"Right now," Vic A. Narurkar, M.D., says, "there's a lot of hype about so-called noninvasive or nonablative and tissue tightening treatments without adequate long-term follow-up or comparative studies." He is a San Francisco-based board certified cosmetic surgeon in private practice, as well as assistant clinical professor of dermatology at University of California, Davis Medical Center, Sacramento, Calif., and president-elect of the American Society of Cosmetic Dermatology and Aesthetic Surgery.
"Choosing the right technology has to do with what one is trying to treat — the extent of the damage and the specific lesions involved, along with giving patients a realistic expectation of what these technologies can achieve," he says. He is to speak at the Cosmetic Boot Camp scheduled Aug. 11-13 in Jackson Hole, Wyo.For example, he says ablative procedures (i.e. those that compromise the epidermis) are very effective for deep damage, such as deep perioral or periorbital rhytides.
Risks, recovery time Although ablative resurfacing remains the gold standard for such problems, fewer physicians are performing ablative resurfacing due to its risks and the recovery time involved.
"Part of the reason also is that the media and less-than-ethical people are promoting the notion that nonablative and ablative procedures achieve equivalent results," Dr. Narurkar adds. "Very often, patients are being talked into procedures that may not achieve the appropriate results, so they come in with expectations that are far beyond what the technology can deliver."
As such, Dr. Narurkar advises physicians to be clear with patients about the limitations of nonablative or fractional technologies.
He says, "I often talk about the phenomenon known as target-specific rejuvenation. If a patient possesses a lot of broken blood vessels and solar lentigines and one uses a nonablative source such as intense pulsed light (IPL) or a vascular and a pigmented laser, the patient will get a dramatic improvement in skin color and texture. A secondary effect is the stimulation of collagen. But these procedures should not be promoted as tissue tightening or wrinkle reduction (treatments). Their primary target is pigment in vessels."
Fractional resurfacing, nonablative technologies As for fractional resurfacing, Dr. Narurkar adds, "the consensus is that fractional resurfacing is intermediary between ablative and nonablative technologies. I don't believe it will address deep rhytides as a CO2 or erbium: YAG will. But it does a pretty good job of addressing texture and pigment. In addition, it may hold the potential for treating certain pigmentary disorders such as melasma, which are very difficult to treat with traditional technologies. However, we still need to study its long-term efficacy."
Nonablative technologies, on the other hand, fall into three basic categories:
Nonablative resurfacing options provide the widest variation in results, Dr. Narurkar cautions.
"Any wavelength, all the way from 500 nm to the infrared spectrum, can stimulate collagen," he says. "But what does that mean to the patient? To what degree does one get collagen contraction?"
Remodeling technologies Among tissue remodeling technologies, unipolar RF devices offer the most extensive research.
"The problem with ThermaCool™ in its initial introduction was the variation in results and the pain associated with the procedure," Dr. Narurkar says. "Newer techniques have reduced some of the pain, but the variability is still a huge factor. Some patients respond and some don't. So results are unpredictable."