Journal of Cosmetic and Laser Therapy

ISSN: 1476-4172 (Print) 1476-4180 (Online) Journal homepage: https://www.tandfonline.com/loi/ijcl20

Stimulation of collagen and elastin production in-

vivo using 1,540 nm Er:Glass laser: assessment of
safety and efficacy

Uwe Paasch & Tamer Said

To cite this article: Uwe Paasch & Tamer Said (2020): Stimulation of collagen and elastin
production in-vivo using 1,540 nm Er:Glass laser: assessment of safety and efficacy, Journal of
Cosmetic and Laser Therapy, DOI: 10.1080/14764172.2020.1728339

To link to this article: https://doi.org/10.1080/14764172.2020.1728339

Published online: 21 Feb 2020.

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JOURNAL OF COSMETIC AND LASER THERAPY
https://doi.org/10.1080/14764172.2020.1728339

Stimulation of collagen and elastin production in-vivo using 1,540 nm Er:Glass laser:
assessment of safety and efficacy
Uwe Paascha and Tamer Saidb
a
Department of Dermatology, Venereology and Allergology, University of Leipzig, 04103 Leipzig, Saxony, Germany; bDepartment of Dermatology,
Venereology and Andrology, Faculty of Medicine, Alexandria University, Alexandria, Egypt

ABSTRACT ARTICLE HISTORY

Introduction: Induction of collagen and elastin remodeling in the human skin can be achieved by non- Received 6 December 2018
ablative fractional laser (NAFXL) and ablative fractional laser (AFXL). Our objective was to compare the Revised 20 July 2019
safety, efficacy, tolerability, and ability to induce collagen and elastin remodeling of NAFXL versus AFXL Accepted 6 February 2020
in a series of treatments over time. KEYWORDS
Materials and Methods: In this prospective, proof of principle, single-case study, the safety, tolerability Laser; 140 nm; 10600 nm;
and efficacy of the laser systems were assessed via histopathology and clinical evaluations including ablative; non-ablative;
photographs. Optical biopsies by means of multiphoton tomography (MPT) were used to evaluate the fractional; collagen; elastin;
induction of collagen and elastin remodeling. remodeling; multi-photon
Results: Treatments by both NAFXL and AFXL were well tolerated. The NAFXL system was found to be tomography; optical biopsy
less painful and resulted in a shorter down- and healing times. MPT findings showed the superior
capability of the AFXL procedure to induce collagen; on the other hand, elastin induction was more
pronounced after NAFXL treatments.
Conclusions: While NAFXL is as effective and safe as the traditional AFXL, it is better tolerated and has
a shorter downtime. Serial optical biopsies over time over time can be a useful tool to assess the
induction of collagen and elastin remodeling in the human skin.

Introduction The characteristics of post-NAFXL and -AFXL spatio-

temporal wound healing have been thoroughly described (7–9).
In the aging population, there is an increasing demand for
On the cellular level, post-fractional wound healing is defined by
minimally invasive treatments that can preserve or improve
a stereotypical sequence of events that are triggered by the activa-
the skin smoothness and tonicity. Several rejuvenation treat-
tion of heat shock proteins (HSP) within the remaining keratino-
ments have been used with varying success in an attempt to
cytes (10). The sequence culminates after three days with the
reverse the dermal and epidermal signs of photo- and chron-
active expulsion of the pigmented irreparable tissue parts (micro-
ological aging (1). The relatively recent introduction of frac-
scopic epidermal necrotic debris, MEND) [1]. Thereafter, dermal
tional laser technology, specifically fractional ablative lasers
remodeling occurs including the removal of existing scar tissue
(AFXL), showed a significant potential in this regard (2,3).
and the induction of collagen and elastin production (11).
On the other hand, non-ablative fractional lasers (NAFXL)
Additionally, HSP70 plays a role in inducing the expression of
therapies are also used in the routine clinical practice to treat
growth factors, such as transforming growth factor-β (TGFβ),
several dermatological conditions; most commonly scar revi-
which is a key element in wound healing (12–15). In total, the
sion (4). Scar improvement was unambiguously demon-
dermal cellular regeneration processes take three months or
strated in a randomized, controlled, split wound study in
longer to materialize (7,16,17).
which NAFXL treatments were applied before and after
Although NAFXL and AFXL systems are currently stan-
surgery (5).
dardized for multiple clinical indications (18), the comparison
AFXL lasers lead to the ablation of the epidermis and
between both systems, including the various laser parameters
dermal wounding accompanied by a significant thermal effect,
and their performance in specific clinical conditions remains
whereas NAFXL mainly exert their effects by applying focused
challenging. Moreover, invasive studies are still needed to
thermal damage while keeping the epidermis intact (6). By
investigate subcellular mechanisms of efficacy and safety
treating the skin in fractions that are smaller than ~0.3 mm in
(19). Novel optical technologies such as optical coherence
diameter, a reaction that involves up to 50% of the skin sur-
tomography (OCT) and reflectance confocal microscopy
face replacing itself is initiated. The columns of treated skin
(RCM) can provide descriptive morphology which is compar-
can reach as deep as the dermal compartment and are called
able to histopathology examinations. In support, both OCT
microscopic treatment zones (MTZ) or microscopic ablation
and RCM successfully described the spatiotemporal closure of
zones (MAZ).
fractional laser-ablated channels in the epidermis and upper

CONTACT Uwe Paasch uwe.paasch@medizin.uni-leipzig.de Department of Dermatology, Venereology and Allergology, University of Leipzig, Philipp-
Rosenthal-Strasse 23, Leipzig, Saxony 04103, Germany.
© 2020 Taylor & Francis Group, LLC
2 U. PAASCH AND T. SAID
dermis (20). Most recently, the concepts of near infrared
femtosecond laser technology and multiphoton tomography
(MPT) were used to develop an in-vivo optical biopsy system.
MPT performs measurements in a contact free manner and
delivers results that are comparable to standard histopathol-
ogy. Therefore, it represents a high-resolution tool that can be
used for the quantitative assessment of skin structures (21).
The aims of this study were (A): to assess the safety,
tolerability and efficacy of a new NAFXL, 1,540 nm Er:Glass
in comparison with an established AFXL, 10,600 nm CO2
using standard laser parameters, and (B) to evaluate if both
of these laser systems are able to induce collagen and elastin
remodeling by means of optical skin biopsies using MPT.
Materials and methods
A 50-years old male with Fitzpatrick skin type II was the
subject of this prospective, proof of principle, single case
study. The study protocol conformed to the ethical guidelines
of the 1975 Declaration of Helsinki. Additionally, the patient
provided a written informed consent to participate in the trial.
Histopathology of ex–vivo human skin was initially con-
ducted to evaluate the safety of the NAFXL Er:Glass
1,540 nm laser. Both laser systems were compared in terms
tolerability and efficacy of by means of clinical evaluations
including pre- and post-photographs and optical biopsies to
evaluate the induction of collagen and elastin remodeling.
Skin explants and histopathology workup
Human skin ex–vivo explants obtained from consented
patients who underwent previous, unrelated dermatological
surgery were used to test the safety of the NAFXL Er:Glass
1,540 nm laser. The average diameter of the skin explants was
3 mm. The applied laser settings were 1,540 nm 10 mm spot
size, and (a): 900 mJ/pulse, 3 stacks, total 2,700 mJ (b), 1,500
mJ/pulse, 3 stacks, total 4,500 mJ, and (c) 1,500 mJ/pulse, 5
stacks, total 7,500 mJ. Each skin sample was immediately fixed
using 4% buffered formalin. Thereafter, skin explants were
embedded into paraffin, sectioned into 4 μm to 6 μm thick
Figure 1. Study subject left forearm. Treatment areas were labeled: (a) 36 days, (b) 28 days, (c) 14 days, and (d) 1 day prior to MPT evaluation. Nevi were used as
landmarks.
slices and stained with hematoxylin and eosin according to an
in-house routine protocol. Biopsies were evaluated under
a calibrated microscope (BX41, Olympus Germany,
Hamburg, Germany) equipped with a digital camera (DP70,
Olympus Germany, Hamburg, Germany). Lesion dimensions
were measured using calibrated CellF software (Olympus
Germany, Hamburg, Germany).
Laser procedures
In preparation for the study, the patient was instructed to
protect the targeted skin areas from natural and artificial UV
radiation for 4 weeks prior to the treatment. All procedures
were performed by a board-certified dermatologist and no
topical or local anesthesia was used. NAFXL, 1,540 nm Er:
Glass laser and AFXL, 10,600 nm, CO2 laser were applied in
a series of parallel treatments over time (days 36, 28, 14, and 1
before MPT). All laser treatments were applied to the left
forearm in fixed designated areas to allow consistent follow
up throughout the study (Figure 1). Following each treatment,
the patient was instructed to use cooling packs on the treated
areas as needed.
The standard AFXL treatments were applied using
a 10,600 nm CO2 laser (Pixel CO2, Alma Lasers Ltd,
Caesarea, Israel). The laser settings used were: spot size
250 µm, pulse duration 1 ms, fluence 40 mJ/pixel, density 4,
1 pass, square grid. For NAFXL treatments, a novel 1,540 nm
Er:Glass laser was used (Harmony XL Pro, Alma Lasers Ltd,
Caesarea, Israel). The laser settings used were 7 × 7 pixel tip,
1,500 mJ/pulse, 91.8 mJ/pixel, 3 sub-pulses, 2 passes, cooling
100% and vacuum off. A plume evacuation system was used
during all laser procedures (TBH 100, TBH GmbH,
Straubenhardt, Germany).
Clinical evaluations
Pain was quantified by the physician using a 1–10 visual analog
scale (VAS), where 0 = no pain and 10 = worst pain ever. Skin
edema was clinically evaluated using a 0–4 scale, where 0 = no
edema, 1 = very slight, 2 = well defined, 3 = moderate to severe,
 JOURNAL OF COSMETIC AND LASER THERAPY 3

and 4 = severe (beef red) to eschar formation. Similarly, skin settings revealed no immediate signs of skin damage neither
erythema was clinically evaluated using a 0–4 scale, where 0 = no at the epidermal nor at the dermal compartment (Figure 2).
erythema, 1 = very slight, 2 = well defined (definite raising),
3 = moderate (~ 1mm), and 4 = severe (more than 1 mm and
extending beyond the target area).
The skin appearance including edema and erythema as Clinical evaluations
assessed at baseline, before each treatment and at each follow- Direct clinical comparisons revealed lower pain levels as well
up visit using 3D imaging (Vectra M1, Canfield, USA) and as a much shorter downtime with the 1,540 nm Er:Glass laser
macrophotography (Nikon D70, lens Micro Nikkor 60 mm). compared to the 10,600 CO2 laser (Table 1). Similarly, skin
The video camera of the DermoGenius Ultra system edema and erythema were much less pronounced following
(DermoScan GmbH, Regensburg, Germany) was used to cap- the 1,540 nm Er:Glass laser compared to the 10,600 CO2 laser
ture ultra-high density (2592 x 1944 pixel) images of the (Tables 2 and 3, Figure 3).
treatment areas with 12-fold magnification, allowing the ana- Dermoscopic examination revealed a subtle difference
lysis of an area of 0.592 cm2. Perifollicular edema and between the two laser systems, no significant damage to the
erythema were also documented by the DermoGenius system. skin was seen after the 1,540 nm laser treatment, while the
AFXL procedure resulted in accentuated ablative areas
(Figure 4). Wound healing and down time were lesser fol-
Optical biopsy
lowing the NAFXL treatments compared to the AFXL-
Optical biopsies were performed by using the MPTflex™ system treated areas (Figure 5).
(JenLab, Saarbruecken, Germany). The MPTflex™ is a tomography
device based on femtosecond multiphoton excitation of fluores-
cent biomolecules like NAD(P)H, flavins, porphyrins, elastin, and
melanin. The extracellular matrix protein, collagen, may be iden- Multiphoton Tomography (MPT)
tified by its interaction with photons, termed as second harmonic An intense induction of collagen at the MAZ was noted at
generation (SHG). Autofluorescence and SHG signals are simul- the site of the AFXL, 10,600 nm CO2 laser 28 days post-
taneously recorded by fast detectors with single photon sensitivity. intervention. On the other hand, an intense induction of
The tomograph consists of a turn-key tunable femtosecond near collagen and even more remarkably elastin was noted at
infrared (NIR) laser, an articulated arm with NIR optics, a beam the site of the NAFXL, 1,540 nm Er:Glass-laser at 28 post-
module with Galvano scanners and piezo driven optics. The intervention (Figure 6).
system also includes a two-photomultiplier (PMT)-detector mod-
ule and a control unit which includes the JenLab image processing
software. Table 1. Results of pain score at each treatment area.
MPT images (20–92 tomograms each) were captured at 28, 36 Days 28 Days 14 Days 1 Day
14, and 1 days following the laser interventions from each CO2 (10,600 nm) 6 4 5 6
Er:Glass (1,540 nm) 3 2 2 3
treatment site and simultaneously from a comparable
untreated control area on the right forearm. Artifactual
colored overlays of two signals were used to demonstrate the
Table 2. Clinical evaluation results of edema using standardized 0–4 scale.
morphological structures of the dermal layers. This enabled
36 Days 28 Days 14 Days 1 Day
the detection of the autofluorescence of elastin and collagen
CO2 (10,600 nm) 0 0 0 4
crosslinks (green) and collagen SHG-signal (red). Er:Glass (1,540 nm) 0 0 0 1

Results
Table 3. Clinical evaluation results of erythema using standardized 0–4 scale.
In-vitro safety evaluation 36 Days 28 Days 14 Days 1 Day
Histopathological assessments of skin explants following CO2 (10,600 nm) 0 0 1 4
Er:Glass (1,540 nm) 0 0 0 2
NAFXL, 1,540 nm Er:Glass laser interventions at various

Figure 2. Standard histopathological evaluation (20x) of 3 mm human skin explants exposed to Harmony XL Pro 1,540 nm showing no evidence of epidermal or
dermal damage after three different set of parameters: (a) 900mJ/Pulse 3 Stacks = 2700J; (b) 1500mJ/Pulse 3 Stacks = 4500J; (c) 1500mJ/Pulse 3 Stacks = 4500J.
4 U. PAASCH AND T. SAID
Figure 3. Treatment areas visualized using Vectra M1, 3D camera, vascular filter.
(a) before laser intervention, (b) 10 min post laser interventions: left clearly
visible erythema post CO2 laser application, right small area with less pro-
nounced erythema post 1,540 nm Er:Glass NAFXL treatment.
Discussion
Since its introduction in 2004, NAFXL has become a widely
established treatment tool in the clinical dermatology practice.
NAFXL treatments are followed by distinguished healing features,
which include a short downtime and a low incidence of side effects
and complications (6). However, the limitation of their clinical
therapeutic effects led to the widespread use of AFXL as a more
efficient alternative. Nevertheless, AFXL is, in contrast, character-
ized by a prolonged wound healing time and marked risks of side
effects and complications (22).
In general, the determination of clinical efficacy of a laser
treatment by means of visual inspection, VAS, photography,
3D-imaging, dermoscopy, and profilometry is subjective and
prone to bias. To date, histopathology assessment remains the
golden standard for the tracking of epidermal and dermal
remodeling and the semi-quantitative analysis of collagen
and elastin production. However, since the approach is inva-
sive, it lacks the ability to monitor and follow up wound
healing over time. In order to address this limitation, novel
Figure 4. Treatment areas as visualized by dermoscopy 10 minutes following the
application of lasers. (a) Post 1,540 nm Er:Glass laser interventions with no visible
signs of skin damage, (b) Post 10,600 nm CO2 laser interventions with clearly
ablation zones.
optical technologies such as OCT and RCM have been sug-
gested as alternatives that could be used to investigate differ-
ent physiological and pathological skin conditions (23,24).
OCT provides a horizontal stack-wise analysis with limited
resolution depth (23), while RCM delivers vertical orientated
pictures with higher penetration depth (25).
In general, noninvasive skin imaging techniques still bear
limitations. The penetration depth and image resolution are
inversely correlated. OCT can penetrate as deep as 2 mm, but
the resolution restricted to 4–10 µm, which imposes a limita-
tion on the assessment quality of deeper skin structures
(26,27). Conversely, RCM has a penetration depth that is
limited to the papillary dermis (0.2 mm) and a high resolution
(1 µm) (28). Similar to RCM, the MPT device used in our
study had a penetration depth of 0.2 mm and a resolution of
<2 µm. Nevertheless, MPT is hypothesized to provide better
visualization of collagen and elastin fibers due to its ability to
capture SHG and autofluorescence signals respectively and
the subsequent demonstration of this information in the
form of artificial colors. The main applications of MPT are
the early detection of skin neoplasia, inflammatory skin con-
ditions and analysis of the skin structures on a subcellular
level, specifically, collagen and elastin (29–32). The system

Figure 5. Wound healing over time: (a) post 1,540 nm Er:Glass 17 days (left),
9 days (middle), and 4 days (right); (b) post 10,600 nm CO2 17 days (left), 9 days
(middle), and 4 days (right).
allows noninvasive, contact free skin visualization with
a resolution that is comparable to the standard histopathology
(33). Since it produces additional information regarding the
collagen and elastin, the skin age and wound healing pro-
cesses can be evaluated by measuring the collagen and elastin
ratio of the skin (34).
Figure 6. MPT horizontal sections showing an artifactual colored overlay of two signals which demonstrates morphological structures of dermal layers: autofluor-
escence of elastin and collagen crosslinks (green) and collagen SHG-signal (red). (a) control untreated area captured at 28 days post-intervention; (b) the site of the
NAFXL, 1,540 nm Er:Glass laser 28 days post-intervention. There is more pronounced elastin induction in addition to an intense and balanced induction of collagen;
(c) the site of the AFXL, 10,600 nm CO2-laser 28 days post-intervention. There is a intense induction of collagen at the typical microsocpic ablation zone.
JOURNAL OF COSMETIC AND LASER THERAPY 5
The immediate effects of the AFXL device used in our
study have been previously assessed by histopathology.
Significant tissue evaporation and coagulation have been
demonstrated following the Pixel 10,600 CO2 laser (35).
To the best of our knowledge, no similar published data
were reported for the NAFXL device. In this study, stan-
dard histopathology following NAFXL, 1,540 nm Er:Glass
laser interventions showed no immediate signs of skin
damage neither at the epidermal nor at the dermal com-
partment. Thus, the safety of the device can be argued.
Similarly, 3D imaging, macro-photography and video der-
moscopy confirmed the absence of immediate skin damage
following the NAFXL, 1,540 nm laser treatments. Our find-
ings are in accordance with other published reports that
document the safety and efficacy of NAFXL treatments
(36,37). In terms of tolerability, the NAFXL, 1,540 nm
laser interventions were characterized by a much lower
pain level and a much shorter downtime compared to the
AFXL CO2 laser interventions.
As regards the wound healing sequence over time, we
report for the first time an intense collagen induction at the
site of the typical MAZ post-intervention using an AFXL,
10,600 nm CO2 laser. The same was reported for the
NAFXL, 1,540 nm NAFXL Er:Glass-laser in addition to
a more accentuated induction of elastin. Collectively,
these findings may illustrate the superior capability of the
AFXL treatments to induce collagen, while more elastin
seems to be present after NAFXL treatments. If this
hypothesis can be confirmed, an early intervention that
combines both AFXL and NAFXL will offer a potential
strategy to induce collagen and elastin and subsequently
the reduction of skin aging, scarring and the promotion
of wound healing. Notwithstanding the clear distinction
between patterns of collagen and elastin induction follow-
ing AFXL and NAFLX, our observations are limited due to
the lack of quantitative autofluorescence signal data.
NAFXL laser intervention is, at minimum, not inferior in
terms of collagen and elastin induction compared to AFXL. It
does however has the advantage of a much lower pain,
6 U. PAASCH AND T. SAID
downtime and frequency of side effects. Conceptually,
1,540 nm NAFXL Er:Glass laser proved to be safe and effective
for the stimulation of collagen and elastin induction as mea-
sured for the first time by MPT-based optical skin biopsies.
Funding
Uwe Paasch received unrestricted research grants from and serves as
consultant for Alma Lasers Ltd, Caesarea, Israel.
References
1. Helbig D, Simon JC, Paasch U. Epidermal and dermal changes in
response to various skin rejuvenation methods. Int J Cosmet Sci.
2010;32:458–69. doi: 10.1111/j.1468-2494.2010.00573.x.
2. Hantash BM, Bedi VP, Kapadia B, Rahman Z, Jiang K, Tanner H,
Chan KF, Zachary CB. In vivo histological evaluation of a novel
ablative fractional resurfacing device. Lasers Surg Med.
2007;39:96–107. doi: 10.1002/lsm.20468.
3. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR.
Fractional photothermolysis: a new concept for cutaneous remo-
deling using microscopic patterns of thermal injury. Lasers Surg
Med. 2004;34:426–38. doi: 10.1002/lsm.20048.
4. Ong MW, Bashir SJ. Fractional laser resurfacing for acne scars: a
review. Br J Dermatol. 2012;166:1160–69. doi: 10.1111/j.1365-
2133.2012.10870.x.
5. Karmisholt KE, Wenande E, Thaysen-Petersen D, Philipsen PA,
Paasch U, Haedersdal M. Early intervention with non-ablative
fractional laser to improve cutaneous scarring-A randomized con-
trolled trial on the impact of intervention time and fluence levels.
Lasers Surg Med. 2018;50:28–36. doi: 10.1002/lsm.22707.
6. Goldberg DJ. Lasers for facial rejuvenation. Am J Clin Dermatol.
2003;4:225–34. doi: 10.2165/00128071-200304040-00002.
7. Helbig D, Bodendorf MO, Grunewald S, Kendler M, Simon JC,
Paasch U. Immunohistochemical investigation of wound healing
in response to fractional photothermolysis. J Biomed Opt.
2009;14:064044. doi: 10.1117/1.3275479.
8. Helbig D, Mobius A, Simon JC, Paasch U. Heat shock protein 70
expression patterns in dermal explants in response to ablative
fractional phothothermolysis, microneedle, or scalpel wounding.
Wounds. 2011;23:59–67.
9. Makowski AJ, Davidson JM, Mahadevan-Jansen A, Jansen ED. In
vivo analysis of laser preconditioning in incisional wound healing
of wild-type and HSP70 knockout mice with Raman spectroscopy.
Lasers Surg Med. 2012; 44:233–44. doi: 10.1002/lsm.22002.
10. Helbig D, Paasch U. Molecular changes during skin aging and
wound healing after fractional ablative photothermolysis. Skin Res
Technol. 2011;17:119–28. doi: 10.1111/j.1600-0846.2010.00477.x.
11. Ozog DM, Liu A, Chaffins ML, Ormsby AH, Fincher EF,
Chipps LK, Mi QS, Grossman PH, Pui JC, Moy RL. Evaluation
of clinical results, histological architecture, and collagen expres-
sion following treatment of mature burn scars with a fractional
carbon dioxide laser. JAMA Dermatol. 2013;149:50–57. doi:
10.1001/2013.jamadermatol.668.
12. Arany PR, Nayak RS, Hallikerimath S, Limaye AM, Kale AD,
Kondaiah P. Activation of latent TGF-beta1 by low-power laser
in vitro correlates with increased TGF-beta1 levels in
laser-enhanced oral wound healing. Wound Repair Regen.
2007;15:866–74. doi: 10.1111/j.1524-475X.2007.00306.x.
13. Barcellos-Hoff MH, Dix TA. Redox-mediated activation of latent
transforming growth factor-beta 1. Mol Endocrinol.
1996;10:1077–83. doi: 10.1210/mend.10.9.8885242.
14. Kilani RT, Guilbert L, Lin X, Ghahary A. Keratinocyte condi-
tioned medium abrogates the modulatory effects of IGF-1 and
TGF-beta1 on collagenase expression in dermal fibroblasts.
Wound Repair Regen. 2007;15:236–44. doi: 10.1111/j.1524-
475X.2007.00210.x.
15. Munger JS, Huang X, Kawakatsu H, Griffiths MJ, Dalton SL,
Wu J, Pittet JF, Kaminski N, Garat C, Matthay MA, et al. The
integrin alpha v beta 6 binds and activates latent TGF beta 1:
a mechanism for regulating pulmonary inflammation and fibrosis.
Cell. 1999;96:319–28.
16. Kilmer SL, Chotzen VA, Silva SK, McClaren ML. Safe and effec-
tive carbon dioxide laser skin resurfacing of the neck. Lasers Surg
Med. 2006;38:653–57. doi: 10.1002/lsm.20399.
17. Rahman Z, MacFalls H, Jiang K, Chan KF, Kelly K, Tournas J,
Stumpp OF, Bedi V, Zachary C. Fractional deep dermal ablation
induces tissue tightening. Lasers Surg Med. 2009;41:78–86. doi:
10.1002/lsm.20715.
18. Bogdan Allemann I, Kaufman J. Fractional photothermolysis–an
update. Lasers Med Sci. 2010;25:137–44. doi: 10.1007/s10103-009-
0734-8.
19. Haedersdal M, Erlendsson AM, Paasch U, Anderson RR.
Translational medicine in the field of ablative fractional laser
(AFXL)-assisted drug delivery: A critical review from basics to
current clinical status. J Am Acad Dermatol. 2016;74:981–1004.
doi: 10.1016/j.jaad.2015.12.008.
20. Banzhaf CA, Wind BS, Mogensen M, Meesters AA, Paasch U,
Wolkerstorfer A, Haedersdal M. Spatiotemporal closure of frac-
tional laser-ablated channels imaged by optical coherence tomo-
graphy and reflectance confocal microscopy. Lasers Surg Med.
2016;48:157–65. doi: 10.1002/lsm.22386.
21. Cicchi R, Kapsokalyvas D, Pavone FS. Clinical nonlinear laser
imaging of human skin: a review. Biomed Res Int. 2014;1–14.
doi:10.1155/2014/903589.
22. Borges J, Manela-Azulay M, Cuzzi T. Photoaging and the clinical
utility of fractional laser. Clin Cosmet Investig Dermatol.
2016;9:107–14. doi: 10.2147/CCID.S77996.
23. Gambichler T, Jaedicke V, Terras S. Optical coherence tomogra-
phy in dermatology: technical and clinical aspects. Arch Dermatol
Res. 2011;303:457–73. doi: 10.1007/s00403-011-1152-x.
24. Puig S. A new era in melanoma. Dermatol Ther. 2012;25:389–91.
doi: 10.1111/j.1529-8019.2012.01529.x.
25. Moscarella E, Rabinovitz H, Oliviero MC, Brown L, Longo C,
Zalaudek I, Piana S, Farnetani F, Lallas A, Argenziano G, et al.
The role of reflectance confocal microscopy as an aid in the
diagnosis of collision tumors. Dermatology. 2013;227:109–17.
26. Mogensen M, Thrane L, Joergensen TM, Andersen PE, Jemec GB.
Optical coherence tomography for imaging of skin and skin
diseases. Semin Cutan Med Surg. 2009;28:196–202. doi: 10.1016/
j.sder.2009.07.002.
27. Welzel J, Lankenau E, Birngruber R, Engelhardt R. Optical coher-
ence tomography of the human skin. J Am Acad Dermatol.
1997;37:958–63. doi: 10.1016/s0190-9622(97)70072-0.
28. Rajadhyaksha M, Marghoob A, Rossi A, Halpern AC, Nehal KS.
Reflectance confocal microscopy of skin in vivo: from bench to
bedside. Lasers Surg Med. 2017;49:7–19. doi: 10.1002/lsm.22600.
29. Fink C, Haenssle HA. Non-invasive tools for the diagnosis of
cutaneous melanoma. Skin Res Technol. 2017;23:261–71. doi:
10.1111/srt.12350.
30. Huck V, Gorzelanny C, Thomas K, Getova V, Niemeyer V, Zens K,
Unnerstall TR, Feger JS, Fallah MA, Metze D, et al. From morphol-
ogy to biochemical state - intravital multiphoton fluorescence life-
time imaging of inflamed human skin. Sci Rep. 2016;6:1–12.
31. Tkaczyk E. Innovations and developments in dermatologic
non-invasive optical imaging and potential clinical applications.
Acta Derm Venereol. 2017; (Suppl 218):5–13. doi: 10.2340/
00015555-2717.
32. Warszawik-Hendzel O, Olszewska M, Maj M, Rakowska A,
Czuwara J, Rudnicka L. Non-invasive diagnostic techniques in
the diagnosis of squamous cell carcinoma. J Dermatol Case Rep.
2015;9:89–97. doi: 10.3315/jdcr.2015.1221.
33. Koehler MJ, Zimmermann S, Springer S, Elsner P, Konig K,
Kaatz M. Keratinocyte morphology of human skin evaluated by
in vivo multiphoton laser tomography. Skin Res Technol.
2011;17:479–86. doi: 10.1111/j.1600-0846.2011.00522.x.

34. Koehler MJ, Konig K, Elsner P, Buckle R, Kaatz M. In vivo
assessment of human skin aging by multiphoton laser scanning
tomography. Opt Lett. 2006;31:2879–81. doi: 10.1364/
ol.31.002879.
35. Trelles MA, Shohat M, Urdiales F. Safe and effective one-session
fractional skin resurfacing using a carbon dioxide laser device in
super-pulse mode: a clinical and histologic study. Aesthetic Plast
Surg. 2011;35:31–42. doi: 10.1007/s00266-010-9553-3.
JOURNAL OF COSMETIC AND LASER THERAPY 7
36. Guertler A, Reinholz M, Poetschke J, Steckmeier S, Schwaiger H,
Gauglitz GG. Objective evaluation of the efficacy of a non-ablative
fractional 1565 nm laser for the treatment of deliberate self-harm scars.
Lasers Med Sci. 2018;33:241–50. doi: 10.1007/s10103-017-2348-x.
37. Yang Q, Huang W, Qian H, Chen S, Ma L, Lu Z. Efficacy and
safety of 1550-nm fractional laser in the treatment of acne scars in
Chinese patients: A split-face comparative study. J Cosmet Laser
Ther. 2016;18:312–16. doi: 10.1080/14764172.2016.1188211.