' general appearance, 82% were rated good or excellent. Regarding patients' opinions, 63% expressed good to excellent general satisfaction.
Conclusions: Treating cutaneous aging with Lux 1540® laser yields satisfactory results and maybe a good option for patients that do not want or cannot undergo more aggressive treatments.



Fractional therapy was introduced in 2004 by Rox Anderson MD/PhD,in light of the necessity to develop a laser-based rejuve- nation treatment that was more effective than non-ablative treat- ments and devoid of the complications of ablative treatments. 1

The fractional laser,which emits microbeams of light – the so- called microthermal zones (MTZ) that penetrate deeply in the skin and heat up the dermis,sparing the epidermis – was then con- ceived. 1 Reepithelialization occurs in about 24 hours,and the necrotic epithelial remains of dermal material and melanin are expelled after 14 days.Among the MTZ there are islands of healthy skin with many melanocytes and dermal papillae stem cells that allow a fast regeneration with reduced risk.The MTZ measure between 70 and 100 µm in diameter and reach on average from 300 to 1,200 Ìm in depth,from the papillary dermis to the middle reticular dermis,depending on the energy employed. 2

Currently,there are several types of fractional non-ablative lasers available (Table 1).The Lux 1540® (Palomar Medical Technologies,Inc.,Burlington,Massachusetts,US),like other equip- ment belonging in that group,has water as its chromophore,with an affinity of medium intensity,causing coagulation (not vaporization like CO2 lasers,which have a much greater affinity for water).

Non-ablative fractional resurfacing presents results that are considered good,yet inferior to those of ablative lasers in the treat- ment of cutaneous photoaging.Other uses include treating atrophic scars,acne scars,surgical and burn scars. 4 Currently,frac- tional non-ablative devices are the only FDA-approved equipment to treat melasma.However,they should be used carefully in treat- ing melasma,and only in cases that are unresponsive to conven- tional therapy. 5

The treatment is conducted in three to five sessions with intervals of about 30 days,depending on the energy employed.The session lasts on average 30 minutes for the whole face.The associ- ated pain is considered tolerable,and can be relieved with topical anaesthesia.Edema and minor erythema occur immediately after the procedure, and last for 1 to 4 days.6 Cool compresses of saline solution or cooling systems (for instance,Zimmer ® or Siberian®) are sufficient to relieve the immediate post-operative symptoms.To reduce the chances of postinflammatory hyperchromia,oral or top- ical corticoids can be used.Photoprotection is necessary,and pro- phylaxis for herpes simplex can be useful when there is a previous history of this disorder and when the procedure needs to be more aggressive.This study''''''''s objective was to evaluate the effects of resur- facing with Lux 1540® in 16 patients.


This was a retrospective study conducted at a private clin- ic in the city of Jundiaí,São Paulo,Brasil.Initially,26 consec- utive patients who underwent facial treatment with and Erbium Glass 1540 nm laser were selected.Of the initial group,4 could not be located,3 were less than 30 years old and 3 were undergoing other treatments concomitantly,leaving 16 patients in the study.

Photographic analysis was performed by a dermatologist not involved in the study,before and after three treatments with Lux 1540®.The pictures were standardized regarding illumina- tion and distance using the digital system Visia (Canfield®, Fairfield,Iowa,US).Two men and 14 women,aged between 32 and 60 (average 46),with light to moderate photoaging and with phototypes II to V,took part in the study.

Patients were anesthetized with a 6.5% prilocaine and 6.5% lidocaine cream 1 hour before the procedure (formulation dis- pensed by the chemist Almaderma,Jundiaí,SP,Brazil).During the session,the asepsis of the skin and one pass of 1540 nm laser, with an approximate overlap of 50%,were performed.The ener- gy employed varied between 50 and 80 mJ/mB,with a 15 ms pulse duration.For comfort,the skin was cooled using the Siberian® device (Industra,São Carlos,SP,Brazil),during and after the procedure,followed by the application of a mask of 10% vitamin C (formula dispensed by the chemist Almaderma). The patients underwent three sessions with 30-day intervals and administered the topical treatment at home (including retinoic or glycolic acid) before and after the sessions.

The patients were contacted 6 to 12 months after the end of treatment and asked about improvement in the following items:spots,sagging,wrinkles,dilated pores,telangiectasias and general satisfaction.The scale employed is presented in Table 2. The variables that were not present in some patients before treatment were considered not applicable and removed from the specific analysis.


The analysis conducted by the evaluator dermatologist is pre- sented in Graph 1.An improvement of good (7 and 8) or excellent (9 and 10) occurred in most patients,for all criteria analyzed.In addi- tion,regarding the improvement of general appearence,82% of patients presented an improvement considered good or excellent (7 to 10).The criterias wrinkles and telangiectasias,obtained the best results (70% and 86%,respectively,of marks rating the improvement either good of excellent).

General patient satisfaction was good or excellent (63%) (Graph 2).It is important to note that the questionnaire was answered at least six months after the last session and all patients observed at least an improvement from moderate to excellent for the criteria pores and wrinkles.For the variable wrinkles,73% considered the improve- ment good or excellent,while for dilated pores that rating was 78%.

The melasma worsened in one patient,representing the 6% who did not notice improvement in the graph (she also rated her sat- isfaction as 0).When treated with topical whitening substances,this patient presented a good response.

Regarding pain (Graph 3),56% of patients considered the pain light, 31% moderate,and 13% strong.No patient rated the pain as very strong.


According to the authors''''''''experience,the fractional Erbium 1540 seems to be a less efficient therapy than ablative resurfacing,yet is nevertheless effective for wrinkles,pores,spots and vessels.Overall it is an effective treatment,with neither the risks nor the very long recovery period typical of ablative lasers.

Although there is plenty of documentation describing the decrease in adverse effects that resulted from the fractioning of abla- tive lasers 1 ,it is considered an aggressive therapy.Cases of scars caused by fractional CO2 laser were published recently, highlighting that ablative procedures,even when fractional,carry risks. 7

There are few studies evaluating the rejuvenation obtained with the equipment in the focus of this article.In the Pubmed data- base,there are 15 articles related to the keyword "Erbium," only 4 of which were dermatology related.From these 4 articles,one is forthcoming,two employed the Aramis ® laser (Quantel) – one writ- ten by Jason R.Lupton et al 8 in 2002 and the other by Fournier and Mordon in 2005. 9 The fourth published study used the Lux 1540®, written by Farkas JP et al in June 2009,even including a histopathological analysis.However the skin sample was collected from the abdominal region,known to have characteristics different from those presented by facial skin.In addition,the variable eval- uated was the depth that the procedure could reach with that equipment and not the clinical improvement of the skin. 3 When searching for the term "Starlux," a pilot study of acne scars in the skin of East Asian patients was found;a search for "Lux" returned no articles.

Unlike in ablative resurfacing procedures – where pain is a great problem,demanding in some cases injectable anaesthesias – this is not an important issue with fractional lasers.More than half of the patients in our study considered the pain as light and none considered it very strong.

Regarding side effects,only one patient (6% of the cases) expe- rienced a worsening of melasma after treatment.This finding cor- roborates the authors''''''''experience,which shows that melasma can worsen in up to 20% of cases after treatment with fractional non- ablative lasers.Regardless,it is worth noting that the non-ablative laser is one of the few such devices approved by the FDA (2008) for treating melasma,which is considered a disorder that is resistant to conventional therapies due to its recurrent character and difficult treatment.Therefore non-ablative lasers are a good alternative. 5

Two patients reported improvement in acne scars (good and excellent) in spite of the fact that evaluating scars was not a study objective.It is known that the Erbium glass 1540 nm does not have the same degree of affinity for water as ablative lasers (Erbium 2940 nm and CO2),which are able to penetrate more deeply in the der- mis with a smaller dispersion of energy,and are thus more useful in treating condition that require greater remodelling of the collagen, such as striae and scars.

The present study presents some limitations.In spite of the small sample,the study patients were selected consecutively as they underwent treatment,meaning the sample was chosen randomly. Performing tests of association among variables was not possible, since a larger sample is necessary to obtain significant and statistical- ly meaningful results.Therefore,this analysis is classified as a descrip- tive study;further studies are required to confirm the discoveries more precisely.


Fractional non-ablative therapy with Lux 1540® seems to be a good option for rejuvenation treatments,especially for those patients who require an effective treatment with reduced recovery time,few reactions and fewer risks than ablative lasers.Further stud- ies are needed to evaluate the improvement percentage accurately, but this study suggests a good general satisfaction with the results achieved using this equipment.


1 . Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional Photothermolysis: a New Concept for Cutaneous Remodeling Using Microscopic Patterns of Thermal Injury.Lasers Surg Med.2004;34(5):426-438.

2 . Alexiades-Armenakas MR, Dover JS, Arndt KA. The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing. J Am Acad Dermatol. 2008;58(5):719-37; quiz 738-40.

3 . Farkas JP, Richardson JA, Hoopman J, Brown SA, Kenkel JM. Micro- islanddamage with a nonablative 1540-nm Er:Glass fractional laser device in human skin. J Cosmet Dermatol. 2009;8(2):119-26.

4 . Haedersdal M, Moreau KE, Beyer DM, Nymann P, Alsbjørn B. Fractional nonablative 1540 nm laser resurfacing for thermal burn scars: a rando- mized controlled trial. Lasers Surg Med. 2009; 41(3):189-95.

5 . Taub AF.Fractionated delivery systems for difficult to treat clinical applications:acne scarring,melasma,atrophic scarring, striae distensae,and deep rhytides. J Drugs Dermatol. 2007; 6(11):1120-8.

6 . Cohen SR,Henssler C,Horton K,Broder KW,Moise-Broder PA.Clinical expe- rience with the Fraxel SR laser: 202 treatments in 59 consecutive patients. Plast Reconstr Surg. 2008;121(5):297e-304e.

7 . Fife DJ, Fitzpatrick RE, Zachary CB. Complications of fractional CO2 laser resurfacing: four cases. Lasers Surg Med.2009; 41(3):179-84.

8 . Lupton JR,Williams CM,Alster TS.Nonablative laser skin resurfacing using a 1540 nm erbium glass laser: a clinical and histologic analysis. Dermatol Surg. 2002;28(9):833-5.

9 . Fournier N, Mordon S. Nonablative remodeling with a 1,540 nm erbium: glass laser.Dermatol Surg. 2005;31(9 pt 2):1227-35; discussion 1236.

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