Fraxel re:store™ FOR LASER RESURFACING

NATURE OF THE PROCEDURE

Just as a damaged painting is delicately restored one small area at a time, or a photographic image is altered, pixel by pixel, fractionated resurfacing improves your appearance by affecting only a fraction of your skin at a time with thousands of tiny microscopic laser spots.

The first and still the gold standard for resurfacing of the skin is the traditional CO2 laser. The advantage of this laser is it full covers the skin with thousands of laser impact sites, and while the superficial wrinkles are burned off, it does produce deeper heat which visible tightens the skin as the procedure proceeds. This stimulates collagen remodeling to support your skin and prevent further wrinkling. The disadvantages of the CO2 laser are the following:

Prolonged healing - At least two weeks of weeping and oozing with three or four months of sunburn type redness after that.
Possible line of demarcation along the jawline where the procedure stopped and your normal skin remains.
Increased chance of scarring.
Increased chance of infection.

Having said that, for the proper patient with the proper condition and in the hands of an experienced laser surgeon, this is still the “gold standard.”

With the advent of the Fraxel lasers, Reliant Technologies learned that you can accomplish almost the same thing without many of the attendant risks. The first laser for this was the Fraxel re:store™. This is an erbium based laser that produces thousands of tiny but deep columns of treatment in your skin, known as microthermal treatment zones (MTZ). This treatment eliminates old epidermal pigmented cells by penetrating deep into the dermis. Just as important, however, are the areas of the skin that the Fraxel re:store™ laser leaves untouched. For every microthermal zone the laser targets and treats intensively, it leaves the surrounding skin unaffected and intact. This “fractional” treatment thus allows the skin to heal much faster than if the entire area were treated at once. Using the body’s natural healing process, these small columns of carefully damaged skin are now filled in by new cells that have migrated from the surrounding untouched skin. These “holes” are filled up with new healthy and tighter tissue to replace previous imperfections. Because of this, there is less chance of abnormal pigmentation, infection, and scarring. The way Fraxel works is the laser carefully targets approximately 20% of the skin surface and creates these microtherrmal treatment zones. The rest of the 80% is completely untouched. The 80% of your skin that is untouched is able to quickly heal and fill in the 20% of your skin that was treated. With fractionated resurfacing, there is less down time than with the traditional CO2 laser resurfacing, and there is less chance for abnormal pigmentation whether lighter or darker. The disadvantage of the Fraxel re:store™ compared to traditional CO2 resurfacing is that one does not obtain quite as much deep thermal heating, so the overall tightening of the skin is less. The trade off, however, is less risk in every single way and quicker healing.

In 2008, Reliant Technologies improved upon the Fraxel re:store by bringing out the Fraxel re:pair. They realized that if the holes were drilled just a little bit deeper even more correction could be obtained with the same margin of safety. The Fraxel re:pair indeed is a CO2 laser, and thus is able to produce deeper holes. The difference is that these holes again only occupy 20% of your skin. The laser pulse uses very high energy but it is produced very quickly such that surrounding skin is not damaged. The Fraxel re:pair laser does hurt more because of this, and when this is used we use local nerve blocks and extra injected local anesthesia. We may also give you oral or injectable pain medicines, but you will be wide awake with no other sedation needed. Fraxel re:pair has thus positioned itself between the Fraxel re:store and the traditional CO2 laser. What are the differences?

The Fraxel re:store is best used for minor, shallow, or superficial acne or chickenpox scarring and abnormal pigmentation. It can also be used in a triple pass for wrinkling, particularly on the upper lip and/or around the mouth or below the eyes. Because this is a somewhat gentler treatment, we recommend (one, two, three or more) separate treatments spaced a month apart. The fees quoted below will apply to EACH treatment. Unlike salons that charge you thousands of dollars up front for a “package” - we won’t do that. You may pay as you go, and each treatment will make a visible difference! If you are satisfied with results of just one treatment, you are welcome to stop there. In fact, our patients are usually so satisfied with the first treatment, they want to go ahead and do the second and third if necessary. In patients with deeper scars or wrinkles, it is often best to plan on three or even four treatments as described above. Because the Fraxel re:store is gentler than the Fraxel re:pair, you will simply have what looks like a mild red sunburn when you leave our office. The redness will be visible, but you won’t be weeping, bloody, or otherwise oozing at all. Although you could go back to work, we do recommend going home with some ice packs and just relaxing. Some patients could literally go back the next day with just mild sunburn appearance, or if done on a Wednesday you could certainly plan on going back to work the following Monday with your make up on. The Fraxel re:pair uses the CO2 laser to produce the identical pattern and nature of these microthermal treatment zones, but now the penetration is deeper. The Fraxel re:pair is recommended for more serious or deeper scarring, or deeper wrinkles. Generally, this deeper penetration does produce more pain, and this procedure is performed by Dr. Coverman or Allison Martin. We will give you a series of local nerve blocks to blunt that pain, and then inject a solution of dilute Lidocaine all over the rest of your face. We may also give you a shot of Demerol and oral Valium or Xanax. You will still be wide awake and able to talk to us, but we do ask you to have someone drive you home.

The advantage of the Fraxel re:pair is that generally you will only need one treatment but the down time may be up to two weeks rather than one. Still, however, some people are completely recovered in one week and ready to apply make-up and/or go back to work.

Both of these procedures are dramatically easier to tolerate than the original CO2 resurfacing and there is measurably less risk and less down time.

At your original consultation with Dr. Coverman or our staff, we will determine which of these two lasers might be best for you, and this discussion will include your medical history, the type of scarring or pigmentation or wrinkles that we are trying to correct, your type of skin, your pain tolerance, and your work, travel, business, and social schedule. We are flexible and this will be an interactive discussion. We will all discuss what is best for YOU but whichever you choose, you will benefit.

Fraxel re:store™ resurfacing can be used to treat the following:

Neck and décolleté
Photoaging
Skin resurfacing
Hands
Freckles anywhere
Scarring
Acne scarring

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FEES

Our fee is all inclusive that includes pre-operative care, the treatment itself, and extensive, close and careful post-operative monitoring. These fees are PER SESSION - EACH SUBSEQUENT SESSION REQUIRES A FULL FEE.

All fees are subject to change. The fee is always what is current at the time of your actual treatment. Old fee schedules, handouts, or web site fees do not apply. Any quoted fees must be in writing and are only good for six months. No “verbal” quotes are accepted.

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SPECIAL PRICING

We do offer “packages” of four prepaid treatments for full face treatments only. The fee per treatment is reduced, so the overall price is less. This is the most economical way to get the best results. Please ask our aestheticians or staff.

If you do not complete the full number of prepaid sessions for any reason, there will be a refund. Each of those used sessions will be deducted from that refund, but only at the full, normal, “single session” price.

If you have purchased a “package,” the package must be started within three months and then finished within six months of starting. After that, any future or uncompleted sessions are always at the then current single session price. We do this because our costs of consumables rises after six months.

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ALTERNATIVES

There are many alternatives for the treatment of wrinkles, pigmentary abnormalities, and/or scars. This can include the injection of Botox for wrinkles, the injection of various “fillers” for wrinkles and scars, and various peels and topical products including Retin A or Renova for all of the above plus for pigmentary problems. Some patients want “tightening”, and although there will be some of this, if a real face lift is desired, then one should consult with a plastic surgeon and discuss getting a traditional facelift. One can use acid peels such as TCA or Obagi blue peels, but these have their own similar risks and side effects. Microdermabrasion is another alternative but typically, even with multiple sessions, that will not approach the efficacy of fractional resurfacing.

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SCHEDULING

A visit with our staff is required. If you are seeing us for pigment, mild wrinkling or scarring, or general mild retexturing or resurfacing, we will have you see our aestheticians, Christi Gonzales or Tammy Hunt. Please indicate this to our front office staff when you call.

Because there will be obvious inflammation and redness, please plan your school, social, travel, and business calendars around this. You may certainly return to school or work the next day - you will be red but not necessarily weeping, oozing, or blistering. It will look like a sunburn. After that there may be a period of obvious peeling and flaking - depending upon your work circumstances, there is no reason you couldn’t be back at work even with this.

There is a $150 non-refundable fee for missed appointments without a 24 hour notice. If you need to cancel, please record the date, time, and name of the person you spoke with.

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PRETREATMENT

If you have ever had herpes or think you may have (cold sores or fever blisters), inform Dr. Coverman or our staff prior to scheduling your appointment. We will give you a series of anti-herpes pills to take the day before the treatment, the day of, and day after. This should help to suppress or prevent herpes from flaring, but there are no guarantees. A herpes flare could cause pain, pigment, infection, and scarring.

Stop all Retin A, acne, and “anti-aging” creams for five days before the procedure.

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TREATMENT DAY

Just prior to the treatment we will call you back and wipe off the numbing cream. You may feel a warm sensation, and in some cases, despite adequate cream you may feel a somewhat unpleasant tingling or burning sensation. Normally this is completely tolerable, but if at any point you find this is not so, we certainly encourage you to tell us and we can inject a local anesthetic. We will be making three passes over your face at 90 degrees each time and the treatment wand literally “rolls” over your skin. During this time, a very precise pattern of MTZ’s will be laid down and the computer figures all of this out. Technically it is very easy to perform and you don’t have to do anything but lay there.

The actual procedure takes about 30 minutes. You will be wide awake. You can talk to us during the procedure.

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POST TREATMENT

At the conclusion of the procedure we recommend that you go right home and stay out of the sun that day and the next. No prolonged sun exposure for two weeks after procedure. We recommend you apply a sun block when you leave and certainly for the next two weeks. We recommend our Elta SPF 41 Physical Sunblock. It is CHEMICAL FREE, won’t burn or sting, and actually helps healing. Wear broad brimmed hats rather than baseball caps and use common sense. Avoid the sun and sunburn! Do not use any other products other than what we gave you for healing - certainly no anti-aging products which may contain Retin A or alpha-hydroxy acids which will burn and sting.

For general comfort we recommend Elta Hydrovase Gel for two days.

You will experience a mild sunburn sensation for 1-2 hours afterward. You may notice redness and swelling which will resolve in 2-3 days. This is normal. Your skin will have a pinkish tone for 5-7 days after that. New epidermal skin will be developing immediately, usually within the first 24 hours. This repair involves:

Bronzing - Your skin may have a bronze appearance for 3-14 days.
Flaking - Your skin will naturally and vigorously exfoliate as the reorganized skin replaces dead tissue. Flaking is similar to a mild sunburn but without the pain.

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POST-TREATMENT PAIN

For normal post-operative pain following most of the procedures that we perform in our office, we do not recommend nor prescribe any of the stronger pain medicines including hydrocodone (Lortab; Darvocet N100; Mepergan Fortis; Ultram). We feel that a combination described below of over-the-counter medicines will be enough. This is what we recommend:

Take one Aleve or Advil pill every 4-6 hours with food. Wash it down well with liquid. Breakfast, lunch, dinner and bedtime snack.
Do not take Aleve or Advil if you are allergic to aspirin, ibuprofen, naproxin, these pills, or have any type of aspirin sensitivity or the syndrome of nasal polyps, allergies, atopic eczema, and aspirin-allergy. Likewise, do not take this if you have any bleeding problems, or have ever had any ulcer disease or similar stomach disease.
We also recommend that you take two Extra Strength (500 mg) Tylenol tablets every 4-6 hours as well at the same time.
Please remember that the side effects of Tylenol have nothing to do with the side effects of Aleve or Advil, thus these may be taken together.
If you have any liver disease or potential liver problems, do not take the Tylenol. Do not take Tylenol if you are allergic to it or acetaminophen. DO NOT DRINK ALCOHOL WITH THIS REGIMEN!

Otherwise, follow the schedule below:

8:00 a.m. - Breakfast
- One Aleve or Advil with breakfast and plenty of water.
- Two 500 mg Tylenol for adults.
Noon to 2:00 p.m. - Lunch
- One Aleve or Advil with lunch and plenty of water.
- Two more 500 mg Tylenol
6:00 p.m. - Dinner
- One Aleve or Advil with dinner and plenty of water.
- Two more Tylenol.
10:00 p.m. to midnight - Bedtime
- One Aleve or Advil at bedtime and plenty of water.
- Two more Tylenol
- Benadryl (diphenhydramine) 25-50 mg for sleep.

The Benadryl is a great idea. It is the main component of most over-the-counter sleeping pills. (Tylenol PM), and is not addicting. Never drink alcohol before or with this, and plan on going right to sleep and sleeping 8 hours. DO NOT take with any other sleeping pill, anti-depressant, MAO inhibitor, or anti-anxiety drug (Xanax, Valium, etc.). Do not drive or operate dangerous equipment.

Thus, in any given day you should never take more than the total of four Advil or Aleve or eight Tylenol total (two every four to six hours).

Normally you should be able to safely do this for one to three days - but never more. If the pain ever worsens or this fails to control it - call our office during normal office hours or the medical exchange (458-1121) after hours.

This combination of Aleve or Advil plus Tylenol is safe, covers you around the clock, and allows you to take two different pain medicines whose side effects don’t cross react with each other assuming you are not allergic to either.

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COMPLICATIONS

Any laser treatment, and any attempt at resurfacing the skin whether by laser, peels, Retin A and so forth is ablative. Technically this is a “burn” to the superficial layers of your skin, but with Fraxel re:store™ it is a controlled burn and only 20% of your skin is treated at any one time. Still however there could be pigmentary changes (whether lighter or darker), mottled pigmentation, scarring, flare of underlying herpes, or infection. There is no guarantee of what percentage of improvement there will be in your underlying condition per area, per treatment session, or overall after all treatment sessions. There is the rare chance of hair loss in the treated areas, and there may be a line of demarcation between the treated areas and the untreated areas. Actually, one of the beauties of fractionated resurfacing is the likelihood of this line of demarcation being dramatically less than with the CO2 laser or any peel.

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FOLLOW-UP

If you haven’t already scheduled your full series of treatments, please do so as you leave each visit. It is best to finish this treatment on a predetermined schedule. Again, we recommend Elta UV Physical 41 sunscreen by itself if you simply must be out in the sun for prolonged periods of time, but otherwise we prefer you stay indoors as much as possible.

The following regimen is highly recommended:

Dove Beauty Bar or other extremely mild soap.
No acne, aging, or any other over-the-counter creams or soaps, astringents and so forth for at least one week afterwards.

If anything doesn’t seem right - CALL US! If there is weeping, oozing, or excess redness or discomfort, please call us. If it is after hours you may reach Dr. Coverman or Allison Martin through the Medical Exchange at 458-1121

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