Ofir Artzi discusses the emergence of hybrid ablative and non-ablative laser devices that promise to expand treatment protocols and improve results 

Ofir Artzi, MD, 
Division of Dermatology, Tel Aviv Medical Center, Tel Aviv, Israel
email: ofira@tlvmc.gov.il

For centuries, facial skin rejuvenation has been the focus of beauty and skin care, and it continues to be listed in the top-ten nonsurgical aesthetic procedures performed each year across the globe1. While the perception of beauty is highly influenced by cultural and psychosocial preferences, facial skin appearance imparts substantial impacts on self-esteem and emotional health2, 3 and a flawless complexion remains a universally sought-after feature. Yet, despite its centrality in the aesthetic field, skin quality remains loosely defined, with few objective and standardized parameters available for the assessment of skin status and treatment outcomes. A consensus definition of skin quality, proposed by a global, multinational panel of dermatologists and aesthetic physicians, laid down skin tone evenness, skin surface evenness, skin firmness and skin glow as the possible categories to be considered when outlining and prioritizing treatment needs4. To improve these (and other) universally accepted different skin quality parameters, a physician should design customized treatment algorithms that address the respective tissue structures and depths according to the patient.

Skin rejuvenation technologies in the current era of consumer-centric healthcare are aimed to improve skin quality while minimizing pain, potential adverse effects, and downtime. In recent years, laser-based skin resurfacing techniques, which currently account for 33.2% of the skin resurfacing technologies market5, have cycled between ablative and non-ablative therapies, with the depth of effect primarily dictated by the location and concentration of their respective chromophores. Most ablative and non-ablative lasers rely on fractional pulse delivery, which has revolutionized the laser resurfacing field of thermally damaged microcolumns separated by untreated healthy zones, which are thought to minimize damage and hasten healing. 

Figure 1 Unique histological pattern unduced by Alma Hybrid™ laser — ablative zone surrounded by coagulation zone and adjacent to it coagualtion zone

While fractional ablative lasers promote epidermal regeneration and dermal remodelling and have been proven highly effective in wrinkle-eradication and skin tightening, they are not suitable for most patients and are linked with high complication rates and substantial downtime6. In contrast, non-ablative modalities trigger thermal processes that elicit reorganization and neogeneration of key dermal elements, while sparing the epidermal layer from injury7. In turn, although clinical outcomes are milder and less durable, requiring repeat sessions, the treatment is considerably more tolerable and requires a shorter recovery time.

In addition, laser-assisted drug delivery has become widely used in the past few years and was reported in studies as an effective approach8, 9. Fractional ablative lasers create microscopic channels that provide access pathways for topically applied drug molecules that would otherwise be too large to traverse the epidermal layer10. There is a wide array of cosmeceuticals and pharmaceuticals that are used for the treatment of different medical indications. The prescription of bioactive cosmetic products before and after application of laser treatments is deemed to be essential by most experts.  

Figure 2 A representative patient. (A) Before and (B) after 3 Alma Hybrid™ laser treatments in a 1:1 ablation to non-ablation ratio

Hybrid lasers as a concept

The continuous quest to provide a favourable balance between the safety and performance of ablative and non-ablative skin rejuvenation techniques and the potential synergistic effects of ablative and non-ablative combination procedures has brought professionals to develop a number of newly marketed ablative and non-ablative hybrid devices that allow for controlled and partially automated customization of resurfacing settings, supported by built-in diagnostic technologies. The tunable parameters render the devices suitable for a wide array of indications, ranging from fine lines and wrinkle reduction to aggressive scar revision and dermatological surgical procedures. More specifically, Halo™ (Sciton, Palo Alto, CA, USA) provides for coincident delivery of fractional Er:YAG and 1470 nm laser pulses, which provides for both superficial pigment manipulation and deep collagen stimulation. The device features an integrated cooling and smoke evacuation mechanism, which enhances patient comfort and ensures user safety. Its dynamic thermal optimization (DTO) feature allows for automatic adjustment of the power of the 1470 nm pulse in response to patient skin temperature11. The Youlaser MT (Quanta System S.p.A., Milan, Italy) is an additional coaxial, simultaneous or sequential, mixed wavelength fractional laser device that combines CO2 and gallium arsenide (GaAs) lasers for a controlled balance of superficial ablative and medium to deep-dermal non-ablative effects. Its OptiSim function facilitates treatment precision by automated estimation of the depth and density of the effects. When compared to CO2 treatment only, the combined treatment was associated with significantly shorter downtime and recovery periods and improved tolerability scores, while eliciting improved wrinkle reduction results in patients with photodamaged facial skin12. Moreover, patients undergoing simultaneous ablative and non-ablative treatment were significantly more satisfied with treatment outcomes. 

Further evolution of the hybrid platforms

Recently a new generation of hybrid laser was introduced into the market. The Alma Hybrid™ (Alma Lasers Ltd., Caesarea, Israel) combines ablative (CO2 laser) and non-ablative (1570 nm laser) beams. More specifically, both wavelengths can be operated individually, simultaneously or sequentially to form endless patterns of skin injury. Its automated ProScan scanner further enables the unique HyGrid™ feature, which allows the user to custom-program the lasing ratios between both lasers to optimize the resurfacing versus dermal regeneration needs. The resulting histological pattern of ablative CO2 and non-ablative 1570 nm beams will be shown side by side, in different ratios and in endless morphologies (Figure 1). 

Complementing the laser effect, laser-assisted drug delivery (IMPACT™) is an evolving technology with potentially broad clinical applications. Using laser pre-treatment followed by topical drug application, physicians can increase the amount of drug that reaches the skin, thereby improving the efficacy of numerous topical treatments. It is known that the uptake of topical compounds is higher through microchannels surrounded by coagulation zones than without these zones. By determining all parameters of ablative/non-ablative beams, such as ratio, depth or width, different drug delivery capabilities might be created. Alma Hybrid integrates the proprietary IMPACT™ ultrasound technology, which enables unique augmented transepidermal delivery of cosmeceutical products and drugs through the microchannels formed by the CO2 laser.

The hybrid lasers are here to stay

Newly emerging combination therapies are offering a more holistic approach to skin rejuvenation by enabling tailored regimens designed to simultaneously target several skin quality features, different anatomical areas and to achieve a multilayer effect, culminating in an overall improvement in skin appearance (Figure 2). This approach promises to expand patient eligibility and enhance patient experience and satisfaction by providing an ideal balance between the durability of treatment outcomes and downtime and complication rates. Increased cumulative experience with such hybrid platforms will facilitate the generation of protocols for customizing treatment regimens.

  Declaration of interest None

  Figures 1-2 © Ofir Artzi, MD 


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