Clinical Procedures in Laser Skin Rejuvenation

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Clinical Procedures in Laser Skin Rejuvenation

Clinical Procedures

in Laser Skin

Rejuvenation


SERIES IN COSMETIC AND LASER THERAPY

Published in association with the Journal of Cosmetic and Laser Therapy

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Clinical Procedures

in Laser Skin

Rejuvenation

Edited by

Paul J Carniol MD FACS

Cosmetic Laser and Plastic Surgery

Summit, NJ

USA

Neil S Sadick MDFAADFAACSFACPFACPh

Sadick Aesthetic Surgery and Dermatology

New York, NY

USA


© 2007 Informa UK Ltd

First published in the United Kingdom in 2007 by Informa Healthcare,Telephone House, 69–77 Paul Street, London EC2A 4LQ. Informa

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be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention.

A CIP record for this book is available from the British Library.

Library of Congress Cataloging-in-Publication Data

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ISBN-10: 0 415 41413 X

ISBN-13: 978 0 415 41413 5

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Contents

List of contributors vii

Note on outcomes x

1 Laser safety 1

William Beeson

2 Evaluation of the aging face 11

Philip J Miller

3 Carbon dioxide laser resurfacing,

Fractional resurfacing and YSGG resurfacing 17

Dee Anna Glaser, Natalie L Semchyshyn and Paul J Carniol

4 Erbium laser aesthetic skin rejuvenation 31

Richard D Gentile

5 Complications secondary to lasers

and light sources 45

Robert M Adrian

6 Nonablative technology for treatment

of aging skin 51

Amy Forman Taub

7 Lasers, light, and acne 69

Kavita Mariwalla and Thomas E Rohrer

8 Treatment of acne scarring 89

Murad Alam and Greg Goodman

9 Nonsurgical tightening 103

Edgar F Fincher

10 Laser treatment of pigmentation

associated with photoaging 111

David H Ciocon and Cameron K Rokhsar

11 Management of vascular lesions 125

Marcelo Hochman and Paul J Carniol

12 Laser treatment for unwanted hair 135

Marc R Avram

13 Non-invasive body rejuvenation

technologies 139

Monica Halem, Rita Patel, and Keyvan Nouri

14 Treatment of leg telangiectasia with

laser and pulsed light 157

Mitchel P Goldman

15 Photodynamic therapy 173

Papri Sarkar and Ranella J Hirsch

16 Adjunctive techniques I: the bioscience of

the use of botulinum toxins and fillers

for non-surgical facial rejuvenation 181

Kristin Egan and Corey S Maas

17 Adjunctive techniques II: clinical aspects

of the combined use of botulinum toxins

and fillers for non-surgical facial rejuvenation 191

Stephen Bosniak, Marian Cantisano-Zilkha,

Baljeet K Purewal and Ioannis P Glavas

18 Adjunctive techniques III:

complementary fat grafting 205

Robert A Glasgold, Mark J Glasgold

and Samuel M Lam

Index 219


Contributors

Robert M Adrian MD FACP

Center for Laser Surgery

Washington, DC

USA

Murad Alam MD

Departments of Dermatology,

Otolaryngology, and Surgery

Northwestern University

Chicago, IL

USA

Marc R Avram MD

Department of Dermatology

New York Presbyterian Hospital-Weill Medical

College at Cornell Medical Center

New York, NY

USA

William Beeson MD AAFPRS AACS

Beeson Aesthetic Surgery Institute

Carmel, IN

USA

Stephen Bosniak † MD

Marian Cantisano-Zilkha MD

Manhattan Eye, Ear and Throat Hospital

New York, NY

USA

Paul J Carniol MD

Cosmetic Laser and Plastic Surgery

Summit, NJ

USA

David H Ciocon MD

Department of Dermatology

Albert Einstein College of Medicine

New York, NY

USA

Kristin Egan MD

Department of Otolaryngology

UCSF

San Francisco, CA

USA

Edgar F Fincher MD PhD

The David Geffen School of Medicine at UCLA

and

Moy-Fincher Medical Group

Los Angeles, CA

USA

Richard D Gentile MD

Facical Plastic and Aesthetic Laser Center

Youngston, OH

USA

Dee Anna Glaser MD

Dermatology Department

St Louis University

St Louis, MO

USA

Mark J Glasgold MD

Department of Surgery

Robert Wood Johnson Medical School

University of Medicine and Dentistry of New Jersey

Piscataway, NJ

USA

Robert A Glasgold MD

Department of Surgery

Robert Wood Johnson Medical School

University of Medicine and Dentistry of New Jersey

Piscataway, NJ

USA


viii List of contributors

Ioannis P Glavas MD

Oculoplastic Surgery

Manhattan Eye, Ear and Throat

New York, NY

USA

Mitchel P Goldman MD

LaJolla Spa

LaJolla, CA

USA

Greg Goodman MD

Department of Dermatology

Minash University

Melbourne

Australia

Monica Halem MD

Department of Dermatology

Miller School of Medicine

University of Miami

Miami, FL

USA

Ranella J Hirsch

Skin Care Doctors

Cambridge, MA

USA

Marcelo Hochman MD

The Facial Surgery Center

Charleston, SC

USA

Samuel M Lam MD

Willow Bend Wellness Center

Lam Facial Plastic Surgery Center and

Hair Restoration Institute

Plano,TX

USA

Corey S Maas MD

Department of Otolaryngology

UCSF

and

The Maas Clinic

San Francisco, CA

USA

Kavita Mariwalla MD

Department of Dermatology

Yale School of Medicine

New Haven, CT

USA

Philip J Miller MD FACS

Department of Otolaryngology

New York University School of Medicine and

The NatraLook Process TM and East Side Care

New York, NY

USA

Keyvan Nouri MD

Department of Dermatology

Miller School of Medicine

University of Miami

Miami, FL

USA

Rita Patel MD

Department of Dermatology

Miller School of Medicine

University of Miami

Miami, FL

USA

Baljeet K Purewal MD

Department of Opthalmology

Lutheran Medical Center

Brooklyn, NY

USA

Thomas E Rohrer MD

Department of Dermatology

Boston University School of Medicine

and

Skin Care Physicians of Chestnut Hill

Chestnut Hill, MA

USA

Cameron K Rokhsar MD FAAD FAACS

Department of Dermatology

Albert Einstein College of Medicine

New York, NY

USA


Neil S Sadick MD

Sadick Aesthetic Surgery and Dermatology

New York, NY

USA

Papri Sarkar MD

Department of Dermatology

Harvard Medical School

Boston, MA

USA

List of contributors ix

Natalie L Semchyshyn MD

Dermatology Department

St Louis University

St Louis, MO

USA

Amy Forman Taub MD

Advanced Dermatology

Northwesten University Department of Dermatology

Lincolnshire, IL

USA


Note on outcomes

Although every effort has been made to ensure that

information about techniques and equipment is presented

accurately in this publication, the ultimate

responsibility rests with the practitioner physician.

Use of these techniques or items of equipment does

not guarantee outcomes or that they are the optimal

procedures available. Procedure results and potential

complications frequently vary between patients:

physicians must evaluate their patients individually

and make appropriate decisions about treatment

based on each analysis. Although it is not always necessary,

when a physician initiates any new therapy on a

patient the use of ‘test spots’ or other tests of limited

areas should be considered for patient response before

initiating the full treatment itself.

Neither the publishers, nor the editors, nor the

authors can be held responsible for errors or for any

consequences arising from the use of information contained

herein. For detailed instructions on the use of

any product or procedure discussed herein, please

consult the instructional material issued by the manufacturer.

Some of the use of technology and procedures

described in this text may be ‘off label’ as

regards the FDA in the USA and may also not have EC

approval in Europe, and are described as such, to be

used at the discretion of the physician.


1. Laser safety

William Beeson

INTRODUCTION

Surgical lasers have opened a new vista for aesthetic

surgery. Laser skin resurfacing is commonplace, as is

laser treatment for vascular lesions, varicosities, and

laser hair removal. Laser blepharoplasty and facelifts,

as well as the employment of the laser in endoscopic

facial surgery, are becoming commonplace.With the

increasing varieties of lasers and the numerous wavelengths

available, laser safety has become a more

complex issue. 1 It is incumbent upon the surgeon to

consider the safety of not only his or her patient, but

also the entire operating room staff.

With the increasing trend for more and more procedures

to be performed in an ambulatory surgical setting,

we find that medical lasers are commonly being

employed in small clinics or office surgical settings. Not

only physicians, but podiatrists, dentists, and others use

lasers on a daily basis in their office clinical practices.The

requirements and principles for the safe use of lasers are

no less stringent in this setting than when the lasers are

employed in a large metropolitan hospital. Laser safety

standards apply equally in all of these settings.

When a physician utilizes a medical laser, they have a

medical, legal, and ethical responsibility to be aware of

the requirements for the safe use of lasers in healthcare

facilities.This means that the physician should be trained

in laser safety and be knowledgeable as to local and federal

regulations, as well as the advisory standards and

professional recommendations for the use of lasers in

their applicable speciality.

CLASSIFICATION OF LASERS

Medical lasers are classified in the USA in accordance

with the Federal Laser Product Performance Standard,

which essentially classifies lasers based on the ability of

the laser beam to cause damage to ocular and cutaneous

structures.The Food and Drug Administration

(FDA) Center For Devices and Radiologic Health

(CDRH) has the responsibility for implementing and

enforcing the Federal Laser Product Performance

Standard and Medical Device Amendment to the

Food, Drug, and Cosmetic Act.

In general, medical lasers are of class III-B or class

IV. Medical lasers can be divided into two broad categories:

those in the visible and mid-infrared range

(roughly 400–1400 nm), in which the focal image on

the retina presents the primary ocular hazard; and

those in the ultraviolet and infrared regions, in which

the main ocular hazard is to the cornea and skin. In

general, class IV laser systems present a fire hazard in

addition to the ocular and cutaneous hazards associated

with class III-B lasers.

A class I laser is considered to be incapable of producing

damaging levels of laser emission. Class II

applies only to visible laser emissions, which may be

viewed directly for time periods ≤ 0.25 s: the aversion

response time (aversion response is defined as movement

of the eyelid or head to avoid exposure to a noxious

stimulant or bright light).This is essentially the

blink reflex time. Only if one purposely overcomes

one’s natural aversion response to bright light can a

class II laser pose a substantial ocular hazard. Class III

lasers may be hazardous by direct exposure or exposure

to specific reflection. A subcategory of class III

(class III-A) consist primarily of lasers of 1–5 nW

power.These pose a moderate ocular problem under

specific conditions where most of the beam enters the

eye.The aiming beam or alignment beam for a laser

usually falls within this range, and can be hazardous

when viewed momentarily if the beam enters the eye.

For this reason, one must take particular caution when


2 Clinical procedures in laser skin rejuvenation

using the alignment beam and be aware that ocular

damage can occur with misuse. Class III-B lasers

comprise those in the 5–500 mW output range. Even

momentary viewing of class III-B lasers is potentially

hazardous. Class IV lasers are those emitting > 500 mW

(0.5 W) radiant power. Most surgical lasers fall within

this class, and pose a potential hazard for skin injury,

ocular injury, and fire hazards.

REGULATIONS

In addition to FDA enforcement, other rules and regulations

apply to the use of lasers in the medical setting.

In recent years, the Occupational Safety and Health

Administration (OSHA) has stressed the need for

employers to inform and educate workers on workplace

risks. This has been of particular importance

with regard to the use of lasers in the workplace.The

Department of Labor has developed guidelines for

Laser Safety Hazard Assessment, which pertain to the

use of medical lasers. 2

Compliance with OSHA rules is an important component

of a laser safety program.

HAZARD CLASSIFICATION

There are no specific OSHA guidelines for assessing

the level of compliance of a facility providing laser

facelifts and laser blepharoplasty. However, the

American National Standards Institute (ANSI) standard

‘Safe Use of Lasers in Health Care Facilities’ (Z-

136.3) is used as a benchmark. All assessments by the

OSHA are made under the ‘general duty clause’,

which states that there is a shared duty between the

employer and employee for establishing and maintaining

a safe working environment.The employer has a

duty to provide the proper safety equipment, appropriate

education and training, and a work environment

free of known potential risks and hazards. The

employee has a duty to attend the training, use of

personal protective equipment, and follow safe work

practices at all times. OSHA compliance officers

respond to requests, complaints, and accidents

reported. Facilities must demonstrate that they have

established policies and procedures, identified proper

personal protective equipment, implemented a

program for education of all employees who might be

at risk for exposure to laser hazards, performed and

documented periodic safety audits, and assured ongoing

administrative control in program surveillance. 3

In addition to governmental agencies such as the

FDA, OSHA, and state departments of health,

nongovernmental accrediting and review organizations

also have guidelines and recommendations for

the laser safety in healthcare facilities.The ANSI is a

nonregulatory body that promulgates thousands of

safety standards in the USA.Working committees have

representation from industry, the military, regulatory

bodies, user groups, research and educational facilities,

and professional organizations. The ANSI also

participates in international standard work through

groups such as the International Organization for

Standardization (ISO).The main objective of the ANSI

is to establish and maintain benchmarks for national

safety through consensus documents.

ANSI Z-136.3 has become the expected laser safety

standard in healthcare. Although it is not regulatory, it

has taken on the impact of regulations through its wide

acceptance. It is used by the OSHA and many accrediting

organizations such as the Joint Commission

(previously the Joint Commission on Accreditation of

Healthcare Organizations, JCAHO) and the Accreditation

Association of Ambulatory Healthcare (AAAHC),

and it is exhibited as reference during litigations.The

standard provides a comprehensive guide for the

development of administrative and procedural control

measures that are necessary for maintaining a safe laser

environment and should be used as the cornerstone

for all clinical laser programs.

It is important to develop a risk management

process regarding the safe use of lasers, consisting of

written policies and procedures, as well as ongoing

evaluations of compliance, and demonstrating timely

and appropriate responses to incidents or accidents

that could occur.Typically, the person responsible for

the management of the laser safety–risk management

program will be the laser safety officer.The ANSI Z-

136.3 standard defines the laser safety officer as ‘an

individual with the training, self-study, and experience

to administer a laser safety program.This individual

(who is appointed by the administration) is authorized

and is responsible for monitoring and overseeing the

control of laser hazards.The laser safety officer shall

effect the knowledgeable evaluation and control of


laser hazards by utilizing, when necessary, the appropriate

clinical and technical support staff and other

resources.’ 4

The laser safety officer should be responsible for

verifying the classifications of the laser systems, hazard

analysis, ensuring appropriate control measures are in

effect, approving all policies and procedures, ensuring

that protective equipment is available, overseeing

instillation of equipment, ensuring that all staff are

properly trained, and maintaining medical surveillance

records. In private practice in small clinical settings,

the physician who owns and runs the practice or clinic

is very likely to serve as the laser safety officer.

All laser users must adhere to the following principles:

Laser safety requirements are no less stringent in

private practice than in a hospital setting.

• The individual laser user must know all professional

standards and regulations and be thoroughly

trained in laser safety.

• The user must ensure that the entire staff are

properly trained in the safe use of lasers.

• There must be an appointed laser safety officer.

• The user must establish and follow standard-based

policies and procedures.

It is important that safety audits be utilized in a routine

manner to be sure that laser safety programs are being

adhered to. ANSI standards require an audit at least

annually. A laser safety audit is an assessment of all

equipment, supplies, and documents involved in performing

laser treatments in a facility. It is supervised

by the laser safety officer and consists of four basic

components:

1. Inventory all equipment and develop a checklist.

2. Inspect every item on the checklist.

3. Document results.

4. Identify action items based on audit results.

In addition to the ANSI, voluntary healthcare accrediting

organizations such as the Joint Commission and the

AAAHC all have standards that apply to the use of

lasers in the medical environment, including the office

surgical setting.

Laser regulation at state and local government levels

has increased significantly in recent years. Regulations

vary from state to state.The current trend is for state

Laser safety 3

regulatory bodies, such as medical licensing boards

and departments of health, to address laser safety issues

by setting standards for credentialing and training.

Regulations will usually dictate the type of individual or

individuals who are qualified to perform laser treatments

and prescribe levels of training to document current

competency with each type of laser being used.

Almost all require personnel using lasers in healthcare

arenas to be cognizant of basic laser safety issues.

Some states allow only physicians to perform laser

surgery, while others allow physician assistants and

advanced practice nurses to perform laser treatments.

Some will allow nurses and other allied health personnel

to perform laser treatments, but only with the direct

supervision of a trained physician. Still other states

permit the use of lasers by paramedical personnel

and ‘others’ in less supervised situations. However, the

current trend is for increased supervision and training.

While some states may not directly address laser

surgery, they do so indirectly by requiring accreditation

of ambulatory surgical or office surgical units. In

these cases, the medical licensing board has subrogated

authority to a national accrediting organization such as

the Joint Commission, the AAAHC, or the American

Association for Accreditation of Ambulatory Surgery

Facilities (AAAASF). Each of these organizations has

developed specific standards that can be applied to

laser use in the medical setting.

In 2005, the Joint Commission, currently in its sentinel

event program, adopted measures for its accredited

organizations to utilize in an attempt to reduce the likelihood

of patient injury from fire resulting from the use of

lasers in the operating room. Since the Joint Commission

accredits the vast majority of hospitals in the USA and

since all Joint Commission-accredited organizations

using medical lasers must adhere to these recommended

standards, one could argue from a legal standpoint that

these are de facto ‘community standards’. The legal

implications of not meeting the accepted ‘community

standards’ if a patient has an injury when being treated

with a medical laser are significant.

It is imperative that any person in a medical practice

who treats with a laser adhere to strict regulations

regarding scope of practice, licensing requirements, and

standardized procedures. It is also extremely important

for the physician’s malpractice insurance carrier to

determine who is covered under the physician’s policy. It

is essential to know if the person doing the laser


4 Clinical procedures in laser skin rejuvenation

treatments is outside his or her scope of practice, as an

insurance company will not insure someone who is illegally

practicing outside the scope of his or her license,

etc. Health practitioners cannot ignore the importance

of this issue for overall success and safety.

At present, there are no national, state, or local certifications

or licensing agencies to qualify the competency

of surgeons, nurses, or technicians in the safe

use of lasers.There is no standardized or universally

accepted certification or training organization. It is,

therefore, important to consider the ANSI guidelines

as well as the recommendations of various professional

medical societies in this regard (Boxes 1.1 and 1.2).

Box 1.1 Recommendations for establishing laser program and

clinical setting

1. Check with medical licensing board in your state

regarding laser regulations

2. Develop laser safety protocols for your facility.

Document training for yourself and your staff

3. Consider formal laser safety officer training and

appoint a laser safety officer

4. Monitor changes in accreditation standards and ANSI

Z-136.3 guidelines

5. Check with your medical liability carrier. Obtain

delineation of coverage for yourself and your staff

regarding the use of lasers in your practice

Box 1.2 Information resources for laser safety guidelines

• American National Standards Institute (ANSI), 11

West 42nd Street, New York, NY 10 036

Laser Institute of America, 12424 Research Parkway,

Suite 125, Orlando, FL 32826

• US Food and Drug Administration (FDA), Center for

Devices and Radiologic Health (CDRH), 9200

Corporate Boulevard, Rockville, MD 20850

• US Department of Labor, Occupational Safety and

Health Administration (OSHA), 200 Constitution

Avenue, NW,Washington, DC 20210

• Joint Commission (formerly JCAHO), 1 Renaissance

Boulevard, Oak Brook Terrace, IL 60181

• Accreditation Association of Ambulatory Healthcare

(AAAHC), 5250 Old Orchard Road, Suite 200,

Skokie, IL 60077

BIOLOGICAL HAZARDS OF LASERS

Laser hazards can essentially be divided into nonbeam-related

hazards and beam-related hazards.The

latter are unique to lasers, and pose the need for

special attention and safety requirements when using

lasers in the medical setting.This relates to the optical

radiation hazard, which can result in damage to both

eyes and skin. Because the eye is considered to be most

vulnerable to laser light, the ocular hazards are considered

of paramount importance. In most cases, the eye

has a natural protective mechanism that limits retinal

exposure to irritants.The blink reflex occurs at about

every 0.25 s and accounts for the aversion response

previously described. However, the intensity of some

laser beams can be so great that injury can occur

before the protective lid reflex.This usually happens

with lasers operating at 400–1400 nm. It is commonly

referred to as the ‘retinal hazard region’. Because of

acoustic effects and heat flow, significant tissue damage

can occur, leading to severe retinal impairment. For

this reason, it is not uncommon to lose all visual function

when exposed to even minimal amounts of laser

energy when that energy is focused on critical areas of

the retina such as the fovea. Such visual loss is generally

permanent, since the neural tissue of the retina has

minimal ability to replicate.

Injury to the cornea and the anterior segment of the

eye is possible from wavelengths in the ultraviolet and

in the infrared beyond 1400 nm.When injury occurs

to the cornea, it is usually superficial and involves the

corneal epithelium. Re-epithelization usually occurs

within 1–2 days, and total recovery of vision usually

results. However, deeper penetration can result in

corneal scaring and permanent loss of vision. Carbon

dioxide (CO 2 ) laser wavelengths pose such a potential

risk. Excimer lasers operate in the ultraviolet range and

pose a potential hazard to the cornea. Ocular injury can

occur from direct penetration of a focused beam.

However, it is more likely that injury will occur due to

accidental ocular exposure to a reflected beam.

Protection from reflected laser beams can be difficult.

The most commonly employed surgical laser today is

the CO 2 laser. Since the CO 2 laser wavelength of

10.6 µm is in the far-infrared region, it is invisible, and

so this potential hazard can go unnoticed. For this


eason it is imperative that precautions be taken at all

times when using CO 2 lasers.This is also true of Ho:YAG

and Nd:YAG lasers.This is in contrast to KTP and argon

lasers, whose emissions are in the visible region.

Reflections most commonly occur from flat metallic

mirror-like surfaces such as nasal speculums or surgical

instruments. Black anodized or abraded–roughened

surfaces can reduce (but not totally eliminate) the

potential for beam reflection. Roughening a surface is

generally thought to be more effective than ebonizing

it, since the beam is diffused to a greater degree. 5

Because of the potential for ocular injury secondary to

beam reflection, it is imperative that proper protection

be afforded to the patient and all operating room

personnel at all times when lasers are in use.

Ordinary optic glass protects against all wavelengths

shorter than 300 nm and longer than 2700 nm.

Polycarbonate safety glasses with sideshields are

suitable for use with the CO 2 lasers if the power is

< 100 W.The glass should have an optical density of 4.

While polycarbonate glasses may be adequate, there

can be burn-through with higher-power lasers.Thus,

even when wearing protective eyewear, one should not

focus the laser beam directly on the shield for any

length of time. Laser safety glasses should always have

sideshields.The optical density rating should be listed

on the sidebar of the eyeglasses.

It is important to realize that many lasers radiate at

more than one wavelength. For this reason, eyewear of

appropriate optical density for a particular wavelength

could be completely inadequate at another wavelength

radiated by the same laser.This is particularly important

for lasers that are tunable over broad wavelength

bands.

When a patient is within a nominal hazard zone

(NHZ), patient eye protection is imperative.The NHZ

is a space within which the level of the direct,

reflected, or scattered radiation during normal operation

exceeds the acceptable maximal permissible

exposure (MPE). Proper eye protection may range

from wet eye pads to laser-protective eyewear. In most

cases, corneal protectors provide the best protection.

Plastic corneal protectors have become popular.

However, in some cases, plastic shields can transfer

thermal energy to the cornea, with resultant injury.

This is especially true with darker-colored shields. 6

CUTANEOUS INJURY

Laser safety 5

While ocular injury is the most devastating direct

beam laser injury, cutaneous hazards do exist.The skin

can be injured either through a photochemical mechanism

or by a thermal mechanism. First-, second-, and

third-degree burns can be induced by visible and

infrared laser beam exposure. Such injuries have been

noted to occur in < 1% of patients, with 10% of surgeons

reporting unintentional burns to either patients

or operating room personnel. 7,8 In most cases, moist

towels draped around the operative site and fireresistant

surgical drapes will provide proper protection.

NON-BEAM-RELATED HAZARDS

In addition to direct laser beam hazards to the eye and

skin, there are non-beam laser hazards that need to be

considered. These include electrical hazards, lasergenerated

airborne contaminants (laser plume), waste

disposal of contaminated laser-related materials

such as filters, and laser-generated electromagnetic

interference.

All medical lasers must operate in compliance with

the National Electric Code (NFPA-70) and with state

and local regulations. Electrical hazards can be related

to damaged electrical cords and cables, inadequate

grounding, and the use of conductive liquids in the

vicinity of the laser when it is in operation. These

problems can usually be minimized with an appropriate

laser maintenance program by qualified biomedical

engineers and adherence to appropriate laser safety

guidelines when operating electrical equipment in the

surgical environment.

Laser-generated airborne contaminants present a

significant problem. Studies have shown the presence

of gaseous compounds, bio-aerosols, dead and live

cellular materials, and viruses in the laser plume.The

laser plume can cause ocular and upper respiratory

tract irritation. The unpleasant odors of the laser

plume can cause discomfort to both the physician and

the patient.The laser plume can cause ocular irritation,

and may be even more of a problem for individuals

who wear soft contact lenses, as the particles can

permeate the lenses and cause prolonged irritation.


6 Clinical procedures in laser skin rejuvenation

However, of greatest concern is the mutagenic and

carcinogenic potential of the compounds contained in

the plume.At a time when the threat from bloodborne

pathogens has led to enhanced awareness of the risks of

contact with blood and blood byproducts, the practice

of universal precautions has taken on a new meaning.

The use of a laser smoke evacuator is imperative. If the

evacuator is held 2 cm from the source of the laser

plume, aerosolization of the particles is minimal.The

suction created in the evacuator tubing is important.

This results in the creation of a vortex that removes

mutagenic debris and prevents aerosolization of the

carbonized particles. (The latter impregnate the tubing,

which should therefore be treated as a biohazard

when it comes to disposal.) In most cases, routine

operating room suction and suction tubing do not provide

adequate evacuation of the laser plume.

While surgical masks may help reduce laser exposure,

their use alone is not adequate. At present, there

is no mask respirator on the market that excludes all

laser-generated plume particles, such as viruses, bacteria,

and other hazards. Surgical masks are not designed to

protect from plume contents. Rather, they are intended

to protect patients from the surgeon’s contaminated

nasal or oral droplets. Specialized surgical masks that filter

out particles down to 0.3 µm with high efficiency are

available and can help to decrease the inhalation of laser

plume particles. While some laser masks are of sufficiently

increased density to remove a higher proportion

of laser-generated particles, their use alone is not adequate.

9 As with smoke evacuator tubing, filters will be

impregnated with potentially dangerous materials, and

should therefore be treated as hazardous waste.

Lasers can create electromagnetic interference.

Electromagnetic radiation generated by lasers can

interfere with other sensitive electronic equipment

present in the facility, such as cardiac telemetry equipment.This

can also affect patients who have pacemakers.The

electromagnetic interference potential of a

laser system is normally described in the manufacturer’s

labeling, or it can be determined by a biomedical

engineer with laser safety officer experience.

FIRE HAZARD

Operating room fires are rare – but when such blazes

do occur, they can be lethal. Potentially flammable

materials such as gauze, cotton, paper surgical drapes,

and plastic endotracheal tubes can be ignited in the

operating room by the laser, and the oxygen-enriched

environment can intensify fires.

Accidental fires are a well-known hazard associated

with laser treatment. It has been estimated that combustion

occurs in 0.4–0.57% of CO 2 laser airway procedures.

10 Others have demonstrated that, in the

presence of oxygen concentrations of 21–25%,

polyvinyl chloride, red rubber, and silicone endotracheal

tubes can rapidly ignite when struck with CO 2

laser beam.The threshold for ignition is increased with

the addition of helium to the oxygen concentration.

This is due to the fact that helium has a higher thermal

density and acts as a heat sink, delaying combustion for

about 20 s. Laser fires have also resulted from the ignition

of polyvinyl chloride endotracheal tubes wrapped

in aluminum tape. 11

In general, medical lasers are class III-B or IV lasers.

Class IV laser systems (emitting > 500 mW radiant

power) present a fire hazard in addition to the ocular

and cutaneous hazards associated with class III-B

lasers. Most surgical lasers fall within this class.

The basic elements of a fire are always present during

surgery.A misstep in procedure or a momentary lapse of

caution can quickly result in a catastrophe. Slow reaction

to the use of improper firefighting techniques and tools

can lead to damage, destruction, or death.

To reduce the threat of a laser fire, it is essential to

understand and to employ the principles of the ‘fire

triangle’. For a fire to start, three components must be

present: heat, fuel, and an oxidizer.The key to laser

safety in this regard is to control all three components.

‘Heat’ represents the flame or the spark. It is the

‘ignition’ for the fire.The nature of the heat source can

be extremely varied – often something that one would

not immediately think of, such as an overhead surgical

light, an electrocautery unit, a drill, or a fiberoptic

light left on a surgical drape.

A ‘fuel’ has to be present for the heat source to

ignite. Once again, the potential ‘fuel’ can be an item

that one would not likely consider, such as a petroleum-based

ophthalmologic ointment. Fuels commonly

encountered in surgery can be divided into five

categories: the patient, prepping agents, linens, ointments,

and equipment.

The key ‘oxidizer’ in the operating room is the

oxygen-rich environment. An oxidizer can be thought


of in this context as something that facilitates ignition

and combustion. Decades ago, anesthesiologists recognized

the hazards of flammable anesthetic agents in the

operating room and eliminated them.Today, oxygen is

one of the key components to deal with in regards to

operating room fires. In the great majority of such

fires that have been reviewed, an oxygen-rich environment

and ineffective management of this ‘oxidizer’

were the key factors in the mishap.

Preventing fires in the operating room is dependent

on disrupting the fire triangle, as all of its components

must be present for a fire to develop. One needs to

control the heat source, manage the fuels, and minimize

the oxygen concentration.

One of the most common errors is inadvertent

activation of the laser. Not infrequently, the surgeon

thinks that he or she is stepping on the cautery foot

pedal when they are actually stepping on the laser

pedal, which activates the dangling laser, whose beam

is directed on a flammable surgical drape (the ‘fuel’).

One of the most basic – but most effective – safety

measures is to eliminate the clutter of multiple foot pedals

for the laser, cautery, liposuction unit, etc. Removing

all of the foot pedals and having only the foot pedal of the

equipment one is using in access range is extremely

important. ANSI standards dictate that there be a

laser-designated operator trained in the safe use of any

particular laser.The responsibility of the laser operator is

to release the laser from standby setting mode when the

surgeon requests its activation and to immediately place

the laser back on standby mode when the surgeon is finished.This

markedly reduces the likelihood of inadvertent

laser activation. It is essential that the laser operator

ensure that there is an appropriate ‘environment’ before

activating the laser.They should scan the room to ensure

that no flammable agents such as acetone or cleaning

agents are present, that all personnel are wearing appropriate

eye protection, that the patient’s eyes are protected,

and that the oxygen has been reduced to room air

levels before the laser, is activated.

Managing the potential ‘fuel’ source is important,

and requires delegation and advanced planning. Proper

prepping techniques are critical. If possible, the use of

alcohol-based prepping solutions should be avoided. It

is important that flammable prep solutions be

removed and not allowed to drip and ‘pool’ on the

drapes under the patient, enabling fumes to accumulate

and possibly be ignited. It is also important to be

alert for potential fire risks on the patient, such as eye

mascara, perfume, and hairspray, of all which can be

flammable.

Minimizing the oxygen environment is extremely

important and must be done in concert with the anesthesiologist.This

requires presurgical discussion regarding

how one plans to perform the procedure, the type of

anesthetic to be used, etc. In many cases, monitored

anesthesia care can be used. It may be possible to reduce

the oxygen concentration being delivered to room air

levels during the time the laser is being activated and to

return immediately to supplemented levels when the

laser is deactivated.This requires coordination between

the surgeon and the anesthesiologist and the ability of

the surgeon to immediately terminate the laser use if the

anesthesiologist notes a precipitous drop in FiO 2 on the

pulse oximeter. If a nasal cannula or a face mask is used

to deliver oxygen, one has to be sure that surgical drapes

are not tented, such that oxygen can pool under them. In

cases where higher levels of oxygen are required by the

patient, and alternating from supplemented oxygen to

room air is not possible, a helium and oxygen combination

may serve to increase the safety margin when

oxygen has to be utilized. Helium acts as a heat sink.

It can delay combustion for up to 20 s. The oxygen

concentration should be maintained below 40%.

Recommendations regarding anesthesia are summarized

in Box 1.3.

Box 1.3 Recommendations regarding anesthesia

Laser safety 7

• Oxygen should be used at the lowest possible

concentration

• Oxygen (or other gases) should never be directed

toward the laser field

• Any mixture of nitrous oxygen and oxygen should be

treated as if it were pure oxygen

• Helium can be used to increase the ignition threshold

• Laryngeal airways (with spontaneous respiration) are

preferred over face masks; if a mask is used, an oxygen

analyzer can be utilized to ensure minimal leakage

• If an endotracheal tube is used, the cuff should be

filled with saline rather than air.The tube should be

wrapped in aluminum or copper tape

• Collared masks, nasal cannulas, or airway materials

should be avoided.

• Anesthetics that are administered either by inhalation

or topically should be nonflammable.


8 Clinical procedures in laser skin rejuvenation

PREPARING FOR FIRES

It is imperative to develop a laser-fire protocol. Being

prepared for fire is an inexpensive insurance and will

minimize the cost in dollars, loss in time, emotional

shock, injury, and possibly death. Preparation involves

a number of steps.The most important is practicing

fire drills to teach all staff about their responsibility

during a laser fire. This should be done similarly to

what is done for medical codes and other routine

disaster drills.

It is surprising how many individuals do not know

how to select a proper fire extinguisher or how to use

one. Most fire extinguishers operate according to the

mnemonic ‘PASS’: Pull the activation pin, next Aim

the nozzle at the base of the fire, next Squeeze the

handle to release the extinguishing agent, and Sweep

the stream over the base of the fire.

There are three classes of fire extinguishers: A, B,

and C. Class C is used for electrical equipment.With

the demise of Halons as fire-extinguishing agents, CO 2

is the best all around fire extinguisher for the use in the

operating room. Halons (bromofluorohydrocarbons)

are damaging to the environment and are no longer

made or sold. However, if a Halon fire extinguisher is

available, it is the optimal one to use. Small CO 2 fire

extinguishers have five-pound charges and weigh

approximately 15 pounds. This is easily enough for

most people to handle and small enough to mount

unobtrusively on the wall in the operating room near

the door. CO 2 fire extinguishers are rated for use

against class B and class C fires in the operating room

setting, although they can be used effectively against

the kinds of class A fires that are likely to occur. CO 2

fire extinguishers emit a fog of CO 2 gas with liquid and

solid particles that rapidly vaporize to cool and smooth

the fire, while leaving no residue to contaminate the

patient. Dry powder fire extinguishers employ primarily

of ammonium sulfate, which is emitted in a

stream against the fire.The powder smothers, cools,

and to some extent disrupts the chemical reaction of

the fire. During use, the powder limits visibility and

covers everything in the surrounding area, which can

damage delicate equipment.The powder irritates the

mucous membranes and its long-term toxicity has

not clearly been determined. Using a powder fire

extinguisher in the operating room will make the

room and much of the equipment unusable for a

period of time. For these reasons, dry powder should

not be used as the first line of defense against operating

room fires. Pressurized-water fire extinguishers are

available, but are heavy and chiefly effective against

only class A fires.

If a laser fire should inadvertently occur, quick action

is imperative.Ventilation should be stopped and anesthetic

gases discontinued.Then the tracheal tube, mask,

and nasal cannula should be removed.The fire should be

extinguished with normal saline.The patient should then

be mask-ventilated with 100% oxygen.The anesthesia

should be continued in order to facilitate injury assessment

to allow the patient to be stabilized. Iced saline

compresses should be applied to areas of burn.A flexible

nasal pharyngoscope or bronchoscope should be used to

survey the upper airway and laryngeal tissues to evaluate

the extent of injury. Foreign bodies and carbonized

debris should be removed. Copious irrigation with normal

saline and Betadine soap can be used to remove carbonized

debris from cutaneous burned areas. Xeroform

gauze and bacitracin ointment can be applied to areas of

minor cutaneous burns. If thermal injury has occurred in

the nasal airway, a light nasal packing with Xeroform

gauze can be used to stent the airway to treat thermal

damaged tissues.

Depending on the severity of injury, it may be

important to consider the use of intravenous steroids.

High-humidity environments should be provided and

oxygenation monitored. Patients may require ventilatory

support for laryngeal edema as a potential problem.

A chest X-ray should be considered in order to

obtain a baseline evaluation to monitor for ‘shock

lung’. Evaluation by other consultants such as a pulmonologist

or ophthalmologist should be considered

when appropriate. Systemic antibiotics such as

cephalosporins should be considered. In all but the

most minor cases, the patient should be observed

overnight. 12

ENVIRONMENT OF CARE

Medical lasers should be used in the appropriate environment.There

should be proper electrical grounding


to minimize potential electrical shock.There should

be proper ventilation and the room should be of sufficient

size to enable the use of smoke evacuators, laser

equipment, and additional personnel needed for

proper laser instrumentation. Treatment should be

performed in a controlled area, which should limit

entry by unauthorized personnel. Proper warning

signs should be displayed at the entry and within the

controlled area. Only those properly trained in laser

safety should be admitted to the controlled area. All

open portals and windows should be covered or

restricted in such a manner as to reduce the transmission

of laser radiation to levels at or below the appropriate

ocular MPE for any laser used in the treatment

area. It should be noted that normal window glass has

an optical density in excess of 5.0 and therefore

should be appropriate for CO 2 lasers at 10:600 µm.

Other lasers require the facility windows to have

additional coverings or filtering.

While it is important that the entryway to the laser

room or treatment area be secured, it is equally

important that emergency entry be permitted at all

times. For this reason, internal locks are not advisable.

If a laser, fire, or explosion should occur, an internally

locked door could prevent appropriate emergency

response. It is important to have proper safety equipment

within the treatment environment.This includes

proper eye protection for all staff, as well as the

patient, a fire blanket, and a fire extinguisher available.

Of equal importance is an appropriate laser plume

evacuation device. In most cases, standard surgical

wall suction does not suffice.

TRAINING

It is imperative that all personnel using medical lasers

be properly trained and that appropriate laser safety

protocol exist within each facility. Acceptable standards

dictate that an individual designated as a laser

safety officer be in charge of developing criteria and

authorizing procedures involving the use of lasers

within the facility, and ensuring that adequate protective

measures for control of laser hazards exist and that

there exist a mechanism for reporting accidents or

incidents involving the laser.

It is also important that accurate records be maintained

for lasers, as well as laser-related injuries.

SUMMARY

Lasers can be employed in a variety of medical settings.When

used properly, lasers can provide dramatic

improvements in the quality of patient care. However,

as with any medical procedure, complications can and

do occur. Close adherence to standard accepted laser

safety protocols can dramatically reduce that risk and

improve the quality of patient care.

REFERENCES

Laser safety 9

1. Sliney DH,Trokel SL. Medical Lasers and Their Safe Use.

New York: Springer-Verlag, 1992.

2. ANSI Z-136.3-2004: American National Standard for

Safe Use of Lasers in Health Care Facilities –. New York:

American National Standards Institute, 2004.

3. Smalley P. Laser safety management; hazards, risks, and

control measures. In: Alster T, Apfelberg D, eds.

Cutaneous Laser Surgery. New York:Wiley-Liss, 1999.

4. ANSI Z-136.3:The Standard For the Safe Use of Lasers in

Health Care Facilities. New York: American National

Standards Institute, 2004.

5. Sliney DH. Laser safety. Lasers Surg Med 1985;16:215–25.

6. US Department of Labor,Title 29: Codes of the Federal

Regulations, Occupational Health and Safety.

7. ANSI Z-136.3-1996: American National Standard for

Safe Use of Lasers in Healthcare Facilities. New York:

American National Standards Institute.

8. Wood RL, Sliney DH, Basye RA. Laser reflections from

surgical instruments. Lasers Surg Med 1992;12:675–8.

9. Ries WR, Clymer MA, Reinisch L. Laser safety features

of eye shields. Lasers Surg Med 1996;18:309–15.

10. Olbricht SM, Stern RS, Tany SV, Noe JM, Arndt KA.

Complications of cutaneus laser surgery. A survey. Arch

Dermatol 1987;103:345–9.

11. Baggish MS. Complications associated with CO 2 laser

surgery in gynecology. Am J Obstet Gynecol 1981;

139:658.

12. Fretzin S, Beeson WH, Hanke CW. Ignition potential of

the 585nm pulse dye laser; Review of the Literature and

Safety Recommendations. Dermatol Surg 1996;22:

699–702.


2. Evaluation of the aging face

Philip J Miller

INTRODUCTION

In this chapter, we will explore the algorithm involved

in analyzing the aging face. But before we even begin

that journey, we must ask the question ‘What is an

aged face?’

While the answer may seemingly be self-apparent,

further contemplation reveals a complexity not first

appreciated. For starters, when is the face considered

‘aged’? Secondly, are all ‘aged features’ that we would

typically list a result of aging? And finally, do we have a

comprehensive and detailed understanding of the

pathophysiology of facial aging, which serves as the

foundation for our analysis?

WHAT IS AN AGED FACE

While the jury may still be out regarding when life

actually begins, one could argue that death begins at

the moment of conception! Life is nothing more than

the balance between anabolic activities and catabolic

activities. Throughout our life, the ratio of anabolic

and catabolic states simply switches. Somewhere along

that continuum, we begin to demonstrate findings on

the outside of our body, particularly the face, where

the catabolic process has increased its relative strength

compared with the anabolic process. From that movement

on, at different rates and in different ratios,

mixed with different environmental exposures, these

processes determine the resulting ‘aged appearance’ of

any one person.

What is considered an aged face in one society may

not in fact be so in another society.We are quite aware

of the tremendous respect and honor awarded to

seniors in the Asian community – and, sadly, not so

present in the Western world.Typical features that we

would readily find people wanting to correct in the

West may in fact be worn as a badge of honor in the

East. Nevertheless, those features are still a result of

the aging process, and identifying them is the purpose

of this chapter.

ARE ALL FEATURES OF AN AGED FACE

DUE TO THE AGING PROCESS?

As Fig. 2.1 demonstrates, a typical aged face will consist

of a myriad of features. However, further inspection

reveals that these features can be divided into two

different categories. One category is chronological

aging alone.These are the features that are never seen

in youthful individuals, they occur as one ages, and

almost everyone who is aged has them. The second

Chronological features:

Those features that

appear in nearly all aged

individuals, and are not

present in the young

Aged features

Fig.2.1 The breakdown of aged features into

chronological and morphological features.

Morphological features:

Those features that

appear in nearly all aged

individuals, but are also

present in some youthful

individuals


12 Clinical procedures in laser skin rejuvenation

Table 2.1 Example of age-specific and non-age-specific features

Aged features Youthful features It depends!!!!

• Wrinkles, fine and coarse • Overall facial fullness/volume • Low lid crease

• Malar depressions • Prominent cheeks • Low brows

• Furrows • Plump lips • Thin lip

• Skin excess • Smooth, unblemished skin • Nasojugal groove

• Actinic changes • Maxillary teeth visible • Nasolabial folds

• Mandibular teeth showing

• Submental fat accumulation

category, I would like to refer to as morphological features.These

are features that, although possessed by all

aged people, are present in some individuals even in

their youth. Examples of these two categories are

listed in Table 2.1. It is interesting to note that features

such as a nasojugal groove or a low-hanging upper lid

crease or even a deepened nasolabial groove are present

in some 6-year-olds. These individuals are certainly

not chronologically aged, nor do they appear to

appear old. Nevertheless, they certainly possess some

of the very features that we readily admit to appearing

in the aged face.

PATHOPHYSIOLOGY OF AGING

A thorough analysis of the aging face begs us to ask us

how it got that way. My impression is that the current

pathophysiological model of facial aging is in its

infancy, and we will see a rapid, indeed exponential,

rise in our understanding of the pathophysiology of

facial aging over the next two decades. Prominent in

this model will be an ever-increasing role of facial volume

depletion as contributing to – if not primarily

responsible for – the ultimate contour irregularities

and transformations that occur in the aged face.The

old model of loss of elasticity, and sagging due to gravity,

will be replaced by a more detailed and comprehensive

understanding of the individual role of and

complex interaction among

• skin aging

• skeletal remodeling

• fat pad atrophy

• subdermal fat loss

• fat deposition

Furthermore, we will find that these processes

inevitably exerts their effects on two anatomical components

that are fixed: the muscle attachments to the

bone and the osseocutaneous ligaments.This complex

reaction of changes and exertions is subject to gravitational

forces, resulting in a more typical aged facial

appearance. Adding to that an increase in muscle tone

in order to maintain facial function, particularly in the

periorbital region, so that decreased visual fields

are eliminated by contracting the frontalis, gives the

characteristic superficial skin findings associated with

the aged face.

YOUTH VERSUS BEAUTY

Where do we begin the aging facial analysis? Do we

start from the surface and proceed sequentially with

our assessment layer after layer? Do we begin at the

scalp and then proceed inferiorly towards the neck?

Do we start at the nasal tip and work posteriorly?

Do we make a global assessment and then work to the

specific areas? Does it matter?

I believe that the analytical algorithm that one uses is

not nearly as important as the ‘ideal’ with which the

patient is being compared.Thus, the real question in

‘aging face analysis’ is not so much ‘Why do they look

old?’ as ‘with what are we comparing the patient’s

face?’Are we trying to restore the patient to their own

youthful appearance or to an idealized youthful appearance?

Do most patients wish to be ‘restored’ to a prior


Fig.2.2 Twins with very different upper eyelid formations.

The female’s upper lids are age-appropriate and beautiful,

but could be considered ‘aged’if these very same features

presented themselves in a 40-year-old.

age, or to look more refreshed and rejuvenated, but

still look their ‘age’. Is there not a component of their

desire, in fact, that struggles with the desire to improve

their appearance while maintaining their essential

features?

Here it is worthwhile to explore the concept of

‘ageless beauty’ – which is ultimately the goal of the

aging face surgery that we perform. ‘Aging face

surgery’ is really a poor term, because it is not really

youthfulness alone that we are attempting to achieve.

Age does not necessarily make one less or more attractive

– although it does play a role.Therefore, beauty

and youth are not necessarily one and the same.Youth,

in my opinion, is not our goal as much as an ageless

appearance, not a particular time period in the

patient’s past. The best result is a face whereby you

cannot tell the patient’s age. One looks at the postoperative

face (not compared with the preoperative face)

and cannot tell whether the patient is 25 or 40.They

possesses volume and fullness.Their face is ageless. It

should be kept in mind that youth is not necessarily

attractive. If we were capable of magically restoring

our patients to their most desirable youthful state,

would they be completely satisfied? Some patients

would be, but others would not. For these patients,

‘aging face procedures’ means not only correcting an

Evaluation of the aging face 13

aging face or features, but also aesthetic facial

features by which we are asked to alter their appearance

to make them more attractive.Therefore,‘aging

face analysis’ may mean a collection of aged and not

necessarily aged features that the patient possesses to

make them more attractive and appear more youthful.

It should be kept in mind that we want to do that

without altering those characteristics that are essential

to the person’s uniqueness – those essential features

that make us look undeniably who we are.These

features may consist of the slight slant of the palpebral

aperture, the position of the malar fat pad, the

dimple on the cheek, the cleft in the chin, or the fullness

of the upper lid. Over the years, some of these

features have been routinely and erroneously thrown

in with the list of aging face features. Consequently,

we are quick to identify them as ‘aged’ and to eradicate

them or modify them in an effort to create an

idealized youthful appearance by removing all that is

considered aged.

Obviously, those features that are essential to one’s

uniqueness should not be tampered with.A wonderful

example of this is seen in my twins (Figure 2.2). My

son has a very prominent upper eyelid crease, whereas

my daughter has a much fuller upper eyelid crease

with a lower brow.While typically a lower brow and

upper eyelid fullness is deemed to be a classic sign of

an aging face, requiring intervention, I submit that this

particular feature in my daughter is her ‘essence’ and

should not be at all manipulated now or 40 years from

now.We have seen this as well in two classical examples,

one being Mr Robert Redford and the second

Mr Burt Reynolds. Both of their periorbital procedures

resulted in what would be considered a youthful

appearance. But their results occurred at the expense

of removing their essential upper eyelid features.Those

essential features for decades had been their ‘brand’;

a masculine hooded upperlid with a low brow.

Therefore, it is important to recognize that in performing

aging face analysis, one needs to separate the

analysis performed on a patient’s features that most

likely were a result of the aging process and those that

were never present at all and would in fact make this

individual appear perhaps more attractive. For the sake

of this chapter, we will focus exclusively on those features

that are a result of the chronological process.


14 Clinical procedures in laser skin rejuvenation

Table 2.2 Fitzpatrick skin types

Type Color Reaction to UVA Reaction to sun

I Caucasian; blond or red hair, freckles, Very sensitive Always burns easily, never

fair skin, blue eyes tans; very fair skin tone

II Caucasian; blond or red hair, freckles, fair Very sensitive Usually burns easily, tans with

skin, blue or green eyes difficulty; fair skin tone

III Darker Caucasian, light Asian Sensitive Burns moderately, tans gradually;

fair to medium skin tone

IV Mediterranean,Asian, Hispanic Moderately sensitive Rarely burns, always tans well;

medium skin tone

V Middle Eastern, Latin, light-skinned Minimally sensitive Very rarely burns, tans very easily;

black, Indian olive or dark skin tone

VI Dark-skinned black Least sensitive Never burns, deeply pigmented;

very dark skin tone

Table 2.3 Glogau wrinkle scale

Skin type Age (years) Findings

1. no wrinkles Early 20s or 30s Early photoaging: early pigmentary changes, no keratoses, fine wrinkles

2. wrinkles in motion 30s to 40s Early to moderate photoaging: early senile lentigines, no visible keratoses,

smile wrinkles

3. wrinkles at rest 50 plus Advanced photoaging: dyschromia and telangiectasia, visible keratoses,

wrinkles at rest

4 only wrinkles 60 or 70s Severe photoaging: yellowish skin color, previous skin malignancy,

generalized wrinkling

SKIN

Among the absolute hallmarks of an aging face are the

changes associated with the skin.The most common

changes associated with facial skin aging are those due

to photoaging (skin damage related to chronic sun

exposure). This results in dyspigmented, wrinkled,

inelastic skin, with associated redness and dryness.

Furthermore, mild to moderate facial wrinkling and

laxity with benign and malignant lesions round out the

skin changes that should be addressed through many of

the techniques presented in this book. See Tables 2.2

and 2.3, which show the Fitzpatrick and Glogau classifications

of skin types and wrinkles respectively.

VOLUME LOSS

It is easy to overlook this particular component of facial

aging. Since surgical procedures reposition and lift, it is

only natural, but incorrectly, assumed that the cause of

that descent is skin laxity and gravity. However, on further

examination, evaluation, and analysis, it is clear that

descent and laxity can result from volume loss.As illustrated

in Figure 2.3(a), a fully inflated balloon appears

robust and lacks contour abnormalities. However, as

seen in Figure 2.3(b), a deflated balloon has the potential

to not only descend, but also become deformed.The

difference between Figure 2.3(a) and 2.3(b) is nota general

laxity of the balloon’s tarp, but rather the volume

inside the balloon. Reinflating the balloon, as opposed

to repositioning the tarp, is responsible for eliminating

all of those identifiable features.

Likewise, many of the features that we will discuss

below are in part due to a loss of volume, and one

should train one’s eyes to appreciate that volume loss in

the following areas: the temporal fossa, the lateral

brow, and the malar eminence. Furthermore, volume

loss may be seen in the lips and perioral region. Finally,

it should be appreciated that overall loss of volume in


a b

the subcutaneous tissue can make certain bony features

much more prominent along the infraorbital rim,

as well as the submandibular triangle, wherein the

submaxillary gland appears quite prominent.

CHIN POSITION

The next step in the facial analysis process is to assess

the location of the chin in relationship to the patient’s

lower lip as well as the surrounding tissue. One should

look for the appearance of jowling, chin ptosis, chin

retrusion, submental fat accumulation and severe

neck skin laxity. Following the path of the mandible

Evaluation of the aging face 15

Fig.2.3 Two identical balloons.The one in (a) is inflated and is rigid and wrinkle-free.The one in (b) is partially deflated,its

surface contains ripples,like wrinkles,and it is lax and subject to deformation from wind or gravity.Human skin is like the tarp

on these balloons.Fully inflated skin appears youthful and robust.Deflated skin sags and reveals wrinkles and furrows.

posteriorly, the next assessment is the general protuberance

and width of the angle of the mandible.

Atrophy and medial displacement of the angle of the

mandible or atrophy of the masseter muscle can in fact

contribute to a narrow and withdrawn facial contour.

The nasolabial lines are now assessed for their presence

and degree, as well as for the contribution made

to these lines by ptotic skin and subcutaneous tissue

superior to them. In my experience, the presence of a

nasolabial fold is less due to ptosis of the malar fat pad

than to atrophy of the malar fat pad with resulting ptosis

(see the balloon concept illustrated in Figure 2.3)

of the resulting subcutaneous tissue. Elevation of the

malar tissue superiorly and slightly posteriorly assesses


16 Clinical procedures in laser skin rejuvenation

the degree of laxity, as well as the overall effect of

repositioning this tissue to efface the nasolabial line

and to reinflate the malar mound.

PERIORAL REGION

The lips are now evaluated for the prominence of the

white roll, the philtral ridge, and robust red lips.The

maxillary teeth should be visible and the mandibular

teeth hidden.White lip wrinkles are also assessed.

PERIORBITAL REGION

Finally, attention is then directed towards the periorbital

region. Signs of upper lid ptosis are identified

and documented. Lower lid laxity and position are

identified and documented. Brow position is similarly

considered. Unlike the current trend of repositioning

the brow cephalically, I find that a lower placed brow

in both women and men, in combination with a more

robust lateral brow fullness, provides a sophisticated

and ageless appearance. An overly elevated brow does

not convey youth. It conveys surprise.The absence and

presence of forehead, glabellar, and periorbital rhytids

are evaluated and documented. Lower lid pseudoherniation

of fat is noted, as is the presence of an infraorbital

hollow.The degree of nasojugal depression is

documented, and photographs taken at an earlier age

are reviewed to ascertain which of the facial features

were present in youth and which were subsequently

acquired with aging.

SUMMARY

Technical expertise, however important to obtaining

excellent and consistent results, is only part of the

equation.The wrong technique performed flawlessly

will typically reveal a result that is below par, while

the correctly chosen procedure performed just satisfactorily

typically results in acceptable if not extraordinary

results.We can only recommend the most

suitable procedure if we perform a thorough and accurate

analysis, and that analysis includes not only an

assessment of the patient’s facial features, but also

their desires, expectations and their notions on which

procedures they feel most comfortable with to get

there.Therefore, proper and thorough analysis is paramount

for it will lead us to selecting the most appropriate

treatment plan and consequent results for any

individual patient and thus predictable and consistent

outcomes.

Nevertheless, analysis cannot be learned in a vacuum.

Analysis inevitably requires that we compare it

with an idealized version, and even then it requires us

to understand the pathophysiology by which we got to

that point, and then we must correlate those findings

with a suitable treatment.

PLAN

Knowledge in all of these domains and re-exploring all

of these disciplines are essential parts of our growth as

physicians.


3. Carbon Dioxide Laser Resurfacing, Fractionated

Resurfacing and YSGG Resurfacing

Dee Anna Glaser, Natalie L Semchyshyn and Paul J Carniol

INTRODUCTION

Although skin resurfacing has been performed for

centuries in the forms of chemical peels, sanding, and

dermabrasion, it was not until the 1990s that lasers

were safely and effectively used as a resurfacing tool.

Initially, carbon dioxide (CO 2 ) lasers with a wavelength

of 10 600 nm (1006 µm) were used as a

destructive tool. Technology advanced quickly in the

1990s from continuous-wave CO 2 lasers to pulsed

CO 2 lasers to help minimize the thermal damage

produced by the older CO 2 lasers. Ultrashort pulse

technology emerged, as did computerized pattern

generator (CPG) scanning devices that allowed for a

more standardized delivery of the laser pulses.

Because of the prolonged healing required and the

risks associated with CO 2 lasers, the erbium :yttrium

aluminum garnet lasers (Er:YAG) lasers with

stronger water absorption (2940 nm) and less thermal

damage were developed. Er:YAG lasers proved

to be excellent ablative tools, with shorter healing

times, but did not provide the same tightening that

was achievable with CO 2 resurfacing. The next

advance came in the form of erbium lasers with

longer pulse widths that could provide more heating

and thermal damage in the skin. The short-pulsed

erbium lasers were combined with CO 2 lasers and

long-pulsed Er:YAG lasers to try to blend the benefits

of shorter healing times with more substantial

skin tightening.

Attempts to improve the laser resurfacing technique

continue to be studied, with a concentrated

effort now looking at nonablative options to induce

dermal remodeling and fractionated skin resurfacing

to minimize the risks from skin ablation and to shorten

the healing times for patients.This chapter will focus

on ablative resurfacing, with an understanding that the

principles behind good patient selection and care will

remain paramount despite continued changes in the

lasers that might be developed.

INDICATIONS

The most common uses for laser skin resurfacing are

to treat wrinkles and acne scars of the face. Any epidermal

process should improve with laser resurfacing,

including lentigines, photoaging, actinic keratosis,

and seborrheic keratosis (Box 3.1). Some dermal

lesions, such a syringomas, trichoepitheliomas, and

angiofibromas, will improve with laser resurfacing,

but results will vary with the histologic depth of the

process. In our experience, there is a high recurrence

rate with dermal lesions. Actinically induced disease,

including actinic keratosis (AK) and actinic cheilitis,

can respond very well to laser resurfacing. Superficial

and nodular basal cell carcinomas have been successfully

treated with the UltraPulse CO 2 laser. The cure

rates achieved by Fitzpatrick’s group was 97% in

primary lesions (mean follow-up 41.7 months). 1 In

addition, the use of laser resurfacing may be used prophylactically

to reduce the risk for the development of

future AK and AK-related squamous cell carcinoma. 2

Prevention of some basal cell carcinomas may be

achieved, although this has not been definitively

demonstrated. 3


18 Clinical procedures in laser skin rejuvenation

Box 3.1 Indications for laser skin resurfacing

• Photodamage

• Rhytids

• Acne scars

• Benign adenexal tumors

• Benign epidermal growths

• Rhinophyma

• Actinic cheilitis

• Actinic keratosis

• Basal cell carcinoma

• Scar revision

Despite the multiple uses, by far the prime use in

our office is for the improvement of facial photoaging,

rhytids, and acne scars.To date, ablative laser resurfacing

is the most efficacious technique we have to treat

perioral rhytids (Fig. 3.1).

a

b

Fig.3.1 Significant reduction in perioral rhytids

at 4 months.

PATIENT SELECTION

The key to successful laser resurfacing is proper

patient selection (Table 3.1). Potential candidates

need to have a realistic expectation of the outcome,

risks, and significant amount of time required to heal,

as well as the time to see the final results. The ‘ideal’

patient has fair skin with light eyes, has no history of

poor wound healing, and is comfortable with wearing

make-up during the postoperative healing period.The

history should specifically address issues that relate to

wound healing, such as immunodeficiency, collagen

vascular diseases, anemia, diet, scarring history,

keloid formation, recent isotretinoin usage, and past

radiation therapy to the area. The history should

include the patient’s general health, current or past

medications, and mental health issues. Diseases

known to koebnerize are also a relative contraindication

– these include psoriasis, vitiligo, and lichen

planus. Diseases that reduce the number of adenexal

glands or alter their function are relative contraindications

and need to be reviewed – these include collagen

vascular diseases such as systemic lupus

erythematosus and scleroderma. A history of herpes,

frequent bacterial infections, or frequent vaginal

candidiasis is not a contraindication, but should be

noted to better plan how to treat the patient during

the perioperative period.

Equally important is to ascertain the pigment

response of the patient (in terms of hyperpigmentation

or hypopigmentation) to sun exposure or injuries.

In our experience, patients with Fitzpatrick skin type

IV are some of the most challenging to treat due to

their risks of postoperative dyschromias. Patients will

need to avoid sun exposure for several months after

the surgery, and the physician needs to document the

patient’s ability to do so along with their ability to use

broad-spectrum sunscreens daily. In the Midwest of

the USA, with four distinct seasons, it is preferable

to perform deep resurfacing procedures during the

winter months to minimize sun exposure. However, a

thorough review of a patient’s travel plans during the

3- to 4-month healing period then becomes important.

Although most patients recognize the risks of a

trip to a warm sunny destination, many may underestimate

the risks with higher altitudes such as with

snow skiing.


Table 3.1 Patient selection

PROCEDURE

Preoperative care

Carbon dioxide laser resurfacing, fractionated resurfacing and YSGG resurfacing 19

Absolute contraindications Relative contraindications

Unrealistic expectations Tendency to keloid formation

Unable/unwilling to perform wound care Tendency to poor wound healing/scar

Isotretinoin therapy within prior 6–12 months History of radiation therapy in area

History of collagen vascular disease

History of vitiligo

Diseases that koebnerize (e.g., psoriasis)

Pregnancy/breastfeeding

Unable/unwilling to avoid sun exposure postoperatively

The preoperative care should begin at the time that the

patient decides to undergo laser skin resurfacing.

Photoprotection and prevention of tanned skin should

be maximized before surgery. Melanocyte stimulation

before the laser resurfacing may increase the risk of

postinflammatory hyperpigmentation after the procedure.A

sunscreen with a sun protection factor (SPF) of

30 or higher should be used daily, along with an ultraviolet

A (UVA) blocker such as zinc oxide, titanium

dioxide, or avobenzone.We advise patients to supplement

sunscreen use with physical measures such as

large sunglasses and hats.

The use of topical therapy before surgery is common

– this might include topical tretinoin, hydroquinone

and antioxidants. It is clear that the use of a

topical retinoid is quite valuable before skin resurfacing

with chemical peels through its action on the

stratum corneum and epidermis. The use of topical

tretinoin can increase the penetration of the peel, provide

a more even peel and enhance healing. 4,5 Due to

the high affinity for water with the CO 2 and Er:YAG

lasers, these lasers are very capable of evaporating the

epidermis without the use of tretinoin.There may be

other effects that could theoretically improve the laser

resurfacing process and healing. Retinoids regulate

gene transcription and affect activities such as cellular

differentiation and proliferation. They can induce

vascular changes of the skin and a reduction and

redistribution of epidermal melanin. 6 Retinoids (at

least theoretically) can speed healing and perhaps

reduce pigmentary changes.Thus, it is our practice to

begin a topical retinoid at least 2 weeks prior to the

procedure – even earlier if possible.

Because of the relatively common development of

postinflammatory hyperpigmentation after laser resurfacing,

especially in the darker skin tones, many physicians

will pretreat with a bleaching agent such as

hydroquinone (HQ). HQ works by inhibiting the

enzyme tyrosinase, which is necessary for melanin

production within the epidermis. It can also inhibit the

formation of melanosomes.There is a clear role for

HQ products after laser resurfacing to treat hyperpigmentations;

this will be discussed later in the chapter.

HQ may not have any clinical effect when used prior

to laser surgery, since the melanocytes that it is working

on are all removed during the laser procedure. It is

certainly not unreasonable to initiate HQ in a 3–5%

cream for those patients at high risk for developing

hyperpigmentation after their procedure. Like the

topical retinoids, it can be irritating and should be discontinued

if it is causing an irritant dermatitis. A rare

side-effect of HQ is exogenous ochronosis, but this

usually occurs only with prolonged use of higher concentrations

and should not develop even in predisposed

individuals within just a couple of weeks. 7

There is no proven role for the use of topical antioxidants,

alpha-hydroxy acids, or beta-hydroxy acids,

but they are often in the skin care regimen of patients

and we do not discontinue their use prior to laser

resurfacing.

Tobacco smoking can delay wound healing, and

patients are strongly encouraged to stop tobacco

use.As an alternative, if the patient is unable or unwilling

to stop smoking at least 2 weeks prior to the


20 Clinical procedures in laser skin rejuvenation

procedure, he or she is encouraged to switch to a

tobaccoless product such as a patch or gum.

The use of oral antiviral therapy is standard practice,

even if the patient does not have a history of herpes

simplex virus (HSV) infections.Typically, famciclovir

or valacyclovir is used in prophylactic doses such as

famciclovir 250 mg twice daily or valacyclovir 500 mg

twice daily. Doses need to be adjusted for renal dysfunction.The

patient begins therapy the day before the

procedure and continues until re-epithelialization

is complete. It can be helpful to keep antiviral therapy

in the office to administer to the patient if he or she

forgot to initiate therapy before the procedure.

The use of prophylactic systemic antibiotics is of

questionable value prior to surgery and remains controversial.

8 A first-generation cephalosporin is typically

used by one of us (NLS), while no antibiotics are routinely

used by the other (DAG). Interestingly, recent

animal studies have shown that CO 2 laser resurfacing

reduces microbial counts of most microorganisms on

lasered skin compared with skin treated using mechanical

abrasion. 9 On the other hand, nasal mupricin is

routinely prescribed (by DAG) for healthcare workers

due to the current high rates of methicillin-resistant

Staphylcoccus aureus (MRSA) in hospitals and nursing

homes. Unfortunately, the incidence of MRSA in the

community is also increasing, and MRSA may be

encountered in non-healthcare workers. 10,11 Surgeons

should monitor their local communities for recommendations

regarding community-acquired MRSA.

There have been no published studies on the use of

antifungal therapy prior to laser resurfacing, although

Candida infections can develop during the postoperative

period, especially when occlusive dressings are

used. It has been our practice, and that of others, to

treat women with a known history or frequent or

recurrent vaginal candidiasis with oral fluconazole

after the procedure, even when using open healing

techniques. 9

Botulinum toxin is routinely administered to our

patients prior to laser resurfacing of the face. Placebocontrolled

studies have demonstrated improved results

when compared with laser resurfacing alone. 12,13 Preoperative

use of botulinum toxin type A can diminish

rhytids as well as textural, pigmentational and other

features of skin aging when used in conjunction with

laser resurfacing. 13 Our preference is to treat at least 2

weeks prior to laser surgery and repeat at approximately

3 months postoperatively.

Patients are given instruction sheets listing skincare

items they will need after the procedure along with

their prescriptions for postcare medications. These

will be discussed later in the chapter.

Laser resurfacing

Before coming into the office for their procedures,

patients are instructed to wash their face well. After

drying, they apply a topical anesthetic cream such as

EMLA (a eutectic mixture of lidocaine 2.5% and

prilocaine 2.5%) under occlusion with a plastic wrap.

This is left intact for 2–2.5 hours. One of us (NLS)

will reapply the topical anesthetic 45 minutes prior to

the procedure.The EMLA not only helps to provide

cutaneous anesthesia, but also hydrates the skin, which

decreases the procedure’s side-effect profile. 14 Further

anesthesia or analgesia can be obtained with nerve

blocks, local infiltration of lidocaine, tumescent anesthesia

or diazepam, and, in our office, intramuscular

meperidine and midazolam, or ketorolac, is used.The

topical agents are removed prior to beginning the laser

procedure.

When using the UltraPulse CO 2 laser (Lumenis,

Santa Clara, CA), the face is treated at 90 mJ/45 W,

and the first pass is usually performed at a density of 7

for central facial areas (periorbital, glabellar, nose, and

perioral): the upper and lower eyelids are treated at a

density of 6 with the energy setting at 80 mJ.The density

should be decreased to 6 and then 5 when feathering

to the hairline and jawline. The first pass is

intended to remove the epidermis, which is wiped free

with a wet gauze in the central facial areas only, and a

second pass is performed to central facial areas at a

density of 4–5 (90 mJ), depending on the tightening

needed. If required, the second pass on the eyelids is

performed at a density of 4. Energies are decreased

towards the periphery of the face. A third pass may be

needed in areas of acne scarring or in the perioral

area with deeper wrinkles. As with any laser procedure,

careful monitoring of tissue response during

treatment is performed to determine the necessity of

any additional passes and energy level used.


A similar approach is taken when using one of the

combined Er:YAG lasers such as the Sciton laser (Palo

Alto, CA).The first pass is used to remove the epidermis

and frequently 25 J/cm 2 (100 µm ablation, zero

coagulation) with 50% overlap is used. A second or

third pass is used to heat and hopefully to induce skin

tightening. Ablative and coagulative settings are used

with a typical second, pass and a commonly used setting

would have 50% overlap with 10 µm ablation and

80 µm coagulation.

Where there are very deep rhytids or scars, the

erbium laser in just the ablative setting can be used in a

single spot to help sculpt the edges. It is important to

remember that when used in the ablative mode, there

is very little (if any) hemostasis, and pinpoint bleeding

can help identify the depth of resurfacing.

Laser resurfacing is best done to the entire face

to avoid lines of demarcation between treated and

untreated skin.The procedure should be carried into

the hairline and at the jaw and chin; a feathering technique

should be used. This includes a zone of

decreased energy, decreased density, or pulse overlap.When

treating a patient with moderate to severe

photodamage, it is important to blend into the neck

as much as possible. One approach is to lightly resurface

the neck with a chemical peel; in our office, a

Jessners and/or glycolic acid peel is used. Another

option is to laser the neck, which will be reviewed

later in the chapter.

Postoperative care

Carbon dioxide laser resurfacing, fractionated resurfacing and YSGG resurfacing 21

Wound care is critical, and regimens vary among

physicians. Occlusive and nonocclusive dressings are

available. Occlusive dressings cover the skin and are

usually removed in 1–3 days. These can decrease

patient discomfort, but may promote infection by harboring

bacteria or yeast.When opaque, the dressings

can mask visualization of the wound, thus delaying the

detection of an infection. Clear dressings (e.g., Second

Skin) allow the patient and medical team to look at the

lasered skin.When used in our office, they are most

commonly removed on the second day postoperatively

and the patient is switched to open healing.

Open dressings or nonocclusive dressings are usually

petroleum-based ointments. Frequent soaking and

cleaning are necessary (at least 4 times daily), followed

by frequent application of petroleum jelly, Aquaphor

ointment or one of the many wound care ointments

that are available. Additives, fragrances, or dyes will

increase the chance of contact allergic or irritant dermatitis

developing and should be limited as much as

possible. In very sensitive individuals, pure vegetable

shortening can be used. Dilute vinegar can be used to

soak and debride the wound, promote healing, and

inhibit bacterial growth.

Wound care needs to be performed until reepithelialization

is complete. Depending on the type of

laser used and how aggressive the surgeon was with his

or her settings, re-epithelialization should be complete

within 5–10 days. Prolonged healing times can

indicate an infection, contact dermatitis, or other

problem, and increases the risks of complications.

COMPLICATIONS AND THEIR

MANAGEMENT

Complications following laser surgery are relatively

infrequent, but when they do occur, they need to be

treated quickly and efficiently to minimize patient

anxiety and long-term morbidity. 15 Obviously, good

patient selection, surgical management, and postoperative

care are necessary to help prevent complications,

but, even in the best of cases, complications do occur

(Box 3.2).

Box 3.2 Complications of ablative laser resurfacing

• Activation of herpes simplex virus (HSV)

• Bacterial infection

• Candidal infection

• Delayed healing

• Prolonged erythema

• Hyperpigmentation

• Hypopigmentation

• Acne

• Milia formation

• Contact dermatitis

• Scarring

• Line of demarcation with untreated skin


22 Clinical procedures in laser skin rejuvenation

Table 3.2 Causative agents encountered in CO 2 laser

infections 16

Organism Percent

Pseudomonas 41.2

Staphylococcus aureus 35.3

S. epidermidis 35.3

Candida 23.5

Enterobacter 11.8

Escherichia coli 5.9

Proteus 5.9

Corynebacterium 5.9

Serratia 5.9

Herpes simplex virus (HSV) 5.9

The most common complications seen immediately

postoperatively are swelling and exudative weeping

related to the degree of wounding. If facial swelling

is severe, oral or intramuscular steroids, and non

steroidal anti-inflammatory agents (NSAIDs) can be

administered. Milia formation is common, with the

development of small white papules, usually < 1mm

in size, which need to be distinguished from pustules.

Papules are an occlusive phenomenon, and will

resolve without treatment.

Infections can occur, and may be bacterial, viral, or

fungal in nature (Table 3.2). 16 Signs and symptoms

include pain, redness, pruritus, drainage (usually not

clear), yellow crusting, and sometimes erosions, vesicles

or pustules may develop (Fig. 3.2). Pruritus, especially,

should alert the physician to a possible infection.

Appropriate evaluation may include tzanck smear,

potassium hydroxide (KOH) prep, gram stain, and

cultures to accurately diagnose the causative agent.

Treatment should begin early, pending culture results.

Fitzpatrick’s group found that half of their patients

who developed a post-laser infection had more than

one microorganism.Thus, broad coverage should be

initiated, and should generally include an agent that

will cover Pseudomonas aeruginosa.

Acne is another complications that can be seen relatively

early in the course. Oral antibiotic therapy and

discontinuation of petroleum-based ointments usually

suffice.Topical acne therapies are not generally well

a

b

Fig.3.2 A postoperative infection at day 3,with redness,

edema,yellow drainage and crusting,and pustules.The

patient noted increasing discomfort and pruritus.

tolerated, due to skin sensitivity, and need to be used

judiciously.

Contact dermatitis can occur, and may be due to an

allergic reaction or an irritant reaction. It may occur

within the first few weeks or months after laser resurfacing.

Redness, pruritus, and delayed healing may be

noted, but vesiculation is rare.Topical antibiotics are

a common cause of allergic contact dermatitis, and

should be avoided. Patients may be using them without

the knowledge of their physician. Topically applied

agents should be reviewed and discontinued. Dyes and

fragrances that are added to laundry detergents, fabric

softeners, and skincare items are also potential causes.

Discontinuation of the offending agent(s) and topical

corticosteroids should be initiated early. 17


Carbon dioxide laser resurfacing, fractionated resurfacing and YSGG resurfacing 23

PIGMENTARY ABNORMALITIES

Hypopigmentation

Lightening of the skin is desirable for most patients

undergoing facial rejuvenation. Patients who undergo

resurfacing of cosmetic units such as the perioral area or

periocular area may exhibit a noticeable difference

between the ‘new’ treated skin and the untreated skin

that exhibits the various dyschromias associated with

photoaging.This should be avoided as indicated previously,

but when faced with such a patient, treating the

remaining skin will lighten the hyperpigmentation and

help to blend in the differences.Although topical agents

such as retinoids and hydroquinones can be used, visible

results take months and are not practical for most

patients. Resurfacing is the fastest way to improve

patients’ appearance in these cases. Depending on the

severity, a chemical peel such as a Jessner’s/35%

trichloroacetic acid (TCA) peel may be sufficient, or

laser resurfacing can be performed. Superficial resurfacing

is all that is required for most, and the Er:YAG laser

is an excellent device.The goal is to remove the epidermis,

and one or two passes maybe all that is required.

This heals rapidly and with minimum risks.

In the very sun-damaged patient, it may be difficult

to find a good stopping point. In these instances, treating

the full face may only accentuate the discoloration

of the neck. Light rejuvenation of the neck can be

done, but may accentuate the damage to the chest.

Light resurfacing can be performed down the neck and

chest area, extending onto the breast – but this may

then accentuate the damage to the arms and forearms,

etc. In these patients, a combination of modalities can

be used: topical agents as described above for the

entire area; laser resurfacing of the face; lighter resurfacing

of the neck and chest (we generally use chemical

agents such as 20–30% TCA or 70% glycolic acid,

but Er:YAG laser resurfacing is used successfully by

many physicians); and chemical resurfacing of the

arms, forearms, and hands with 20–30% TCA or 70%

glycolic acid.

Another option is the use of nonablative laser technology

such as the ‘Photofacial’ technique. Several

intense pulsed light (IPL) systems are now available,

which use a broad-spectrum intense pulsed light

source with changeable crystals attached to the hand-

Fig.3.3 Persistent depigmentation 2½ years

following CO 2 laser resurfacing that was performed in the

perioral area only.

piece to filter out undesirable wavelengths. This

modality has been applied to the face, neck, chest, and

upper extremities. Numerous treatment sessions are

required, but are generally well tolerated, with little

to no ‘healing-time’ for the patient.The fluence varies

with skin type and area, but the neck is generally

treated more conservatively and using lower fluences.

It is important that the operator carefully place the filters

to avoid overlapping and also to prevent skipped

areas or ‘footprinting’.

Depigmentation

True depigmentation of the skin following laser resurfacing

is more difficult to treat than the pseudohypopigmentation

described above. The skin acquires a

whitish coloration and does not flush or change color

with normal sun exposure (Fig. 3.3). A slight textural

change can even be noted at times such that make-up

does not ‘stick’ to the skin well or does not last as long

as make-up applied to other areas.The latter represents

superficial scarring or fibrosis. It can occur after

any form of resurfacing, but it is more commonly

encountered with CO 2 laser resurfacing and is much

less common with Er : YAG resurfacing. Like pseudohypopigmentation,

depigmentation seems to be more


24 Clinical procedures in laser skin rejuvenation

evident when cosmetic units are treated individually

or when a cosmetic unit such as the upper lip is treated

more aggressively than the surrounding skin.

Depigmentation has been considered a permanent

complication of CO 2 laser resurfacing.When evaluated

histologically, there is a varying quantity of epidermal

melanin present. Residual epidermal melanocytes are

present, indicating that repigmentation should be possible.

Mild perivascular inflammation has been noted

in 50% of biopsies, and superficial dermal fibrosis was

present in all biopsies. 18 This suggests that the pathogenesis

of the laser-induced hypopigmentation may be

related to a suppression of melanogenesis and not

complete destruction of the melanocytes.

Grimes et al 18 have reported successful treatment of

hypopigmentation following CO 2 laser resurfacing

using topical photochemotherapy twice weekly. 18 Seven

patients were treated with topical 8-methoxpsoralen

(0.001%) in conjunction with UVA therapy. Moderate

to excellent repigmentation was demonstrated in 71%

of the patients. Using the same reasoning, narrowband

UVB and an eximer laser may both be effective.

Narrowband UVB, which emits at 311–312 nm, has

been reported to be efficacious for vitiligo, while

excimer lasers emit at 308 nm and can be targeted

to a given site. 19 Alexiades-Armenakas et al 20 have

reported two patients who were treated for laserinduced

leukoderma using an excimer laser. They

speculate that repigmentation is related to the stimulation

of melanocyte proliferation and migration,

along with the release of cytokines and inflammatory

mediators in the skin.

Potential disadvantages of any of these therapies,

however, include the time necessary to see repigmentation,

cost, erythema and pruritus during therapy, and

hyperpigmentation of skin immediately surrounding

the treated skin, which can take months to return to

normal. Unfortunately, the results are mixed, and

return to baseline can occur after therapy is discontinued.

Repigmentation has been an unrealistic goal, and

until more data are available on investigative tools such

as phototherapy, an honest discussion must take place

with the patient. Additional resurfacing of the unaffected

skin may be helpful to reduce any hyper pigmentation

or dyschromia if present, but will only help to

reduce the differences with adjacent areas. Once again,

care should be taken not to re-treat too aggressively.

Scarring

The development of scarring following laser surgery is

perhaps the most feared and distressing complication

encountered. Deeper wounds are more likely to result

in scarring, which is not usually encountered unless

the wound extends into the reticular dermis.

However, since this is the level that is generally targeted

with the CO 2 laser to eradicate wrinkles, acne

scars, and varicella scars, cosmetic surgeons will be

faced with scarring if they perform enough procedures.

Hypertrophic scars can develop anywhere, but

are most likely to occur around the mouth, chin,

mandibular margin, and less often over other bony

prominences such as the malar and forehead regions.

Nonfacial skin is also more likely to develop scarring

due to the relative paucity of pilosebaceous units and

adenexal structures. It has been the experience of one

of us (DAG) that patients with a history of acne scarring,

regardless of prior isotretinoin use, are more

likely to develop delayed wound healing and hypertrophic

scarring when compared with the average

patient.

The surgeon should be alerted to possible scarring

when there is delayed wound healing for any reason.

Infections need to be treated early and aggressively.

Candidal, bacterial, and herpetic infections can delay

healing, prolong the inflammatory stage, and increase

the chance that the wound will heal with scar development.

Likewise, contact dermatitis that is not controlled

early and poor wound care are potential

precursors for postoperative scarring.

Early on, the treated skin may appear redder than

the surrounding skin. As the process continues, textural

changes can be discerned with palpation of the

area (Fig. 3.4), and, as time progresses, a mature scar

will develop. In the early stages, topical steroids may

have a role.A medium to potent steroid should be used

twice daily, but should be applied only to the area of

concern and not to the entire lasered area. If prolonged

erythema alone is noted without any discernible

textural changes, a class II or III steroid may

suffice but if thickening or induration is present, a class

I steroid should be considered.The patient needs to be

monitored closely so that steroid-induced atrophy,

stria, or telangectasia do not develop and so that

progression of the scarring can be followed.


a

b

Carbon dioxide laser resurfacing, fractionated resurfacing and YSGG resurfacing 25

Fig.3.4 (a) Persistent erythema with textural changes at

6 months post CO 2 laser resurfacing.(b) Scar development

present at the lip 6 months post CO 2 laser resurfacing.

Intralesional glucocorticosteroids are probably

more effective than topical steroids if textural changes

and induration have developed.We typically use triamcinolone

acetonide diluted to a concentration of 2.5–5

mg/cm 3 for facial scars, but will use 7.5–10 mg/cm 3

for very thick or indurated scars. A 30-gauge needle is

used to minimize further trauma to the area, and the

injection is given into the superficial dermis of the

scar. Injections can be repeated every 2–4 weeks,

depending on the response or progression of the scar.

Treatment should be continued until the skin returns

to the same texture and consistency as the surrounding

tissue. Overtreatment can result in atrophy, and

telangectasia can develop.

Some surgeons use occlusion therapy in the early

stages of scarring. A very large number of silicone gel

dressings have become available over the past few

years. If utilized, they should be applied to the scar

daily and worn for 12–24 hours per day as tolerated.

A mild dishwashing detergent can be used to clean the

dressing. An onion skin extract, Menderma gel (Merz

Pharmaceuticals, Greensboro, NC), is also marketed

to improve and prevent scarring. Its efficacy in not

known, and patients using any such product need to

be monitored for irritant and allergic contact

dermatitis.

Another treatment used after laser surgery to treat

scars is 5-fluorouracil (5-FU). 21 This antimetabolite is

a pyrimidine analog and works by inhibiting fibroblast

proliferation. A concentration of 50 mg/cm 3 is

injected into the scar and a total dose of 2–100 mg is

used each injection session. Although effective, the

injections are quite painful.The addition of Kenalog

should be considered and is mixed such that 0.1 cm 3 of

Kenalog 10 mg/cm 3 is added to 0.9 cm 3 of the 5-FU

(45mg 5-FU). Less pain and potentially greater

efficacy are associated with the latter solution.

Approximately 0.05cm 3 is injected per site, separated

by approximately 1 cm. Injections should be performed

two or three times weekly initially, and only

the indurated portions of the scar should be injected.

Side-effects include pain with injection, purpura, and

rarely superficial tissue slough.

Flashlamp-pumped dye laser (FLPDL) therapy is

effective, and was first described by Alster. 22 The

settings typically used with the 585 nm FLPDL are

5–7.5 J/cm 2 with a 7 mm spot size or 4–5J/cm 2 with

a 10 mm spot size. Newer vascular lasers and intense

pulsed light sources are also being used to treat surgical

scars.The V Beam (Candela Corp.,Wayland, MA)

has a wavelength of 595 nm and a cryogen spray to

help cool the epidermis is our preferred laser for

scars. Broad-spectrum, intense pulsed light such as the

VascuLight (Lumenis, Santa Clara, CA) has been effective

with a 570 nm filter.Treatments are administered

at 3- to 4-week intervals, and generally will require a

minimum of 2–4 treatment sessions.

Patients may develop anxiety about having ‘more

laser surgery’ if they have already developed a scar

from previous laser surgery, but these techniques are

generally well tolerated and with minimal risks.

Because of the low fluences used, purpura generally

does not develop. Although well accepted as an effective

treatment, not all studies have demonstrated good

results using the pulsed dye laser for scars. In a study

by Wittenber et al, 23 the flashlamp pulsed dye laser and

silicone gel sheeting showed improvement in scar


26 Clinical procedures in laser skin rejuvenation

blood flow, volume, and pruritus, but the results were

no different than the controls.

Combining modalities will ensure the best results in

reduction of scar volume and erythema and improvement

of texture. Laser therapy can be added to the

regimen after the scar has begun to show flattening

with 5-FU or steroids.Thus, fibroblast activity is suppressed

by 5-FU, inflammation is suppressed by corticosteroids,

and pulsed dye laser suppresses angiogenesis

and endothelial cell growth factors.

Concomitant use of the CO 2 laser and the pulsed

dye laser has been described for nonerythematous

scars. 24 The CO 2 laser is used to de-epithelialize the

scar; total vaporization of the scar is not suggested.

Then the 585nm pulsed dye laser is used with fluences

of 6–6.5 J/cm 2 with a 7 mm spot.

Finally, resurfacing can be tried for scars that have

not responded to the treatment modalities already

described.This, however, can result in further scarring,

and should be used judiciously.The patient needs

to be counseled extensively regarding the potential

risks.The scarred area and a small amount of normal

appearing skin surrounding the scar should be anesthetized

with local anesthesia. Either a CO 2 Er:YAG

laser can be used, but we prefer the Er:YAG system

since it provides ablation with little thermal injury.The

scarred area should be ablated superficially with an

additional pass to blend with the surrounding skin.

Wound care is performed in the standard fashion.

Less commonly, hypertrophic scars are hyperpigmented.

In these cases, either a pulsed dye laser or

a pigment-specific pulsed dye 510 nm laser and a

532 nm frequency-doubled neodymium (Nd):YAG

laser can be used to lighten the scar.The immediate

endpoint is the production of an immediate ash-white

color. ‘Significant’ or ‘average’ improvement can be

achieved in approximately 75% of scars. 25

SPECIAL CONSIDERATIONS

Resurfacing cosmetic units

For patients who are not willing to undergo entire face

resurfacing and who have deep rhytids limited to the

perioral area, CO 2 laser resurfacing can be combined

with more superficial resurfacing. The preoperative

care is the same, but the face is first resurfaced or

peeled to the desired depth. When using chemical

peeling, the face is first degreased with alcohol or acetone.

Jessner’s peel is applied and then TCA is applied

directly onto the skin in concentrations of 20–35%,

depending on the desired results. Application of the

TCA is performed one cosmetic unit at a time to

decrease discomfort and to monitor for the desired

level of frost. A hand-held fan or cooling device will

enhance the patient’s comfort. Once the peel or

superficial laser resurfacing has been performed, the

perioral area can be treated with the more aggressive

CO 2 or Er:YAG lasers as described above.The peeled

skin will be red and clearly identifiable to the laser surgeon.Wound

care is the same as previously described.

Due to the smaller surface area that is more deeply

treated, there is less total swelling and exudative

drainage. This approach is especially popular in our

patients who are ready to undergo a second resurfacing

procedure for the mouth area but have retained

satisfactory results to the rest of their face.

Neck resurfacing

Due to the relative paucity of adenexal structures in

the neck, rejuvenation procedures need to be performed

judiciously.The use of the Er:YAG laser to improve

photoaging was established in the late 1990s, but only

modest improvements were seen. 26 The desire to

improve results led to the use of the CO 2 laser, but

with mixed results. In 2001, Fitzpatrick and Goldman 27

published a study on 10 subjects using the UltraPulse

CO 2 laser. Despite no complications being seen at the

initial neck test areas, 40% of the patients had complications

observed at 3–6 months, including patchy

hypopigmented scarring (with and without textural

changes) in the lower portions of the neck. Despite

some obvious improvements noted in the color

and texture of the skin (although no improvement in

wrinkling was observed), it was concluded that the

risks outweighed the potential benefits, at least at the

three different parameters studied. In 2006, Kilmer

et al 28 reported their experience in performing CO 2

neck resurfacing in over 1500 patients. Only 2 patients

developed hypopigmentation. Over 99% of the neck

cases in this study were treated concomitantly with

facial resurfacing. Any patient who had undergone


prior neck radiation was excluded from neck CO 2

resurfacing. Topical EMLA was used as previously

described in this chapter with a second application 45

minutes before the procedure. Lower energy densities

were used as the treatment proceeded down the neck.

Epidermal debris was not wiped off the neck, in order

to minimize additional trauma.

Fractional CO 2 resurfacing

Carbon dioxide laser resurfacing, fractionated resurfacing and YSGG resurfacing 27

Carbon dioxide laser resurfacing can give the most

dramatic improvements, in terms of smoothing skin,

decreasing rhytids, removing lentigines and tightening

facial skin. However, due to the typical associated

length of recovery it remains unpopular with patients.

Other lasers have been developed to try to achieve a

more carbon dioxide laser resurfacing type of

improvement with a relatively brief recovery period.

One of these is fractional CO 2 laser resurfacing and the

other is the new YSGG resurfacing laser.

Although fractional lasers are now available in several

different wavelengths, the fractional 10 600 nm

carbon dioxide laser can offer some of the beneficial

ablative and tightening effects associated with traditional

Carbon dioxide laser resurfacing.

In fractional photothermolysis, a fraction of the skin

surface is treated with the laser, resulting in small

zones of thermal injury bridged by surrounding areas

of untreated skin. 29

Since, only a fraction of the skin is treated, reepithelialization

occurs relatively quickly by migration

of epithelial elements from the adjacent untreated

skin, into the lasered areas.

The fractional CO 2 laser (Active Fx, Lumenis, Inc.,

Santa Clara, CA, USA), produces small spots (approximately

1.3 mm) that are scanned using the computerized

pattern generator. Between the spots there are

areas of untreated skin.

This laser is designed to decrease the possible lateral

thermal effects of the laser, while allowing the deeper

thermal heating effects in each of the treated areas for

stimulation of neocollagen production and inducing

skin contraction.

Since the laser treatment is fractionated the lateral

heating effects are decreased by leaving adjacent

untreated areas which allow for heat dissipation.

Furthermore the device’s CoolScan TM setting allows

the spots to be placed in a “random” pattern, which

skips from one region to the next rather than treating

sequential adjacent areas. This allows for additional

thermal relaxation between pulses resulting in less

overall thermal injury, and quicker recovery. Posttreatment

erythema resolves more rapidly.

The treated areas are smaller and placed in a less

dense manner than in traditional CO 2 laser resurfacing.

Settings are variable and are based on patient need

in terms of acceptable downtime and degree of photodamage

or acne scarring.

Initially, post treatment patients develop area of punctate

crusting surrounded by areas of unlasered skin. As

could be anticipated this also becomes pink and develops

mild swelling. Typically, the third author has the

patients keep the area moist until it completely reepithelializing.This

can be achieved by application of

Aquaphor (Beiersdorf,) every 8 hours or other dressings

with a moisturizing effect.The third author also

routinely gives antivirals starting twenty four hours

prior to the laser treatment. Each physician, must

decide in their own prophylaxis and after care regimens.

Typically patients can resume their regular activities

4–7 days post treatment. Although the results are not

as dramatic as with traditional carbon dioxide laser

resurfacing the third author’s patients have been

pleased with the results of these treatments.They have

noted improvement in their skin texture, wrinkles,

and lentigines as well as some mild skin tightening.

More aggressive settings can also be used for more

dramatic results dramatic results with a consequent

increase in patient downtime. Patients with deep

rhytids and significant skin laxity who are willing to

deal with the healing process associated with CO 2

resurfacing can have a non-fractionated resurfacing.

A different type of fractional CO 2 laser is currently

under development (Reliant Technologies, Mountain

View, CA USA).This laser penetrates the skin more

deeply than the traditional CO 2 laser and may allow a

greater tightening effect. (presented at American

Society of Dermatologic Surgery Annual meeting,

palm Desert, CA, October 2006)

Another alternative to fractional CO 2 resurfacing is

the 2790 nm laser. (the Pearl, Cutera, Brisbane,

California.) This laser is designed to resurface similar

to an erbium laser but to provide deeper associated

thermal effects to create greater collagen stimulation


28 Clinical procedures in laser skin rejuvenation

and skin tightening.The effect is between the effect of

the typical erbium laser and the carbon dioxide laser. It

is used to improve skin smoothness, reduce mild wrinkles

and decrease hyperpigmentation.

THE FUTURE

Fractional laser, contiguous laser and plasmakinetic

resurfacing will undoubtedly continue to advance and

improve. Further improvements in patient outcomes

may be obtainable with combination therapy including

using nonablative lasers, fillers, neurotoxins, and cosmeceuticals.The

push continues for less invasive, more

efficacious tools with added predictability and safety.

The key is to a successful resurfacing practice hower,

still involves proper patient selection, good technique

and wound care, and the early identification and management

of complications.

REFERENCES

1. Iyer S, Bowes L, Kricorian G, Friedli A, Fitzpatrick RE.

Treatment of basal cell carcinoma with the pulsed carbon

dioxide laser: a retrospective analysis. Dermatol Surg

2004;30:1214–18.

2. Iyer S, Friedli A, Bowes L, Kricorian G, Fitzpatrick RE.

Full face laser resurfacing: therapy and prophylaxis for

actinic keratoses and non-melanoma skin cancer. Lasers

Surg Med 2004;34:114–19.

3. Kilmer SL, Semchyshyn N. Ablative and nonablative facial

resurfacing. In: Goldberg DJ, ed. Laser Dermatology.

Berlin: Springer-Verlag 2005:83–98.

4. Hevia O, Nemeth AJ, Taylor JR. Tretinoin accelerates

healing after trichloroacetic acid chemical peel. Arch

Dermatol 1991;127:678–82.

5. Vagotis FL, Brundage SR. Histologic study of dermabrasion

and chemical peel in an animal model after pretreatment

with Retin-A.Aesth Plast Surg 1995;19:243–6.

6. Kang S, Leyden JJ, Lowe NJ, et al Tazarotene cream for

the treatment of facial photodamage. Arch Dermatol

2001;137:1597–604.

7. Penneys NS. Ochronosis-like pigmentation from hydroquinone

bleaching creams. Arch Dermatol 1985;

121:1239–49.

8. Nester MS. Prophylaxis for and treatment of uncomplicated

skin and skin structure infections in laser and

cosmetic surgery. J Drugs Dermatol 2005;4:20–5.

9. Manolis E,Tsakris A, Kaklamanos I, Siomos K. In vivo

effect of carbon dioxide laser skin resurfacing and

mechanical abrasion on the skin’s microbial flora in an

animal model. Dermatol Surg 2006;32:359–64.

10. Crum NF, Lee RU,Thornton SA, et al. Fifteen-year study

of the changing epidemiology of methicillin-resistant

Staphylococcus aureus.Am J Med 2006;119:943–51.

11. Fritsche TR, Jones RN. Importance of understanding

pharmacokinetic/pharmacodynamic principles in the

emergence of resistances, including community-associated

Staphylococcus aureus. J Drugs Dermatol 2005;4:4–8.

12. Zimbler M, Holds J, Kokoska M, et al. Effect of botulinum

toxin pretreatment on laser resurfacing results: a

prospective, randomized, blinded trial. Arch Facial Plast

Surg 2001;3:165–9.

13. West T, Alster T. Effect of botulinum toxin type A on

movement-associated rhytides following CO 2 laser resurfacing.

Dermatol Surg 1999;25:259–61.

14. Kilmer SL, Chotzen VA, Zelickson BD, et al. Full-face

laser resurfacing using supplemented topical anesthesia

protocol.Arch Dermatol 2003;139:1279–83.

15. Fitzpatrick RE, Geronemus RG, Grevelink JM, Kilmer

SL, McDaniel DH. The incidence of adverse healing

reactions occurring with UltraPulse CO 2 resurfacing

during a multicenter study. Lasers Surg Med 1996;

Suppl 8:S34.

16. Sriprachya-Anunt S, Fitzpatrick RE, Goldman MP, Smith

SR. Infections complicating pulsed carbon dioxide laser

resurfacing for photoaged facial skin. Dermatol Surg

1997;23:527–35.

17. Railan D, Kilmer SL. Ablative treatment of photoaging.

Dermatol Ther 2005;18:227–41.

18. Grimes P, Bhawan J, Kim J, Chiu M, Lask G. Laser

resurfacing-induced hypopigmentation: histologic alterations

and repigmentation with topical photochemotherapy.

Dermatol Surg 2001; 27:515–20.

19. Hong S, Park H, Lee M. Short-term effects of 308-nm

xenon-chloride excimer laser and narrow-band ultraviolet

B in the treatment of vitiligo: a comparative study.

J Kor Med Sci 2005;20:273–8.

20. Alexiades-Armenakas MR, Bernstein LJ, Friedman PM,

Geronemus RG.The safety and efficacy of the 308-nm

excimer laser for pigment correction of hypopigmented

scars and striae alba.Arch Dermatol 2004;140:955–60.

21. Fitzpatrick R.Treatment of inflamed hypertrophic scars

using intralesional 5-FU. Dermatol Surg 1999;25:736–7.

22. Alster T. Improvement of erythematous and hypertrophic

scars by the 585-nm flashlamp-pumped pulsed dye laser.

Ann Plast Surg 1994;32:186–90.

23. Wittenberg G, Fabian B, Bogomilsky J, et al. Prospective,

single-blind, randomized, controlled study to assess the

efficacy of the 585-nm flashlamp-pumped pulsed-dye


Carbon dioxide laser resurfacing, fractionated resurfacing and YSGG resurfacing 29

laser and silicone gel sheeting in hypertrophic scar treatment.Arch

Dermatol 1999;135:1049–55.

24. Alster T, Lewis AB, Rosenbach A. Laser scar revision:

comparison of CO 2 laser vaporization with and without

simultaneous pulsed dye laser treatment. Dermatol Surg

1998;24:1299–302.

25. Bowes LE, Nouri K, Berman B, et al.Treatment of pigmented

hypertrophic scars with the 585 nm pulsed dye

laser and the 532 nm frequency-doubled Nd : YAG laser

in the Q-switched and variable pulse modes: a comparative

study. Dermatol Surg 2002;28:714–19.

26. Goldman MP, Fitzpatrick RE, Manuskiatti W. Laser resurfacing

of the neck with the erbium : YAG laser. Dermatol

Surg 1999;25:736–7.

27. Fitzpatrick RE, Goldman MP, Sriprachya-Anunt S.

Resurfacing of photodamaged skin on the neck with

an UltraPulse carbon dioxide laser. Lasers Surg Med

2001;28:145–9.

28. Kilmer SL, Chotzen VA, Silva SK, McClaren ML. Safe and

effective carbon dioxide laser skin resurfacing of the

neck. Lasers Surg Med 2006;38:653–7.

29. Manstein D, Herron GS, Sink RK,Tanner H,Anderson R.

Fractional photothermolysis: a new concept for cutaneous

remodeling using microscopic patterns of thermal

injury. Lasers Surg Med 2004; 34:426–38.

30. American Society of Dermatologic Surgery Annual

Meeting, Palor Desert, CA, October 2006.


4. Erbium laser aesthetic skin rejuvenation

Richard Gentile

MODALITIES OF SKIN REJUVENATION

Aesthetic skin rejuvenation (ASR) is certainly not a

new process, and historical accounts date back as many

as four millennia (2000 BC). For thousands of years,

humans (both male and female) have been utilizing

treatments to improve the appearance of a poor complexion

or to enhance the beauty of a natural complexion.

Throughout the ages, humans have sought out

simple, elective cosmetic methods to improve highly

visible and undesirable permanent cutaneous signs:

facial wrinkles and residual facial scars that may follow

ailments such as acne, smallpox, and chickenpox. 1 The

first examples of such ‘treatments’ were apparently

noted in ancient Egypt and recorded in the famous

Edwin Smith Surgical Papyrus, the oldest medical document

in existence. 2 The description of the wrinkleremoval

recipe prepared from hemayet fruit included

the composition and the technique for application.

Ancient Greece and the Roman Empire are both well

represented in the quest for more beautiful skin, and

Cleopatra (whose name has been synonymous with

beauty through the ages) wrote a book on beautification

that was quoted by Galen and other medical writers.

Her recipes were quoted well into the Middle

Ages. Due to the lack of sophisticated medical technology,

many of these treatments relied on what we would

now call homeopathic ‘spa’ products and abrasives.

The transition to utilizing chemicals for ASR occurred

in the early to mid 1800s. Phenol was first prepared in

1842 by the French chemist August Laurent and presented

at the 1867 Paris Exhibition.The mid to late 1800s

also found Hebra 3 utilizing various acids, alkalis, and

other corrosives to treat freckles and melasma. It is not

clear whether Hebra treated wrinkles with these chemical

agents. Chemical agents facilitating ASR (particularly

phenol) became more widely utilized in the early 1900s,

and George Miller MacKee 4 became a proponent of

chemical ASR after first experimenting on himself.

In 1953, Abner Kurtin 5 published ‘Corrective surgical

planing of the skin’, capturing the imagination of

plastic surgeons and dermatologists. He proposed dermabrasion

as a better method to improve acne pits and

scars. Kurtin’s description of dermabrasion actually

reintroduced Ernst Kronomayer’s dermabrasion

procedure, which Kronomayer had introduced in

Germany in 1905. Dermabrasion, chemical peeling

(trichloroacetic acid (TCA) and phenol) were considered

standards for ASR until the 1990s.

The last decade has seen unprecedented technological

development of lasers, other light sources, and

radiofrequency (RF) approaches for ASR.They have

dominated the ASR arena, although a reverse trend

towards a return to chemical exfoliation exists in some

practices. Currently lasers, other light sources, and RF

devices are generally classified as ablative and nonablative.

Goldberg 6 has reviewed the four different tissue

interactions of laser, light, and RF with regard to the

biological effects of ASR devices on skin and adjacent

structures. The description traces the evolutionary

development of these devices:

1. The initial devices ablated the epidermis, caused

dermal injury, and provided a significant thermal

effect (carbon dioxide (CO 2 ) lasers).

2. Subsequent devices caused highly selective

epidermal ablation, with minimal thermal effects

(erbium : yttrium aluminum garnet (Er:YAG)

short pulsed lasers).

3. Later devices ablated the epidermis, caused dermal

injury, and provided variable thermal effects (dualmode

and long- or variable-pulsed Er:YAG lasers).

4. The more recent evolution of devices do not ablate

the epidermis, wound the dermis and provide


32 Clinical procedures in laser skin rejuvenation

minimal thermal effects (nonablative lasers and

light sources).

The fifth generation of devices (not mentioned by

Goldberg) are nonablative or subablative devices that

produce a more substantial thermal effect for skin tightening

and rejuvenation, and include mono- and bipolar

RF devices, with or without optical energy, and infrared

and fractionated devices.Variable-pulsed Er:YAG lasers

are also included in this category, as these devices have

been developed to provide higher degrees of thermal

effects at the level of the dermis and perhaps below as

one function of their clinical application.

EVOLUTION OF USE OF ERBIUM

LASERS IN AESTHETIC AND MEDICAL

DERMATOLOGY

As reviewed by Ronel, 7 laser technology applied to skin

resurfacing was discovered to yield more predictable

depths of injury when compared with chemical peels or

dermabrasion.The first laser used for laser-assisted skin

rejuvenation (LASR) was a pulsed CO 2 laser that

Fitzpatrick and colleagues modified from a device that

had been developed for otolaryngological and gynecological

use. It was initially utilized for periorbital and

perioral LASR, but initial appraisals of substantial aesthetic

improvement led to its use for full facial rejuvenation.The

CO 2 laser quickly became the workhorse for

LASR, and its advantages and limitations became well

recognized. Although the long-term skin rejuvenation

and tightening provided by this device are unparalleled,

marked erythema persisting for weeks or months and

permanent (sometimes delayed) hypopigmentation

occur at a rate that is not acceptable for many patients.

In some patients, as with a deep phenol peel, the recovery

‘downtime’ can approach 2 weeks, which may be

unacceptable for those with active lifestyles or work

obligations. Subsequent to the laser boom of the early to

mid 1990s, further research led to the development of

other lasers for LASR.The aim was to employ a more

precise laser beam, resulting in less intense adverse sideeffects

and a shorter recovery period. In 1990, Kaufman

and Hibst 8 reported on the cutaneous laser ablative

effects of the mid-infrared Er:YAG laser utilized in

short pulses.They employed the laser on pig skin and on

experimental patients, treating superficial lesions such

as epidermal nevi. Precise control of epidermal ablation

was achieved, with small ablation depths and also thermal

necrosis rates that did not exceed 50 µm. Kaufman

and Hibst 8 concluded that the laser should have potential

for LASR, but also noted that, due to the limited

dermal thermal depths of action, bleeding could be a

problem.

The Er:YAG laser was first introduced as a bonecutting

tool in the USA in 1996, but commercial availability

for LASR followed the completion of Food and

Drug Administration (FDA) studies of photodamage.

Initial enthusiasm for the Er:YAG laser was high due to

its ability to operate at a more superficial level and with

greater precision. Collagen contraction was noted to be

1–2% during lasing, reaching 14% in the long term.

Concurrent with its introduction, some short

comings of the Er:YAG laser became apparent.A major

disadvantage of the superficial and fleeting energy

absorption of the Er:YAG laser is its poor ability to

maintain hemostasis.There is not much ‘heat sink’ in the

wound, so thermal necrosis does not significantly

impair the laser’s subsequent ablation, but blood in the

wound bed does make controlling wound depth difficult.The

blood spatter also creates more of a biological

hazard to the surgeon and assistants.The other limitation

of the Er:YAG laser is that there is less collagen

contraction, although this may be due to the fact that

comparable depths of resurfacing are not being accomplished

due to the lack of hemostasis.The shortcomings

of the short-pulsed Er:YAG laser led to some technological

modifications, which included a longer variable

pulse duration as well as the development of lasers with

‘dual-mode’ capabilities.These dual-mode capabilities

allow the operator to dial in the depths of ablation as

well as the thermal effects (coagulation) desired.

ERBIUM LASER PHYSICAL

PROPERTIES AND LIGHT–TISSUE

INTERACTION

Erbium laser physical properties

Solid state lasers have lasing material distributed in a solid

matrix.Yttrium aluminum garnet (YAG,Y 3 Al 2 (ALO 4 ) 3 ) is

a synthetic crystalline material of the garnet group


Fig.4.1 Yttrium aluminum garnet (YAG,Y 3 Al 2 (AlO 4 ) 3 ) is

used for synthetic gemstones.When doped with neodymium

(Nd 3 ) or erbium (Er),YAGs are used as the lasing medium in

lasers.

(Fig. 4.1) used as the active laser medium in various solid

state lasers.YAG is commonly ‘doped’ with other elements

to obtain a specific laser wavelength. In the

Nd:YAG laser, the dopant is the rare earth element

neodymium. In the Er:YAG laser, it is another rare earth

element, erbium (Fig. 4.2). Er:YAG lases at a wavelength

of 2940 nm. Its absorption bands suitable for pumping are

wide and are located between 600 and 800 nm, allowing

for efficient flashlamp pumping (Fig. 4.3).The dopant

concentration used is high: about 50% of yttrium atoms

are replaced. The Er:YAG laser emission couples well

with water and bodily fluids, making these lasers especially

useful in medicine and dentistry: Er:YAG lasers are

used for treatment of tooth enamel as well as aesthetic

dermatological applications. Er:YAG lasers are also used

for noninvasive monitoring of blood sugar.The mechanical

properties of Er:YAG are essentially the same as those

of Nd:YAG. Er:YAG lasers operate at relatively eye-safe

wavelengths (radiated incident through the lens is

absorbed in the eye and does not damage the retina),

work well at room temperature, and have high slope

efficiency. Er:YAG laser light is pale green.

Erbium laser light–tissue interaction

(biophotonics)

There are four primary interactions of laser light

with tissue (Fig. 4.4). The first interaction is surface

reflection. There may also be scattering. This is then

Erbium laser aesthetic skin rejuvenation 33

Fig.4.2 Elemental erbium is a rare silvery rare earth

metal.Erbium is associated with several other rare

earth elements in the mineral gadolinite from Ytterby in

Sweden (from which both the names yttrium and erbium

are derived).

followed by absorption by the target, and some of the

light may be transmitted through the tissues on the other

side of the target.The absorption of laser light in tissue is

a remarkably strong function of wavelength.The result is

that lasers of different wavelengths have qualitatively and

quantitatively different interactions with tissue (Fig. 4.5).

The thermal relaxation time depends very strongly

on the absorption length.The absorption length is the

distance the laser light travels in tissue before it is 63%

absorbed.Taken together, these two parameters determine

a critical power density. This is the minimum

power density that must be used to limit thermal damage

to a depth equal to one absorption length (Table

4.1). For the Er:YAG laser, the absorption length is

0.001 mm, the thermal diffusion time is 4 µ, the critical

power density is 600 W/mm 2 , and the critical

pulse energy is 0.0025 J/mm 2 .

In addition to the initial interactions of light with the

target, subsequent interactions can be summarized as

having photothermal, photochemical, or photoacoustic

effects on the target. As is widely recognized, the

Er:YAG wavelength of 2940 nm is absorbed 12–18 times

more efficiently by superficial (water-containing) cutaneous

tissue than is the CO 2 laser emission at 10 600 nm.

Considering the typical short-pulse erbium pulse duration

of 250 µs, a cutaneous ablation depth of 10–20 µm

is accomplished at a fluence of 5. The vaporization

threshold of the Er:YAG laser is 0.5–1.7 J/cm 2 . The

fluence and depth of tissue ablation are directly related.


34 Clinical procedures in laser skin rejuvenation

Highly reflective

mirror

Er:YAG crystal

Flashlamp (pump source)

For every 1 J/cm 2 , 2–4 mm of tissue depth is ablated.

This allows for precise control of tissue ablation. It

occurs with minimal residual thermal damage and can be

compared with the 20–60 µm of tissue damage per standard

pass of the CO 2 laser with 150 µm of residual thermal

damage per standard pass.

Pulsed laser energy causes controlled vaporization

of the skin according to the principles of selective

photothermolysis. Target tissues contain chromophores

with absorption peaks that selectively absorb

the particular wavelength of the laser pulse. Tissue

adjacent to the chromophore absorbs the energy to a

much lesser degree. The interaction of target tissue

with the CO 2 laser is predominantly a thermomechanical

reaction that leads to target destruction of

dermal vessels and proteins. The Er:YAG laser interacts

with tissue via a photomechanical reaction.

(Laser medium)

Optical resonator

Partially reflective

mirror

Fig.4.3 Laser pumping is the act of energy transfer from an external source (flashlamp) into the laser gain medium (the

Er:YAG crystal).Stimulated emission occurs when a population inversion occurs,with more members in an excited state than in

lower-energy states.

Backward scattering Forward scattering

Laser beam

Direct

reflection

Absorption

Transmission

Laser

output

Fig.4.4 Biophotonics examines the interface of

laser and human tissue and is characterized by

reflection,absorption,scatter,and transmission.

Absorption of the optical laser energy causes immediate

ejection of the dessicated tissue from its location

at supersonic speeds.This popping sound (like a

cap gun) is audible and represents the microexplosion

taking place at the tissue level.The translation of

Er:YAG laser energy into mechanical work is an

important factor that protects the surrounding tissue:

minimal thermal energy remains to dissipate and

cause collateral damage.

COMMERCIALLY AVAILABLE

ERBIUM LASERS

While it is beyond the scope of this chapter to detail

every Er:YAG laser manufactured, we do want to review

some models that are or have been commercially


a

b

Absorption coefficient (cm −1 )

Penetration depth (mm)

10 5

10 4

10 3

10 2

10 1

10 0

10 −1

10 −2

10 −3

−1

Protein

available so that the laser’s unique specifications and

design can be understood.These will be listed as shortpulsed

systems, dual-mode systems, and variablepulsed

systems.

Wavelength (µm)

Type of laser CO2

1

Hemoglobin

Melanin

10

Scatter

Erbium laser aesthetic skin rejuvenation 35

Er:YAG

KTP

Pulse dye

Depth of Penetration

Alexandrite

Water

10−4 0.1 1 10

0

1

2

3

4

0

Excimer

Pigmented

tissue

Unpigmented

tissue

KTP

Nd:

YAG

Ho: Er:

YAG YAG

Wavelength (µm)

CO 2

Ultraviolet Visible Infrared

Fig.4.5 Biophotonics also examines laser absorption (a) and tissue penetration (b) as functions of wavelength,pulse duration,

and thermal relaxation time.Selective photothermolysis describes the process of wavelength-specific target destruction.

Short-pulsed Er:YAG systems

The prototype of the Er:YAG short-pulsed systems,

and one of the first to market in 1996, was the

Diode

Nd:YAG


36 Clinical procedures in laser skin rejuvenation

Table 4.1 Critical power densities and minimum coagulation depths a

Absorption length Thermal Critical power Critical pulse

(minimum damage zone) diffusion density energy

Laser (mm) time (s) (W/mm 2 ) (J/mm 2 )

Argon ion 0.1 pigmented 0.4 0.6 0.25

∞ unpigmented — — —

Doubled Nd:YAG (KTP) 0.1 pigmented 0.4 0.6 0.25

∞ unpigmented — — —

Nd:YAG 5 100 0.1 13

Hol:YAG 0.4 1 1 1.0

Er:YAG 0.001 4 × 10 −6 600 0.0025

CO 2 0.02 0.002 50 0.040

Electrocautery 2 16

a Wavelength and thermal relaxation time determine the critical power density.This is the minimum power density that must be used to limit thermal

damage to a depth equal to one absorption length. Short-absorption-length lasers such as Er:YAG are capable of producing less thermal damage than

lasers with long absorption lengths. In order to achieve this desirable effect, these strongly absorbed lasers must be operated at high power density. When

laser energy is delivered in a pulsed mode, it is possible to limit the tissue damage to one absorption length while working at an average power density

less than the critical value. This result is only possible if the pulsed energy exceeds the critical value shown in the last column.

Coherent Ultrafine Erbium (Fig. 4.6). At the time of

its release in 1996, the UltraFine Erbium was advocated

for incision, excision, ablation, vaporization, and

coagulation of soft tissue, including superficial skin

resurfacing, precision microplaning, etching, and tissue

sculpting.The laser vaporizes 20–50 µm of tissue

with very little thermal effect. It is equipped with a

computerized pattern generator as well as a variablewidth

handpiece. The laser has a maximum output

of 3000 mJ and pulse variability from 200 to 600 µs.

We have used this laser for 10 years, and it has been

very reliable. Others like it include the ConBio CB

Erbium/2.94 and the recently introduced Friendlylight

portable laser, which is highly transportable.

The Nexgen Pixel is a short-pulsed Er: YAG laser

that utilizes a pixel grid pattern of 49 or 81 ablations,

sparing intervening epidermis.The planned ablation is

20–50 µm per pass for epidermal ablation.

Dual-mode Er:YAG systems

Dual-mode, different laser type

Recent developments in Er:YAG lasers have led to the

combination of ablative and coagulative pulses (hence

Fig.4.6 The Coherent UltraFine Er:YAG laser

was one of the first to be available commercially,

in 1996.


the term dual-mode), which allow much deeper vaporization

with significant control of hemostasis. One of the

earliest dual-mode systems was the Sharplan DermaK.

(Both Coherent and Sharplan brands are now owned by

Lumenis.) Both the CO 2 laser and Er:YAG laser are clinically

proven to be effective technologies for ablative skin

rejuvenation.Yet, alone, each laser has its limitations. In

order to provide physicians access to the best characteristics

of each laser wavelength, Sharplan combined a

high-power Er:YAG laser and a subablative CO 2 laser in

the blended DermaK system. DermaK has the unique

capability to deliver both Er:YAG and CO 2 beams simultaneously

(K blend mode) to the same tissue area for skin

rejuvenation.

The Er:YAG laser carries out accurate ablation of

superficial layers, opening the way for the CO 2 laser

to affect the deeper tissue layers. DermaK combines

the best of both the Er:YAG and CO 2 lasers for

improved clinical efficacy. It replicates the precise tissue

ablation and minimal necrosis found in Er:YAG

systems and significantly controls the heating of

deeper tissue layers, typical of CO 2 systems.The concurrent

delivery of both wavelengths provides the

physician with enhanced control over hemostasis (dry

erbium technique), thereby increasing the range of

applications of the Er:YAG laser. The CO 2 mode of

the DermaK delivers sufficient thermal energy to seal

small blood vessels throughout the surgical procedure,

creating the benefit of a clean, dry surgical field.

Simultaneous operation of both the Er:YAG and CO 2

lasers minimizes the number of passes required for a

given procedure, thereby minimizing erythema and

decreasing the recovery time. At the same time, the

dual wavelengths allow more overall energy to be

transferred to the tissue, increasing the ablation depth

and controlling thermal impact. DermaK can also

perform many standard CO 2 laser surgical and aesthetic

incisional procedures, such as blepharoplasty.

There is generally no need for deep sedation when

treating most body areas in LASR.

Same laser type, variable pulse duration

Another dual-mode system is the Sciton Contour

(Fig. 4.7) The Contour Er:YAG contains not one but

two Er:YAG lasers providing 45 W of power.The engineers

use a technology called optical multiplexing to

Erbium laser aesthetic skin rejuvenation 37

Fig.4.7 The Sciton Profile is an example of a

second-generation Er:YAG laser.Such lasers are known

as dual-mode devices.

generate multiple variable-length ‘macropulses’ to generate

high tissue fluence.At 50% overlap, fluences of up

to 100 J/cm 2 can be generated for aggressive vaporization.

Sufficient energy can be delivered to remove the

epidermis in one pass. The optical multiplexing also

allows the laser to be used in an ablative mode, a combined

ablative/coagulative dual mode, or a pure coagulative

mode. The ablative mode is characterized by a

short (200 µs) suprathreshold pulse. The dual-mode

ablation/coagulation is achieved by an ablative pulse

immediately followed by a relatively long subablative

pulse.The coagulative mode consists simply of a series

of subablative pulses.The Sciton Contour is the model

for many current lasers featured below.


38 Clinical procedures in laser skin rejuvenation

Table 4.2 Dermatological conditions treatable with the Er:YAG laser

• Becker nevi • Trichoepitheliomas • Miliary osteomas

• Compound nevi • Sebaceous hyperplasia • Papillomas

• Naevi spili • Eruptive hair cysts • Café-au-lait spots

• Verrucae • Xanthelasma • Syringomas

• Epidermal nevi • Adenoma sebaceum • Basal cell carcinoma

• Xanthelasma • Angiofibroma • Squamous cell carcinoma

• Syringomas • Hidradenoma • Telangiectasia

• Milia palpebrarum • Morbus Favre–Racouchot • Rhinophyma

• Seborrhoic keratoses • Lentigines • Hailey–Hailey disease

• Darier’s disease (familial benign pemphigus)

Variable-pulse Er:YAG systems

Introduced in 2002, the Fontona laser systems feature a

proprietary VSP (Variable Square Pulse) technology.

This allows the practitioner to accommodate the laser

pulse duration and its fluence according to the needs of

the specific application (Fig. 4.8). By means of digital

online energy regulation, the energy of each pulse is

actively controlled to match the required value while

the laser is in operation.This enables the practitioner to

treat selected tissues without heating the surrounding

tissue unnecessarily.With a short pulse width, the VSPshaped

Er:YAG laser induces minimal thermal effects to

underlying tissue while rejuvenating the superficial skin

layers through ablation of the epidermis.This allows the

practitioner to offer effective skin rejuvenation treatments

with higher comfort levels and shorter recovery.

By increasing the pulse duration, more heat is diffused

in the skin and a resulting collateral thermal effect is

achieved. Long-pulsed lasers characteristically have

pulse durations of the order of milliseconds, in contrast

to short-pulse durations of the order of microseconds.

These thermal effects produce pronounced collagen

contraction and new collagen stimulation in the dermis.

Clinical trials have proven a light ablative effect on the

epidermis, relatively noninvasive stimulation of new

collagen formation, and no post-treatment downtime.

Fotona’s stacked pulse technology provides a purely

nonablative Er:YAG laser SMOOTH mode for skin

rejuvenation treatments.The thermal SMOOTH mode

allows dermal remodeling and rejuvenation without

affecting the epidermis.

The Cynosure CO3 laser has a similar variable-pulse

technology, featuring pulse durations of 0.5, 4, 7, and

10 ms.

Ablation speed

High power

Short pulse

Low power

Long pulse

0 0.5 1.0 1.5

Pulse duration (ms)

Fig.4.8 Biophotonics has also resulted in understanding

dosimetry of pulse duration and fluence in an attempt to

achieve more collateral thermal damage with the Er:YAG

laser in order to achieve better hemostasis as well as collagen

contraction.

The FDA has recently given approval for use in the

USA of the BURANE XL Er:YAG laser, which also features

variable triple-pulse technology.The BURANE XL

features a specially designed and patented pulse sequence

for each application (coagulation, scars, and wrinkles)

that heats the deeper skin layers to a specific temperature

while protecting the epidermis by allowing it to cool

down during the pauses of the pulse sequences.All these

dosimetry models are based on longer pulse duration and

subablative laser energies for subablative dermal heating.

CLINICAL DERMATOLOGICAL

APPLICATIONS OF ERBIUM LASERS

Due to its superficial action and tendency to not promote

dermal scarring, the Er:YAG laser is well adapted

to ablating and etching superficial cutaneous neoplasms

and cutaneous blemishes (Fig 4.9).The high ablative

Thermal effect


a

c d

potential results in microexplosive destruction of the

skin lesions without the associated scarring that would

result from epidermal or dermal excisions. Numerous

clinical applications are listed in Table 2.

CLINICAL AESTHETIC APPLICATIONS

OF ERBIUM LASERS

LASR with a short-pulsed Er:YAG laser is most commonly

used for the improvement of fine rhytides. In

patients with moderate photodamage and rhytides,

modulated Er:YAG laser skin resurfacing results in

greater collagen contraction and improved clinical

Erbium laser aesthetic skin rejuvenation 39

Fig.4.9 This patient presented for removal of an irritated seborrheic keratosis,as shown in the preoperative photograph

(a).The lesion is excised by sharp intradermal excision (b).The underlying dermal components are ablated and the edges are

‘feathered’(c).The final result is shown in (d).

b

results compared with short-pulsed Er:YAG systems.

The clinical improvement of severe rhytides treated

with a modulated Er:YAG laser can be impressive (Fig.

4.10).There are conflicting reports as to whether or not

the endpoints of CO 2 LASR can be reached even when

ablating to similar depths. Newman and colleagues

compared a variable-pulse Er:YAG laser with traditional

pulsed or scanned CO 2 laser resurfacing for the treatment

of perioral rhytides. 9 Although a reduced duration

of re-epithelialization was noted with the modulated

Er:YAG laser (3.4 days vs 7.7 days with a CO 2 laser),

the clinical results observed were less impressive than

those following CO 2 laser resurfacing. Er:YAG laser systems

may greatly improve atrophic scars caused by acne,


40 Clinical procedures in laser skin rejuvenation

a b

c

Fig.4.10 This treatment took place over two sessions.(a) Preoperative photograph.(b) Following excision/ablation of

seborrheic keratosis with basal cell carcinoma.The patient then elected to have aesthetic full-face LASR 1 year postoperatively and

is shown 4 days (c) and 12 days (d) post LASR,with multiple excision ablations.

d


trauma, or surgery. In a series of 78 patients,Weinstein

reported 70–90% improvement of acne scarring in the

majority of patients treated with a modulated Er:YAG

laser 10 . Pitted acne scars may require ancillary procedures,

such as subcision or punch excision, for optimal

results.These procedures can be performed either prior

to or concomitant with Er:YAG laser resurfacing.

ERBIUM LASER TECHNIQUES

Cutaneous ablative surgery

In treating superficial epidermal lesions such as irritated

seborrheic keratoses, the primary lesion can be

ablated or an epidermal shaving of the lesion followed

by ablative pulses can be performed. On most treatments

with the short-pulsed laser system, the fluence

is set to 5, which corresponds to about 20 µm of ablation.The

lesion ablation is continued until the entire

lesion is vaporized.The adjacent dermis is ‘feathered’

to taper the cutaneous margins of the lesion.

‘Dry erbium’

This is a fairly new term, with the ‘dry erbium’ representing

an epidermal ablation that does not extend

into the papillary dermis, where bleeding is encountered.

Often, this treatment is done with subablative

levels of laser energy and is associated with rapid

recovery and a result that is intermediate to microdermabrasion

or photorejuvenation but not as significant

as superficial laser resurfacing.

Superficial LASR

The technique used for superficial LASR is to set the

fluence to 5 and use three passes.This equates to about

40–60 µm of ablation. After the inititial ablation, the

same settings are maintained until punctuate bleeding

is encountered.

Medium-depth LASR

The techniques utilized for medium-depth LASR will

be influenced by the Er:YAG laser technology available

Erbium laser aesthetic skin rejuvenation 41

and by other techniques that the laser surgeon can call

upon.With longer-pulsed or dual-mode systems and

progression beyond 60–80 µm, there may be bleeding

from the dermal plexus, which will slow the procedure

down. It is our preference to change our technique

if we wish to accomplish a deep LASR for

moderate to deep rhytides.When employing a combination

technique for the full face, we generally

perform the CO 2 laser resurfacing in the first pass,

followed by Er:YAG laser ablation of the char.When

using ablative bipolar RF (BPRF) (Visage, Arthrocare

Corp.), we ablate the epidermis and then heat the

dermis (Fig. 4.11) with several passes of ablative

BPRF.This technique serves to contract dermal collagen

without excessive thermal damage to the deeper

dermal layers.When treating acne scarring, we sometimes

convert to dermal sanding in the deeper dermal

layers.

Deep LASR

Essentially the same techniques are utilized as in

medium-depth treatment, but the deeper dermal

treatment is performed with more passes.This is frequently

necessary for deeply creased upper lip rhytids.

It is important to always use a graduated approach

for deeper techniques and to treat the facial skin

with an appreciation of the skin thickness in each facial

area as well as the depth or degree of the rhytids.We

occasionally utilize a fractionated CO 2 laser pass after

completing the medium-depth LASR. This involves

spatially separated pulses of the CO 2 laser over the

treatment area. The smallest possible spot size is

utilized, with no overlapping of pulses.

PATIENT SELECTION AND

PERIOPERATIVE MANAGEMENT

As with most aesthetic facial procedures, appropriate

patient selection and reasonable patient expectations

are the cornerstones of any successful intervention. A

complete medical and surgical history should be

obtained prior to any recommendations.

The contraindications to laser resurfacing are unrealistic

patient expectations, a tendency toward keloid

or hypertrophic scar formation, isotretinoin use


42 Clinical procedures in laser skin rejuvenation

within 6 months prior to surgery, and a lack of patient

compliance with postoperative instructions. Other

medical considerations include identifying patients

with reduced numbers of adnexal skin structures, such

as those with scleroderma, burn scars, or a history of

prior ionizing radiation to the skin. These patients

should be approached with caution. Long-term use of

skin pharmaceuticals such as glycolic acid products or

retinoids may thin the dermis and alter the depth of

penetration of the LASR. A history of previous skin

rejuvenation procedures is noteworthy, because these

procedures could potentially slow the wound healing

process due to the presence of fibrosis. Patients who

have undergone prior transcutaneous lower lid blepharoplasty

or have limited infraorbital elasticity may

be at increased risk for postoperative ectropion.When

applicable, patients who smoke should be discouraged

from doing so before and after surgery to reduce the

risk of delayed or impaired wound healing.

Physical examination of the treatment area includes

careful attention to Fitzpatrick skin type and specific

areas of scarring, dyschromia, and rhytid formation.

For patients desiring periorbital laser treatment, the

eyes must be examined for scleral show, lid lag, and

ectropion. Other epidermal pathology should also be

noted, including seborrheic keratoses, solar lentigines,

actinic keratoses, and cutaneous carcinomas.The

author prefers to address this during the LASR, but

some lesions may need to be addressed prior to the

LASR.

Fig.4.11 Combination resurfacing techniques

utilize other modalities to achieve the same

endpoint that multiplexing pulse duration achieves.

Ablative bipolar radiofrequency or fractional CO 2

laser treatment to the upper dermis enhances

hemostasis and collagen contraction.

LASR can lead to reactivation of latent herpes

simplex virus (HSV) infection or predispose the

patient to a primary infection during the re-epithelialization

phase of healing. Prophylactic antiviral

medication should be prescribed during the postoperative

period, regardless of a patient’s HSV history. 11

Currently used regimens include famciclovir 250 mg

twice daily, acyclovir 400 mg three times daily, or

valacyclovir 500 mg twice daily. The medication may

be administered the day before or on the morning of

laser resurfacing, and should be continued for 7–10

days or until re-epithelialization is complete.

Antibiotics for bacterial prophylaxis may be prescribed;

however, little data exist to support their

use, because of the relatively low incidence of postoperative

bacterial infections reported. The routine

use of antibiotic prophylaxis may increase the incidence

of antibiotic resistance and predispose patients

to organisms of increased pathogenicity.When used,

cephalosporin (cephalexin), semisynthetic penicillin

(dicloxacillin), macrolide (azithromycin), or

quinolone (ciprofloxacin) is administered 1 day

before or on the morning of surgery, and is continued

until re-epithelialization is complete.The use of topical

antibiotics on the laser-induced wound may be

recommended, but neomycin-based products should

be avoided due to a 10% incidence of sensitivity to

this compound.

Postoperative wound care can follow an open or

closed method.With the closed method, a semiocclusive


dressing (Flexan) is placed on the denuded skin.These

wound dressings have been shown to accelerate the rate

of re-epithelialization by maintaining a moist environment.

In addition, decreased postoperative pain has

been reported with their use.The closed method may

create a low-oxygen environment that may promote the

growth of anaerobic bacteria and subsequent infection.

As such, many proponents of the closed technique currently

endorse removal of the dressing with wound

inspection 24–48 hours after the procedure, followed

by topical emollients.The open wound technique consists

of frequent soaks with cool saline or Domeboro

solution.These soaks are followed by the application of

ointment to promote re-epithelialization while allowing

adequate visualization of the resurfaced wound.

Er:YAG laser resurfacing ablates superficial cutaneous

tissue and causes a thermal injury to denuded

skin.Therefore, some adverse effects are to be expected

and should be considered complications.These ‘sideeffects’

of cutaneous laser resurfacing include transient

erythema, edema, burning sensation, and pruritus.

Short-pulsed Er:YAG laser resurfacing procedures are

associated with a significantly shortened period of reepithelialization

and erythema when compared with

the CO 2 laser. However, when equivalent depths of

ablation and coagulation are achieved with the aforementioned

modulated systems, postoperative healing

times are comparable.

LASER RADIATION SAFETY AND

ERBIUM LASERS

All laser devices distributed for both human and animal

treatment in the USA are subject to Mandatory

Performance Standards.They must meet the Federal

laser product performance standard, and an ‘initial

report’ must be submitted to the Center for Devices

and Radiological Health (CDRH) Office of

Compliance prior to the product being distributed.

This performance standard specifies the safety features

and labeling that all laser products must have in order

to provide adequate safety to users and patients. A

laser product manufacturer must certify that each

model complies with the standard before introducing

the laser into US commerce.This includes distribution

Erbium laser aesthetic skin rejuvenation 43

for use during clinical investigations prior to device

approval. Certification of a laser product means that

each unit has passed a quality assurance test and that it

complies with the performance standard.The firm that

certifies a laser product assumes responsibility for

product reporting, for record-keeping, and for notification

of defects, non-compliance, and accidental radiation

occurrences. A certifier of a laser product is

required to report the product via a Laser Product

Report submitted to the CDRH. Er:YAG lasers belong

to safety class IV; i.e., these lasers are high-power

lasers (500 mW for continuous-wave and 10 J/cm 2 or

the diffuse reflection limit for pulsed), which are hazardous

to view under any condition (directly or diffusely

scattered), and are a potential fire hazard and a

skin hazard. Significant controls are required of class

IV laser facilities.

AVOIDANCE AND TREATMENT OF

COMPLICATIONS

Complications of Er:YAG laser resurfacing should be

differentiated from temporary ‘side-effects’ of the procedure.Temporary

side-effects of Er:YAG laser resurfacing

include transient erythema, edema, burning

sensation, and pruritus. Healing times are short for the

short-pulsed systems, but second- and third-generation

models are designed to function more on a par with

CO 2 laser systems and so the complication profile may

be similar, but appears to be intermediate in terms

of the most frequent complications of prolonged

erythema, hyper- or hypopigmentation, and dermal

fibrosis or scarring. In addition to the complications

mentioned above, mild complications of Er:YAG laser

resurfacing include milia, acne exacerbation, contact

dermatitis, and perioral dermatitis. Moderate complications

include localized viral, bacterial, and candidal

infection.The most severe complications include disseminated

infection and the development of ectropion.

Diligent evaluation of the patient is necessary during

the re-epithelialization phase of healing.This is important,

because a delay in recognition and treatment of

complications can have severe deleterious consequences,

such as permanent dyspigmentation and scarring.As

always, patient selection and avoidance of these


44 Clinical procedures in laser skin rejuvenation

procedures in any patient predisposed to delayed or

abnormal cutaneous wound healing will reduce the frequency

of severe postoperative sequellae.

Although short-pulsed Er:YAG laser resurfacing has

a significantly better adverse-effect profile and complication

rate when compared with pulsed or scanned

CO 2 laser resurfacing, long-term data for the modulated

Er:YAG laser systems are not yet available.

Because the modulated Er:YAG laser systems may be

used to create zones of collateral thermal damage

similar to those created by the CO 2 laser, further studies

are necessary to determine the incidence of delayed

hypopigmentation.

REFERENCES

1. Goldman MP, Fitzpatrick RE. Cutaneous Laser Surgery:

The Art and Science of Selective Photothermolysis, 2nd

edn. St Louis, MO: Mosby-Year Book, 1999:339–436.

2. Kotler R. Chemical Rejuvenation of the Face. St Louis,

MO: Mosby-Year Book, 1992:1–35.

3. Hebra F, Kaposi M. On Diseases of the Skin, Including

Exanthemata. London: New Sydenham Society, 1874:

Vol 3:22–23.

4. MacKee GM, Karp FL.The treatment of post acne scars

with phenol. Br J Dermatol 1952;64:456–9.

5. Kurtin A. Corrective surgical planing of skin. Arch

Dermatol Syph 1953;68:389.

6. Goldberg DJ. Lasers for facial rejuvenation. Am J Clin

Dermatol 2003;4:225–34.

7. Ronel DN. Skin resurfacing, laser: erbium YAG.

eMedicine. http://www.emedicine.com/plastic/topic

108.htm (accessed November 2006).

8. Kaufmann R, Hibst R. Pulsed 2.94-microns erbium–YAG

laser skin ablation – experimental results and first clinical

application. Clin Exp Dermatol 1990;15:389–93.

9. Newman JB, Lord JL, Ask K, McDaniel DH. Variable

pulse erbium:YAG laser skin resurfacing of perioral

rhytides and side-by-side comparison with carbon dioxide

laser. Lasers Surg Med 2000;26:208–14.

10. Weinstein C. Modulated dual mode erbium CO 2 lasers

for the treatment of acne scars. J Cutan Laser Ther 1999;

1:204–8.

11. Tanzi EL: Cutaneous laser resurfacing: erbium:YAG.

eMedicine. http://www.emedicine.com/derm/topic

554.htm (accessed November 2006).


5. Complications secondary to lasers

and light sources

Robert M Adrian

INTRODUCTION

The name laser is an acronym for Light Amplification by

Stimulated Emission of Radiation. In 1917, Albert

Einstein was the first to theorize about the mechanism

that makes lasers possible, called ‘stimulated emission’.

In 1958, Charles Townes and Aurthur Schawlow theorized

about a visible laser system that would use infrared

or visible electromagnetic energy. Although some controversy

exists regarding the individual who invented

the first laser, Gordon Gould, who first used the term

‘laser’, has been credited with inventing the first light

laser. In 1965, the carbon dioxide (CO 2 ) laser was

invented by Kumar Patel. Since that time, there has been

a tremendous increase in theoretical and practical laser

knowledge, resulting in an explosion of laser technology

used in thousands of everyday applications.

One of the first individuals to report on the effects

of lasers on the skin was Leon Goldman, whom many

consider to be the father of laser medicine. Goldman’s

pioneering work using pulsed (ruby) and continuouswave

argon lasers serves as the foundation for our

present understanding of laser medicine and surgery.

The first lasers used to treat skin conditions were

continuous-wave CO 2 dioxide, argon, and argonpumped

tunable dye lasers.The major disadvantage of

continuous-wave lasers is that the side-effects are

related to how long the beam is in contact with the

target (dwell time), and are thus operator-dependent.

This resulted in high rates of complications, primarily

in the form of scarring.

In the late 1980s, the first pulsed lasers became available

with the introduction of the flashlamp-pumped

pulse dye laser by the Candala Corporation. Pulsed

lasers were a major advance in laser medicine, since

energy delivery was now selectable and dwell time on

tissue became an independent factor in treatment.The

introduction of pulsed lasers greatly reduced the incidence

of scarring secondary to laser treatment.The subsequent

addition of cutaneous cooling during laser

delivery was another significant advance in cutaneous

laser surgery. Epidermal protection and increased

patient comfort secondary to cooling served to advance

the art and science of laser medicine.

In the early 1980s, there were few major companies

providing lasers for cutaneous application.Today, there

are dozens worldwide, and hundreds of laser devices are

available for use in the treatment of numerous congenital

and acquired skin conditions. Along with the explosion

of interest in cosmetic laser surgery came a tremendous

number of ‘new’ users of this technology.As a result, we

have seen a significant increase in side-effects and

complications associated with the use of lasers.

Since most laser and light sources ultimately are

designed to heat targets, complications secondary to

treatment using lasers and light sources is most often

related to excessive thermal energy delivered during

the procedure. It is this excess thermal energy that

most often contributes to unfavorable clinical results.

In this chapter, we will not address side-effects of

lasers that are common or anticipated and often

unique to the laser or light source used, but will rather

confine our discussion to complications that are events

not generally expected as a result of treatment.

Complications secondary to lasers and light sources

may be minor or serious, but all need prompt and

accurate diagnosis and treatment to prevent further

patient morbidity. As shown in Box 5.1, there are

numerous potential complications seen as a result of

the use of lasers and light sources. Box 5.2 lists some


46 Clinical procedures in laser skin rejuvenation

of most common causes of complications resulting

from the use of lasers and light sources (Figs 5.1–5.3).

Box 5.1 Complications of lasers and light sources

• Ocular complications:

− Corneal

− Retinal

• Infection of personnel

• Hyperpigmentation

• Hypopigmentation

• Blistering

• Crusting

• Delayed wound healing

• Infection

• Cutaneous infarction

• Scarring

Box 5.2 Causes of complications from lasers and light sources

• Lack of basic knowledge and training on a specific

treatment modality

• Incorrect choice of laser or light source to treat a

clinical condition

• Failure to adequately recognize the clinical condition

confronting the operator

• Failure to anticipate, recognize, and treat common or

uncommon postoperative complications

• Failure to refer patients with evolving or nonresponding

complications to more experienced

colleagues − ‘When you’re in a hole, stop digging.’

• Failure to adequately screen and counsel patients

prior to the procedure, thus avoiding postoperative

disappointment and frustration for both patient and

treating individual

LACK OF OPERATOR KNOWLEDGE

AND EXPERIENCE

The single most important cause of postoperative complications

is lack of proper training and experience of

the treating individual. The explosion of interest in

cosmetic laser treatments has served as a magnet for

those who wish to provide such services primarily for

the purpose of financial gain. Unfortunately, most of

these individuals are not willing to spend the time or

Fig. 5.1 Severe herpes simplex infection post carbon

dioxide laser resurfacing (by permission of Jean Rosenbloom)

monetary investment learning the basic science of laser

surgery, treatment protocols, and techniques necessary

to provide safe and effective laser and light source-based

procedures. So-called ‘weekend warriors’ abound.This

is a term used to describe ‘laser experts’ who are constantly

unleashed on an unsuspecting public after a few

hours at an evening or weekend training session.

The use of a given laser or light source by any individual

should be complemented by a complete understanding

of cutaneous structure and function, basic

dermatology, laser safety and physics, infectious diseases

of the skin, cutaneous wound care, and management of

common side-effects and complications. It is inconceivable

how any individual without prior knowledge or

training in dermatology could reasonably fulfill all of the


Fig.5.2 Severe hypertrophic scarring secondary to CO 2

laser burn

above prerequisites during a single evening or weekend

‘laser seminar’. My views are not meant to suggest that

only dermatologists or plastic surgeons are suitable to

perform laser- or light-based procedures, but rather

that non-dermatologist physician specialists or allied

health professionals should spend the necessary time

and effort to become properly trained prior to turning

themselves loose on their patients or clients.

INCORRECT CHOICE OF LASER OR

LIGHT SOURCE FOR A GIVEN

CONDITION

Despite the fact that there are hundreds of lasers and

light sources available to treat cutaneous conditions,

Complications secondary to lasers and light sources 47

Fig.5.3 Hypertrophic scarring after long-pulse YAG laser

treatment of a tattoo.

there are relatively few tissue targets or chromophones

available within the skin (Box 5.3). Although

it may seem intuitive, many individuals will often

use a given laser or light source to treat a condition

that is not within the technological scope of the

device (Figs 5.4–5.6). Although one might conclude

that this was related to lack of knowledge and experience,

I have found that it is more often related to

monetary consideration on the part of the operator.

Common sense would suggest that one would choose

a laser or light source that would reasonably address

the target chromosphere – however, many examples

of laser clinical condition mismatches are seen in

clinical practice.

Box 5.3 Cutaneous chromophones

• Melanin

• Oxygenated hemoglobin

• Reduced hemoglobin

• Water

• Tattoo ink

• Iron

• Medication-induced pigment

• Foreign-body pigments


48 Clinical procedures in laser skin rejuvenation

a

b

FAILURE TO RECOGNIZE THE

PRESENTING CLINICAL CONDITION

Most physicians and allied health professionals with

training in cutaneous medicine can properly recognize

the clinical condition confronting them. Unfortunately,

inexperienced or untrained individuals often fail to recognize

the presenting condition, resulting in worsening

of the condition or complications from treatment.

What excuse could one offer for treating a nodular

melanoma as a hemangioma or a linear verrucous

nevus, or tuberous sclerosis as warts, other than lack of

knowledge on the part of the physician? In addition,

many serious medical conditions, such as collagen

Fig.5.5 Perioral scarring secondary to CO 2 laser

resurfacing.

Fig.5.4 Scarring and pigmentation from improper use of

an IPL Device Fig.5.6 Scarring of the chest after CO 2 laser resurfacing.

vascular disease, congenital neurocutaneous syndromes,

and vascular anomalies, present for cosmetic

treatment while actually needing proper diagnosis and

treatment rather than simply ‘cosmetic’ improvement.

FAILURE TO ANTICIPATE,

RECOGNIZE AND TREAT

COMMON POSTOPERATIVE

COMPLICATIONS

Most laser and light source treatments are accompanied

by various postoperative side-effects, which are defined

as conditions that are expected and directly related to


Fig.5.7 Scarring from smooth laser treatment of a tatoo

the procedure itself. Examples include purpura secondary

to pulsed dye laser treatment, pinpoint bleeding

and crusting from Q-switch laser treatment, and

swelling and weeping of the skin after CO 2 or Er:YAG

laser resurfacing. Complications, on the other hand, are

conditions that may or may not be expected, but are

caused by the procedure and are of significant nature to

require proper diagnosis and treatment. Such complications

can be relatively minor, such as mild hypo- or

hyperpigmentation, edema, or minor crusting. Serious

complications include bacterial, fungal, or viral infections;

severe pigment disturbances; and hypertropic and

keloidal scarring. Sepsis and systemic allergic reactions,

although less common, may be life-threatening, and need

prompt proper diagnosis and treatment by skilled, welltrained

individuals. Failure to recognize and skillfully

address these complications is a major cause of postlaser

morbidity.

FAILURE TO TIMELY REFER PATIENTS

WITH EVOLVING OR

NONRESPONSIVE COMPLICATIONS

TO MORE EXPERIENCED

COLLEAGUES IN A TIMELY MANNER

All practitioners of laser- and light-based techniques,

regardless of experience, have encountered

Complications secondary to lasers and light sources 49

postoperative complications. Morbidity secondary to

postoperative complications can often be greatly

reduced in most cases by arriving at the correct diagnosis

and providing prompt treatment. Physicians who

fail to refer in a timely manner most often do so

because they actually fail to accurately diagnose the

presenting condition itself. Most often, I have encountered

failure to recognize and treat postoperative viral

(herpes) and fungal (Candida) infection. Many patients

are treated for weeks with the wrong diagnosis, only

to rapidly heal when proper diagnosis and treatment is

intiated. Unfortunately, lack of training and lack of

experience lead to a failure of proper diagnosis and

treatment, causing significant morbidity for patients.

Again, proper training and experience are the primary

causes of late referral of complications.

FAILURE TO ADEQUATELY SCREEN

AND INFORM PATIENTS PRIOR TO

THE PROCEDURE

The cornerstone of a successful cosmetic and laser

practice is informed consent.Why? Because an adequately

informed patient will understand the risks,

benefits, and possible outcomes prior to the procedure.

Preoperative counseling with blunt and honest

answers prior to the procedure all but eliminate the

likelihood of postoperative patient dissatisfaction

and complaints. I have found that patients are much

more relaxed post-treatment when they had undergone

a detailed discussion covering risks, benefits, and

realistic outcomes prior to the procedure. In my opinion,

informed consent is the single most important

factor leading to a smooth postoperative experience.

SUMMARY

There is no doubt that the use of lasers and light

sources has been one of the most significant advances

in cosmetic medicine and surgery in the last century.

Millions of people have benefited from new technologies

to treat a wide variety of congenital and acquired

medical and cosmetic conditions. Unfortunately, many


50 Clinical procedures in laser skin rejuvenation

practitioners fail to undergo adequate training, resulting

in an unacceptable number of complications secondary

to the use of these new technologies.

Blame can be placed on all those involved: laser

companies who will sell or rent a laser or light source

to ‘any willing provider’ regardless of their level of

training or experience; practitioners who themselves

fail to undergo the necessary training in order to provide

safe and effective laser procedures; and finally the

patients themselves, who fail to adequately evaluate

the training and experience of their provider prior to

the procedure and then complain that they had an

unfavorable result or complication.The internet age

has given patients powerful tools to ‘interview’ physicians

online, narrowing down the list of local experts

who will most likely provide more successful and safer

outcomes than their inadequately trained colleagues.

The explosion of laser day-spas, med-spas and nonphysician-supervised

‘laser centers’ presents a growing

challenge to patients to seek out experts in their community

and avoid those who may ultimately do more

harm than good.


6. Nonablative technology for

treatment of aging skin

Amy Forman Taub

ABLATIVE VERSUS NONABLATIVE

To understand nonablative technology, it is important

to understand ablative technology, which came earlier.

Understanding the difference between the two

technologies puts their respective advantages and

weaknesses into perspective.

Ablative

In ablative skin resurfacing, the outer layers of skin are

vaporized and replaced by new collagen and epidermis

as wound healing occurs over days to weeks. Ablation

is possible because water has a high absorption coefficient

in the infrared region. The most widely used

lasers for ablative resurfacing are the pulsed 10 600 nm

carbon dioxide (CO 2 ) and 2940 nm erbium : yttrium

aluminum garnet (Er:YAG) lasers.The Er:YAG wavelength

is more efficiently absorbed by water, and thus

leaves little residual heat deposition to collateral tissue,

whereas the CO 2 laser deposits more heat in the

surrounding area.This may be an important stimulus

to collagen renewal and hence skin tightening and

rhytid effacement, 1 but leads to more complications.

In either case, the mechanism of renewal is epidermal

and dermal injury, which denatures collagen and activates

fibroblasts, causing the synthesis of new collagen

and extracellular matrix material. 2

Nonablative lasers were developed in response to

the two fundamental problems with ablative lasers:

long periods of downtime and the risk of long-term

hypopigmentation and scarring.

Nonablative

Nonablative lasers attempt to spare the epidermis and to

influence the dermis directly with light and/or radiofrequency

(RF) energy.With no epidermal wound, there is

no recovery period and thus no interruption of life’s

daily routines. Although efficacy is less than that of ablative

laser procedures, the dermal wound response from

nonablative laser treatments stimulates new collagen

production and repairs tissue defects. 3 Energy is

deposited 100–500 µm below the skin surface, where

most histological changes (solar elastosis) associated with

photoaging occur. Nonablative laser procedures target

the dermis and avoid epidermal damage by cooling during

treatment, 4–10 as well as targeting chromophores

other than water: hemoglobin, melanin, and collagen. In

addition, the wavelengths utilized for nonablative lasers

are in the visible and near-infrared region of the electromagnetic

spectrum and penetrate to the upper and

mid-dermis – the target zone.

A variety of studies 5,7,11–19 indicate that skin tightening

and wrinkle reduction months after nonablative

laser or light therapy are associated with collagen

remodeling.This relationship was established by comparing

clinical improvement with changes in histological

characteristics, ultrastructure, and biochemical

constituents known to play a role in wound healing

and the production of dermal collagen.

Microablative

Fractional photothermolysis (FP) has recently

been introduced for ‘microablative’ resurfacing. 20,21


52 Clinical procedures in laser skin rejuvenation

a b c d

100 µm

0 days

100 µm

1 days

Although FP is associated with limited downtime and

usually requires multiple sessions, its main mechanism

is via tissue ablation; thus, it has features of both

ablative and nonablative techniques.

In the novel FP technique, a 1550 nm laser creates a

pattern of microscopic thermal wounds rather than

uniform thermal damage in the skin.These microthermal

zones (MTZs) are typically 100 µm wide and

300 µm deep and are surrounded by undamaged

tissue, thus promoting a rapid healing response.The

density and space between MTZs can be adjusted for

a given energy level, and adverse effects, pain, and

discomfort are manageable. 20,22

This results in more rapid epithelialization than with

ablative therapy, as well as deeper penetration into the

dermis, with the possibility of eliminating abnormal

dermal deposits and/or breaking up scars mechanically

(Fig. 6.1). Clinical examples are shown in Figs

6.2 and 6.3.

100 µm

3 days

100 µm

Fig.6.1 Photomicrograph of skin treated with fractional device,15 mJ. At 0 days,one can see thermal denaturation of the

epidermis and dermis,with no effect to the structural integrity of the stratum corneum (remains intact).At 1 day post treatment,

a vacuole is overlying the re-epithelized epidermis and the zone of thermal denaturation in the dermis.The vacuole is known to

contain epidermal necrotic debris and dermal contents.At 3 days post treatment,one can see a compacted MEND (‘microscopic

epidermal necrotic debris’– this is actually a misnomer,as there is epidermal and dermal content) overlying the epidermis (which

appears almost completely healed) and the thermally denatured dermis.At 7 days post treatment,one can see that the MEND is

starting to exfoliate,while the epidermis has regained full thickness.The dermal aspect of the lesion also appears to have started

healing,with an influx of cellular activity in and around the vicinity of the lesion.(Photomicrograph courtesy of Reliant

Technologies,Inc.)

7 days

NONABLATIVE TECHNOLOGIES FOR

PHOTOREJUVENATION

Many nonablative devices have been developed over the

past 10 years.There are infrared devices targeting superficial

collagen with nonspecific heating, pulsed dye lasers

(PDLs), which heat the vessels and radiate heat into the

other parts of the dermis, long-pulsed neodymium

(Nd):YAG lasers, intense pulsed light (IPL) devices, lightemitting

diode (LED) devices, photodynamic therapy

(PDT), and the new tissue tightening devices designed to

cause three-dimensional changes in the skin through

nonablative methods. Each of these modalities will be

discussed in the following sections.

Laser or visible light technology

In photorejuvenation, technologies with wavelengths

in the visible spectrum target the upper dermis. Many


a b

lasers and light sources have been developed with the

principal use in mind of removing excessive epidermal

pigmentation, reducing upper dermal telengiectasia,

and improving the texture and tone of the skin. It has

been noted by a number of investigators that these

modalities also seem to improve superficial wrinkles

and cause some skin smoothing and tightening.

Pulsed dye laser

As the first laser developed to apply the principle of

selective photothermolysis, the 585 nm PDL remains the

gold standard for the treatment of vascular lesions. 23

Zelickson et al 13 reported the first investigation of

the PDL for the treatment of sun-induced facial

rhytids. Histological examination revealed dermal

changes consistent with collagen remodeling. These

results were confirmed in 2000 by Bjerring et al 24

who, by altering the pulse duration, obtained cosmetic

improvement without purpura. Tanghetti et al 25

reported similar clinical improvements in facial dyspigmentation

and wrinkling after single-pass and double-pass

treatment with either 585 nm or 595 nm PDL

devices. In a controlled, split-face study, Hsu et al 26

reported improvements in surface topography of 9.8%

(one treatment) and 15% (two treatments), supported

by histological evidence of collagen remodeling.

Key studies are summarized in Table 6.1.

Nonablative technology for treatment of aging skin 53

Intense pulsed light

Fig.6.2 Before (a) and after (b)

three treatments of a woman with

melasma and textural irregularities

treated with a fractional device,

6–8 mJ,density level 6,with eight

passes.(Photographs courtesy of Amy

Forman Taub MD.)

Generally considered the gold standard for the nonablative

treatment of superficial photodamage, IPL therapy

achieves selective photothermolysis with noncoherent

polychromatic light (about 500–1200 nm). Due to the

broad spectrum of visible light, the two main chromophores,

hemoglobin and melanin, can be effectively

targeted with only one piece of technology.The minimal

risk and downtime associated with this procedure have

contributed to its success. 8

Two key studies were reported in 2000. Bitter 11

showed that serial full-face treatments with IPL visibly

improved wrinkling, irregular pigmentation, skin

coarseness, pore size, and telangiectasias in more than

90% of patients with little downtime.The patient satisfaction

rate exceeded 88%. A clinical example and

photomicrographs of biopsy specimens are shown in

Figs 6.4 and 6.5, respectively. Goldberg and Cutler 27

showed that IPL therapy nonablatively improved facial

rhytids and skin quality with minimal adverse effects.

Other studies are summarized in Table 6.2. Using

treatment parameters similar to those used by Bitter,

Negishi and colleagues 28,29 showed that IPL improved

pigmentation, telangiectasias, and skin texture of

Asian skin. Goldberg and Samady 30 revisited perioral

rhytids, using different IPL parameters and comparing

results with those of a 1064 nm Nd:YAG laser. Patient


54 Clinical procedures in laser skin rejuvenation

a b

c d

satisfaction rates were similar, although blistering and

erythema were more common with IPL. In a

93-patient study, Sadick et al 31 showed that up to

five full-face IPL treatments resulted in significant

Fig.6.3 (a,b) A 27-yearold

man whose acne scars had

been treated three times

unsuccessfully with

trichloroacetic acid (15%)

peels.(c,d).After a single

fractional photothermolysis

session,the acne scars are

markedly improved 4 weeks

later.Skin texture was also

improved.(Reproduced with

permission from Hasegawa T,

Matsukura T,Mizuno Y,Suga

Y,Ogawa H,Ikeda S.Clinical

trial of a laser device called

fractional photothermolysis

system for acne scars.J

Dermatol 2006;33:623–7.)

improvement in a variety of clinical indications of

photoaging. A newer technology combining IPL with

RF (electro-optical synergy, or ELOS) was evaluated

by Sadick et al 31 and found to be at least as efficacious


Table 6.1 Studies of the use of the pulsed dye laser (PDL) for photorejuvenation

for pigmentation and vascularity but potentially more

advantageous for pore size, superficial rhytides, laxity

and texture due to the addition of the RF modality

which can penetrate more deeply into the dermis to

stimulate collagen remodeling.

Nonablative technology for treatment of aging skin 55

Areas/ Wavelength

conditions (nm)/Fluence

No. of treated (No. (J/cm 2 )/Pulse Adverse Follow-up

Ref patients of treatments) duration (ms) Efficacy effects (months)

13 20 Mild to severe 585/3.5–6.5/ 9/10 with mild to moderate Transient Up to 14

perioral and 0.45 wrinkling showed 50% or purpura,

periorbital greater improvement at swelling

wrinkles (1) 6 months, 3/10 with

moderate to severe

wrinkling showed clinical

improvement at 3 months

24 40 Facial 585/2.4/ Statistically significant None Up to 6

wrinkles (1) 0.350 decreases in Fitzpatrick

class I, II, III wrinkles

25 17 Facial 585 or 595/ Clinically observable None 6

dyspigmentation 3–4/0.5 improvement in

and wrinkling (4) dyspigmentation

and wrinkling for

all subjects

26 58 Periorbital 585/2.4–2.9/ Improvements in surface Minor pain 1, 3

wrinkling 0.35 topography of 9.8% during initial

(1 or 2) (one treatment) and treatment, minimal

15% (two treatments) temporary reddening

a

Fig.6.4 A 54-year-old woman:(a) before and (b) 4 weeks after five full-face intense pulsed light (IPL) treatments.Note the

improvement in fine wrinkles and skin texture.(Reproduced with permission from Bitter PH Jr.Noninvasive rejuvenation of

photodamaged skin using serial,full-face intense pulsed light treatments.Dermatol Surg 2000;26:835–42.

b

Potassium titanyl phosphate

The 532 nm wavelength of the potassium titanyl

phosphate (KTP) laser device is readily absorbed by

oxyhemoglobin and melanin, 34 making it especially


56 Clinical procedures in laser skin rejuvenation

a

b

Fig.6.5 Photomicrographs of biopsies of forehead skin

from (a) the untreated forehead and (b) the treated forehead

4 weeks after the fifth IPL treatment.(Reproduced with

permission from Bitter PH Jr.Noninvasive rejuvenation of

photodamaged skin using serial,full-face intense pulsed light

treatments.Dermatol Surg 2000;26:835–42).

effective for treating red and brown discolorations due

to photodamage 35 and inducing growth of collagen and

elastin fibers when endothelial damage causes the

release of cytokines. 34 Combining the KTP laser with

the 1064 nm Nd:YAG laser device 15,35 makes use of the

greater penetration depth of the longer wavelength to

create a synergistic effect that further improves skin

quality and wrinkle reduction beyond what is achievable

by KTP alone (Figure 6.6). 15

The efficacy of the KTP laser is comparable to that of

IPL. 36 The smaller spot size and ergonomic flexibility of

the KTP handpiece, however, promote ease of use and

allow practitioners to focus on resistant lesions. 34

Although fewer treatments are required, the risk of

erythema and edema is higher with the KTP laser 21

and the treatment is less tolerable. 36

The results of key studies are presented in Table 6.3.

Photomodulation

In photomodulation, a light-emitting diode (LED) is

used to manipulate cellular activities without thermal

effect. 37 McDaniel and colleagues showed 37,38 that they

could upregulate procollagen synthesis and downregulate

matrix metalloproteinase (collagenase) in fibroblast

culture with specific pulse sequences and

durations of low-energy, narrowband, or coherent

light.The effects were strongest when 590 nm LED

devices were used.

These findings led to a multicenter trial in which 90

patients with photodamaged skin received eight LED

photomodulation treatments using a full-panel 590 nm

nonthermal full face LED array delivering 0.1 J/cm 2

with a specific sequence of pulsing treatments over 4

weeks. 12 More than 90% showed improvement in at

least one Fitzpatrick photoaging category and 65%

showed improvement in facial texture, background

erythema, fine lines, and pigmentation, all without

pain or adverse effects. Improvements peaked in 4–6

months after the final treatment.The clinical results

were supported by post-treatment histological studies

that showed increased collagen in the papillary dermis.

The use of combination 633 nm and 830 nm LED

light therapy for the treatment of photodamaged skin

has been reported by two groups. 19,39 In a 31-patient

study, Russell et al 39 treated facial rhytids nine times

and noted (1) 25% to 50% improvement in photoaging

scores of 52% of patients and (2) significant

patient-reported improvement in periorbital wrinkles

in 81% of patients 12 weeks after the final treatment.

In a similar 36-patient study, Goldberg et al 19 reported

very similar results. Electron microscopic data of posttreatment

tissue showed collagen fibers of increased

thickness. Adverse effects were limited to mild

erythema in one patient.


Table 6.2 Studies of the use of intense pulsed light (IPL) for photorejuvenation

Nonablative technology for treatment of aging skin 57

Areas/ Cut-off filter

conditions (nm)/Fluence

No. of treated (No. (J/cm 2 )/Pulse Adverse Follow-up

Ref patients of treatments) duration (ms) Efficacy effects (months)

27 30 Perioral 645/40–50/7 16/30 patients had some Transient 6

rhytids improvement, 9/30 erythema,

(1–4) substantial improvement blistering

11 49 Full face/overall 550 or 570/ 75% of patients Mild, temporary 1

photorejuvenation 30–50/ reported erythema, blisters,

(mean 4.94) 2.4–4.7 ≥ 50% overall darkening of

improvement lentigines and

freckles

28 97 Facial 550 or 570/ 88.4% of patients reported 0a (Asian photorejuvenation 28–32/2.5–5 ≥ 51% improvement

skin) (3–6) in pigmented lesions,

77.7% reported ≥ 51%

improvement in

telangiectasias, 77.3%

reported ≥ 51%

improvement in

skin texture

30 15 Perioral 590/755/ On 1–10 scale, mean Blistering, Up to 6

rhytids (3–5) 40–70, 3–7 patient satisfaction scores erythema

6.4 (at 590 nm), 6.2

(at 755 nm) at 6 months

with IPL

39 36 Facial 550–590/ 91.7% of patients reported Transient 6

(Asian freckles 25–35/4 very or extremely satisfied erythema, pain,

skin) (1–3) hyperpigmentation,

crusting

32 47 Facial rhytids, 550/570/ Long-term improvement Temporary swelling, 6

vascularity, 28–34/2.4–4 in rhytids, vascularity, erythema, crusting,

dyschromia,

pore size

dyschromia, pore size purpura

33 23 Midfacial 500–690, Improvement in surface Discomfort during 1

photoaging 890–1200/ texture, mottled treatment, transient

(3) 24–30/pulse hyperpigmentation/ focal vesiculation,

duration not solar lentigines, erythema/ crusting, erythema

reported telangiectasias

31 93 Wrinkles, elastosis, 560 or 640/ Significant reduction in Temporary erythema, 6

vascular and 20–44/2–7 wrinkles, elastosis, vascular edema, purpura,

pigmented lesions and pigmented lesions; hyperpigmentation

of face (up to 5) improvement in 90% of

patients at 6 months;

patient satisfaction high

a Results were evaluated at the end of the third treatment.


58 Clinical procedures in laser skin rejuvenation

a b

Fig.6.6 A 51-year-old woman:before (a) and (b) 6 months after six treatments with combined potassium titanyl phosphate

(KTP) and neodymium :yttrium aluminum garnet (Nd:YAG) lasers.Note the overall improvement in erythema,pigmentation,

skin tone and texture,pore tightening,and rhytid reduction.(Reproduced with permission from Lee MW.Combination 532 nm

and 1064 nm lasers for noninvasive skin rejuvenation and toning.Arch Dermatol 2003;139:1265–76.)

Table 6.3 Studies of the use of the 532 nm potassium titanyl phosphate (KTP) laser for photorejuvenation

Areas/ Fluence

conditions (J/cm 2 )/

No. of treated (No. Pulse Adverse Follow-up

Ref patients of treatments) duration (ms) Efficacy effects (months)

15 50 Face (3–6) 7–15/7–20 All patients had Mild, temporary Up to 18

mild to moderate erythema, edema;

improvement in sensitivity to heat

appearance of rhytids, and recurrence of

moderate improvement flushing and

in skin toning and texture, telangiectasias in

great improvement in patients with

reduction of pigmentation rosacea; mild to

and redness; KTP results moderate pain

superior to 1064 nm laser during and

results after treatment

34 7 Periorbital 10–14/ Noticeable overall Temporary mild 2

and midfacial 13–17 improvement in all erythema

(4) patients, all patients

pleased with results

36 17 Facial 7–9/30 Average improvement Pain during treatment; 1

dyschromias and 42%/30% for vascular/ temporary edema and

telangiectasias pigmented lesions erythema, crusting of

(1) dyschromias

LEDs are promising, as they are less expensive to

manufacture, they take only seconds of irradiation, and

they are painless. They have also been used to reduce

inflammation in sunburn and provide palliation for breast

cancer metastatic to the chest wall, and more novel indications

for this modality may be discovered in the future.


a b

Photodynamic therapy

PDT uses a light-activated photosensitizing agent

to create cytotoxic singlet oxygen within abnormal

tissue. Because the photosensitizer accumulates preferentially

in abnormal cells, PDT selectively destroys

these target cells without damaging surrounding

tissue.Although PDT with δ-aminolevulinic acid (ALA)

is approved by the US Food and Drug Administration

(FDA) only for the treatment of actinic keratosis (AK)

in the face and scalp, the technique is being used

to treat a wide variety of skin conditions (including

photorejuvenation) because of its efficacy, safety

profile, and minimal downtime. 40

Photodynamic rejuvenation denotes the use of PDT

to improve the clinical manifestations of photodamage.

41 Touma et al 42 showed that 1-hour ALA incubation

provided approximately the same improvement in

photodamage as 14- to 18-hour ALA incubation and

that ALA–PDT could be used to treat broad areas of

photodamage. A variety of studies have led to the recommendation

40 that either IPL (preferred), blue light

(alternate), or PDL (other) be used to activate the

photosensitizer when ALA–PDT is used for photorejuvenation.

One of the advantages of PDT is its ability to

be performed with many different technologies.

Protoporphyrin IX is the photoabsorbing molecule, and

although absorption is greatest at 417 nm (blue light),

there are multiple Q-bands of absorption up to about

Nonablative technology for treatment of aging skin 59

Fig.6.7 Before (a) and after (b) four monthly treatments with blue light and δ-aminolevulinic acid photodynamic therapy.

(Photographs courtesy of Michael Gold MD.)

650 nm. This means that IPL, PDLs, KTP lasers, red

light, and LED diodes all will activate the photosensitizer

and be able to produce a photodynamic treatment.

Another huge advantage of PDT is that it can eradicate

precancerous cells while improving photodamage

(Fig. 6.7).

Blue light, red light, LEDs, 43 ELOS, 44 PDLs, and

IPL have been used in PDT for photorejuvenation.Two

topical photosensitizers are currently in use: ALA and

methyl aminolevulinate.

Studies of the use of IPL or blue light are shown in

Table 6.4. Split-face studies 45–47 have shown the superiority

of PDT with IPL versus IPL alone.

Long-wavelength lasers and light

sources for collagen stimulation

Collagen remodeling with the use of infrared lasers has

been extensively studied. Early studies 7,16,17 using the

1320 nm Nd:YAG laser showed minimal to visible clinical

improvement in facial rhytids, with histological evidence

of dermal collagen 1–6 months after the final of

a series of treatments. Results with the 1540 nm

Er:glass laser were less encouraging, possibly because

collagen denaturation and dermal fibroplasia had

occurred too deeply in the dermis to improve wrinkles.

5 A 24-patient study 52 showed gradual clinical

improvement in mild to moderate facial rhytids during

and 6 months after a series of three once-monthly

treatments with a 1540 nm Er:glass laser device. An


60 Clinical procedures in laser skin rejuvenation

Table 6.4 Results of photodynamic therapy with δ-aminolevulinic acid (ALA–PDT),using intense pulsed light (IPL) or blue

light,for photorejuvenation.

Ref No. of ALA contact Light No. of Improvement, clearance, Adverse Follow-up

patients time (hours) source treatments or response rate (%) effects (months)

48 10 1 IPL 3 90 (crow's feet); 100

(tactile skin roughness);

90 (mottled

hyperpigmentation);

70 (facial erythema);

83 (actinic keratosis)

— 3

49 32 Short Blue 1 90 (actinic keratosis); — —

contact 72 (skin texture);

59 (skin pigmentation)

50 17 1 IPL 1 68 (actinic keratosis); 55 Mild 1, 3

(telangiectasias); 48 transient

(pigment irregularities); erythema,

25 (skin texture) edema

45 Not — IPL 3a ,2b 80 (ALA–PDT–IPL) — 1

available vs 50 (IPL) photoaging;

95 vs 65 (mottled

hyperpigmentation);

55 vs 20 (fine lines)

46 13 — IPL 3a 55 (ALA–PDT-IPL) vs Erythema, 3

29.5 (IPL) crow’s feet;

55 vs 29.5 (tactile skin

roughness); 60.3 vs

37.2 (mottled

hyperpigmentation);

84.6 vs 53.8 (facial

erythema); 78 vs 53.6

(actinic keratosis)

edema

51 10 1 IPL 2a 1.65a (ALA–PDT–IPL) Temporary 6

vs 1.28c (IPL) erythema, mild

edema,

desquamation

47 20 0.5–1 IPL 3a ,2b 80 (ALA–PDT–IPL) vs Mild stinging 1

45 (IPL) global score; during treatment;

95 vs 60 (mottled temporary

hyperpigmentation); 80 vs erythema, scaling,

80 (fine lines); 95 vs edema, oozing,

90 (tactile roughness); crusting,

75 vs 75 (sallowness) vesiculation

a Split face,ALA–PDT–IPL vs. IPL.

b Full face, IPL alone.

c Mean clinical grade (1= 25% improvement, 2= 25–50%; 3 = 51–75%; 4 = 76–100%).

Adapted with permission from Nestor M, Gold M, Kauvar A, et al.The use of photodynamic therapy in dermatology: results of a consensus conference.

J Drugs Dermatol 2006; 5:140–54.


a b

increase in dermal collagen was not observed until several

months after the final treatment. A recent review

of clinical trials with the 1540 nm Er:glass laser 53 confirmed

that collagen remodeling and improvement

were gradual, and emphasized the importance of

explaining this to patients.

With regard to the 1064 nm Nd:YAG laser, the

studies of Lee 15,54 revealed subtle and gradual

improvements in wrinkles, skin laxity, and overall

appearance, supported by histological evidence of

collagen remodeling. In another study, 55 a series of

four treatments with a 1450 nm diode laser

(SmoothBeam, Candela Corp.,Wayland, MA) resulted

in mild to moderate improvement in facial rhytids in

all 25 patients treated and increases in dermal collagen

6 months after the final treatment.The treatment

was well tolerated, and adverse effects were transient

and limited to erythema, edema, and postinflammatory

hyperpigmentation.

Two other groups 56,57 have reported clinical evaluations

of the 1064 nm Nd:YAG laser. Dayan et al 56

found an approximately 12% reduction in Fitzpatrick

scale scores for coarse wrinkles, a 17% reduction for

skin laxity, and a 20% overall improvement. Taylor

and Prokopenko 57 reported a 30% improvement in

wrinkles and skin laxity and an approximately 16%

improvement in texture, pores, and pigmentation.

Dang et al 58,59 focused on head-to-head comparisons

on mouse skin. In one study, 58 they compared the

histological, biochemical, and mechanical responses

associated with the Q-switched 1064 nm Nd:YAG laser

Nonablative technology for treatment of aging skin 61

Fig.6.8 Before (a) and after (b) two treatments with electro-optical synergy (ELOS) with pulsed light and ELOS with a diode

laser.(Photographs courtesy of Macrene Alexiades-Armenakas MD,PhD.)

and the 1320 nm Nd:YAG laser.The 1064 nm laser produced

a 25% greater improvement in skin elasticity, a

6% greater increase in skin thickness, and an 11%

greater hydroxyproline synthesis (a measure of collagen

content 59 ) by the second month after treatment.

Type III collagen increased markedly after 1064 nm

laser treatment, while type I collagen increases were

greater after treatment with the 1320 nm laser.

In another study 59 comparing a 595 nm PDL (Vbeam,

Candela Corp.,Wayland, MA) with a 1320 nm Nd:YAG

laser (Cooltouch II, ICN Pharmaceuticals Inc., Roseville,

CA), PDL treatment produced a greater increase in dermal

thickness, hydroxyproline levels, and type I and type

III collagen, while improvement in skin hydration was

greater with the 1320 nm laser. However, none of these

differences was statistically significant.

Orringer et al 60 assessed collagen remodeling after a

single treatment of photodamaged skin with either

a 585 nm PDL (NLite, ICN Pharmaceuticals Inc.)

or 1320 nm Nd:YAG laser (Cooltouch II, ICN

Pharmaceuticals Inc.).At 1 week post treatment, histological

examination revealed statistically significant

increases in type I procollagen messenger RNA expression

(47% and 84% above pretreatment levels for the

585 and 1320 nm lasers, respectively), as well as induction

of primary cytokines, matrix metalloproteinases,

and type III procollagen.

Doshi and Alster 61 evaluated the combination RF and

diode laser (ELOS: Polaris WR, Syneron Medical Ltd,

Israel) for the treatment of facial rhytids and skin laxity.

This device delivers RF and 910 nm diode laser energy


62 Clinical procedures in laser skin rejuvenation

sequentially through a bipolar electrode tip with

epidermal cooling. Three treatments were given at

3-week intervals to 20 patients with mild to moderate

rhytids and skin laxity. Optical and RF fluences ranged

from 30 to 40 J/cm 2 and from 50 to 85 J/cm 3 , respectively.

The prospective study showed a mean clinical

improvement of superficial rhytids at 6 months of

1.63/4. For skin laxity of the jowl and cheek, improvement

scores reached 2.00/4 at 6 months. Patient

assessments were similar. Side-effects were mild. In a

combined study 62 of ELOS with both IPL and a diode

laser (Fig. 6.8), overall effectiveness scores in multiple

measures of photodamage was approximately 26%.

NONABLATIVE TECHNOLOGIES FOR

SKIN TIGHTENING

From the evidence that collateral heating of the dermis

while targeting vascular and pigmented lesions created

new collagen and decreased wrinkles sprang the idea of

bulk dermal heating. Bulk dermal heating requires relatively

deep energy deposition over a period of seconds

as opposed to microseconds, with cooling to protect

the epidermis.The intent of tissue tightening is to actually

lift or firm tissue in a three-dimensional manner.

This is not the same as stimulating collagen to fill in

superficial scars or wrinkles, but a deeper shift in tissue

Fig.6.9 Partially denatured collagen

after Thermage treatment as 160

microns by electron microscopy.

(Reproduced courtesy of Dr.Brian

Zelickson and Thermage Corp.)

volumes, leading to a remodeling of the entire soft

tissue envelope, a completely new aesthetic capability.

Collagen fibers consist of protein chains held in a

triple helix. When collagen is heated, non-colavent

bonds linking the protein strands together are ruptured,

producing an amorphous arrangement of randomly

coiled chains. 63 As the chains rearrange, fibers

of the denatured collagen become shorter and thicker.

Heat-induced contraction of collagen and long-term

fibroblastic stimulation are is the basis for the treatment

of skin laxity. 64

For exposures lasting several seconds, the denaturation

temperature of collagen has been estimated at 65°C. 65,66

In practice, however, collagen denaturation has a complex

dependence on temperature described by the Arrhenius

reaction-rate equation.This relationship may not hold for

very short time exposures to heat, because the kinetics of

collagen denaturation are not known. 66

There are two technologies supported by peerreviewed

literature at present for evaluation: RF and

broadband infrared (IR) light.

Radiofrequency-based tissue

tightening

RF energy interacts with tissue to generate a current

of ions that, when passed through tissues, encounters

resistance. This resistance, or impedance, generates


Table 6.5 Studies of the use of radiofrequency (RF) for skin tightening

Nonablative technology for treatment of aging skin 63

Ref No. of Fluence Areas Adverse Follow-up

patients (J/cm 2 ) treated Efficacy effects (months)

73 40 — Face, 70% of patients Moderate pain 1, 2, 3

anterior noticed significant during treatment;

neck improvement in 3/40 patients

skin laxity and experienced

texture at 3 months superficial blistering

74 15 52 (only Face 14/15 patients responded; Minimal 6–14

for 2 nasolabial folds: 50% of discomfort

patients patients had at least 50% during treatment

treated with improvement; cheek contour: in all patients;

1cm2tip) 60% had 50% improvement; superficial

mandibular line: 27% had at

least 50% improvement;

marionette lines: 65% had

at least 50% improvement.

burn (1 patient)

69 86 58–140 Periorbital Fitzpatrick wrinkle scores Minimal erythema, 6

wrinkles, improved by 1 point or edema, 2nd-degree

brow more in 83.2% of patients; burn; small residual

position) 50% of patients satisfied scar at 6 months in

to very satisfied; 61.5% of

eyebrows lifted by 0.5 mm

3 patients

70 16 — Cheeks, jaw 5 of 15 patients contacted Mild, transient 6

line, upper neck were satisfied with results erythema and edema

78 17 125–144 Brow, jowls, Gradual tightening Mild, temporary 4

nasolabial folds,

puppet lines

erythema

75 50 97–144 Mild to Significant improvement Mild and temporary 6

(cheeks) moderate in most patients; patient edema, erythema,

74–110 skin laxity satisfaction was similar rare dysesthesia

(neck) in neck to observed clinical

and cheek improvement

68 24 — Upper third Objective data showed Pain during 4–14 weeks

of face; brow non-uniform (asymmetric) treatment;

elevation; improvement; patient redness

forehead, satisfaction low; 72.7%

temporal said they would not have

regions the procedure again;

results not predictable

57 7 73.5 Face; laxity, About 16% median None 2–6

wrinkles, pores, improvement in wrinkles

pigmentation, and skin laxity; about 16%

texture improvement in texture,

pores, and pigmentation;

patients satisfied; improvement

maintained 2–6 months


64 Clinical procedures in laser skin rejuvenation

heat in proportion to the amount of impedance.

Tissues with high impedance will be heated more than

tissues of low impedance. 67

Traditional RF devices used in skin surgery deliver

therapeutic energy through the tip of an electrode

in contact with skin. The concentrated thermal

energy produces heat at the surface of the skin, which

injures both the dermis and epidermis. 68 To reduce

heat-induced epidermal injury while heating the dermis,

developed the ThermaCool, a device that delivers

RF energy to the skin via a thin capacitive coupling

membrane that distributes RF energy over the tissue

volume beneath the membrane’s surface (rather than

concentrating the RF energy at the skin surface) while

cooling the epidermis by cryogen spray. 69,70 Although

the deep dermal layer can theoretically reach temperatures

exceeding 65°C, permitting the heat-sensitive

a b

collagen bonds to go beyond their 60° denaturation

threshold, the temperature of the epidermis is maintained

between 35°C and 45°C. 68 A study of the histological

and ultrastructural effects of RF energy

suggested that collagen fibrils contract immediately

after treatment and that production of new collagen is

induced by tissue contraction and heat-mediated

wounding (Fig. 6.9). 71

The first clinical study of the ThermaCool assessed

skin contraction, gross pathology, and histological

changes for a range of RF doses. 70,72 Iyer et al 73

reported that 70% of patients noticed skin laxity

improvement 3 months after a single RF treatment and

that improvement increased with additional treatments.

A subsequent report described a prototype

device designed to produce heat in the dermal layer of

tissue while protecting the epidermis by cryogen spray

Fig.6.10 Before (a) and 8 months after (b) tissue tightening treatments:one radiofrequency treatment on the left side of the

face and two broadband infrared light device treatments on the right.Note the decreased depth of the nasolabial folds and

marionette lines,the firming of the skin over the mid cheek and the restoration of the shape of the face toward an oval,instead of

a rectangle.(Photographs courtesy of Amy Forman Taub MD.)


Table 6.6 Studies of the use of broadband infrared (IR) light for skin tightening

cooling. 74 Of the 15 patients,14 responded to a single

treatment without wounding or scarring. Pain was

used to indicate the tolerability of treatment. Patients

resumed normal activities immediately after treatment.

Other RF studies that followed are summarized in

Table 6.5. In each study, patients had a single treatment,

local anesthesia was used during treatment, and

results were evaluated by comparing pre- and posttreatment

photographs. Improvements with a single

treatment were gradual and subtle and lasted for several

months. Higher fluences were required with thick

skin. 69 When low fluences were used, improvements

were less pronounced. 70,75

Initially, it was believed that the highest fluences

would yield the best results. However, this was accompanied

by significant patient discomfort and a relatively

high rate of significant side-effects, 76 such as

scars and changes in skin surface textures (e.g., indentation

or waffling). A different model based on a

lower-fluence, multiple-pass protocol was shown via

ultrastructural analysis of collagen fibril architecture

to provide much more collagen deposition deeper in

the dermis than the high-fluence protocol. 77 This is

believed to yield more consistent results, higher

patient tolerability, and fewer complications. Recent

advances include specialized tips for more superficial

areas (eyelids) and body areas (arms and abdomen).

Nonablative technology for treatment of aging skin 65

Device

No. of (No. of Fluence Local Treatment Adverse Follow-up

Ref patients treatments) (J/cm 2 ) anesthesia target Efficacy effects (months)

79 25 1100– 20–40 For first 5 Forehead; Immediate Small Up to 12

1800 nm patients lower improvement in 22 burns

(1–3) face and patients, persisted

neck for follow-up period;

all patients satisfied

80 42 1100– 30–38 Sometimes Face, Improvement Transient 4

1800 nm neck, moderate or minor

(2) abdomen higher in 52.4% swelling

of patients and

erythema,

rare blister

Infrared light-based tissue tightening

A broadband infrared light tightening device has

recently been developed as an alternative technology

for tissue tightening (Titan, Cutera, Brisbane, CA).

This generates energy of up to 50 J/cm 2 energy at

1100–1800 nm wavelengths, with pre- and postcooling

being built into the multisecond pulse.The long

wavelengths of near- and mid-IR radiation offer three

major advantages over shorter wavelengths: (1) deeper

penetration into the dermal layer (2) less absorption

by melanin, and (3) reduced risk in dark-skinned

patients. 56 This device targets the dermis at a depth of

1–2 mm, which is more superficial than the RF device.

The author has found this to be an advantage for thinner

skin, whereas the RF technology may be better for

thicker skin with more subcutaneous tissue attached –

but these observations are anecdotal. However, in

many skin types, the results may be similar (Fig. 6.10).

Studies of the use of infrared light in tissue tightening

are summarized in Table 6.6.

THE FUTURE AND CONCLUSIONS

A major advantage of nonablative techniques is that

treatment requires little or no downtime for patients.

The importance of this feature is evident from the


66 Clinical procedures in laser skin rejuvenation

growth and proliferation of nonablative devices since

they were introduced in the late 1990s. Disadvantages

are that efficacy is modest and multiple treatments are

required to achieve results. Future efforts will be

focused on increasing efficacy and reducing the number

of treatments, making treatment more affordable

for more patients.

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2003;29:124–8.

56. Dayan SH,Vartanian AJ, Menaker G, Mobley SR, Dayan

AN. Nonablative laser resurfacing using the long-pulse

(1064-nm) Nd:YAG laser. Arch Facial Plast Surg 2003;

5:310–15.

57. Taylor M, Prokopenko I. Split-face comparison of

radiofrequency versus long-pulse Nd-YAG treatment of

facial laxity. J Cosmet Laser Ther 2006;8:17–22.

58. Dang YY, Ren QS, Liu HX, Ma JB, Zhang JS. Comparison

of histologic, biochemical, and mechanical properties of

murine skin treated with the 1064-nm and 1320-nm

Nd:YAG lasers. Exp Dermatol 2005;14:876–82.

59. Dang Y, Ren Q, Hoecker S, et al. Biophysical, histological

and biochemical changes after non-ablative treatments

with the 595 and 1320 nm lasers: a comparative study.


68 Clinical procedures in laser skin rejuvenation

Photodermatol Photoimmunol Photomed 2005;21:

204–9.

60. Orringer JS, Voorhees JJ, Hamilton T, et al. Dermal

matrix remodeling after nonablative laser therapy. J Am

Acad Dermatol 2005;53:775–82.

61. Doshi S, Alster T. 1,450 nm long-pulsed diode laser for

nonablative skin rejuvenation. Dermatol Surg 2005;31:

1223–6.

62. Alexiades-Armenakas M. Rhytides, laxity, and photoaging

treated with a combination of radiofrequency, diode

laser, and pulsed light and assessed with a comprehensive

grading scale. J Drugs Dermatol 2006; 5:731–8.

63. Lennox MA. Febrile convulsions in childhood; a clinical

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64. Ruiz-Esparza J. Near painless, nonablative, immediate

skin contraction induced by low-fluence irradiation with

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65. Koch D. Histological changes and wound healing

response following noncontact holmium:YAG laser

thermal keratoplasty.Trans Am Ophthalmol Soc 1996;

94:745–802.

66. Ross E, McKinlay J, Anderson R.Why does carbon dioxide

resurfacing work? A review. Arch Dermatol 1999;

135:444–54.

67. Taub A. Harnessing radiofrequency energy. Skin Aging

2003;11:52–8.

68. Bassichis BA, Dayan S, Thomas JR. Use of a nonablative

radiofrequency device to rejuvenate the upper one-third of

the face. Otolaryngol Head Neck Surg 2004;130:397–406.

69. Fitzpatrick R, Geronemus R, Goldberg D, et al.Multicenter

study of noninvasive radiofrequency for periorbital tissue

tightening. Lasers Surg Med 2003;33:232–42.

70. Hsu T, Kaminer M.The use of nonablative radiofrequency

technology to tighten the lower face and neck. Semin

Cutan Med Surg 2003;22:115–23.

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ultrastructural evaluation of the effects of a radiofrequency-based

nonablative dermal remodeling device: a

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72. Kilmer S. A new, nonablative radiofrequency device: preliminary

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with a nonablative radiofrequency device: a lifting experience.

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tightening, J Drugs Dermatol 2006;5:771–8.


7. Lasers, light, and acne

Kavita Mariwalla and Thomas E Rohrer

INTRODUCTION

Acne vulgaris is an exceedingly common multifactorial

disease of the pilosebaceous unit, believed to affect

approximately 40 million adolescents and 25 million

adults in the USA alone. 1 It is thought to be physiologic

in adolescence due to its affect on nearly 85% of young

people between the ages of 12 and 24 years. 2 However,

12% of adult women and 3% of adult men will have

clinical acne until the age of 44. 3 Many authors have

described that, in addition to long-term scarring, which

can be disfiguring, patients with acne often carry significant

psychosocial morbidity, including anxiety, sleep

disturbances, clinical depression, and suicide. 4–8

In many cases, acne can be successfully treated using

conventional topical or oral medications such as

antibacterials, antimicrobials, and retinoids. However,

this approach often has drawbacks involving side-effect

profiles, length of treatment, and patient compliance.

9–13 With oral retinoids, practitioners are faced

with federally mandated paperwork that takes not only

time, but also several patient visits in order to deliver

treatment. 14,15

For the subset of patients who have failed these

treatment modalities, laser and light-based systems

have emerged as standalone and adjunct therapies.

These devices work by targeting the components of the

pilosebaceous unit that lead to acne lesions, namely

either the resident bacterium Propionibacterium acnes,

inflammation, or the pilosebaceous unit itself.

THE BUILDING BLOCKS OF ACNE

VULGARIS

In order to select the appropriate device for treating

acne, it is essential to understand the pathogenesis of

the acne lesion itself (Fig. 7.1). Acne vulgaris can be

broken down into lesion types based on pathogenesis

and severity: comedones, inflamed papules, nodules,

and cysts. The majority of data involving laser and

light-based therapies are based on the treatment of the

non-cystic form of acne vulgaris.

Simply put, acne has four main pathophysiological

features: hyperkeratinization, sebum production,

bacterial proliferation, and inflammation. The early

comedone is produced when there is abnormal proliferation

and differentiation of keratinocytes in the

infundibulum, forming a keratinous plug. This leads

to impaction and distention of the lower infundibulum,

creating a bottleneck affect.As the shed keratinocytes

form concretions, the sebum in the follicle thus

becomes entrapped.This stage represents the noninflammatory

closed comedone. As accumulation

increases, so too does the force inside the follicle

itself, eventually leading to rupture of the comedo

wall, with extrusion of the immunogenic contents

and subsequent inflammation. Depending on the

nature of the inflammatory response, pustules, nodules,

and cysts can form.

One factor in the pathogenesis of acne vulgaris is the

role of the resident P. acnes found deep within the sebaceous

follicle. 16–18 P.acnes is a slow-growing, gram-positive

anaerobic bacillus. It contributes to the milieu of

acne production in the lipid-rich hair follicle by producing

proinflammatory cytokines (e.g., interleukin-1

(IL-1) and tumor necrosis factor α (TNF-α)), as well

as many lipases, neuraminidases, phosphatases, and

proteases.True colonization with P. acnes occurs 1–3

years prior to sexual maturity, when numbers can

reach approximately 10 6 /cm 2 , predominantly on the

face and upper thorax. 19 Although some suggest that

the absolute number of P. acnes does not correlate

with clinical severity, 16 it is common belief that the


70 Clinical procedures in laser skin rejuvenation

Sebaceous

lobule

P. acnes

proliferation

Sebaceous

lobule

regression

The pilosebaceous unit

Inflammatory papule/pustule

Hair shaft

Pore

Resident P. acnes

Sebum

Hair shaft

Pore

Retained keratin

and lamellar

concretions

Inflammation

Fig. 7.1 The pathogenesis of acne. Lasers & light based devices target either the pilosebaceous unit, to decrease sebum

production or improve sebum flow out of the gland, or the resident Propionibacterium acnes to combat acne vulgaris. Comedones

result from hyperkeravatosis at the level of the infundibulum along with increased sebum secretion.As the accumulated keratin and

sebum form a plug, inflammation and proliferation of P. acnes produces the clinically inflammatory acne papule.


proinflammatory mediators released by these bacteria

are at least partially responsible for the clinical acne

lesion.

In practice, acne is predominantly found on the face

and to a lesser degree on the back, chest, and shoulders.The

majority of studies using laser and light-based

systems target acne on the face, although we present

data from a limited number of studies performed elsewhere

on the body.

CLINICAL EXPERIENCE AND

CONSIDERATIONS

Patient screening

As new laser- and light-based systems emerge for the

treatment of acne vulgaris, the selection of patients

and the type of device to use for each one can seem

daunting. In our clinical practice, we use a series of

simple guidelines before initiating laser or light-based

therapies.

1. Is the patient a topical or oral medication failure?

2. Has the patient tried isotretinoin or are there

circumstances that make isotretinoin a less-thanideal

medication for the patient?

3. Is the patient’s acne mainly comedonal or are there

inflammatory acne papules as well? To what extent

is the patient’s acne nodulocystic?

4. Does the patient have acne and acne scarring?

It is important to keep in mind that most laser

systems will work to some extent. Topical and oral

medications should be optimized and are generally

continued during the initial phase of treatment with

any of the devices. Occasionally, laser and light-based

treatments may be used as first-line therapy, with or

without topical and oral medications, in patients

presenting with both active acne and acne scars who

also want treatment of their scars.

The patient encounter

In the initial evaluation of the patient, it is important

to set realistic expectations. Although many patients

see dramatic improvement with laser and light-based

therapy, some see little to no improvement. Compared

with conventional therapy, laser and light devices

require no daily routine, are not altered by antibiotic

resistance, have few systemic side-effects, and are easy

to administer, and some (infrared and radiofrequency

devices) offer significant textural improvement of acne

scars. On the other hand, these modalities are much

more expensive, involve some degree of patient discomfort

during treatment, have post-treatment recovery/downtime

due to erythema, and require multiple

trips to the dermatologist’s office. As with any laser

procedure, patients’ skin phototype and underlying

psychosocial disturbances should be considered.

Choosing the appropriate laser

In most practices, the choice of device depends on

what is available to the practitioner.When multiple

devices are available, it is crucial to keep in mind the

area of involvement and the presence of scarring. For

example, in large areas such as the chest and back,

treatment with infrared lasers with a 4–6 mm spot size

is generally too time-consuming and painful for the

patient. Instead, for wide treatment areas, light-based

therapy with or without δ-aminolevulinic acid can be

used. In cases of significant acne scarring, infrared

lasers are often used, since these devices are also frequently

employed to improve the texture of the skin,

including scars.The ultimate decision, however, is up

to the individual practitioner and the patient, and

should be evaluated in terms of what the treatment is

targeting: the sebaceous gland or P. acnes itself.

TARGETING P.ACNES

Lasers, light, and acne 71

P. acnes produces and accumulates endogenous porphyrins,

namely protoporphyrin, uroporphyrin, and

coproporphyrin III, 20,21 as part of its normal metabolic

and reproductive processes.These porphyrins absorb

light energy in the near-ultraviolet (UV) and blue

regions of the spectrum, and can be visualized by

Wood’s lamp (365 nm) examination, under which they

fluoresce coral red. 22

Porphyrins have two main absorption peaks, the Soret

band (400–420 nm) and the Q-bands (500–700 nm),

which make them susceptible to excitation by lasers and


72 Clinical procedures in laser skin rejuvenation

Extinction

coefficient

> 2×10 5

L mol −1 cm −1

Soret band

Q-bands

400 600

Wavelength (nm)

Fig. 7.2 Excitation spectrum of protoporphyrins.The Soret

band represents the highest peak of light absorption and thus

sensitizer activation, while the Q-bands represent the several

weaker absorptions at longer wavelengths. Because the

highest peak of absorption of porphyrins is on the blue

region (415 nm), this wavelength is used by several light

source systems for acne treatment.

NH

Photons

N

Basic porphyrin structure

N

HN

Excited porphyrin molecules

light sources emitting wavelengths in the visible light

spectrum (400–700 nm) (Fig. 7.2). Once induced,

these photosensitizers generate highly reactive freeradical

species, which cause bacterial destruction 23,24

(Fig. 7.3).The singlet oxygen formed in the reaction is

a potent oxidizer that destroys lipids in the cell wall of

P. acnes. Although absorption and photodynamic excitation

are most efficient between the wavelengths of 400

and 430 nm, with enough light, the reaction may be initiated

with a variety of different wavelengths.

Porphyrin concentration, effective fluence, wavelength

of the emitted photons, and temperature at which

the reaction is carried out all play a role in P. acnes

photoinactivation. 25

Photoinactivation of P.acnes with

visible light

UVA/UVB

After sunlight exposure, as many as 70% of patients

report improvement in their acne. 26 It is not known

whether the UV or visible light component is primarily

Reactive oxygen

free radicals

Destruction of lipids

in cell wall of P. acnes

Fig. 7.3 Mechanism of P. acnes destruction by visible light interaction with porphyrins.When exposed to absorbed light wavelengths,

porphyrins act as photosensitizers and generate highly reactive free-radical species, one of which is singlet oxygen.These

radicals are potent oxidizers and destroy the lipids in the cell wall of P. acnes.


esponsible for this effect. In vitro experiments have

shown that P.acnes can be inactivated by low-dose near-

UV radiation; however, given the potential carcinogenicity

of UVA and UVB therapy, in vivo studies have

not been able to justify this means of acne treatment,

regardless of the treatment parameters. 27,28

Conclusion: While anecdotal evidence of acne

improvement over the summer has a rational basis, the

potential side-effects of prolonged UV radiation are

unacceptable risks, and other modalities should be

sought.

Blue light

The strongest porphyrin photoexcitation coefficient

(407–420 nm) lies in the Soret band. It comes as no

surprise, then, that irradiation of P. acnes colonies with

blue light (415 nm) leads to bacterial destruction.

In vitro, colony counts of P. acnes have decreased by

four orders of magnitude 120 minutes after exposure

to a metal halide lamp with a wavelength of

405–420 nm (ClearLight, Lumenis Ltd, Santa Clara,

CA). Kawada et al 29 used this light source on mild to

moderate acne lesions in 30 patients and found a 64%

mean acne lesion count reduction after 10 Clearlight

treatments over a 5-week period with a one- to twoorder

decrease in P. acnes colony count in correlated in

vitro experiments.The study showed that papules and

pustules improved more than comedones, but 10% of

patients actually experienced an increase in acne.

Another study utilizing the blue light source failed to

show bacterial count changes by polymerase chain

reaction (PCR) after therapy; however, damaged

P. acnes were observed at the ultrastructural level. 30

Shalita et al 31 used the ClearLight to treat 35 patients

with lesions on the face and back using 10-minute light

exposures twice weekly over a 4-week period.There was

an 80% improvement of noninflammatory and a 70%

improvement of inflammatory lesions as assessed 2 weeks

after the last treatment. Using the same device, Elman

et al 32 carried out a split-face double-blind controlled

study (n =23) in which patients were treated a total of

eight times for 15 minutes (420 nm, 90 mW/cm 2 ). In

this group, 87% of the treated sides showed at least a 20%

reduction of inflammatory acne lesions with a 60% mean

reduction of lesions in responders that remained steady at

Lasers, light, and acne 73

2, 4, and 8 weeks post therapy. In the same trial, Elman

et al 32 treated 10 patients with papulopustular acne in a

split-face dose-response study, exposing them to

narrowband visible blue light (90 mW/cm 2 ) for either 8

minutes or 12 minutes. Although there was a more than

50% decrease in inflammatory lesions in 83% of the

treatment areas, there was little difference between

8- and 12-minute exposure times (a decrease of 65.9%

versus 67.6%, respectively). 32

Success in the treatment of acne vulgaris with the

blue light may be dependent on the lesion morphology.

For example, Tzung et al 33 showed a 60%

improvement in papulopustular lesions in skin phototypes

III and IV with four biweekly treatments (F-36

W/Blue V, Waldmann, Villingen-Schwenningen,

Germany) and worsening of nodulocystic acne in 20%

of patients (n =28).

Using a different blue light source (Blu-U, DUSA

Pharmaceuticals, Inc.,Wilmington, MA), Gold et al 34

found an average 36% reduction in inflammatory acne

lesion counts after 4 weeks of biweekly 1000-second

light therapy sessions, compared with a 14% reduction

in patients using 1% clindamycin solution twice daily.

The authors of this study, however, acknowledge that a

limiting factor in their trial was sample size (n =13 for

the clindamycin arm and n= 12 for the light therapy

arm), making it difficult to draw a conclusion regarding

diligent topical antibiotic use versus blue light

therapy alone. In fact, if all patients entered into the

study are considered, there is no difference in the

amount of clearing.

Conclusion: Blue light is effective for papules and

pustules more than comedones, and carries the risk of

worsening nodulocystic acne. It is effective in varying

skin types.

Combination blue and red light

One of the main restraints of blue light therapy for

acne is that it is highly scattered in human skin and thus

penetrates poorly. Red light, while less effective in

photoactivating porphyrins, 35 has increased depth of

penetration into the epidermis to reach the porphyrins

in the sebaceous follicles. Red light can also potentially

induce anti-inflammatory effects by stimulating

cytokine release from macrophages. 36


74 Clinical procedures in laser skin rejuvenation

In combination, red and blue light may act synergistically

by exerting both antibacterial and anti-inflammatory

effects. Papageorgiou et al 37 compared the

simultaneous use of red and blue light to treat acne

vulgaris in a randomized single-blind control study

with blue light phototherapy versus 5% benzoyl peroxide

in a total of 140 patients with mild to moderate

acne. After 84 consecutive treatments of 15 minutes

(cumulative doses 320 J/cm 2 for blue light and

202 J/cm 2 for red light), the authors noted a final

improvement of 76% in inflammatory lesions, which

was significant compared with the results of blue light

or benzoyl peroxide alone.

Conclusion: Combination blue and red light may

act synergistically; however, the length of treatment

requires patient compliance and diligence.

Yellow light

Intense yellow light at 585 nm theoretically penetrates

deeper than blue light, and, using the same principle of

P. acnes porphyrin excitation, offers another alternative

to laser devices. Edwards et al 38 studied 30 patients

with mild to moderate facial acne and exposed each

side of their face to 3.0, 1.5, or 0.1 J/cm 2 (sham)

twice a week for 4 weeks.At 6 weeks after completion

of therapy, patients who received 3.0 J/cm 2 had a 23%

improvement in Leeds acne score, with a 21%

decrease in total lesion count.This system relies on a

light-emitting diode (LED) and may offer some benefit

to patients with mild acne.

Conclusion: Intense yellow light may improve mild

acne, although alternatives exist in the blue light and

combined blue and red light modalities that have shown

greater efficacy than yellow light alone. Long-term

efficacy data are not yet available for the LED.

Intense pulsed light

Intense pulsed light sources emit a broad band of light

with wavelengths generally ranging from 500 to

1200 nm. Although less selective by nature, these

devices emit wavelengths of energy that are absorbed

by many chromophores and therefore can be used to

treat a variety of conditions. The Palomar LuxVO

(Palomar Co., Burlington, MA) handpiece provides

wavelengths of 400–700 nm and 870–1200 nm. Gupta

et al 39 studied this device in 15 patients with

Fitzpatrick skin phototypes I–V. Each patient received

three to five treatments spaced 1–2 weeks apart

(11 J/cm 2 , 60–100 ms pulse width, and three to four

passes over the entire treatment area) and was followed

up 3 months after completion of the last treatment.The

authors found no significant difference in

noninflammatory lesion counts, but did note a significant

reduction in mean comedone, papule, and pustule

counts as well as a significant improvement in global

severity grade of acne. In the skin type V group, mild

crusting associated with postinflammatory hyperpigmentation

was noted, but resolved with time.

Conclusion: IPL may be an effective and safe treatment

option for mild to moderate inflammatory acne

lesions in a variety of skin types.

Pulsed light and heat

Knowing that porphyrins have the highest excitation

spectrum at lower wavelengths and yet in order

to reach P. acnes a greater depth of penetration is

required, which can only be accomplished through

longer wavelengths, one of the dilemmas of lightbased

therapy for acne vulgaris was how to combine

these two properties. As a result, Radiancy Inc.

designed proprietary technology for the simultaneous

delivery of pulsed light and heat energy (LHE) through

the ClearTouch system (430–1100 nm, 35 ms,

3–9 J/cm 2 , and spot size 22 mm × 55 mm).The LHE

technology primarily rests on the principle that, like

any other photochemical reaction, the efficiency of

porphyrin induced P. acnes destruction is determined

by the rate of production of excited porphyrins.The

rate of porphyrin excitation is related to four factors:

(1) the concentration of porphyrins; (2) the photon

flux; (3) the temperature of the chemical reaction; and

(4) the wavelength of the photons. 40

One of the advantages of a pulsed light source compared

with continuous-wave mode devices is the ability

to provide many more photons at peak power. 41 For


a b

example, a 3.5 J/cm 2 pulsed wave light source with a

35 ms pulse width delivers 10 000 times more photons

than a continuous-wave 10 mW/cm 2 light source.The

disadvantage of using pulsed light is oxygen (ratelimiting)

depletion and therefore rapid reaction saturation.

Because the range of emitted wavelengths

emitted by this device is broad, both antibacterial and

anti-inflammatory effects are induced, since the peak

absorption of endogenous porphyrins is covered as

well as that of hemoglobin in blood vessels proximal to

the inflamed acne papule.

The efficacy of a combination of heat and light is also

quantitatively justified through the Arrhenius equation,

which states that the higher the temperature, the

faster a given chemical reaction will proceed. 42 Thus,

the ability to deposit heat through conduction from a

nonoptical, exogenous source may reduce inflammation

and even speed up the photodynamic reactions.

This was shown by Kjeldstad et al, 23 who, using

330–410 nm near-UV light, found that in vitro photoinactivation

of P. acnes increased as the temperature

increased in intervals of 10 ° C, 20 ° C, and 37 ° C, with

reciprocal increase in P. acnes colonies with decreased

temperature.

Elman and Lask 43 studied the efficacy of the

ClearTouch system (Radiancy Inc., Orangeburg, NY)

in 19 acne treatment-naive patients with inflammatory

and noninflammatory acne lesions. Each patient

received a total of eight 10-minute treatments (two

passes) over a period of 1 month (430–1100 nm,

3.5 J/cm 2 , 35 ms pulse, and 22 mm × 55 mm spot

size). One month after treatment, noninflammatory

acne lesions were 79% ± 22% clear, while inflammatory

lesions were 74% ± 20% clear.Two months after

the last treatment, noninflammatory and inflammatory

lesion counts were reduced by 85% and 87%, respectively.

Gregory et al 44 also studied the ClearTouch

system in a multicenter blinded control trial of 50

patients suffering from mild to severe acne who discontinued

all treatment 4 weeks prior to the start of

the trial. Patients served as their own control and

received two passes biweekly for 1 month. Four weeks

later, the authors noted a mean 60% reduction in

inflammatory lesion counts, compared with a 32%

increase in the control phase, with erythema as the

only reported side-effect (Fig. 7.4).

Conclusion:The technological basis of pulsed light and

heat makes intuitive sense by allowing practitioners to

target both P. acnes and the sebaceous gland. As a result,

this device is successful in treating both inflammatory

and noninflammatory acne vulgaris.

Laser

Lasers, light, and acne 75

Fig.7.4 Before (a) and after treatment (b) with the ClearTouch system (Radiancy Inc.),a device that emits wavelengths between 430

and 1100 nm in pulses of 35 ms and a low fluence (3–7.5J/cm 2 ).This system,which combines light and heat damage to allow for

deeper skin penetration and antibacterial effect for acne treatment,is used biweekly for 1 month with two passes during each therapy

session.(Photographs courtesy of Dr Helena Regina de Brito Lima.)

532 nm KTP laser

The 532 nm (green) potassium titanyl phosphate

(KTP) laser has as its target chromophores oxyhemoglobin

and melanin.As such, it is typically used to treat

telangiectasia and superficial pigmented lesions.

However, since this laser has a greater optical penetration

depth into skin than blue light, it has the innate


76 Clinical procedures in laser skin rejuvenation

ability to activate bacterial porphyrins along with

some nonspecific collateral thermal injury to sebaceous

glands, and is generally well tolerated.Thus, it

has also been trialed in the treatment of acne vulgaris.

Baugh and Kucaba 45 studied the effect of the Aura

KTP laser (Laserscope, San Jose, CA) in 21 subjects

with mild to moderate facial acne in a split-face singlecenter

prospective trial. Patients who had been treated

with systemic antibiotics in the 8 weeks prior, topical

therapy in the 2 weeks prior, or oral retinoids in the 6

months prior to the start of the trial were excluded.

Individual pulses of 12 J/cm 2 with a 30–40 ms pulse

width and a 1–5 Hz frequency were delivered with the

use of a continuous contact cooling tip (Laserscope

VersaStat I, which cools the skin to −4 ° C) twice a week

for 2 weeks.The control area was treated with contact

cooling alone. Results demonstrated the greatest

improvement in acne papules (>45% reduction) at 1

week, which deteriorated by 4 weeks to just over 35%

reduction, with no improvement in infiltrated lesions

at 4 weeks. Acne pustules showed the most improvement

at 4 weeks, while comedone improvement did

not exceed 13% reduction at either 1 or 4 weeks post

treatment.Total percent improvement in comedones,

papules, pustules and infiltrated lesions was 25% 1

week after treatment and 21% 4 weeks after treatment.

Subjectively, 47.6% of patients felt 70–79%

overall satisfaction with the therapy. Of note, none of

the subjects experienced post-treatment redness or

irritation.

Using the Aura (Iridex, Mountainview, CA) KTP

laser (4 mm spot size, 7–9 J/cm 2 , 20 ms pulse, and

3–5 Hz), Bowes et al 46 carried out a prospective splitface

study involving 11 patients using 6–10 passes per

half-face for 2 weeks. A moderate decrease in mild to

moderate acne lesion count was noted after 1 month

(36%), versus a 1.8% increase in the control group.

Sebum production also decreased (28%), but there

was minimal effect on P. acnes as measured by fluorescence

photography.

Subsequently, Lee 47 reported on her experience

with the Aura for facial and trunk acne by treating 25

patients with KTP alone, 25 patients with laser

followed by topical medications and cleansers, and

125 patients with concomitant laser and topical treatment.

A majority (90%) of the 125 patients treated

simultaneously with laser and topical agents had

80–95% improvement, which was similar to the

group who followed their laser treatment with topical

agents. Fifty percent of the 125 patients maintained

results over 4 months without additional treatment.

The laser-only group had more flares, less clearance,

and slower response times in comparison. These data

suggest that although the laser alone induces a limited

response, it may be beneficial in combination therapy

for acne treatment.

Conclusion: The KTP 532 nm laser can induce a

reduction in inflammatory facial acne, although longterm

suppression is variable.This laser is less successful

in comedone treatment, and may be best used as an

adjunctive therapeutic with topicals.

Pulsed dye laser: 585 nm

Similar to the KTP, the chromophore for the flashlamp-pumped

pulsed dye laser (PDL) is oxyhemoglobin,

making it particularly suitable for reducing the

‘red’ component of clinically apparent acne lesions. In

addition, as discussed earlier, 585 and 595 nm yellow

light can be used to photoexcite porphyrins and

reduce P. acnes.

Seaton et al 48 demonstrated a 49% reduction in

inflammatory lesion counts (regardless of severity

at baseline) versus 10% in controls 12 weeks after a

single pass of the 585 nm PDL (5 mm spot size,

1.5–3.0 J/cm 2 , and 350 µs pulse; NLite System, ICN

Pharmaceuticals Inc., Costa Mesa, CA). Other studies

using the same device, however, were less encouraging.

In a randomized blinded placebo-controlled trial of 26

patients with mild to moderate acne, Orringer et al 49

showed only a trend towards improvement that was

not statistically significant in mean papule counts,

mean pustule counts, or mean comedone counts.

Grading of serial photographs also showed no significant

differences in Leeds scores for treated skin at

baseline and at week 12 compared with untreated skin

at the same time points. 49 Although the two groups of

investigators used the same device setting, the number

of laser pulses used to treat each patient varied.

Orringer et al 48 used 385 per patient, while Seaton


a b

et al 50 used at least 500 pulses per patient, which may

contribute in part to the difference in results.

Pulsed dye laser: 595 nm

Alam et al 51 reported significant acne clearance in 25

subjects using a 595 nm PDL (7 mm spot size,

8–9 J/cm 2 , 6 ms pulse).These treatment parameters

may be more suitable for acne, given the increased

depth of penetration as well as longer pulse duration

and higher fluence (Fig. 7.5).

Conclusion: Because the pulsed dye laser is able to

affect the ‘red’ component of acne and has a good depth

of penetration, it may be suitable for patients with mildto-moderate

inflammatory acne. However, the results

have been widely variable – from no improvement to

near 50% reduction.

In summary: targeting

P.acnes

Lasers, light, and acne 77

Fig.7.5 a) Patient with acne and post acne erythema before treatment.b) Same patient 6 weeks later,following two treatments

with the pulsed-dye laser.

The modalities thus far discussed directly or indirectly

rely on the biological property of porphyrin as

a photosensitizer to induce the destruction of P. acnes

colonies in vivo and clinically improve acne vulgaris.

Although light therapy in the 400–420 nm range

coincides with porphyrin peak excitation, longer

wavelengths allow for deeper dermal penetration.

Unfortunately, since P. acnes is a rapid regenerator,

acne clearance is generally short-lived (at most 3

months), and therefore treatments must be continued

on an ongoing basis. Given this limitation, it is

questionable whether these laser and light-based

systems are a significant enough improvement over

topical therapies to justify the expense and time

needed to treat.


78 Clinical procedures in laser skin rejuvenation

TARGETING THE

PILOSEBACEOUS UNIT

The sebaceous gland is under many influences during

adolescence.The ensuing increase in sebum production

plays a primary role in acne formation.Although targeting

P.acnes is one approach to ameliorating acne vulgaris,

another involves targeting the pilosebaceous unit itself.

By reducing the size, and therefore the sebum output, of

the gland, or by straightening out the tubule by which it

drains, several devices have been shown to significantly

reduce acne for extended periods of time.

Photodynamic Therapy

Glycine + Succinyl CoA → ALA → Prophobilinogen → Hydoxymethylbilane →

Uroporphyrinogen III → (Uroporphyrinogen) III → Protoporphyrinogen III →

Protoporphyrin IX → Heme


Ferrochelatase

Fig. 7.6 Devices using topical application of δ-aminolevulinic acid (ALA) are effective because they take advantage of the

heme synthesis pathway, leading to protoporphyrin IX.When the protoporphyrin IX is photoactivated, the singlet oxygen and free

radicals produced are not only cytotoxic to P. acnes but also damage the pilosebaceous unit itself.

Photodynamic therapy (PDT) has recently been used in

the treatment of acne vulgaris. This method uses a

photosensitizer and low-intensity visible light that,

together, produce cytotoxic oxygen radicals. One of the

advantages of this method is that the photosensitizer can

be selectively applied and illumination can be focused.

In addition, this system is equally effective on all strains

of P.acnes, regardless of antibiotic resistance. 52

δ-Aminolevulinic acid

Topical δ-aminolevulinic acid (ALA) is preferentially

taken up by pilosebaceous units and incorporated

into the heme synthesis pathway, resulting in the production

of protoporphyrin IX.When photoactivated,

protoporphyrin IX produces singlet oxygen molecules

and free radicals, which are cytotoxic (Fig. 7.6). In

addition, it has been shown that the addition of ALA

actually enhances intracellular porphyrin synthesis

itself. 53

PDT has also been used in combination with ALA in

the treatment of nonmelanoma skin cancer, actinic

keratoses, acne vulgaris, viral warts, and other dermatoses.

54 The combination of topical ALA application

followed by PDT results in cytotoxic free-radical

production and death of P. acnes, as well as damage to

the pilosebaceous unit itself. ALA application times as

brief as 15–60 minutes followed by red, blue, or

intense pulsed light, PDL, diode lasers, or LED

sources have all been shown to be effective.

ALA and red light

In a study of 22 patients with chest and back acne,

Hongcharu et al 55 found that the majority of protoporphyrin

IX production was localized in the sebaceous

glands and hair follicles after three hours application of

ALA under occlusion. Subsequently, these authors

used a broad band 550–700 nm red light source at a

fluence of 150 J/cm 2 , and were able to show a persistent

decrease in acne lesion counts for 10–20 months

following one to four treatments. Histology revealed

damaged and even destroyed sebaceous glands. Sebum

excretion rate, sebaceous gland size, and follicular

bacterial counts also all decreased. Adverse effects,

often typical of ALA–PDT treatment, included erythema,

crusting, pain, and hyperpigmentation. Itoh

et al 56 reported an intractable case of acne vulgaris on

the face that, after treatment with ALA–PDT (4-hour

drug incubation, 635 nm), remained clear at 8-month

follow-up. A subsequent study by the same group 57


evaluated 13 subjects and demonstrated a reduction in

new acne lesion counts at 1, 3, and 6 months following

PDT treatment.

ALA and blue light

Pain-free treatments with few side-effects have been

described with four weekly treatments using the blue

light after short ALA incubation periods (15 minutes).

58 In 15 patients with moderate to severe acne,

the combination of 1-hour ALA incubation and blue

light led to a continued reduction in acne lesion counts

in responders up to 72% at 3 months after the last

treatment. 59

ALA and red light diode laser

Pollock et al 60 investigated the use of a red light diode

laser (CeramOptec GmbH, Bonn, Germany) in combination

with 20% ALA cream applied under occlusion

for 3 hours.Ten patients with mild to moderate

acne of the back were treated weekly for 3 weeks

(635 nm, 25 mW/cm 2 , and 15 J/cm 2 ) and assessed 3

weeks after the last treatment. ALA–PDT-treated

areas demonstrated a significant reduction in acne

lesion counts, but not in P. acnes concentration as

assessed by P. acnes swabs or sebum excretion. It is

possible, as Pollock et al 60 suggest, that another mechanism

of action may play a role in the response of acne

to ALA–PDT. They also suggest that perhaps PDT,

rather than destroying P. acnes, damages the bacterium

so that it is unable to function normally.They speculate

that when the bacterium is swabbed and put into an ideal

culture environment, it grows normally, thus giving an

inaccurate picture of what is occurring deep in the

pilosebaceous unit.

ALA and polychromatic visible light

Oral ALA followed by exposure to polychromatic

visible light from a metal halide lamp resulted in

marked improvement based on a physician clinical

assessment score in 61% of 51 patients treated for

intractable acne on the body. Kimura et al 61 administered

the ALA at a dose of 10 mg/kg, which produced

no liver dysfunction. However, adverse effects did

occur, and consisted of slight discomfort, burning and

stinging during the irradiation.

Lasers, light, and acne 79

ALA and IPL

Hwang and Seo 62 compared two light spectra of IPL

(Ellipse, DDD, Denmark), namely VL (555–950 nm)

and HR (600–950 nm) with varying application times of

ALA (1 hour vs 4 hours).They followed patients at 1, 4,

14 and 24 weeks after a single treatment, and found no

difference in the number of comedones or inflammatory

acne lesions when comparing 1-hour and 4-hour ALA

incubation times. Of the two, the 600–950 nm applicator

was more efficient than the 555–950 nm applicator

in reduction of inflammatory acne. Given these data, and

the risk of hyperpigmentation, Hwang and Seo 62 concluded

that ALA should be applied for a short time. Gold

et al 54 enrolled 15 patients who underwent four weekly

treatments (ClearTouch, 3–9 J/cm 2 ) after 1 hour incubation

with ALA, and found a 71.8% reduction in

inflammatory acne lesions at 12-week follow-up in 80%

of the patients.This was an increase from a 68.5% reduction

1 month after treatment. Of note, none of the

treated lesions recurred at 3-month follow-up.

ALA and PDL

In one of the few studies using patients with mild

to severe acne including cystic and inflammatory

lesions, Alexiades-Armenakas 63 used a combination of

ALA–PDT with the 595 nm PDL. Topical ALA was

applied for 45 minutes on the face, followed by a single

minimally overlapping pass with the long-pulsed PDL

(595 nm, 7–7.5 J/cm 2 , 10 ms, 10 mm spot size, and

dynamic cooling spray 30 ms) in 14 patients, who were

then followed monthly for 13 months. Controls were

treated with conventional therapy (oral antibiotics,

oral contraceptives, or topicals) or PDL only.

Complete clearance occurred in 100% of the patients

in the PDL–PDT-treated group, with a mean of 2.9

treatments being required to achieve complete clearance.

In the control groups, mean percent lesional

clearance rate per treatment was 77%. The mean

percent lesional clearance per treatment was 32% in

the PDL-only group and 20% in the oral antibiotic and

topical group, although the number of patients in these

two control groups was small (n = 2 for each).

Nonetheless, the PDT–laser combination was well

tolerated, with minimal erythema lasting 1–2 days

without evidence of crusting, blistering, or dyspigmentation.

This pilot study demonstrated that PDL


80 Clinical procedures in laser skin rejuvenation

Stratum corneum

Dermis Hair

follicle

Sebaceous gland

Epidermis

Sebaceous gland

Dynamic cooling device spray

Dynamic cooling device

pulse cools and protects

the epidermis

may be an efficacious combination with ALA to

achieve clearance in patients with varying stages of

acne from comedones to cysts.

Conclusion: Topical ALA application enhances the

production of porphyrins and not only can induce cytotoxic

effects on P. acnes but can also target sebaceous

glands for destruction.The end-result is a decrease in

acne, which varies depending on the light source used

for illumination.

Indocyanine green

Carotenoids are the natural chromophore in sebum,

with an absorption range of 425–550 nm.The problem

with using a laser in this wavelength range is the number

of unintended components of the skin that will absorb

this wavelength, resulting in unwanted side-effects such

as blood coagulation.The ideal wavelength to use is in

the ‘optical window’, which is 600–1300 nm. 64 The

only barrier is that local chromophores do not absorb in

this wavelength. However, indocyanine green (ICG, a

tricarbocyanine dye) is a chromophore with peak

absorption at 805 nm, which can be applied topically

and is known to be preferentially accumulated by sebaceous

glands. In combination with diode lasers, ICG is

thought to cause both photodynamic and photothermal

effects within P.acnes and the pilosebaceous unit.

Laser pulse

Laser penetrates the

skin to base of the

sebaceous gland

Thermal injury to the

sebaceous gland

Fig.7.7 Lasers at 1320,1450,and 1540 nm (mid-infrared) have shown impressive clearing of acne lesions.The lasers heat the

dermis,in bulk,including the upper and mid-dermis,where sebaceous glands are primarily located.As a result,a potential reduction in

the size and sebum output of the sebaceous gland,or a straightening of the infrainfundibular tubule,occurs and there is an

improvement in acne.Side-effects associated with these lasers are pain,transient erythema and edema,and a risk of hyperpigmentation.

Tuchin et al 65 treated 22 patients with inflammatory

acne lesions on the back and face. An 803 nm

(OPC-BO15-MMM-FCTS diode laser, Opto Power

Corp., Tucson, AZ) or 809 nm (Palomar Medical

Technologies, Inc., Burlington, MA) diode laser was

used after occlusive ICG application for 5 or 15

minutes.The combination of ICG and laser produced

less inflammation, lesion flattening, and reduction in

P.acnes and sebum production compared with no treatment,

ICG alone, and laser-only-treated areas. A subsequent

pilot study for moderate to severe acne lesions

showed that multiple treatments with ICG and a nearinfrared

diode laser improved skin for as long as 1

month without side-effects when compared with a single

ICG-laser treatment session. 66

In one of the select studies to look at body acne, Lloyd

and Mirkov 67 treated patients with 5% ICG microemulsion

for 24 hours under occlusion and then treated them

with a 810 nm diode laser (4 mm spot size, 810 nm,

40 J/cm 2 , and 50 ms pulse; Cyanosure, Inc.). Histology

showed evidence of selective necrosis of the sebaceous

glands. Using these parameters, the group then treated

10 patients with back acne, and their preliminary clinical

results showed a decrease in acne in the treatment area at

3-, 6-, and 10-month follow-up. It should be noted that

treatment did not lead to immediate resolution of acne

lesions, which cleared through the skin’s own healing

process. However, the treated regions remained lesionfree

for extended periods of time, leading Lloyd and


a b

Mirkov 67 to speculate that ICG-diode laser treatment did

cause thermal damage in the sebaceous gland.

Conclusion: ICG and long-pulsed diode lasers are an

effective way to target sebaceous glands by applying an

exogenous chromophore to the skin, however downsides

include incubation time and pain during treatment

due to collateral heating.

Infrared lasers

Isotretinoin use is known to cause shrinkage of sebaceous

glands, with a resultant reduction in sebum

output. Interestingly, although sebum concentration

returns to normal after therapy discontinuation, many

patients remain clear of acne. This has led to the

hypothesis that even a temporary alteration of sebaceous

glands may be sufficient to induce long-term

Lasers, light, and acne 81

Fig.7.8 a) Patient with severe acne and acne scarring prior to laser treatment.b) Same patient 6 weeks later,following five

treatments with a 595 nm pulsed-dye laser and 1450 nm infrared divide laser (Smoothbeam Laser,Candela Corp.,Wayland MA).

acne clearance.The distribution of sebaceous glands is

highly variable in the dermis; however, infrared lasers

target water, which is the dominant chromophore in

the sebaceous gland. Consequently, mid-infrared laser

light, which has a depth of penetration into the superficial

dermis, is able to produce a zone of injury in the

superficial dermal layer that may injure sebocytes and

arrest the overproduction of sebum and disrupt the

pathogenesis of acne itself. Alternatively, infrared

lasers may be affecting the infundibulum of the pilosebaceous

unit and improving the sebum flow out of the

gland (Fig. 7.7). In any event, infrared lasers have been

shown to significantly clear acne for extended periods

of time (Fig. 7.8). Infrared lasers encompass the 1320,

1450 and 1540 nm wavelength devices.

1450 nm

In a multipart trial, Paithankar et al 68 demonstrated that

the 1450 nm diode laser with cryogen spray cooling


82 Clinical procedures in laser skin rejuvenation

(Smoothbeam, Candela Corp., Wayland, MA) could

induce thermal injury confined to the dermis histologically

after irradiation of ex vivo human skin. Using rabbit

ear skin as an in vivo model, treatment with the

Smoothbeam produced histological alteration of sebaceous

glands within the dermis at day 1 and day 3, with

recovery from initial injury by day 7. Next, Paithankar

et al 68 conducted a human trial, using the 1450 nm diode

laser (average fluence 18 J/cm 2 ) for four treatments separated

by 3 weeks each, and demonstrated a reduction of

acne lesions in 14 of 15 patients at 6-month follow-up.

Importantly, only 1 of the immediate post-treatment

biopsies yielded sebaceous glands, indicating that selective

targeting of the sebaceous gland is possible, as the

histology demonstrated thermal coagulation of the sebaceous

lobule and follicle with no epidermal alteration.

Long-term biopsies taken at 2 and 6 months post treatment

showed sebaceous glands that had returned to their

pretreatment state.

In a blinded multicenter study, 45 patients received

four monthly treatments with the 1450 nm diode laser

(14 J/cm 2 ), of whom 26 had at least 65% improvement

in lesion counts 1 month following treatment. 69 At 6

months, 5 patients required no additional intervention.

Mazer and Fayard 70 reported 18-month remission rates

in 29 patients who avoided any additional acne-modifying

treatments such as laser or topical or oral therapy

after four treatments with the 1450 nm diode laser

(12–14 J/cm 2 , 35-dynamic cooling spray 35 ms, 6 mm

spot size, and no overlapping whole-face treatment)

every 4–6 weeks.They noted that initially there was an

average 74.8% reduction in total acne lesion counts

(maximum 88.5%, minimum 49.4%), which showed

only a slight deterioration to 71.8% at 18 months

(maximum 88.5%, minimum 47.9%).

A pilot study demonstrated the safety of the 1450 nm

laser in the treatment of inflammatory facial acne in 28

Indian patients with skin type IV or V. 71 Each patient

was treated with four sessions at 21-day intervals, alternating

with glycolic acid peels on the 10th day after

laser treatment.The control group of 28 patients was

treated with glycolic acid peels only. The results

demonstrated a reduction in lesion count of 40% after

one treatment, 57% after two treatments, and 85%

after four treatments, with recurrence in 7.1% of the

group at 6 months. In comparison, lesion counts in the

control group decreased by 17.9% after one peel and

51.8% after four peels. However, 96.4% of the patients

in the control group experienced recurrence at 6

months. Postinflammatory hyperpigmentation was

seen in only 3.6% of patients. This low incidence of

postinflammatory hyperpigmentation may have been

due to the concomitant use of glycolic acid peels.

Jih et al 72 compared the dose response of a 1450 nm

diode laser (prototype laser supplied by Candela

Corp.,Wayland, MA) in 20 patients with skin phototypes

II–VI and an age range of 18–39 years.Topical

lidocaine (5% Ela-Max) was applied to the entire face

1 hour before laser treatment, and patients were evaluated

via split face comparisons after treatment with

either 14 or 16 J/cm 2 for three treatments. At 12month

follow-up, similar reductions in inflammatory

acne lesion counts were observed (76.1% reduction

using 14 J/cm 2 vs 70.5% reduction using 16 J/cm 2 ).

One of the downsides of 1450 nm diode treatment

is the level of discomfort reported by some patients.

As a result, widespread use of this laser in younger

populations has been limited. Bernstein 73 reported his

experience in six subjects with active papular acne

who were treated in a split-face randomized trial

monthly for 4 months. Half of the face was treated

with a single pass (12–14 J/cm 2 ), while the other half

was treated with a double-pass at a lower energy

(8 J/cm 2 ), and subjects were evaluated 2 months after

the final treatment. Bernstein 73 reports a 78% reduction

in acne counts on the single-pass-treated side and

a 67% reduction on the half of the face treated with

the lower energy. Importantly, patients had an average

pain rating of 5.6 on a scale of 1 (minimum) to 10

(maximum) with the high-energy single pass and 1.3

with the lower-energy double pass.

The 1450 nm laser in combination with

other therapies

Using the 1450 nm laser as an adjunct in patients

who were on oral and/or topical acne treatments,

Friedman et al 74 observed an 83% decrease in inflammatory

facial acne lesion counts following three treatments

at 4- or 6-week intervals. Side-effects were

transient and local, including erythema, edema, and

pain during treatment. Similarly, Astner et al 75 used

the SmoothBeam as an adjunct to conventional

acne therapy in 13 patients who continued their


a b

medications during four treatments spaced 4–6 weeks

apart (12–14 J/cm 2 ). They noted a mean 54.6%

improvement in lesions counts which persisted for the

6-month follow-up period of the study.

The 595 nm PDL has been used in combination with

the 1450 nm diode laser in a study of 15 patients with

inflammatory facial acne. First, patients were treated

with the 595 nm PDL (10 mm spot size, 6.5–7.5 J/cm 2 ,

and 6–10 ms pulse;Vbeam, Candela Corp.,Wayland,

MA) followed by a single pass with the 1450 nm diode

(6 mm spot size, 10–14 J/cm 2 , and dynamic cooling

spray at 30–40 ms). Glaich et al 76 reported a mean acne

lesion count reduction of 52% after one treatment, 63%

after two treatments, and 84% after three treatments.

This combination may be successful due to the dual

targeting of the sebaceous gland (1450 nm laser) and

P.acnes (595 nm PDL) (Fig. 7.9).

Wang et al 77 carried out a study in which 19

patients with Fitzpatrick skin types II–IV and active

Lasers, light, and acne 83

Fig.7.9 a) Patient with significant acne and acne scarring prior to treatment.b) Same patient 6 weeks later, following four

treatments with a 595 nm pulsed-dye laser and a 1450 nm infrared laser (Smoothbeam Laser,Candela Corp.,Wayland MA).

inflammatory acne, who had discontinued all topical

and systemic anti-acne medications 3 weeks prior to

the first treatment and had not used isotretinoin in the

previous 6 months, were randomized and controlled

to receive a combination treatment on one side of the

face and laser only on the other side. Each patient

received a total of four treatments 3 weeks apart and

attended two follow-up visits at 6 and 12 weeks after

the last treatment. In those patients receiving combination

therapy, one side of the face was treated with

microdermabrasion with six passes at the full setting

(Vibraderm, Dermatherm, Irving, TX). Following

this, the face was treated with the SmoothBeam

1450 nm laser (Candela Corp, MA; 13.5–14 J/cm 2 ,

6 mm spot size, and dynamic cooling spray at

30–40 ms). Photographs of the patients at baseline and

at 3, 6, and 12 weeks post treatment were evaluated by

an independent observer, who counted the total number

of acne lesions.Wang et al 77 found no statistically


84 Clinical procedures in laser skin rejuvenation

significant difference in acne reduction with the

addition of microdermabrasion to the treatment plan

(61% clearance with laser alone and 54.4% clearance at

12 weeks for microdermabrasion and laser), nor was

there a significant difference in patient pain level or discomfort.

Interestingly, there was also no difference in

sebum production from baseline compared with 12

weeks post treatment.This is consistent with the notion

that thermal damage of the sebaceous glands immediately

after treatment is quickly reversed.

Conclusion: Studies suggest that the 1450 nm diode

may have clinical utility as primary therapy for inflammatory

acne, or as an adjunctive acne treatment in patients

needing greater clearance than topicals or systemic

antibiotics alone can provide.

1540 nm

The 1540 nm erbium (Er) : glass laser (Aramis,

Quantel Medical, Med-Surge Technologies, Dallas,

TX), induces new collagen formation 79,80 and has primarily

been used for wrinkle reduction. Studies by

Boineau and Kassir 80,81 have shown success with this

laser wavelength in acne vulgaris as well.Twenty-five

patients with lesions on the back and face underwent

four treatments with the 1540 nm laser (10 J/cm 2 ,

3 ms pulse, 5–6 pulse train mode, and 2 Hz) at

monthly intervals, and experienced a 78% mean

lesion count reduction. 81 In a separate study evaluating

the face only, 20 patients with skin phototypes

I–IV had an 82% decreased lesion count at 3 months

after four biweekly treatments (8–12 J/cm 2 and 3–6

pulse train mode). 82 An advantage of this system is the

decreased oiliness reported by patients in both trials

and the lack of immediate or delayed adverse effects.

Angel et al 82 found a mean acne count reduction of

78% on 18 patients 2 years following treatment with

this device.

Conclusion: The 1540 nm Er : glass laser may be

appropriate for back and face acne in varying skin phototypes,

although only a few trials have been conducted

with this system.

1320 nm

Although no studies have been published on the

efficacy of the CoolTouch (Laser Aesthetics, Inc., CA)

1320 nm laser system in the treatment of acne, the

company was FDA-approved for this use in 2003.

Most of the studies involving the 1320 nm device have

evaluated its efficacy in acne scar remodeling.The dermal

layer is targeted by using water as the primary

chromophore.The effect of dermal damage is collagen

remodeling and re-epithelialization, leading to a more

youthful-appearing epidermis.

Radiofrequency

Radiofrequency devices are used to treat moderate

and severe acne through volumetric heating. A handheld

piece housing a treatment tip containing a coupler

allows for an even application of heat while a spray of

cryogen is delivered to avoid an epidermal burn; the

result is the creation of an inverted thermal gradient

such that the surface remains coolest while heat is

delivered to the dermis.

Ruiz-Esparza and Gomez 83 used the ThermaCool

(Thermage, Inc., Hayward, CA) device and observed

an excellent response in 18 of 22 patients (82%), and a

modest response in 9%. Furthermore, they noted clinical

improvement in acne scarring.While these results

are encouraging, the limited follow-up time (1–8

months), and small study size (n = 22) underscore the

need for larger studies with longer follow-up.

Avram and Fitzpatrick 84 compared the efficacy of

SmoothBeam and Thermage (Thermage, Inc.,

Hayward, CA) in alleviating both acne and acne scars.

Twenty patients with moderate acne (more than

eight inflammatory lesions) had half the face treated

with SmoothBeam (1450 nm and 12–16 J/cm 2 ) and

the other half treated with Thermage (settings

13.5–15.0) during a total of three treatments spaced

4 weeks apart. At the 6-month post-treatment follow-up,

a 72% improvement in active acne on the

half-faces treated with SmoothBeam was found,

compared with a 60% improvement in the halffaces

treated with Thermage. However, Thermage

improved acne scarring by 46%, compared with 38%

with SmoothBeam. Ice pick scars were the worst

responders.


Conclusion: Radiofrequency devices can be used for

moderate to severe acne, and may also simultaneously

help with the texture and appearance of acne scarring.

In summary: targeting the

pilosebaceous unit

In targeting the sebaceous gland, PDT, infrared lasers,

and radiofrequency devices are all effective to varying

degrees because they attempt to change a key link

in the chain of events leading to an acne lesion. In

theory, by damaging enlarged sebaceous glands, sebum

overproduction is decreased, if not eliminated, for a

period of time. As it stands now, however, this still

remains a theory, as only mild sebaceous gland alteration

has been proven histologically. Even though this

temporary alteration may be sufficient to result in

long-term acne clearance, studies have yet to demonstrate

sebaceous gland ablation. In those studies where

sebocyte alteration was evaluated, return to pretreatment

histology was noted in the long term. Further

studies are also needed to document histological

changes in the infundibular region that would improve

the flow of sebum from the gland.

FUTURE TRENDS

The idea of a portable handheld device to treat acne vulgaris

is becoming one of the emerging technologies in

laser and light based therapies.The Zeno (Tyrell, Inc.,

Houston,Texas, USA) was approved in June 2005 by the

FDA as an over-the-counter device for the treatment of

mild to moderate acne vulgaris, and is proposed to work

through the induction of heat-shock proteins, which

then kill resident P. acnes. 85 No preliminary results

regarding the efficacy of this device have yet been published;

however, clinical trials are currently underway

and the product is available for consumer purchase.

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75. Astner S,Anderson R and Tsao S.

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77. Wang SQ, Counter JT, Flor Me and Zelickson BD.

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83. Ruiz-Esparza J, Gomez JB. Nonablative radiofrequency

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85. Retrieved from http://www.myzeno.com.


8. Treatment of acne scarring

Murad Alam and Greg Goodman

INTRODUCTION

Optimal treatment of acne scarring is prevention of

the same by aggressive treatment of active acne. 1,2

Failing that, the treatment of acne scarring may require

the sequential application of several corrective procedures.

Even so, the degree of improvement is typically

incomplete, as scar can be concealed but not

removed.

DEFINITION AND CLASSIFICATION

OF ACNE SCARS

Before appropriate therapies can be selected, acne scarring

needs to be qualitatively and quantitatively assessed. 3,4

The simplest operational definition of acne scar is a visible

textural abnormality that was historically preceded

by active acne at the same site, and if biopsied, would

reveal histological evidence of a scar. In practice, it may

be difficult to confidently assert the provenance of a

particular scar, since the active process – acne or something

else – leading to its creation may be temporally

remote.Yet there are typical configurations of scarring

that are usually believed, based on visual inspection

alone, to be highly likely to have been caused by acne.

Acne scars can be classified based on shape and

depth. One recently proposed classification recognizes

three types of scars (Fig. 8.1): 4

• ice-pick scars are V-shaped nicks with a pinpoint

base that may culminate in the shallow papillary

dermis or in the deep reticular dermis

• boxcar scars are rectangular scars with vertical

walls and a flat base, and these may also be shallow

or deep

• rolling scars are gently undulating scars that resemble

hills and valleys, are less well-demarcated, and

tend to be less focally deep

Alternatively, acne scars can be considered hypertrophic,

atrophic, or a combination thereof: 3,5

• grade 1 acne scarring is distinguished by erythematous,

hypopigmented, or hyperpigmented macules

(Fig. 8.2)

• grade 2 is distinguished by mild atrophy or hypertrophy,

similar to the rolling scars described previously

• grade 3 is distinguished by moderate hypertrophy

or atrophy that is visible at social distances of 50 cm

or greater, and rolling and shallow box car scars, as

well as moderate hypertrophic and keloidal scars

• grade 4 is distinguished by severe atrophy or hypertrophy

that cannot be flattened by stretching the

skin between thumb and forefinger

Fig 8.1 Stylized cross-sectional view of ice-pick,rolling,

shallow boxcar,and deep boxcar scars (from left to right).The

upper horizontal dashed line denotes the normal depth of

ablation with resurfacing procedures,the three lines in a

pyramidal array represent fibrous bands securing the rolling

scar to the dermal–subcutaneous junction.(Based on the acne

classification popularized by Jacob,Dover,and Kaminer.)


90 Clinical procedures in laser skin rejuvenation

Fig 8.2 Postinflammatory hyperpigmented macules of the

cheek after resolution of active acne.

The classification of acne scarring as a function of individual

skin type is less well described. It is known that

some individuals are more prone to develop scarring

following resolution of acne papulopustules or cysts,

whereas others may only have transient erosions

or discoloration that eventually remits. In general,

patients who have previously developed acne scarring

remain at risk for further scarring following active

acne in the future. Acne scarring of equivalent depth

and type may also be more noticeable on patients with

darker skin types or pigmentary abnormality. For

instance, the light and shadow of darker skin may

accentuate the apparent depressions associated with

acne scarring; similarly, rosacea or centrofacial redness

may demarcate and define the borders of acne scars on

the cheeks.

AGE OF ACNE SCARS AND

ACTIVE ACNE

To some extent, the appropriate treatment for acne

scars is predicated on their age. Specifically, if scars are

red, a series of laser treatments with pulsed-dye laser

or intense pulsed light may be especially useful for

reducing this blush if the scars are not more than a few

years old. 6,7 In cases when active acne has resolved

during the past 6–12 months, caution should be exercised

when approaching the treatment of scarring. It is

possible that the superficial resolution of acne may not

be indicative of a cessation of the deep process, and

invasive procedures such as subcision or resurfacing

may restimulate cyst formation.

It is essential to adequately treat and inactivate all

ongoing acne before treatment on any scarring can

commence.The presence of active acne strongly militates

against the treatment of any coexisting acne

scars.These acne scars may either not be mature – and

hence may be susceptible to exacerbation or inflammation

– or mature themselves but their treatment

may trigger nearby active acne. An in-depth consultation

with the patient is required to convey this concern.

It should be explained that the deferment of acne

scar treatment does not indicate reluctance to treat

acne scars or lack of expertise in such treatment;

rather, the postponement is necessary because immediate

treatment may worsen the combined adverse

visual effect and symptomatology of the active acne

and acne scarring. Active acne cysts may enlarge and

drain, or become painful, and the active acne inflamed

by manipulation may lead to further acne scarring.

A final caveat entails the treatment of acne scarring

in patients with pre-existing conditions that may lead

to poor scar healing. Such conditions may be managed

like acne scarring in the context of active acne: treatment

of the scars may be delayed or embarked upon

very gingerly so as to preclude inadvertent exacerbation.

Most authorities suggest that invasive procedures

for acne scarring be undertaken only 1 year after completion

of oral isotretinoin treatment for resistant cystic

acne. A complete history should elicit information

about such treatment; the timing, type and degree of

success associated with prior acne scarring improvement

procedures; any tendency to produce keloids or

hypertrophic scars after surgery or injury; any tendency

to hyperpigment after injury; disorders, such as

collagen vascular diseases, that impede wound healing;

bleeding diatheses; disorders that predispose to infection;

recurrent cold sores; allergies to antibiotics and

medications; and psychological disorders, including

depression, anxiety, factitial disorders (e.g., compulsive


picking, self-mutilation, etc.) and medication for these.

Picking behaviors are exceedingly common, especially

in young women who have an obsessive need to ensure

the perfection of their skin, and a consequent urge to

extirpate pimples and textural abnormalities with their

nails and other implements.The physician should carefully

explain that picking after procedures to reduce

acne scarring will worsen this scarring and be highly

counterproductive. If the patient seems unable or

unwilling to grasp this concept, or appears unlikely to

to adhere to a postoperative regimen, expert consultation

with a psychologist or psychiatrist is desirable

prior to proceeding with surgery.

PATHOGENESIS OF ACNE SCARRING

The pathogenesis of acne scarring is too complex an

issue to discuss fully here, but recent research indicates

that intensity of scarring may be associated with the

extent of inflammation associated with active acne.

Specifically, the type and timing of the cell-mediated

immune response may be associated with the degree of

post-acne scarring. 8 In one study, the cellular infiltrate

and nonspecific immune response were initially greater

but later reduced in patients who did not subsequently

develop scars. However, in patients who did develop

post-acne scarring, the initially smaller specific immune

response later increased.

MANAGEMENT OF ACTIVE ACNE

If the patient does have active acne, a brief discussion

about treatment of acne scars should be followed by

implementation of a plan to stop the production of

new acne lesions. Treatment of active acne can take

12–18 months or more before a steady state of nearclearance

is reached. If prior measures to control

active acne have included the use of isotretinoin, a

minimum of 12 months and as much as 18 months

should elapse prior to treatment of acne scarring.

Once patients understand that treatment of active acne

is a necessary prerequisite for treatment of acne scarring,

they may be more compliant with acne treatment

than in the past.

Treatment of acne scarring 91

Lack of new acne lesions for a few weeks or 1–2

months does not necessarily presage a remission of

active acne.This may simply be a cyclical or fortuitous

reduction in acne that may not persist. If some degree

of active acne remains persistent, continuing efforts to

manage this should continue even as invasive treatments

for acne scarring are commenced. Sometimes

patients will continue to develop one or two small

papules every few weeks even when on maximal therapy

for acne.At some point, after treatment with topical

and oral antibiotics and retinoids, the surgeon may

have to decide to proceed with acne scarring treatment

despite the occasional occurrence of active acne.

TYPES OF TREATMENTS FOR ACNE

SCARRING: RESURFACING,

NONABLATIVE THERAPY,

INCISIONAL SURGERY, INJECTION,

CYTOTOXIC THERAPIES

The number and range of treatments for acne scarring

is vast. Indeed, the options are so plentiful that even

experienced practitioners need to group and classify

therapeutic options to simplify decision-making. One

grouping recognizes four major categories:

• treatments for altering the color of the acne mark

or scar

• excisional and incisional surgery, including most

punch techniques

• augmentation by autologous and nonautologous

methods

• treatments for increasing or decreasing collagen

deposition around the scar

The last method, which includes nonablative, partially

ablative, and ablative resurfacing by any means, subsumes

the largest number of discrete interventions.

Notably, since techniques within a given category are

similar in terms of invasiveness, downtime, risk, and

efficacy, practitioners may need to master only one or

two treatments per category to provide patients with a

complete range of therapeutic options. Finally, since

even the most invasive acne scarring treatments in the

hands of experienced physicians are unlikely to result


92 Clinical procedures in laser skin rejuvenation

in near-total resolution of scarring, a series of treatments

that work synergistically should be selected.

Some procedures are more risky and may be associated

with delayed healing, and the practitioner should

determine the level of risk preferred by the patient. In

sum, for best outcomes, it is preferable to be (1)

expert at a few procedures rather than to be passably

familiar with a large number and (2) collaboratively

with the patient, develop a rational, sequential treatment

plan that cumulatively provides the best possible

outcome.

‘Resurfacing’ denotes treatments that entail removal

or destruction of the epidermis and partial-thickness

dermis. Subsequent to resurfacing procedures, dermal

and epidermal re-epithelialization occurs, usually over

a period of 1–2 weeks. Post treatment, there is a reduction

in acne scars that occurred in the skin strata that

were resurfaced. Resurfacing is associated with risk of

hypopigmentation and scar, which can occur if the

depth of ablation reaches the bulge region of the hair

follicle. Common resurfacing procedures can rely on

thermal, chemical, or mechanical injury, and include

laser ablation, medium to deep chemical peels,

dermabrasion, and plasma resurfacing.

‘Nonablative’ therapies are those that do not fully deepithelialize

the epidermis and dermis but rather deliver

subdestructive energies that induce skin remodeling.

Most commonly, nonablative therapies induce thermal

injury by application of a range of laser and light sources,

but other energy devices, such as bipolar and monopolar

radiofrequency (RF), may be used.

Between resurfacing and nonablative therapies are

an intermediate set of treatments referred to as ‘partially

ablative’ or ‘minimally ablative’.Typically, these

create a penetrating epidermal and dermal injury only

over a small percentage of the treated skin surface

area. Downtime is consequently reduced over that of

resurfacing, but efficacy may be better than for nonablative

treatments. Common examples of partially

ablative therapies are fractional resurfacing as well

as skin needling and rolling.

‘Incisional surgery’ entails cutting into the skin, and

may also include removal of skin, or excision. Pitting

or ‘ice-pick’ scarring can be treated by punch excision,

punch grafting, or punch elevation. Rolling scarring

can be improved by subcision: minute cuts in the skin

followed by abrasion of the underside of the dermis.

Large, mixed acne scarring in a linear array can be

removed by standard elliptical excision.

In some cases, the skin may be pierced but not cut as

pre-packaged injectable fillers or autologous fillers are

instilled under acne scars to raise them flush to the

skin. ‘Injection’ therapy for acne scars has advanced

since the introduction of a range of new soft-tissue

augmentation materials over the past decade. Such

materials include autologous fat, human collagen,

hyaluronic acid derivatives, calcium hydroxyapatite,

silicone, and other agents.

Cytotoxic therapies may be most relevant for hypertrophic

acne scars. Either medical or radiation therapies

may be used to mitigate the growth of exuberant

scars on the chest, face, and back. Intralesional agents

such as 5-fluorouracil (5-Fu), bleomycin, and verapamil,

topical agents such as imiquimod, as well as radiation

treatment may help flatten scars.

ACNE SCAR TREATMENT BY

RESURFACING

Resurfacing is commonly accomplished by laser, chemical

application, or dermabrasion.To some extent, the

choice of procedure is a function of the age of the

treating dermatologist, and prevailing fashions when

he or she trained.

Laser resurfacing remains a gold standard for safety

in ablative resurfacing. In this procedure, a carbon

dioxide (CO 2 ), erbium : yttrium aluminum garnet (Er:

YAG), or hybrid laser device is used to vaporize the

epidermis and partial-thickness dermis.As a calibrated

laser is used, tissue removal is precise, reproducible,

and minimally operator-dependent; especially when a

computerized pattern generator (CPG) is used, even

and consistent skin removal is achieved.The CO 2 laser

provides the deepest injury, some immediate tissue

contraction, hemostasis through its cauterizing effect,

and the overall best clinical effect achievable by laser,

but downtime with multiple-pass resurfacing can be

1–2 weeks.The Er:YAG laser is associated with less

invasive ablation that is more suited to the treatment of

fine acne scarring or photoaging, but downtime until

complete re-epithelialization can be half as long. Since

intraoperative bleeding can complicate and hence

limit multiple-pass Er:YAG laser resurfacing, some


hybrid devices include a small CO 2 laser to facilitate

coagulation; alternatively, a low-power and highpower

Er:YAG laser can be paired in the same box for

this purpose. Hybrid devices may also provide a clinical

effect intermediate between classic Er:YAG and

CO 2 laser resurfacing. Using an Er:YAG laser after

CO 2 laser resurfacing can remove a thin layer of debris

and devitalized tissue, and speed healing. Notably,

post-treatment erythema after CO 2 laser resurfacing

can last 2–3 months, although it can be concealed with

make-up. Outcome data indicate that most patients are

very pleased with the outcome of their laser resurfacing

procedure at 3 months post treatment, and remain

so at 18 months; in the immediate postoperative

period, the anxiety associated with wound-healing

and temporary disfigurement causes mild, transient

concern in some. 9

In dermabrasion, the skin is smoothened by mechanical

abrasion analogous to sanding.The skin is scraped

away with a wire brush or a spinning disk-like burr

covered with diamond particles; in some cases, true

medium- or fine-grit sandpaper that has been autoclaved

and wrapped around the finger or instrument

like a thimble may be used to treat small areas.

Dermabrasion has become less popular since the advent

of HIV and other bloodborne infectious diseases that

can be spread by aerosolized particles of skin and blood.

Unlike laser resurfacing, dermabrasion is more operator-dependent,

as the pressure applied can modify the

depth of treatment.Acquiring and maintaining adequate

anesthesia during dermabrasion can be challenging, and

certain areas, including the eyelids, nose, malar prominence,

and jawline, can be difficult to treat.There are no

controlled studies comparing laser resurfacing with dermabrasion

for acne scarring, but in the anecdotal experience

of the authors, laser resurfacing appears to be

more consistently efficacious. Dermabrasion may, however,

be less prone to cause post-treatment erythema

than laser resurfacing. Hypopigmented macules associated

with acne scars (Fig. 8.3) have in some cases been

reported to be improved following needle dermabrasion

(using a tattoo gun without pigment) or focal

manual dermabrasion. 10,11

Medium and deep chemical peels are another resurfacing

technique. Medium-depth peels typically consist

of sponge application of trichloroacetic acid (TCA),

20–35%, after degreasing of the skin; sometimes, a

Treatment of acne scarring 93

Fig.8.3 Hypopigmented cheek scars that are slightly

atrophic.

prepeel with Jessner’s solution may be performed to

improve even peel penetration. Depending on the

duration of application and the number of layers of

solution, a deeper or shallower effect can be achieved.

The benefits of medium-depth peeling are that no

expensive machinery, such as a laser, is required. Also,

there is no aerosolization of infectious particles.At the

same time, peels are relatively operator-dependent,

and pooling of solution in facial crevices can result in

uneven treatment from less experienced practitioners.

In general, medium-depth peels provide a shallower

ablation than CO 2 laser resurfacing. Deep chemical

peels, most notably the Baker–Gordon or phenol peel,

are deeper-penetrating but carry two potential risks:

(1) the potential cardiotoxicity of phenol requires

intraoperative monitoring during full-face peeling;

and (2) porcelain-white hypopigmentation will occur

after treatment. For patients with focal acne scarring

who always wear make-up, deep peels may be a safe

option due to the small surface area treated and the

ability to conceal depigmentation post-operatively. A

special localized case occurs when a toothpick, or the

sharp wooden end of a cotton-tip applicator created

after the applicator has been deliberately broken, is

dipped in a very concentrated solution of 95% or

100% TCA and then applied to the base of an icepick

scar. This resurfaces the pinpoint base of the

scar, and permits repair by granulation, which can fill

in the scar. 12


94 Clinical procedures in laser skin rejuvenation

A more recent variant of resurfacing is plasma resurfacing.This

uses the ‘fourth state of matter’ to precisely

injure epidermis and underlying dermis without inducing

immediate sloughing of the epidermis. As such,

plasma resurfacing has similarities to single-pass CO 2

laser resurfacing.A plasma cloud of electrons removed

by radiofrequency sparking of nitrogen gas is absorbed

by the skin, but the epidermis is not truly ablated. In

process, it seems to resemble a medium-strength TCA

peel, but may give deeper and more impressive

results, seemingly without much risk of hypopigmentation

and scarring, although it is a comparatively new

technique.The gentler approach, and the persistence

of partially injured epidermis as a biological dressing,

minimizes fluid loss, crusting, and delayed healing.

Healing usually occurs within a week.

There are some similarities regardless of the resurfacing

technique used.Tumescent or local anesthetic,

combined with nerve blocks and at least oral sedation,

is usually employed. Beyond this, conscious sedation

or general anesthetic may be used, especially for laser

resurfacing. Post treatment, some method of dressing

(either closed or open) is used to protect the deepithelialized

skin as it heals. For at least 1 week, the

patient cannot be present at work or social engagements.

In darker-skinned patients, post-inflammatory

hyperpigmentation is a virtual certainty; in Asian and

African-American patients, such color change may last

a year or longer before gradually resolving.The risk of

infection is mitigated by initiating oral antibiotics and

antivirals before the resurfacing procedure.

ACNE SCAR TREATMENT BY

NONABLATIVE THERAPY

During the past 5 years or so, nonablative therapy has

largely replaced ablative therapy for the treatment of

acne scars. In nonablative therapy, directed energy,

usually thermal, is used to induce tissue modification

and collagen remodeling in the dermis.The benefits

compared with ablative therapy are that skin deepithelialization

does not occur, and nonablative

therapy is therefore a ‘lunchtime’ procedure that is

associated with little or no downtime.Transient erythema

and mild edema resolving over hours to days

are often the only post-treatment effects. Since

nonablative therapy tends to be a milder procedure

than ablation, multiple treatments may be required

and/or these treatments may be combined with other

acne treatment methods.

Since heating of the dermis can induce remodeling of

the dermis and improvement of embedded acne scars,

a range of laser and light devices can be used. Indeed,

virtually any laser or light device, used appropriately,

can achieve modest improvement in acne scars.Among

those that have been used in this capacity are the

pulsed-dye laser, the potassium titanyl phosphate

(KTP) laser, and intense-pulsed light.These are vascular-selective

machines that, apart from improving surface

topography, can also reduce the erythema that may

encircle and hence accentuate acne scars of the central

face. Multiple treatments, often 3–6 or more about a

month apart, are needed to reduce redness and cause

some textural change.

A class of nonablative lasers has been especially successful

at improving acne scars. These mid-infrared

lasers include the 1064 nm neodymium (Nd):YAG, 13

1320 nm Nd:YAG (Cool Touch), 14–18 1450 nm diode

(Smoothbeam), 19 and 1540 nm Er:glass (Aramis), as

well as intense-pulsed light machines with a similar

range (Titan, 1100–1800 nm). Such devices have been

shown in numerous studies to significantly improve

rolling, boxcar, and ice-pick scars of the cheeks, perioral

areas, and elsewhere.The main limitation is intraoperative

discomfort, which may be sufficient to require

topical and oral pain medications. In darker-skinned

patients, the risk of postinflammatory hyperpigmentation

is significant and may suggest the use of the

1540 nm device.

Nonablative therapy can also be performed with RF

devices, including those using monopolar and bipolar

technologies. RF energy, in cadaver skin, can shrink the

fibrous septae, 20 and may also have collagen-remodeling

effects.While it is typically used for tightening sagging

facial or body skin rather than for rectification of acne

scars, RF treatment, like treatment with broadband

infrared light, may ameliorate acne scars.

When acne scars are mild, textural abnormality

may be minimal, and the primary visual feature may be a

halo of erythema that highlights the scar. Such redness

can be removed by a series of treatments with vascularselective

lasers or light sources, 21 such as the pulsed-dye

laser, the KTP laser, and the intense-pulsed light device.


Post-treatment effects are minimal erythema and

edema, which resolve within a few hours to a day. Such

treatments may be also appropriate for patients who

desire a very minimal intervention, and can tolerate

little or no downtime. Acne excoriée, which may be

associated with erythematous macules, has also been

successfully treated with vascular laser and psychotherapy.

22 It is believed that erythematous acne scars can be

treated even when they are immature, by pulsed-dye

laser immediately after suture removal. 23 Unlike erythematous

macules, hyperpigmented and hypopigmented

macules are better managed passively. Q-switched lasers

for pigment and tattoos are minimally effective in reducing

post-inflammatory hyperpigmentation, and may

even exacerabate such pigmentation at high fluences; 24,25

gentle nonablative glycolic acid, salicylic acid, Jessner’s

solution, and retinoic acid peels may be less prone to

aggravate brown areas. 26,27 In general, pigmentation of

scars in olive-skinned patients will fade gradually over

3–18 months, if strict sun avoidance and sun protection

are practiced in association with a topical preparation,

such as hydroquinone, kojic acid, and azelaic acid. 28,29

White macules may be very difficult to treat, and may

only be transiently repigmented with repeated treatments

with the 308-nm excimer laser, phototherapy, or

application of autologous cultured melanocytes.

Microdermabrasion, a topical therapy that entails

spraying of aluminum oxide crystals on the epidermis,

is popular and frequently touted as beneficial for acne

scarring. 30 However, objective evidence of the efficacy

of microdermabrasion for treatment of acne scarring

is minimal.What little improvement can be achieved

appears to require repeated, intense sessions and the

elicitation of pinpoint bleeding, which is seldom

induced. Microdermabrasion should not be confused

with dermabrasion, a highly effective ablative therapy

for acne scars.

ACNE SCAR TREATMENT BY

PARTIALLY ABLATIVE THERAPY

For treatment of acne scars, resurfacing provides maximal

improvement and nonablative therapy offers the

promise of convenience and safety.To wed these two

desirable outcomes in a single therapy, so-called ‘partially

ablative’ treatments have been devised. These

Treatment of acne scarring 95

methods are used to resurface only a portion of the

skin area treated, thus allowing maintenance of skin

integrity, fewer side-effects, and more rapid healing.

One pioneering method of partially ablative therapy

is fractional resurfacing. Using a diode-pumped 1550 nm

erbium laser, fractional resurfacing (Fraxel, Reliant

Technologies, Mountain View, CA) creates a grid

pattern of microthermal zones of tissue coagulation

but an intact stratum corneum. 31,32 Over a period of

days after treatment, microscopic epidermal and dermal

necrotic debris is expelled, and collagen remodeling

occurs at the affected areas. A series of treatments

can resurface virtually the entire surface area, but by

fractionating treatments, downtime is minimized and

the serous crusting of typical resurfacing is avoided. It

has been shown that high-energy treatments are more

effective for the treatment of acne scarring; such treatments

do not ablate more surface area, but provide a

greater volume of thermal injury.

A simpler, less precise approach to partially ablative

therapy is skin rolling or needling.These procedures

purport to achieve on a macroscopic level what fractional

resurfacing can do on a microscopic level. In

needling, 11 a fine 30-gauge needle held by a hemostat

is used to serially puncture a 2–3 mm deep grid pattern

on the skin, including epidermis and dermis.

Fibrous bands holding down acne scars are released,

and the coagulum resulting from the pinpoint intradermal

bleeding can raise depressed scars and instigate

granulation tissue. For larger scars, a tattoo gun without

pigment 11 or a rolling pin may be used. Rolling is

performed with a needle-studded rolling pin 33 – a

metal cylinder implanted with needle-like protrusions

– that is pressed against the facial or extrafacial skin

and rotated around the long axis to make an array of

microperforations until some bruising is observed. In

both rolling and needling, pinpoint bleeding occurs

and is managed by application of pressure. Epidermal

healing occurs with minimal crusting in a few days,

and dermal trauma culminates in collagen remodeling.

This process, also referred to as ‘collagen induction

therapy’ can be repeated a few weeks later.Anatomical

areas that respond poorly to this treatment include the

nose and periorbital regions. Synergies may accrue if

rolling is used in combination with other treatments,

such as nonablative laser, vascular laser, subcision, or

blood transfer.


96 Clinical procedures in laser skin rejuvenation

Fig.8.4 Rolling scars amenable to subcision can occur

periorally,on the upper and lower cheeks,and at the temples.

Subcision can also be highly effective for nasal scars (not

shown).

ACNE SCAR TREATMENT BY

INCISIONAL SURGERY

Apart from ablative, partially ablative, and nonablative

external smoothening techniques, cutting surgery can

be used to treat acne scars. One minimally invasive

surgical technique for rolling scars is subcision, which

is preceded by instillation at the site of scarring of

anesthesia – local for small areas and tumescent

for larger areas. Developed by Norman and David

Orentreich, 34,35 subcision (Figs. 8.4 and 8.5) requires

insertion of an 18–26-gauge Nokor or similar needle,

or even a blunt canula, into the superficial subcutis.

Depth of insertion is contingent on the degree of scar

indentation, with intradermal positioning more appropriate

for shallow scars and deep dermal placement for

deeper scars. The needle is then rotated so that the

spearlike tip is parallel to the skin, and the needle is

used to tent the skin. Back-and-forth rasping movement

of the needle along the underside of the dermis

releases fibrous attachments holding down scars and

stimulates the growth of reactive fibrosis that gradually

fills the deadspace underlying newly loosened scars. In

a manner similar to liposuction, fanning movement of

the needle and triangulation of each scar from different

entry sites helps elevate scars. Especially if widespread

treatment is being performed, intraoperative

bruising and bleeding is minimized by using tumescent

a

b

Fig.8.5 (a) In subcision,the rasping needle is used to

release the fibrous bands connecting rolling scars to the deep

skin structures.(b) Simultaneous tenting of the skin with the

needle minimizes the risk of injury to neurovascular

structures.

anesthesia, or copious quantities of a dilute 0.5% lidocaine

with 1:200 000 solution, and allowing the anesthesia

to sit for 20–30 minutes before commencing


Table 8.1 Common fillers for acne scarring (USA)

Filler type Filler name Method of use Persistence

needle insertion. Postoperative ecchymoses and edema

can last 1–3 weeks.To avoid a flare of cystic acne after

treatment, susceptible patients with some active acne

may be treated with oral tetracyclines for several

weeks before and after subcision.

Individual deep boxcar or ice-pick scars can be resistant

to nonsurgical treatment. At times, the best

approach can be to cut these out.A time-honored technique

uses a biopsy punch to treat such scars. If the

targeted scar fits precisely within the punch, circumferential

cutting with the punch can cause elevation of the

scar as lateral and deep fibrous bands are severed and the

plug containing the scar spontaneously elevates.This is

referred to as punch elevation. Alternatively, if the scar

is very deep and well embedded, the central plug may

be removed, as in the case of a punch biopsy.Then the

created defect may either be sewn end-to-end, to create

a slit-like scar (i.e., punch excision), or filled with a similar

shaped plug harvested from an uninvolved scar (i.e.,

punch grafting). At times, a series of deep scars may be

present in a linear or curvilinear array. Such scars may

be revised by removal of a strip of epidermis and dermis

using the techniques of elliptical excision and bilayered

closure with eversion. If a patient requires punch or linear

excision as well as resurfacing for treatment of acne

scars, it is preferable to perform the excisions first, as

the re-epithelialization following the ablative procedure

will conceal the excision lines.

Perifollicular hypopigmentation of acne scars, especially

those of the trunk, remains highly resistant to

treatment. If papular and facial, hypopigmented scars

Treatment of acne scarring 97

Human-derived

Autologous Blood aspirate Can be injected deep or superficially Weeks to months

Fat Injected deep for rolling scars Weeks to months, portion of effect

may be permanent

Heterologous Human collagen Fine superficial scars, or layering in 2–3 months

dermis

Non-human-derived

Temporary Hyaluronic acid Versatile, for deep and medium injection 6–9 months

Calcium Deep, for rolling scars (off-label) 1 year

hydroxyapatite

Permanent Liquid silicone Rolling scars (not FDA-approved) Many years

may be treated with fine-needle diathermy, and grafting

procedures useful in vitiligo may also be considered.

Minigrafting is limited in efficacy, since the

spread in pigment from the graft sites to the surrounding

scars appears to be restricted, 36,37 but epidermal

suspensions of cultured and noncultured cells are

promising new therapies. Newly available automated

commercial kits for trypsin epidermal separation (Re-

Cell) may simplify the grafting process. 37,38

ACNE SCAR TREATMENT BY FILLERS

Filler injection is a minimally invasive method of

scar improvement that can be combined with other

treatments. Also known as soft-tissue augmentation

materials, fillers can be autologous, heterologous, or

synthetic; additionally, they can be prepackaged or

harvested prior to use.

Until the 21st century, the primary Food and Drug

Administration (FDA)-approved prepackaged augmentation

material was bovine collagen. Since then,

human-derived collagen (Cosmoderm and Cosmoplast),

hyaluronic acid derivatives (Restylane, Juvederm,

Hylaform, Hylaform Plus, and Captique), calcium

hydroxyapatite (Radiesse – pending FDA approval,

used off-label), and liquid silicone (used off-label) 39

have been used frequently (Table 8.1).While bovine

collagen required skin testing to exclude allergy,

none of the newer fillers do, although they should

not be used in patients with known sensitivity to their


98 Clinical procedures in laser skin rejuvenation

constituents. In terms of persistence of action, silicone

is near-permanent; calcium hydroxyapatite has a

longevity of 1–1.5 years, hyaluronic acid derivatives of

6–9 months, and collagens of 2–3 months. Longerlasting

fillers are injected deeper (Fig. 8.6), at the dermal–subcutaneous

junction, for correction of deeper

acne scars. Liquid silicone must be injected in very

small aliquots, using the ‘microdroplet’ technique, to

minimize the risk of a delayed immune response.

Unless silicone is being used, patients should be

advised that the correction provided by fillers is temporary.The

first time a filler is used, a short-acting one

like collagen or hyaluronic acid should be considered,

because it is important to establish that the cosmetic

effect is appropriate before this is made longstanding

with a more persistent filler.

In general, fillers are more successful for improvement

of rolling scars rather than bound-down ice-pick

or boxcar scars. If rolling scars are being treated, subcision

may precede use of fillers.The subcised scars are

more mobile and likely to float up after injection of

filler material into their bases.

Not all fillers are prepackaged. Autologous fillers

that can be harvested before injection include blood

and fat. Blood can be removed via blood draw and then

injected deep into atrophic or depressed acne scars. 40

Injection can be repeated at monthly intervals, and can

result in raising of the scar both by direct volume

ZYDERM I

ZYDERM II

ZYPLAST

Fig.8.6 The depth of injection of filler agents is contingent on their viscosity and duration of action,with thicker,

longer-lasting materials injected at the dermal–subcutaneous junction (lower arrow),and finer materials like

collagens injected higher.

effect and by initiation of a wound-healing cascade

that causes reactive fibrosis. For fine, shallow acne

scars, injection of blood can be performed using a

1ml syringe and 30-gauge needle to raise a bruised

bleb high in the dermis; this can be combined with

postinjection vascular laser treatment at approximately

50–75% the normal fluence to activate the

hemoglobin chromophore and thus facilitate scar

involution while reducing redness. Laser treatments

may be repeated at monthly intervals.Another autologous

filler is fat. 41 Autologous fat can be harvested

from the abdomen or hips and then injected via a

fine cannula into an area of depressed rolling scars.

Excess fat can be frozen for later use, although

defrosted cells are not viable but rather serve as a

biocompatible filler. Fat transfer with fresh fat can

provide some permanent correction, with a fraction

of the implanted cells continuing to thrive at the

recipient site. Current research indicates that use of

adult adipose-derived stem cells can augment the

effect of fat transfer. The degree of fat transfer correction,

and its persistence, is paradoxically inversely

related to the quantity of fat transplanted: filling the

defect area to turgidity can reduce fat survival by

impairing vascular supply to the living cells. Like

blood injection, fat transplantation can be repeated.

Unlike blood transfer, fat transfer is inappropriate

for shallow superficial scars.


a

b

Fig.8.7 Lower cheek,chin,and perioral acne scarring

before (a) and after (b) fat transfer,subcision,and laser

resurfacing.

TREATMENT OF HYPERTROPHIC

ACNE SCARS

Acne scars, particularly of the chest and back, can

become hypertrophic, and rarely keloidal. Management

of such scars is similar to that of hypertrophic scars

caused by other phenomena. Recently, it has become

evident that intralesional injection of cytotoxic agents

may induce remission of selected hypertrophic

scars. 42,43

Cytotoxic agents may be an alternative to the treatment

of hypertrophic and keloidal scars with highstrength

intralesional corticosteroids. 44–47 5-Fu at a

concentration of 50 mg/ml may be combined in an

80:20 ratio with a low-potency intralesional steroid

solution.A typical scar is filled with 0.1–0.3 ml of this

mixture, and a total of about 1 ml used per injection

session. Intralesional verapamil has also been reported

to be of some utility when injected at a concentration

a

b

of 2.5 mg/ml, with 0.5–2 ml per scar. 48 Topical

imiquimod 49 may be an adjunctive prophylactic treatment

applied at the surgical site immediately after surgical

keloid excision, but treatment efficacy has not

been consistently seen. Radiation therapy can successfully

shrink keloids; however, in younger patients, and

at head and neck sites, the associated long-term risks

can preempt this approach.

CONCLUSIONS

Treatment of acne scarring 99

Fig.8.8 Chin and jawline area scarring (a) that is

diminished after skin rolling and subcision (b).

Treatment of acne scarring, itself a complex problem,

requires a well-organized plan, a willing patient, and a

skilled physician. Usually a range of techniques,

including more or less ablative resurfacing, surgery,

and injection, are required (Figs 8.7 and 8.8). Scarring

cannot be entirely erased, and treatment of scarring in

a field of active acne can exacerbate the latter; for this


100 Clinical procedures in laser skin rejuvenation

reason, the best treatment of acne scarring remains the

prevention of active acne.

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layer suspension. Br J Dermatol 2002;147:893–904.

39. Barnett JG, Barnett CR.Treatment of acne scars with liquid

silicone injections: 30-year perspective. Dermatol

Surg 2005;31:1542–9.

40. Goodman GJ. Blood transfer: the use of autologous blood

as a chromophore and tissue augmentation agent.

Dermatol Surg 2001;27:857–62.

Treatment of acne scarring 101

41. Goodman, GJ. Autologous fat transfer and dermal grafting

for the correction of facial scars. In: Harahap M,

ed. Surgical Techniques for Cutaneous Scar Revision.

New York: Marcel Dekker, 2000:311–49.

42. Meier K, Nanney LB. Emerging new drugs for scar

reduction. Expert Opin Emerg Drugs 2006;11:39–47.

43. Saray Y, Gulec AT.Treatment of keloids and hypertrophic

scars with dermojet injections of bleomycin: a preliminary

study. Int J Dermatol 2005;44:777–81.

44. Lebwohl M. From the literature: intralesional 5-FU in the

treatment of hypertrophic scars and keloids: clinical

experience. J Am Acad Dermatol 2000;42:677.

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McGrouther AD.The effects of a single dose of 5-fluorouracil

on keloid scars: a clinical trial of timed wound

irrigation after extralesional excision. Plast Reconstr Surg

2001;108:1218–24.

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bleomycin.Ann Dermatol Venereol 1996;123:791–4.

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Dermatol Surg. 2003;29:1050–1.


9. Nonsurgical tightening

Edgar F Fincher

INTRODUCTION

During the natural course of aging, the face undergoes a

series of predictable changes. The skin loses its elasticity

through a loss of integrity of both collagen and

elastin fibers in the dermis, resulting in visible static

rhytids and deeper furrows. Furthermore, a loss of adipose

tissue, most notably in the midface, leads to volumetric

depletion of the underlying soft tissue support of

the facial skin. The result of these two changes is a

gravitational descent of the facial tissues that contributes

to hollowing of the cheeks, descent of the malar fat

pads, and deepening of the nasojugal, malar–palpebral,

and nasolabial folds.This can be further compounded by

the effects of exposure to ultraviolet radiation, which is

known to accelerate the aging process by promoting

elastolysis, collagenolysis, and dyschromia.

An increased number of patients are seeking consultation

for treatment options in an effort to reverse

many of these visible signs of aging. Our population is

becoming more concerned with its appearance and is

becoming more proactive in seeking out procedures

that will reverse the aging process. Furthermore, the

general trend continues to be for patients seeking less

invasive procedures with less downtime. In the past,

cervicofacial rhytidectomy, deep chemical peels, or

full-face laser resurfacing 1,2 were the only options for

achieving significant rejuvenation.These procedures

delivered excellent results; however, these results

came at the cost of significant downtime. Over the past

3–4 years, several new devices have arrived on the market

providing alternatives to traditional skin tightening

procedures. These newer devices utilize volumetric

heating of the dermis, through either radiofrequency

or near-infrared energy, as a non-ablative method to

tighten the skin.The physiological basis of the effect is

a result of the effects of the heating upon collagen

fibers in the dermis. Collagen fibers are triple-helix

protein chains, which denature and become an amorphous,

random-coil structure upon heating. 3 This

results in shortening of both the length and diameter

of collagen fibrils. Ross et al 4 have suggested that after

collagen shortening, fibroblasts in the heated region

begin the synthesis of new collagen fibers, resulting in tissue

remodeling at the cellular level, and skin tightening at

the cosmetic level. Currently, there are two significant

noninvasive skin tightening devices available on the

market. Other devices are available and others are

soon to be released; however, none of these has

demonstrated reliable results. The first device, the

ThermaCool TC, utilizes radiofrequency (RF) energy

to heat the dermis and create skin tightening, while the

second device, the Titan, uses near-infrared light to

achieve the same end.These procedures deliver safe

and effective skin tightening with the promise of no

downtime. Although the overall results are variable

and may be only modest, many patients with only early

signs of aging, or those with active lifestyles or busy

careers, will often opt for a lesser procedure in

exchange for less downtime. For those patients who

suffer from extensive skin laxity on deep rhytides or

who desire maximal rejuvenation, rhytidectomy and

laser resurfacing continue to be the gold standards by

which all procedures are compared. Careful patient

selection and counseling and establishing appropriate

expectations become extremely important when

determining the appropriate procedure for the

patient.


104 Clinical procedures in laser skin rejuvenation

MONOPOLAR RADIOFREQUENCY

Background

Approved by the US Food and Drug Administration

(FDA) in the spring of 2003 to elevate the brow,

ThermaCool TC (Thermage Inc., Hayward, CA) has

been used in a number of different applications to

reduce skin laxity in the face and upper neck. The

ThermaCool TC is now FDA-approved for treating

rhytids on all areas of the body. It works by delivering

a safe, alternating-current monopolar RF signal in a

nonablative, uniform fashion to tissues. Operating at a

frequency of 6 MHz, the ThermaCool TC generates

heat in the underlying skin tissues by virtue of resistance

(impedance).The amount of resistance will vary

depending upon the tissue composition, and studies

have shown that the higher tissue resistance, and thus

the major thermal effect, is in the dermis and subcutaneous

layers. To prevent injury to the epidermis, a

direct-contact dynamic cryogen cooling system is

incorporated into the handpiece to ensure uniform

constant cooling throughout the treatment period.The

depth of effect of the ThermaCool TC depends on the

geometric size of the treatment tip, while the degree

of the effect depends on the conductive properties of

the tissue.With the standard medium-depth 1.5 and

3.0 cm 2 tips, approximately 60–70% of the energy

is delivered to the dermis at a depth of around

2–2.5 mm.The remaining 30% dissipates throughout

the surrounding and deeper tissues, providing significant

heating at depths of around 4–5 mm. Tissues

possessing a higher impedence, such as fat, tend to

generate a greater degree of heat, resulting in a deeptissue

thermal effect. 5,6 A second factor in understanding

the clinical effects of the ThermaCool TC is the

effect on the fibrous septae within the fat compartment.

Studies have demonstrated that a large amount

of the RF energy is dissipated or channeled through

the fibrous septae that separate the fat compartments.

This effect leads to heating of these fibrous bands and

their subsequent shrinkage to further contribute to the

overall skin tightening effect. Monopolar RF therefore

provides not only dermal heating and tightening, but

also deep tissue effects that contribute an additive

effect to the global skin contraction.

Treatment Parameters

The use of the ThermaCool TC as a deep-tissue tightening

procedure enables patients to experience a safe

and effective treatment for mild to moderate skin

laxities. Its benefits include a quick recovery period

and an excellent safety profile. The major drawback

of the procedure, however, is the discomfort experienced

by some patients undergoing treatment.

Thermal energy can lead to sensations of deep heat,

burning, or a sharp stabbing pain.These can often be

minimized with the use of topical anesthetics or oral

analgesics; however, the use of complete sedation or

anesthesia is not recommended as it prevents any

patient feedback, which is an important safety measure

of this device. Recommendations are for physician

operators to adjust energy levels based upon

patient feedback. The maximal treatment parameter

should be set to a point where the patient experiences

moderate, but comfortable, heating. Pain, discomfort,

or intense heating should not be allowed, as

this lowers the threshold for overheating, burns, or

deep-fat atrophy.

Current protocols involve performing multiple

passes (three to five) at low to moderate fluences

instead of the previously recommended single-pass

high-fluence protocol. Studies have demonstrated that

this multiple-pass lower-fluence protocol provides

equivalent collagen contraction and skin tightening as

the single-pass high-fluence treatment.

The current protocol utilized in our office includes

two complete passes at maximal fluence across the

entire treatment area. Maximal fluence, in this case,

is defined as the highest setting that the patient can

comfortably tolerate. We ask the patient to report

discomfort on a scale of 1–10, where maximal tolerability

means 6–7. The majority of these pulses will

elicit only minimal discomfort; however, several

areas, such as the malar prominence, the preauricular

region, along the mandible, over the sternocleidomastoid,

and the supraorbital areas, are reliably the

most painful areas to treat, and a decreased fluence

or only a limited number of passes may be used in

these areas if discomfort is high. Once the two

complete passes have been achieved, an additional

three or four focal passes are performed along key


Fig.9.1 This patient was being assessed midway through

her treatment.She had undergone two complete passes

followed by three focal passes to the left side of the face only.

Signs of immediate skin tightening are evident as softening of

the nasolabial fold,slight elevation of the malar fat pad,and

softening of the jowl.

a b

tightening points. These areas typically include the

skin overlying the lateral malar area and zygoma,

lateral to the nasolabial fold, and along the mandible.

These passes continue until visible tissue tightening is

observed (Fig. 9.1).

Clinical effects

Nonsurgical tightening 105

The data compiled from research thus far suggest that

this novel RF device provides a safe and effective technique

to tighten the skin of the face and upper neck 6–13

(Fig. 9.2).The tissue tightening effects of the Therma

Cool TC have also been analyzed in split-face studies,

providing direct comparisons between control and

experimental treatments in the same patients. This

objective, split-face study determined that RF treatment

resulted in remarkable improvements in brow

position, superior palpebral crease, angle of the eyebrow,

and jowl surface area. 12 After a single treatment,

patients on average exhibited 4.3 mm of brow elevation,

1.9 mm of superior palpebral crease elevation

along the midpupillary line, and 2.4 mm of brow

Fig.9.2 A patient before (a) and 3 months after (b) monopolar radiofrequency (ThermaCool TC) treatment to her entire face.

Although results are often difficult to appreciate using standard two-dimensional photography,careful examination shows

moderate improvement along the nasolabial fold and mandibular line.


106 Clinical procedures in laser skin rejuvenation

elevation along the lateral canthal line. In addition,

the peak angle of the eyebrow became more acute by

an average of 4.5°, and there was a mean decrease of

22.6% in the surface area of the jowls. 12 Especially

noteworthy is that these results were achieved without

significant downtime or serious side-effects.

An important issue with this device is that it is well

recognized that there is some variability in the

expected response from patient to patient, with some

patients showing only limited improvement. Several

studies have been published analyzing criteria for determining

which patients are most likely to respond to

treatment. In a group of patients evaluated over a 6month

period following treatment, it was determined

that there was improvement in submandibular and

upper neck skin laxity in 17 out of 20 patients.

Subjects who did not respond to treatment were found

to be older than 62 years. 9 This age-dependent

response was also supported in a study by Hsu and

Kaminer, 6 who performed a single RF treatment in the

lower face and neck of 16 patients. It was found that

younger patients responded better to RF treatment,

with the average age of patients not showing satisfactory

outcomes from the treatment being 58, compared

with 51 in the group of patients showing clinical

improvement. The ineffectiveness of the procedure on

older patients can theoretically be attributed to the fact

that collagen bonds are replaced by irreducible multivalent

crosslinks with age. This renders the functional

basis of RF tissue tightening ineffective, as the thermal

injury caused by RF treatment cannot break collagen

bonds held together by multivalent crosslinks.

The deep tissue tightening effects after RF treatment,

coupled with the low side-effect profile and

noninvasive techniques, makes the ThermaCool TC a

safe and effective alternative to surgery in patients

with mild to moderate skin laxity. Further studies on

RF treatment still have to be carried out, however, as

the duration of tightening in treated patients has yet to

be determined.

Side-effects and limitations

The ThermaCool TC device has been on the market

for over 3 years at the time of writing. Over that

period of time, it has demonstrated an extremely safe

track record. The evolution of the device has

included multiple safety updates to the equipment,

including the addition of multiple thermal sensors on

the treatment tip in order to constantly monitor and

adjust epidermal temperature, an enhanced dynamic

cooling system to also maintain safe parameters, and

modifications to the recommended treatment energies

and profiles. RF tissue tightening can also result

in temporary side-effects, such as focal erythema,

edema, skin tenderness, mild burns, and rare dysesthesia.

6–12 Generally, these effects last only a few

hours, but have been reported to persist for several

days to over a week.The complication of treatment

with the ThermaCool TC giving rise to the greatest

concern was the rare occurance of focal fat atrophy.

Early in the course of the history of the ThermaCool

TC, there were several cases of permanent fat atrophy

that occurred following treatment. Although

these cases were few and restricted to a small number

of users, these permanent alterations created

a great deal of concern about the safety of this device.

Further investigation revealed that these complications

were the effects of excessively high energy

delivered to areas of high fat content. The net effect

of short-pulse high-energy RF energy was necrosis

or melting of the underlying fat, with residual

permanent defects. The treatment protocols were

subsequently modified to ensure that treatments

were conducted well within safe limits. The current

protocols described above include multiple-pass low

to moderate energy levels to achieve the desired

effect.

Other potential side-effects include the risk of scarring

or temporary blisters. The actual incidence of

these effects is extremely low when protocols and

treatment techniques are followed. If a blister occurs,

it is generally very superficial and can be successfully

managed by treatment with moist occlusion, with an

anticipated recovery time of around 1 week. The

biggest attraction of this device, unlike many other

technologies available these days, is that it truly meets

the zero-downtime claim. Any sort of side-effect is

extremely rare, and the vast majority of patients will

immediately return to their daily activities without

interruption.


Newer applications and

additional uses

New treatment protocols are being developed for

off-face and eyelid applications with the ThermaCool

TC. A new 0.25 cm 2 tip is available for treating the

upper eyelid.This is intended for use in patients with

early blepharochalasis. This ‘eye-tip’ has a different

energy profile than the standard 1.5 or 3.0 cm 2

medium-depth tips.The heating profile of the ‘eye-tip’

is more superficial, and it is thus appropriate for the

thin skin of the upper eyelid. Again, a multiple-pass

low-energy treatment protocol is used for the upper

eyelid. Appropriate patients for eyelid treatment are

young patients with early eyelid laxity. Patients with

fat herniation or excessive skin redundancy are better

served by surgical blepharoplasty.

‘Tummy by Thermage’ is the latest treatment protocol

to be announced by the Thermage Corporation.

Although many users have been performing treatments

to the abdomen, arms, and legs for years, this

new protocol is the first to be approved by the company.

This protocol also uses the 3.0 cm 2 mediumdepth

tips in a multiple-pass low-energy treatment

protocol. Fluences are adjusted based upon patient

comfort levels, and typically range from 352.0 to

354.5. A new variation in treatment technique is what

sets this protocol apart from previous ones. The

abdominal treatments are performed using the temporary

marking grids; however, the pulses are delivered

in a staggered partially overlapped protocol.The operator

alternates between squares and circles to provide

a 25% overlap. This stacking or partial stacking of

pulses prolongs the thermal profile to provide

enhanced skin tightening.The ability to stack or partially

overlap pulses also raises the question whether

similar applications on the face or neck can safely provide

greater skin tightening in these areas.

The use of RF energy in combination with tumescent

liposuction is another area of potential application.

Although this treatment combination is not

recommended by the Thermage Corporation due to

an uncertainty in RF energy distribution through

partially undermined or tumesced tissues, many

operators have empirically reported enhanced outcomes

with this combination. In our practice, we

routinely utilize this approach with cervicomental

liposuction and have performed a limited number of

abdominal cases to achieve maximal skin contraction.

It must be stressed that there is no patient feedback

under tumescent anesthesia and that this procedure

should only be performed by experienced operators

with fluence settings that are well within the usual

and safe limits.

NEAR-INFRARED SKIN TIGHTENING

Background

Nonsurgical tightening 107

A newer device for noninvasive skin tightening is

the Titan by Cutera (Cutera, Inc., Brisbane, CA).

Currently, the Titan is FDA-approved for dermal heating

and is used in an off-label application for cosmetic

treatments. The Titan produces dermal heating

through the emission of near-infrared light between

1100 and 1800 nm. This near-infrared spectrum of

light has water as the target chromophore, thus in turn

causing heating of the dermal tissue to a depth of

1–2 mm. Similar to RF tissue tightening, the ultimate

effect of dermal heating is thermal modification, leading

to secondary collagen synthesis and remodeling of

skin tissue.The major difference between these two

devices is the thermal profile. As previously mentioned,

the monopolar Rf device (ThermaCool TC)

focuses the majority of its energy at a depth of approximately

2 mm; however, there is still deeper penetration

of approximately 30% of the energy to depths of

around 4–5 mm. Furthermore, the RF energy dissipates

through other structures such as the fibrous septae

that may also contribute to tissue tightening.The

Titan device deposits its energy in a very discrete area

around 1–2 mm, with little deeper diffusion, thus providing

focused tissue heating in the dermis.

The Titan XL handpiece has a large spot size

(1 cm × 3 cm), and can emit pulses of light up to 8.1 s,

making it the only infrared light of its kind. As with

RF tissue tightening devices, contact heating of the

skin would normally cause damage to the epidermis.

As a result, the Titan employs a pre-, parallel, and

post-contact cooling system through a sapphire

window, providing epidermal protection. Contact


108 Clinical procedures in laser skin rejuvenation

cooling is employed in combination with a surface gel.

The use of refrigerated gel is highly recommended to

provide additional cooling, epidermal protection, and

nhanced patient comfort.

Controlled clinical trials that objectively examine the

effects of the Titan are, as yet, unpublished. However,

two papers have provided some preliminary evidence

that are worth mentioning. In the first, Ruiz-Esparza

et al 14 reported on a series of 25 patients treated with the

Titan for eyebrow lifting only, eyebrow lifting in addition

to cheek and neck skin laxity, and lower face only.

The shortcomings of this paper were that there was no

objective measurement of clinical changes nor was there

standardization of the treatment parameters. Patients

received a wide range of energy settings, with a large

variation in the number of total pulses, and a few patients

even received multiple treatment sessions. The results

from the series showed that 22 out of 25 patients displayed

improvement in at least one of the treated areas.

The three patients who did not respond at any treatment

site had no similar differences in age, sex, or skin type.

In addition, the series also compared the effects of low

fluence versus high fluence on the clinical outcome.

Patients were divided into two subgroups: the first

group of patients received low-fluence (20–25 J/cm 2 )

treatments and less than 150 total pulses. The

second subgroup received higher-fluence treatments

(≥30 J/cm 2 ) and a higher number of total pulses

(150–360). The results demonstrated that although the

lower-fluence subgroup experienced significantly less

discomfort, they showed relatively little or no response

to the treatment. In contrast, groups receiving higher

fluences produced beneficial results. 14 Side-effects

reported in this series included three patients who experienced

superficial second-degree burns, which selfresolved.

There were no other reported complications.

A second study, by Zelickson et al, 15 reported on the

histological effects of treatment with the Titan device.

These authors evaluated the immediate tissue effects of

the infrared device on cadaveric forehead skin and live

abdominal skin to determine the depth of collagen fibril

denaturation. In the cadaveric forehead skin, treatment

with fluences of 50 J/cm 2 and 100 J/cm 2 lasting 5–10

seconds resulted in collagen fibril denaturation in the

depth range between 1 and 2 mm. Abdominal skin

treatments (with fluences of 30 J/cm 2 , 45 J/cm 2 , and

65 J/cm 2 ) showed similar results, as the 0–1 mm and

1–2 mm depth ranges showed a significant amount of

collagen fibril denaturation.The 0–1 mm range showed

a lesser severity in collagen denaturation, however, as

the cooling function of the Titan worked to preserve

epidermal integrity. The results from this study show

that thermal injury caused by the Titan induces the

desired immediate tissue effects at an optimal depth

beneath the skin believed to be responsible for producing

the beneficial cosmetic effect achieved from deeptissue

tightening. A shortcoming of this study was that

there was no long-term follow-up on the actual clinical

effects of the treatment.

Combination Technology

Newer combination technology, such as the ReFirme

(Syneron LTD, Yokneam, Israel), combined bipolar

radiofrequency with broad spectrum light source and

have also shown promising results for skin tightening

in a painless fashion.

Treatment parameters

Similar to monopolar RF, energy settings with the

Titan device are determined based upon patient comfort.The

maximal energy is considered to be the level

at which the patient experiences mild discomfort.This

can be defined as feeling a moderate heating sensation

for a split second, or as experiencing 6 out of 10 on a

pain scale. It is not recommended that this level be

exceeded, as there is potential for overheating of the

skin, with subsequent blistering. In our practice, the

Titan device has been used to treat the forehead, midface,

neck, chest, arms, legs, and abdomen. Energy

levels vary depending upon the treatment site and

patient tolerance. Regardless of the area treated,Titan

treatments consist of multiple nonoverlapping passes

delivering low energy.The total number of passes is

usually around three to five to achieve visible tightening

of the treated area.

Clinical effects

As with other nonsurgical skin tightening devices, the

exact degree of skin tightening will be variable. This


a b

makes the endpoint difficult to predict for both surgeon

and patient. Another important factor to note is the

delay to achieving the final endpoint. In most of our

cases, patients did not achieve maximal correction until

3–5 months post treatment. Even at this point of maximal

correction, many of the changes were difficult to

perceive without examining preoperative photographs.

The most common areas to show improvement with the

infrared tightening were the mandibular line, which

became more defined with a less prominent jowl area.

The second most common area to demonstrate

improvement was an elevation of the malar fat pad and

concomitant softening of the nasolabial fold (Fig. 9.3).

In our hands, this device provided limited improvement

in the neck and brow regions. It is extremely important

to point out these factors and limitations to patients

during preoperative consultation so that realistic expectations

can be set appropriately.

Side-effects and limitations

The delivery of infrared light to the skin under appropriate

guidelines is an extremely safe modality.

Reports of adverse events thus far are limited to a very

small number of superficial scars. The majority of

these have occurred on the upper forehead, and it is

believed that reflected energy from the underlying

cranium was responsible for thermal injury to the

skin. It is important to follow the recommendations

for low-energy multiple-pass treatments with extra

caution over bony prominences such as the forehead,

mandible, and malar prominence. Furthermore,

sufficient contact gel must be used in order to provide

adequate coupling for surface cooling.

Future directions

A question that is yet to be determined is whether serial

treatments provide greater correction than a single

treatment. For example, is it beneficial to perform three

monthly treatments with infrared skin tightening to

enhance the final outcome? Although no published data

currently exist, many of our patients believe that they

receive extra benefit from their multiple treatments. In

theory, one would expect that the amount of collagen

contraction achieved with one treatment session is

certainly not maximal and that further contraction

could be achieved with additional treatments.The ideal

energy settings, number of passes, and the treatment

interval are all variables that are not known or well

understood.The only way to clearly determine this is

through careful morphometric analysis in a split-face

study and through continued close monitoring and

collection of data from patient treatments.

SUMMARY

Nonsurgical tightening 109

Fig.9.3 A patient before (a) and 3 months after (b) a single full-face treatment with near-infrared (Titan) skin tightening.

Typical results include moderate tightening along the mandibular line,along with attenuation of the jowls and nasolabial folds.

We have discussed two noninvasive devices on the

market that are appropriate for treating early skin

laxity. Both of these devices provide zero-downtime

treatments, and therein lies their true strength. No

other treatments available can provide zero downtime


110 Clinical procedures in laser skin rejuvenation

with the potential for some degree of correction.

Although the amount of correction is variable and, at

times, limited, many patients cannot afford or are

unwilling to spend 2–3 weeks recovering from a surgical

procedure.These two devices, therefore, offer alternatives

to traditional lifting procedures when patients

can not afford the downtime and are willing to accept

a lesser degree of lifting.

The area of noninvasive skin tightening is still relatively

new, and we, as operators, are still learning how

to maximize our results. Certainly, the future will

bring us further technological advancements and other

new devices that will enhance our ability to perform

less-invasive and noninvasive rejuvenation.

REFERENCES

1. Alster TS, Garg S. Treatment of facial rhytides with a

high-energy pulsed carbon dioxide laser. Plast Reconstr

Surg 1996;98:791–4.

2. Khatri KA, Ross EV, Grevelink JM, et al. Comparison of

erbium:YAG and carbon dioxide lasers in resurfacing of

facial rhytides.Arch Dermatol 1999;135:391–7.

3. Lennox G. Shrinkage of collagen. Biochim Biophys Acta

1949;3:170–87.

4. Ross EV, Naseef GS, McKinlay JR, et al. Comparison of

carbon dioxide laser, erbium:YAG laser, dermabrasion,

and dermatome: a study of thermal damage, wound

contraction, and wound healing in a live pig model:

implications for skin resurfacing. J Am Acad Dermatol

2000;42:92–105.

5. Tunnel JW, Pham L, Stern RA, et al. Mathematical

model of nonablative RF heating of skin. Lasers Surg

Med 2002;14(Suppl):318.

6. Hsu TS, Kaminer MS. The use of nonablative radiofrequency

technology to tighten the lower face and neck.

Semin Cutan Med Surg 2003;22:115–23.

7. Fitzpatrick R, Geronemus R, Goldberg D, et al.

Multicenter study of noninvasive radiofrequency for periorbital

tissue tightening. Lasers Surg Med 2003;33:

232–42.

8. Ruiz-Esparza J, Gomez JB. The medical face life: a noninvasive,

nonsurgical approach to tissue tightening in the

facial skin using nonablative radiofrequency. Dermatol

Surg 2003;29:325–32.

9. Alster TS, Tanzi E. Improvement of neck and cheek

laxity with a non-ablative radiofrequency device: a lifting

experience. Dermatol Surg 2004;30:503–7.

10. Fisher GH, Jacobson LG, Bernstein LJ, et al. Nonablative

radiofrequency treatment of facial laxity. Dermatol Surg

2005;31:1237–41.

11. Koch RJ. Radiofrequency nonablative tissue tightening.

Facial Plast Surg Clin North Am 2004;12:339–46.

12. Nahm WK, Su TT, Rotunda AM, et al. Objective changes

in brow position, superior palpebral crease, peak angle of

the eyebrow, and jowl surface area after volumetric

radiofrequency treatments to half of the face. Dermatol

Surg 2004;30:922–8.

13. Kilmer SL. A new nonablative radiofrequency device:

preliminary results. In: Arndt KA, Dover JS, eds.

Controversies and Conversations in Cutaneous Laser

Surgery. Chicago: American Medical Association Press,

2002:93–4.

14. Ruiz-Esparza J, Shine R, Spooner GJR. Immediate skin

contraction induced by near painless, low fluence irradiation

by a new infrared device: a report of 25 patients.

Dermatol Surg 2006;32:601–10.

15. Zelickson B, Ross V, Kist D, et al. Ultrastructural effects

of Titan infrared handpiece on forehead and abdominal

skin. Dermatol Surg 2006;327:897–901.


10. Laser treatment of pigmentation

associated with photoaging

David H. Ciocon and Cameron K Rokhsar

INTRODUCTION

Cumulative exposure to the sun can induce clinical and

histological changes in the skin, commonly called photoaging

or dermatoheliosis. This occurs primarily in

patients with fair skin types (Fitzpatrick 1 to Fitzpatrick

3 skin types) who have experienced repeated solar

injuries over the years, such as lifeguards and outdoor

laborers. 1 Clinically, photoaging represents a polymorphic

response to sun damage that manifests variably as wrinkles,

skin roughness and xerosis, irregular mottled pigmentation,

telangiectasias (poikiloderma of Civatte),

actinic purpura, sallowness (also known as Milian

citrine skin), and brown macules or solar lentigines.

Besides fair skin, other risk factors for the development

of photoaging include difficulty in tanning, ease of sunburning,

a history of sunburn before the age of 20,

advancing age, smoking, male gender, and living in areas

with high ultraviolet (uv) radiation (high altitudes). 2

Individuals who develop photoaging often have a

genetic susceptibility to photodamage and can experience

sufficient actinic damage to develop skin cancers

such as basal cell cancer or melanoma.

The areas primarily affected by photoaging include

the face, the V area of the neck and chest, the back and

sides of the neck, the backs of the hands and extensor

arms, and, in women, the skin between the knees and

ankles. Photodamaged skin typically appears attenuated,

atrophic, scaly, wrinkled, leathery, and, in some

cases, furrowed and ‘cigarette paper-like’. In persons

of Celtic ancestry, photoaging can produce profound

epidermal atrophy without wrinkling, making the skin

appear almost translucent and making dermal structures

such as blood vessels more visible.

Because of its predilection for visible parts of the

body, photoaging-induced pigmentation can have significant

psychosocial impact on affected individuals.

Unfortunately, treatment of such pigment alterations

has been difficult. Each year, millions of dollars are

spent by consumers seeking ‘quick-fix’ solutions for

the cutaneous stigmata of aging. In 2002, more than 5

million nonsurgical and 1.5 million surgical cosmetic

procedures costing more than $13 billion were performed

in the USA. 3 We can only expect such numbers

to increase in the coming decades as our aging

population expands, given increases in life expectancy

and growing consumer demand for improvements in

cosmetic appearance.

While photoprotection with either chemical or

physical sunscreens remains the mainstay of care for

patients with photoaging-induced pigmentation, additional

topical treatments in the form of retinoids,

steroids, chemical bleaches such as hydroquinone,

hydroxy acids, and chemical peels are also available.

Unfortunately, many of these topical treatments are

only able to affect changes at the level of the epidermis,

while most textural and tinctorial changes in sundamaged

skin are caused by alterations in structures in

the upper and deep dermis.

The introduction of laser and visible-light technology

over the past 30 years has revolutionized our

understanding and treatment of photoinduced pigmentation

by more selectively targeting pigmented

molecules and structures in the dermis without damaging

the overlying epidermis.They have also proven

useful in more directed treatment of epidermal pigmentation.

In this chapter, we will review some of

the more common pigmented lesions associated with


112 Clinical procedures in laser skin rejuvenation

photoaging as well as the most current and effective

laser modalities available for their treatment.

SOLAR LENTIGINES

Solar lentigines are the most common of pigmented

lesions induced by photoaging. 4 They are macular,

hyperpigmented lesions ranging in size from a few millimeters

to more than a centimeter in diameter.They

tend to be multiple and grouped and bear a predilection

for sun-exposed surfaces, including the face, neck,

hands, and forearms.Alternative names for solar lentigines

include actinic lentigines, liver spots, age spots, and

sunspots. As with photoaging, the incidence of solar

lentigines increases with time, affecting more than 90%

of Caucasians older than 50 years.When evaluating individuals

with suspected solar lentigines, clinicians must

take care in distinguishing them from ephelides, lentigo

simplex, pigmented actinic keratoses, flat seborrheic

keratoses, melanocytic nevi, and malignant melanoma.

While they can be usually differentiated on the basis of

history and clinical appearance, some cases may warrant

a biopsy.

Although numerous non-laser therapies have been

shown to be effective for solar lentigines, including

retinoic acid, mequinol, and cryotherapy, many of them

require repeat applications over extended periods of

time to achieve significant cosmetic improvement. In

addition, lightening with topical treatment is usually

temporary and incomplete, with the lesions recurring

immediately following cessation of therapy.The primary

advantage of laser treatment of solar lentigines is that

most can be removed completely in one to three treatments,

depending on the modality, which provides

patients with more immediate satisfaction.

The primary target in a solar lentigo is the pigment

melanin. Because of the broad absorption spectrum of

melanin, which ranges from 351 to 1064 nm, various

lasers have been used to treat solar lentigines, most

with excellent results. Lasers used in published

reports include the pulsed dye (585–595 nm), copper

vapor (511 nm), krypton (520–530 nm), frequencydoubled

Q-switched neodymium : yttrium aluminum

garnet (Nd:YAG) (532 nm), Q-switched ruby

(694 nm), Q-switched alexandrite (755 nm), Qswitched

Nd:YAG (1064 nm), carbon dioxide (CO 2 )

(10 600 nm), and argon (488–630 nm) lasers. 4 For the

purpose of this review, we will concentrate on three

laser modalities widely regarded as the safest and most

effective for the treatment of solar lentigines: the Qswitched

ruby laser, the Q-switched alexandrite laser,

and the Q-switched Nd:YAG laser.

The Q-switched ruby laser (QSRL) was developed

to emit light in very short pulses that is preferentially

absorbed by melanin, thereby reducing damage to

other skin structures. Q-switched lasers can induce

both photothermal and photomechanical reactions.

These lasers generate high-energy radiation that leads

to a rapid rise in temperature (1000°C), resulting in

evaporation of targeted pigments within the skin and

vacuolization (photothermal damage). The collapse

of the temperature gradient that is created between

the target tissue and the surrounding tissue also

causes fragmentation of the target (photomechanical

damage).

The use of the QSRL for the treatment of solar

lentigines was described in a study of eight women

with 196 solar lentigines on their forearms. 5 Therapy

was delivered as a single brief pulse of 40 ns to a 4 mm 2

area.A single course of treatment resulted in fading of

the lesions without scarring and no recurrence within

a 6- to 8-week follow-up period. Histopathological

examination of biopsy specimens showed vacuolization

of superficial pigmentation to a maximum

depth of 0.6 mm immediately after treatment. Immunohistochemical

examination of specimens stained with

anti-melanocyte-specific antibodies did not indicate

remaining melanocytic structures in moderately

pigmented lesions.

Another Q-switched laser that has been also shown

to be effective for lentigines is the Q-switched

Nd:YAG (QSNd:YAG) laser at 532 nm.A three-center

trial evaluated the effectiveness of the frequencydoubled

QSNd:YAG laser (532 nm, 2.0 mm spot size,

10 ns) in removing benign epidermal pigmented

lesions with a single treatment. Forty-nine patients

were treated for 37 lentigines. 6 Treatment areas were

divided into four quadrants, irradiated with fluences of

2, 3, 4, or 5 J/cm 2 and evaluated at 1- and 3-month

intervals following treatment. For lentigines, response

was dose-dependent, with greater than 75% pigment

removal achieved in 60%