Lasers and Lights

Proceduresin Cosmetic DermatologJy

SeriesEditor: Jeffrey S. DoverMD FRCPC AssociateEditor: Murad Alam MD

Lasersand Lights Volumell Rejuvenation - Resu rfacin g- Treatmentof EthnicSkin -Treatment of Cellulite Secondedition Editedby David J. GoldbergMD JD Director Skin Laser& SurgerySpecialists of New York and New Jersey,Hackensack, N.J. Clinical Professorof Dermatologyand Director of LaserResearch, Mount Sinai Medical School, Clinical Professorof Dermatology and Director of Dermatologic Surgery, UMDNJ- New Jersey Medical School; Adjunct Professorof Law, Fordham Law School,New York, NY, USA DVDrditor ThomasE. RohrerMD Clinical Associate Professorof Dermatology, Boston University School of Medicine, Chestnut Hill, MA, USA SeriesEditor Jeffrey S. Dover MD FRCPC Associate Professorof Clinical Dermatology, Yale University School of Medicine, Adjunct Professorof Medicine (DermatologyJ, Dartmouth Medical School, Director, SkinCare Physicians,Chestnut Hill, MA, USA AssociateEditor Murad Alam MD Chief, Section of Cutaneous and Aesthetic Surgery, Department of Dermatology, Northwestern University, Chicago, IL, USA Proceduresin CosmeticDermatologJy SeriesEditor: Jeffrey S DoverMD FRCPC AssociateEditor: Murad Alam MD

BotulinumToxin, second edition @ Liposuction@ Akutair Carruthers MA BM BCft FRCPC FRCP(Lon)and C. William Hanke MD MPH FACP and Gerhard Jean Carruthers MD FRCSC FRC (OPHTH) F/SOPRS Sattler MD ISBN 978 - 1-4 160-42 1 3 -6 rsBN978 1-4160-2208-4 SoftTissue Augmentation, ScarRevision Secondedition @ KennethA. Arndt tvto Jean Carruthers MD FRCSC FRC (OPHTH) FASOPRSand ISBN97 8 - 1 -41 60-3 1 3 1-4 Alastair Carruthers MA BM BCft FRCPC FRCP(Lon) ChemicalPeels @ ISBN 978 - 1-4 160 -42 1 4 -3 Mark RubinMD Cosmeceuticals rsBN97 8 - 1 -4 1 60- 307 1 -3 Zoe Diana DraelosMD HairTransptantation @ ISBN978-1 4160-0244-4 Robert S. Haber MD and Dowling B Stough tvto Lasersand Lights: Volume | @ rsBN978 1-4160-3104-8 Vascula r. Pigmentationo . ScarsMed ica I Applications Treatmentof LegVeins @ Dauid L GoldbergMD ID ISBN97 8 - 1 -4 1 60 -2 3 86-9 Murad Alam MD and Tri H. Ngryen MD ISBN 978 - 1-4 1 60- 3 159 - 8 Lasersand Lights: Volume ll, Blepharoptasty secondedition @ @ Ronald L. Moy MD and Edgar F Fincher Reiuvenation. Resurfacing. Treatment of Ethnic ISBN: 978-.1-41 60-2996-0 Skino Treatment of Cetlutite Dauid l. GoldbergMD ID AdvancedFace Lifting @ rsBN - -4 -9 978 1 160-42 1 2 Ronald L. Moy MD and Edgar F Fincher PhotodynamicTherapy, second edition tsBN 978 -1 -4 160-2997 -7 Mitchel P Goldman MD ISBN 97 8 - 1-4 160 -42 1 1-2

Contents

SeriesPreface vll SeriesPreface First Edition viii Preface ix Listof Contributors xi r @ LaserSkin Resurfacing Christopher B. Zachary, Cameron K Rokhsar, Richard E. Fitzpatrick z @ AblativeLaser Resurfacing ll 29 Zakia Rahman, Melissa Bogle 3 @ NonabtativeLaser Resurfacing 43 Ellen S Marmur, David J Goldberg 4 @ SkinTightening with Radiofrequency 55 Macrene Alexiades-Armenakas,Michael S. Kaminer 5 LaserTreatment of EthnicSkin 73 Henry H. L. Chan, Taro Kono 6 @ LaserTreatment of Celtutite 8t Adam M Rotunda, JaggiRao, Mitchel P Goldman 7 Complicationsin Laser and Light Surgery 99 Tina S. Alster, Elizabeth L. Tanzi lndex 713

SeriesPreface Proceduresin Cosmetic Dermatology

Four years ago we began a project to produce "Procedures in Cosmetic Dermatology", a series of high quality, and practical, up-to-date, illustrated manuals on procedures in cosmetic dermatology. Our plan was to provide dermatoio- glsts dermatologic surgeonswith detailed books accompaniedby instructional DVD's containing all the information ".td ihey needed to master most, if not all of the leading edge cosmetic dermatology techniques. Thanks to the efforts of our superb book editors, chapter authors, and the tireless and extraordinary publishing staff at Elsevier,the serieshas been more successfulthan any of us could have hoped. Over the past 3 years,thirteen volumes have been introduced, which have been purchased by thousands of physicians ail over the world. Originally published in English, many of the texts have been translated into different languagesincluding Italian, French, Spanish, Chinese, Polish, Korean, Portuguese,and Russian. Oui commitment to you is to convey information that is practical, easyto use, and up to date Since new devices and minimally invasivetechniques are continually being refined in this rapidly changingarea, the time has now come to inaugurate second editions of these books During the next few years updated texts will be released.The most time-sensitive books will be revised first, and others will follow. This series is an ever evolving project. So in addition to second editions of current books, we will be introducing entirely new books to cover novel procedures that may not have existed when the seriesbegan. Enjoy and keep learning. Jeffrey S. Dover MD, FRCPC and Murad Alam MD SeriesPreface Proceduresin CosmeticDermatology

\A&riledermatologists have been procedurally inclined since the beginning of the specialty, particularly rapid change has occurred in the past quarter century. The advent of frozen section technique and the golden age of Mohs skin cancer surgery have led to the formal incorporation of surgery within the dermatology curriculum More recently technologicalbreakthroughs in minimally invasiveprocedural dermatology have offered an agingpopulation new options for improving the appearanceof damaged skin. Procedures _ for rejuvenatrngthe skin and adjacent regions are actively sought by our patients. Significantly, dermatologists have pioneered devices, technologies and medications, which have continued to evolve at a startiing pace Numerous major advances,including virtually all cutaneous lasersand light-source based procedures, botulinul exo- toxin, soft-tissue augmentation,dilute anesthesialiposuction, leg vein treatments, chemicai peels, and hair transplants, have been invented, or developed and enhanced by dermatologists. Dermatologists understand procedures, and we have specialinsight into the structure, function, and working of skin. Cosmetic dermatologistshave made rejuvenation accessjbleto risk-aversepatients by emphasizingsafety and reducing operativetrauma. No ipecialty is better positioned than dermatology to lead the {reld of cutaneous surgery u.hile meeting patient needs. dermatology . _As grows as a specialty, an ever-increasingproportion of dermatologistswill become prolicient in the delivery of different procedures. Not all dermatologrstsr,vi11 perform all procedures, and some will perform very few, but even the less procedurally directed amongst us must be well-versed in the details to be able to guide and ejucate our patients Whether you are a skllled dermatologic surgeoninterested in further expanding your surgicalrepertoire, a complete surgical novice wishing to learn a few simple procedures, or somewhere in betrveen, thii book and this series is for you 'Procedures The volume you are holding is one of a seriesentitled in Cosmetrc Dermatology' The purpose of each book is to serve as a practical primer on a major topic area in procedural dermatology. If you want to make sure you find the right book for your needs,you may wish to lnow what this book is and what it is not. It is not a comprehensivetext grounded in theoretical underpinnings. It is not exhaustively referenced It is not designedto be a completely unbiased review of the world's literaiure on the sublect. At the same tlme, rt is not an overview of cosmetic procedures that describesthese in generalitieswithout providing enough specific iniormation to actually permit someoneto perform the procedures And importantly, it rs not so hear,rtthaiit can serve as a door- stop or a shelffiller \ hat this book and thrs seriesoffer is a step-by-step,practical guide to performing cutaneoussurgical procedures. Each volume in the serieshas been edited by a known authority in that subfield. Each editor has recruited oiher eouallv practical-minded, technically skilled, hands-on clinicians to write the constituent chapters. Most chapterr hnlr" t-o authors to ensure that different approachesand a broad range of opinions are incorporated On the other hand, the two authors and the editors also collectively provide a consistencyof tone A uniform template has been used within each chapter so that the.reader will be easily able to navigate ali the books in the series.Wthin every chapter, the authors succinctly tel1 it like they do it The emphasisis on therapeutic technique; treatment methods are discussed with an eye to appropriate indications, adverseevents, and unusual cases.Finaliy, this book is short and can be read in its entirety on a long plane ride. We believe that brevity paradoxicallyresults in greater information transfer because cover-to-covermastery is practicable. We_hope you . enjoy this book and the rest of the books in the series and that you benefit from the many hours of clinical wisdom that have been distilled to produce it Pleasekeep it nearby, *h"." you can reach for it when you need it. Jeffrey S. Dover MD FRCPC and Murad Alam MD Preface

In the first edition of Laser and Lights the concept of selectivephotothermolysis was thoroughly explored in its application to the laser and laser-likelight treatment of the skin. The enormous popularity of the first edition, accompanied by the rapid proliferation of new material, has now led to a second edition of this now hlghly popular book. Much like that which was described in the first series,readers will find that each chapter is dedicated to a specific topic. In all there are sevenchapters of this book. Chapters are written to give both the beginning and experienced laser physician a practical clinical everyday approach to using cutaneous lasers and laser-like devices. Appropriate patient selection and choice of technology is emphasized. An overview of treatment strategies,indications and contraindications is stressed Where appropriate advancedtreatment tips are provided A11chapters contain selected future readings and clinical photographs. Many chapters contain useful treatment videos This volume begins with a chapter on ablative laser skin resurfacingfollowed by chapters dedicated to fractionated resurfacing,non-ablative skin remodeling, and non-ablative skin tightening The final three chapters are dedicated to laser treatment of ethnic skin, cellulite and finally complications. Lasersand Lights represents a wonderful practical guide to the use of laserson the skin' David J. Goldberg MD To the women in my life

My grandmothers, Bertha and Lillian

My mother, Nina

My daughters, Sophie and Isabel

And especially to my wife, Tania

For their never-ending encouragement,patience, support, love, and friendship

To my father, Mark - a great teacher and role model

To my mentor, Kenneth A. Arndt for his generosity, kindness, sense of humor, joie de vivre, and above all else curiosity and enthusiasm

At Elsevier, Sue Hodgson who conceptualized the series and brought it to reality and Claire Bonnett for polite, persistent, and dogged determination.

Jeffrey S. Dover

Elsevier'sdedicated editorial staff has made possible the continuing successof this ambitious project. The new team led by Claire Bonnett, Anne Bassett and the production staff have refined the concept for the second edition while maintaining the series' reputation for quality and cutting-edge relevance. In this, they have been ably supported by the graphics shop, which has created the signature high quality illustrations and layouts that are the backbone of eacir book. We are also deeply grateful to the volume editors, who have generously found time in their schedules, cheerfully accepted our guidelines, and recruited the most knowledgeable chapter authors. And we especially thank the chapter contributors, without whose work there would be no books at all. Finally, I would also like to convey-and my debt to my teachers, Kenneth Arndt, Jeffrey Dover, Michael Kaminer, Leonard Goldberg, and David Bickers, my parents, Rahat and Rehana Alam.

Murad AIam Listof Contributors

MacreneAlexiades-Armenkas MDPhD TaroKono MD Assistant Clinical Professor,Yale University School of Chief of Laser Unit, Department of Plastic and Medicine, New York, NY, USA Reconstructive Surgery, Tokyo Women's Medical University, TinaS. Alster tvto Tokyo, Japan Director, Washington Institute of Dermatologic Laser Surgery; EttenS. Marmur MD Clinical Professorof Dermatology, Georgetown University Assistant Professor,Chief, Division of Dermatologic and Hospital, Washington DC, USA Cosmetic Surgery, Mount Srnai School of Medicine, New York, MelissaBogle tvto NY, USA Director, The Laser and Cosmetic Surgery Center of Houston; ZakiaRahman MD Associate Clinical Professor,The University of Texas Anderson Clinical Instructor of Dermatology, Affiliated Stanford Cancer Centre, Houston, TX, USA University School of Medicine, USA HenryH. L. ChanMBBS MSc MD FRcp FHKcp FHKAM laggiRao MD FRcPc Honorary Clinical Associate Professor,The University of Hong Associate Clinical Professorof Medicine, Division of Kong/The Chinese University of Hong Kong, Hong Kong Dermatology, University of Alberta, Edmonton, Alberta, RichardE. Fitzpatrick ruo Canada Associate Clinical Professorof Dermatology, University of CameronK. Rokhsar MD California, San Diego, CA, USA Associate Dermatology Associatesof San Diego County, CA Assistant Clinical Professorof Dermatology, Mount Sinai DavidJ. Goldberg tvto School of Medicine, New York, NY, USA Director Skin Laser & Surgery Specialistsof New York and New Jersey, Hackensack,NJ; Clinical Professorof AdamM. RotundaMD Dermatology and Director of Laser Research,Mount Sinai Medical Director, Dermatology Researchand Development, Medical School, New York, NY, USA; Clinical Professorof Allergan, Inc, Irvine, CA and Clinical Instructor, Divrsion of Dermatology and Director of Dermatologic Surgery, UMDNJ- Dermatology, David Gefter School of Medicine, University of New Jersey Medical School; Adjunct Professorof Law, California, CA, USA Fordham Law School, New York, NY, USA ElizabethL. Tanzi MD MitchelP. Goldman MD Co-Director, Washington Institute of Dermatologic Laser Medical Director, La Jolla Spa MD, La Jolla, CA Clinical Surgery and Clinical Instructor, Department of Dermatology, Professorof Dermatology/Medicine, University of California, John Hopkins Medical Center, Washington DC, USA San Diego, CA, USA ChristopherB.Zachary MBBS FRCP MichaelS.Kaminer MD Professorand Chair, Department of Dermatology, University Assistant Professorof Dermatology, Yale Medical School, of California, Irvine, CA USA Dartmouth Medical School, Hanover, NH, USA

LaserSkin Resurfacing CarbonDioxide (CO,) and Erbium :yttrium'aluminum- garnet(Er:YAG) Lasers Christopher B. Zachzry, Cameron K. Rokhsar, fuchardE. Fitzpatrick

INTRODUCTION C and HIV, the use of this technique has almost vanished in the United States.) In a precisely controlled manner, it 'looking There are social and economic benefits to good' can be used to effectively remove the outer damagedskin For most of us, this means looking as good as we might, layers and promote the development of new collagenand given the genes our parents donated. It's why we primp, epidermis Due to the tissue tightening effects and the manicure, and beautify ourselvesbefore going out to work. resulting collagen shrinkage after COz 1aser,a firmer and This is simply a fact. One only needs to turn on the tele- more healthy appearanceresults. vision, peruse a newspaper,or drive down a busy street to This chapter will provide you with step-by-stepinstruc- see advertisementsencouraging participation in a myriad tions on how to use the CO2 laser to maximize the treat- of cosmetic proceduresto improve physical attractiveness ment of wrinkles, photodamage,and acnescars of the face. and reverse the appearancesof aging. The business of Most importantly, we will explain how to choosethe ideal selling youth shows no sign of slowing. In the late 1990s, patient, how to identify the patient that has the high ablative skin resurfacing fell out of favor in many circles potentiai for postoperativecomplications, detail the instru- becauseof the longer healingtimes, persistent rednessand ments and techniques used, and delineate pre- and post- the potential for adversesequelae. Other newly developed operative care in great detail Advanced tips on ways to and promising nonablative rejuvenating techniques took avoid pitfalls and potential complicationswill be addressed the forefront However in our opinion, despite the hoopla, in detail. Finally, we will conclude with resurfacingof the many nonablative methods have produced somewhat neck in addition to combined laser procedures. mediocre results. While physiciansand patients continue Photodamageis the result of a iifetime's exposure to 'lunch-time' to hope for easy,painless, and effective pro- environmental UV radiation. It is represented by changes cedures,most of the deviceswe have right now are simply in the skin that include fine to deep wrinkles, increased not going to be comparable to the carbon dioxide (COr) skin laxity, and a leathery, pebbly, or coarseskin texture and erbium:yttrium-aluminum-garnet (Er:YAG) proce- When severephotodamage is present, one may see thin- dures. It would not be too surprising to see laser skin ning of the skin, dryness and roughness,dyspigmentation, resurfacing have a degree of resurgencesince it remalns telangiectasias,and easybruising. the most effective and predictable method to reversethe Acne scarring can appear anywhere on the face, but signsof photodamage and aging. patients most commonly present with scars on the mid Laser resurfacing may be intimidating to some physi- cheek and temple areas. Soft atrophic scars with gently ciansbecause in lessexperienced hands comphcationsmay sloping edgesrespond quite dramatically to laser resurfac- 'ice-pick' 'cliff-drop' be high and patient satisfactionmay be poor. Here we will ing, whereas or depression scars or describeour methods for the effective use of the CO2 laser deep scarswith sharply defined borders do not respond as for facial resurfacingafter two decadesof experience well Therefore, the patient must be advised accordingto 'cliff-drop' The first published report of the COz laser being used the type of scars they display. Scars with for resurfacingwas for the treatment of actinic cheilitis in borders and deep depressionsmay be amenableto punch 1968. Initially it was considered too dangerousto use on excisionsand closure,which may be performed simultane- large surface areas,as it easily promoted scarring It was ously or 6-12 weeks before laser resurfacing oftne area, not until the late 1980s that there were reports of suc- as laser resurfacing will often not entirely eradicate such cessfui treatment of wrinkles using the COz laser For lesions(Fig. r.r) many experienced laser surgeons/use of COz laser resur- There are many cutaneouslesions, both congenital and facing remains the treatment of choice for facial rhytides, acquired, that are amenable to the CO2 laser such as acne scars, and improvement of photodamage (One benrgn adnexal tumors, including syringomataand follicu- caveat: traditional dermabrasion is possibly the very best lar tumors, angiofibromata,actinic and seborrheic kerato- treatment for acne scarring, though because of hepatitis ses, actinic cheilitis, lentigines, and verruca vulgaris, in Lasersand LightsVoLume 1l

Fig. 1.1 Pattentwith deep acne scars (A) Preoperativeappearance (B) Afterresurfacing and punchexcisions, immediately postoperation (C) Fourdays postresudacing (D) Longterm results LaserSkin Resurfacing addition to scars,both post-traumatic and post-surgical. For more extensive and comprehensive information regarding the COz laser, there are severaltextbooks that are very useful (seeTables r.r-r.3) Fitzpatrickskin Ctinicatdescription RoshanKetab 02L-669 50 639 type PATIENTSELECTION Type I Alwaysburns easily, never tans CO2 laserresurfacing is used to successfullyimprove mild, Typell Alwaysburns easily, tans minimally moderate, and severe photodamage, and atrophrc acne scars.It can effectively reduce uneven facial pigmentation, Typelll Burnsmoderately, tans gradually textural irregularities, and fine-to-deep lines Most com- Type lV Burnsminimally, always tans well monly, it is those patients who begin to display signs of Type V Rarelyburns, tans proJusely moderate photodamage who seek advice regarding treatment Some might consider laser resurfacing too TypeVl Neverburns; deeply pigmented aggressivefor those patients in their twenties or thirties (Datafrom Goldman MP, FitzpatrickRE 1999Cutaneous laser who only display signs of early photodamage. The most surgery,2nd edn.Mosby, St Louis,MO)

Class Wrinkting Score Degreeof etastosis

Finewrinkles 1-3 Mild:fine textural changes with subtly accentuated skin lines

tl Fineto moderatedepth wrinkles; 4-O Moderate:distinct popular elastosis (individual papules moderatenumber of lines withyellow translucency under direct lighting) and dyschromia

Fineto deepwrinkles; numerous t-9 Severe:multipapular and confluentelastosis (thick- lines;with or withoutredundant skin ened,yellow, and pallid)approaching or consistent folds withcutis rhomboidalis

(Datafrom FitzpatrickRE, GoldmanMP, Satur NS, Tope WD 1996Pulsed carbon dioxide laser resur{acing of photo-agedfacial skin, Archivesof Dermatology132:395-402)

Advantages Disadvantages

Treatmentof mildrhytides Fewerpasses, more superficial Lessdramatic imorovement and photodamage resudacing The riskmay outweighthe benefit:the Lessrisk of adversesequelae such as treatmentmay be too aggressiveto treat a scarring,hypo- or hyperpigmentation, relativelyminor problem eMhema Patientsare oftenhigh maintenance and Likelyto completelyremove rhytides may be unsatisfiedwith the results withlonglasting results irrespectiveof the improvement Treatmentof severerhytides Markedimprovement common Moreaggressive treatment wilh more and photodamage Simultaneouslytreat precancerous or passesand longerdown-time verysuperficial nonmelanoma skin Higherrisks for adversesequelae such as cancers scarring,erythema, dyspigmentation Significant psychologic improvement May needmultiple treatments to obtainfull Patientsare moreeasily pleased, even benefit il photodamageand rhytidesare not Maintenanceof benefitsmay be morevaried completelyeradicated

(Adaptedfrom Goldman MP, FitzpatrickRE 1999Cutaneous laser surgery,2nd edn. Mosby, St Louis,MO) Lasersand Lights Volume ll

dramatic improvement is seen in the patient wrth severe photodamage,when 5 l0 years of rejuvenation might be apparent after healing However, the more aggresstvethe treatment, the longer the downtime, and the higher the risk of side effects Both the patient and physician should have realistic expectations before treatment proceeds Furthermore, it is important to comprehend the advantagesand disadvantages of treating a patient early versus late (Table 1.3). There are important criteria based on a patient's skin type that may influence treatment. lVhereas postinflammatory hyperpigmentation is an adverse sequel in 20-30% of patients with type II skin, it occurs in 90-10006 with type IV skin or darker fsee later discussion;Table I . I ] . Patients with Fitzpatrick skin types IV-VI can certainly be treated, but with the realization that these patients have a 1000/o risk of hyperpigmentation, which usually appearsI month after treatment and may take some months to resolve unless appropriately treated. Many regard the ideal patients for facial laser resurfacing are Fitzpatrick skin types I-III, with moderate-to- severe photodamage and rhytides (Fig. r.z), and/or soft atrophic acne scarswith sloped borders (Fig.r.3) We are actually quite happy to use either the COz or Er:YAG laser on darker skin types also Patients should have a medical history free of risk factors for scarring, poor wound healing, or infection. Most importantly, they must have reaiistic expectations: a patient who expects 1000/o improvement should be avoided. Furthermore, Datients must be capable of ardently following the post-care Ieglmen.

EXPECTEDBENEFITS

Most commonly, there is an improvement in photodamageand scarringof 500/0,but the level of improvement can range from 200/oto 900/0.In other words, severe photo- damagebecomes more moderate, moderate damagemore mild, and miid damage may resolve completely. Most importantly, the skin appearsmore youthful and robust, and less weathered and atrophic. Additionallv, with collagen remodeling, the ski.t *ill continue to improve up to 6 months post-treatment Our studies show that long term results are excellent (Fig.t.4). In some patients, .tf to 4 years afrer treatment there remained 800/oof the improvement that was seenat 90 days (Fig. r.5) As would be expected, the lines that Fig. 1.2 Remarkable tend to reappear first are dynamii lines such as in the improvementof facialrhytides (A) Before treatment (B) 3 monthsposttreatment periorbital, perioral, glabellar, or forehead regions In our studies, we have found significant maintenance of results when comparing 3 month versus 25 month scores,reveal- ing an averageimprovement periorally of 49o/oversus 370lo respectively, while periorbital scores were 460/oversus The popularity of ablative resurfacing has diminished 3170improved. Patient satisfactionwas 55% for the peri- somewhat during the past 5 years due to the fear of oral areasand 8070for the periorbital area (Fig.r.6). Ninety adversesequelae, the amount of downtime involved, and percent ofthose patients treated were pleasedthey under- the growing popularity of nonablative forms of resurfac- went the procedure, and would recommend it to others ing, which do not achievesimilar results. Some physicians Other investigatorsreport similar results. have grown frustrated because of the frequent 'hand LaserSkin Resurfacing

Fig. 1.3 Atrophicacne scarring.(A) Beforetreatment. (B) 3 monthspost-treatment

Fig. 1.4 Long term resultsof COzlaser resurfacing are sustainedin patients (A) Beforetreatment (B) Post-treatment.(C) 10 year followup demonstratesthat longterm improvementis maintained

holding' that some patients may require. However, there cations that occur postoperatively commonly occur due to is no substitute for the remarkable results that COz laser improper technique, instrumentation, and/or choice of resurfacingcan produce. As long as careful and complete candidates, inadequate postoperative management/ or a education is provided for the patient, and proper pre- and secondary event that extends the wound deeper than postoperative care is followed, the patient will be very intended (i.e., infection, dermatitis, trauma). Not uncom- oleased with the outcome and believe that facial laser monly, sequelae include prolonged erythema, hyperpig- iesurfacing was well worth the effort. mentation, hypopigmentation, acne and milia, and contact Expected side effects that occur postoperatively include dermatitis. Problematic sequelae include infections, pruritus, edema, erythema, and wound exudates. Compli- increased scleral show or ectropion, corneal abrasions, Laser5.rndLights VoIume I

Fig. 1.5 Long term results of improvementof rhytidesin a patientwith penoral rhytdes (A) Before treatment (B) One month post-trearmenr (C) Seven years post-treatment (D,E) lmprovement of perioral rhytidesfollowing CO, resurfacing

Fig 1 6 (A,B) Post-treatmentimprovement of peflorbitalrhyttcles with CO-. aser resurfacinq LaserSkin Resurfacing

'Targeted hypertrophic scars, and delayed-onset permanent hypo- scarring present. resurfacing' is an important pigmentation These adverse sequelae, and others, will concept For example, a candidate with only mild photo- be discussedin detail in the followine sections. damagemay only require a singlepass with the COz laser. However, in someone with very severe rhytides, after a OVERVIEWOF TREATMENT STRATEGY single pass with the CO2 laser, one can continue with a second and third passin the areasof severephotodamage. To maximize the benefits of COz laser resurfacing, one Therefore it is important to carefully look at the patient's must carefully analyzeand evaluatewhat it is to be treated. skin and note the areasof most severephotodamage. We CO2 laserresurfacing should not be an identicai and purely r.,"i11discuss our methods in great detail in the following mechanical procedure from patient to patient, but should sectlons. be specifically tailored to a patient's needs according Box r.r contains our CO2 laser resurfacingconsultation to the amount and level of photodamage, rhytides, or form, which prompts the examiner to ask pertinent

Patientname: History Allergies Currentoral Rx Hx HSVintection lcold sores o. feverblisters) Hx yeastinfection Hx accutaneuse Hxtobacco use Hx alcoholuse Currenttopical Rx Hx priorblepharoplasty AHA Hx priorfacelift Tretinoin Hx priorbrowlift SPF Hx priordermabrasion Bleach Hx priorTCA peel VitaminC Hx priorphenol peel Hx keloids/hypertrophicscars Hx radiationtherapy Hx skin/woundinfection Hx melasma Hx of vitiligo Hx skinpigment darkening after trauma Hx collagenvascular disease Hx psoriasis Hx scarring/etiology: l_lx eCZema Fitzpatrickskin type: ill Photoaging scale: 1123 Peri-oral Actinickeratoses |456 Peri-orbitai Seborrheickeratoses |t789 Cheeks Lentigines Forehead lvlelasma Neck Scarring: None Surgical Peel/ DA Other Diagnosis: Recommendations:UPCO, laser resurfacing + Site Anesthesia: LOCiir| ^^^l (.oprcar/+^^i^^r // nerve^^".,^ orocKs)ar^^ lV Sedation Generaanesthesia Procedure/ Alternatives/ Risksdlscussed? YES NO At pre-op.visit will need: Pre-op.skin prep.: Hibiclensfacial wash q d 3 3D pre-op Bact.ooan;ntranasal q d 3 3D pre-op Pre-op.topicals: Pre-op.orals: Tretinoin qhs Analgesic Or Renova qns Antiviral: Bleach bid Antibacterial: SPF oaily VtaminC ^.1 Epiquin-micro Other Lasersand Lights Volume ll questions and collect vital history on a patient in order to the patient is allergic to any of the medications above, determine if he/she is a proper candidate, and how the alternativesare prescribed that provide similar antibacte- procedure should be tailored to his/her needs. rial, antifungal, or antiviral protection. The patient rs also The photoagingscale (see Box 1.1) is a nine-point reminded to avoid aspirin, ibuprofen, and vitamin E for cllnical classificationsystem that is utilized to evaluatethe 10 days prior to the procedure to avoid excessbleeding. degree of wrinkling and photodamage (see Table I 2) Patients are classifiedinto one of three groups correspond- o Anesthesia ing to mild, moderate, and severe wrinkling, which will Local anesthesia,IV sedation, or general anesthesiamay represent the depth and number of wrinkles, and the be used for patient comfort. Local anesthesiais provided degree of elastosis and dyschromia. To evaluate the with topical anesthetics such as EMIA (2 5% lidocaine; responsivenessof scarsto the CO2 laser,you may estimate 2.50/oprilocaine) or L-M-XS lidocaine, liposome the level of improvement by gently stretching the area of [5% encapsulated) placed on the skin surface for l-2 hours skin with the scars. Atrophic scars will flatten upon prior to the procedure. The skin needsto be appropriately stretching the skin However, deep pitting acne scarswill prepared by thorough washing prior to the application not stretch, and this is a predictor that they will likely not of the topical respondto laserresurfacing. anesthetic,which needs to be applied thickly and with occlusion for maximal efficacy. Beware the use of high-concentration compounded topical anesthetics, some of which have been applied to large areas with TREATMENTTECHNIQUE disastrouseffects. Many dermatologic surgeonsmay palr this with local nerve o Equipment blocks. * The Cadillac of CO2 lasersis the Ultrapulse CO2 laser wrth computer pattern generator (CPG) and . Operativeprocedure: preparation 3 mm spot size handpiece However there are many Facrallaser resurfacingwith the COz laser takes approxr- excellent lasersthat can deliver high energy short mately 1-2 hours to complete Preparation begins with pulse CO2 laser to the skin. the placement of moist cloth towels to surround the area "i" Sterile gloves to be treated (Fig.r.Z). Metal corneal shieldsare placed to {. Smoke evacuatorwith sterile tubing and wand protect the patient's eyes (Fig. 1.8). All members in the room during procedure 'f" Gauze and cotton-tipped applicators soaked in sterile the must alsowear eye protection. saline Independent of the brand of CO2 laser being used, the method of treatment is the same: using single pulsed .F Damp sterile cloth towels vaporizationswith minimal overlap but with the intent to "1.Metal corneal shields, procaine drops, Celluvisc leaveno untreated gapsbehind in the skin (Fig.t.q) \Mhen (caramellosesodium) solution treating the perioral area, extend the treatment to abut .ir Wet tongue blades the vermilion border, but use caution when crossingit If over-treated, the vermilion line may be blunted, scarred,

TREATMENTALGORITHM . Preoperativeevaluation A thorough preoperative evaluation is a vital component of the treatment process This is usually conducted approximately 2 weeks prior to the procedure and consists of a complete history and focused physical examination. Consistent photographs are taken of the patient in the forward, oblique, and side views. Prophylactic medications are prescribed, which often include an appropriate antibiotic or combination thereof fciorofloxacin 500mg PO b.i.d for 10 days, dicloxacillin f00mg fO b.i.d. for l0 days), an antifungal (fluconazole 100 mg PO q.d. for 5 days), and an antiviral fvalacyclovir HC1 500mg b.i.d. for l0 daysJ.All of the aforementioned medications are to be started the morning of (or possibly the night before) the procedure. If the patient has a history of herpes virus infection in the areato be treated, the antiviral medication is started at a higher dose (500 mg Fig. 1,7 Wet towelsare carefullyplaced around the treatmenlarea t.i.d. for 14 days], three days prior to the procedure If for the oatient'sorotection LaserSkin Resurfacing

Fig. 1.8 Cox lasereye shields:1 mm stainlesssteel, polished interior, dull exterior.These are availablein threesizes

Fig.1.10 Dessicated debris after the first pass is removedwith wet gauzeor cottontip applicators

second pass, obvious tissue tightening is visualized and tissue ablation seemsless dramatic although 30-50 pm of dermis is still ablated. Remember, the more passes,the deeper the resurfacing, the more marked the improvement, but these advantagescome with longer healingtime and greater persistenceof postoperative erythema.

. Operativeprocedure: mild photodamage andacne scars The least aggressiveapproach is used in patients with mild photodamage and mild scarring Often only a single pass with the CO2 laseris performed with or without a reduced Fig. |.9 lt is imponantfor passesto be placedadjacent to each fluence. We use Coherent's (now LumenisJ UltraPulse other,minimizing overlap while ensuring that no areas are missed CO2 laser, with the first pass utilizing the CPG at an energy of 300 mJ, settings of pattern 3 or 5, density 6, size9 The first passremoves the epidermis. \Arhatremains or thickened, and patients may express dissatisfaction is gray-white desiccatedtissue debris, which can be wiped 'disappearing ' with a lip As a positive element, the tissue away with saline-soakedgauze and cotton-tipped applica- tightening that develops in the cutaneous tissue of the tors. However, if a patient has only mild photodamage it upper lip tends to evert the lip, which can provide a is beneficial to leave this desiccated epidermal debris on pleasingappearance. the skin, as it serves as a biological dressing, providing Prior to treatment, assessmentsshould be made as to hydration to the skin, decreasingpain, inflammation and the number of passeswith the laser that are necessary, postoperative pigmentary problems, and aids in other and if so, in what areas. The most common areas to aspectsof wound healing. perform a second or third passare the glabellar and forehead areas,the periorbital areas,the nasolabialand peri- . Operativeprocedure: moderate oral areas. If more than one pass is intended, the debris overlying the skin should be removed to enhance the photodamageand acnescars laser-tissueinteraction (Fig.r.ro). Further passeswith the Patients with moderate photodamage and acne scarrlng laser should be oriented at right anglesto the first pass,as usually require more than a single passprocedure as they this will decreasethe risk of a streakingappearance to the are seekinga greaterdegree of improvement. First, a single skin postoperatively. The second pass can be performed passusing the CPG handpiece at energy of 300 mJ, set- on the full face or localized to specific areas.With the tings of pattern 3, size of 9, density of 6. The desiccated Lasersand Lights Volume ll

debris is then removed, which exposes the underlying . Postoperativeprocedure dermis. A second passis then performed using the same There are two general approachesto postoperative care: laser parameters as with the hrst pass,or the density may open or closed wound treatment. be reduced to decreasethe thermal effects if efforts are In the open technique, immediately postoperatively, being made to decreasehealing time With the second the areatreated is coveredwith moist salinegauze, and the pass, obvious tissue tightening of the dermis can be patient is transferred to the recovery room. Postopera- observed.Ifless tightening is desired, a lower pulse energy tively, careful instructions are given to the patient to soak [200 mJ) may be selected.An alternative, and more con- the areas with a water and vinegar preparation (1 tsp servativeprocedure, would be to do targeted resurfacing vinegar to I pint of water) at least four to five times per In other words, a single full-face pass, wipe away the day This is an attempt to deter infection of the entire epidermal debris, then a second pass only in areas that surfacetreated, which is a large open wound The patient require additional tightening or have deeper rhytides or must alsobe fastidiousregarding keeping the skin continu- scars This approach produces respectableoutcomes, with ously coated with petrolatum to prevent the development the advantageof faster recovery and fewer side effects of crusting or scabbrng,which will delay wound healing. because of a less aggressivetreatment. The 3 mm hand- If only a single pass with the laser is performed, the piece can then be used over deeper lines and wrinkles to epidermis generallybegins to peel in about 4 days, and the sculpt areasthat may need further tightening or finesse. peeling is usually complete by 7-8 days. Erythema is minimal and fades in 2-4 weeks. If the desiccateddebris o Operativeprocedure: severe photodamage was wiped away, the healingtime extends to l0-14 days, and acnescars length of erythema is also extended, usually 6-8 T;|il" In patients with severe photodamage or scarring, a third We subscribeto a combination of closed and then ooen pass may be necessary After wiping away debris, and techniques Immediately post resurfacing, an occlu;ive drying the treatment area, this passshould be directed at dressingis applied to the entire area (Silon mask), which areasthat require the most improvement First, a full-face stays in place for 3 days In our opinion, this speedsthe passis performed as previously described. The epidermal rate of healing (Fig.r.rr) Three days after resurfacing,the debris is wiped away and a second full-face pass is per- mask is removed, and the patient is instructed to apply formed using CPG settingsof pattern 3, size9, and density petrolatum to all areas Appointments are made on days 5. A third pass can then be performed in areasthat still l, 3, and 7 following surgery. Inquiries regardingpain are require improvement, most commonly the glabella, the made during each postoperativevisit, and careful instruc- perioral area,and the medial cheeks The 3 mm handpiece tions are given to the patient so they understand what to can then be used to sculpt and soften the edges of deep expect. Most importantly, they are instructed to prevent wrinkles or scars It is important to remember that because crusting by frequent soaking and lubrication of the de- the jawline is more susceptibleto adverseeffects, in par- epithelialized areas (Box r.z). Pain after day 2 is uncom- ticular hypopigmentation and scarring, this area should mon, generally an indication of dryness or infection, and always be treated with a single pass only. must be investigated. Cultures are extremely important, as a clinical diagnosis can be difficult Infection can be o Operativeprocedure: periorbital area bacterial, viral, or fungal. If a bacterial infection rs suspected, pseudomonasor Staplrylococcusa1.lreus are often When addressingthe periorbital areas, the settings are the culprits Herpes simplex and zoster can occur after slightly changedto reflect the thinner, more tenuous skin. laser resurfacing, usually after stopping the prophylactic With the first pass with the CPG (energy 200-300 mJ), medication. Restarting the medication at full dosagewill the pattern is 5 usually with a density of 5, size 9. If a be helpful Candida infection is usually evident with the second pass is performed, the density is decreasedto 4 presence of satellite lesions, disproportionate erythema, No more than two passesare ever performed in the eyelids and poor wound healing. Fortunately it responds rapidly with the CPG After one or two passesusing the CPG to fluconazole or ketoconazole.This topic will handpiece, the 3 mm spot size handpiece is used as a fDiflucan) be sculpting device. discussedin more detail in the subsequentsections. Preoperative topical medications may be restarted One of the difficulties in laserresurfacing is recognizing if there are no complications at 3-4 weeks after treatment. when to stop treating an area.We recommend that treatment should be discontinued in an area if there is visual elimination of a wrinkle or scar,if yellow-brown discoloration is seen (indicating thermal damagel, and if treatment TROUBLESHOOTING AND IMPORTANT TIPS no longer elicits collagen shrinkage or tissue tightening. In order to obtain a reproducible and predictable cosmetic With the energiesused with the CPG, our studies have outcome, it is important to keep in mind certain principles shown that a plateau of ablation and tissue tightening is in using the CO2 laser Not only does adhering to the fo1- reached between three and four passes.As such, we limit lowing guidelinesmake the procedure safer,but it ensures the maximum number of passesto anv area to three. happier patients: LaserSkin Resurfacing

AFTERYOUR PROCEDURE ',." lt rnaybe soothingto applyfrozen pea ice packscovered withgauze to yourface for the journey home * Alwayswash your hands before bringing them near your face Avoidtouching your face as muchas possibleUse a O{lp to adjustSilon if necessarY d" Youwill have a cleardressing called Silon on yourface Tryto keepit in placefor at least3 days Youmay use a smal amountof petroleumjelly (Vaseline) under the edgesto helpit adhere,or secureit witha softheadband * Soakexposed treated areas with gauze pads saturatedin of vinegarand water (1 teaspoonof white a solution 'tingles' vinegarto a cup of coolwater) lf it toomuch at first, you maydecrease the amountof vinegarIo 1/z reaspoonand gradually increase it as youbecome accustomedto it Youmay chooseto sprayyour face with thevinegar water solution in betweensoaks .1.The more frequently you soak, the faster the skin will heal andthe more comfortable you will be Soakevery 1-2 hours while awaketo gentlyremove the weepingthat 'soft occursand to preventthe buid up of crusts'The v negarmakes the water slightly acidic and helpskill any surfacebacteria lf thecrust remalns after soaking, do not rubit as th s maycause bleeding and disturbthe healing Youcan gently swab the area wrth a cleanQ-tip and let thecrust slide off gently ,:- Useartif icia tearsliberally throughout the day and Lacrilubeointment at nlghtto moisturizeand lubricate youreyes -:" ALWAYSKEEP AREAS WHICH ARE NOT COVERED BY SILONLUBRICATED WITH VASELINE * Applyice packs(or bags of frozenpeas) every few hours Fig. 1.11 The Silonmask is utilizedin the {irst3 daysimmediately forthe first 48 hoursTo insurethat the Silon does not afterCO2 resurfacing This mask has the advantageof beingclear In oeeloff with the ice pack,cover the area wlth moist addition,the poroussurface of the mask allowsfor adequateascetic ga-zepads oerore placi"g the packs acid soaks {, Takeall prescribed medication as ordered ,1"Sleep on yourback with your head elevated using two or rnorepillows This will help to reducethe swelling A pillowunder the knees or undereach arm helps keep you In place Eatsoft, cold foodsas toerated Avoidsalty foods for the I Resurfacethe completecosmetic unit. It is important "i" firstweek as theymay prornote swelltng Should the skin to remember that there is often a textural change aroundthe mouth feel swoJlen and tight, drink with a after significant skin rejuvenation. \A4renperforming straw CO2 laser resurfacingin skin types I-III, great care .r You maywash your hair after the Silonmask is removed, hotwater or directthe stream on tne must be taken to treat an entire cosmetic unit, butdo notuse treatedarea Vaselinecan be removedfrom your hair with otherwise clear lines of demarcation may arise that dishwashingliquid will be unacceptableto patients. These lines of ":, Avoidheavy exercise, perspiring, or exposingthe skin to demarcation are exceedingly difficult to blend once thesun for 2 weeksSunscreen and make-upmay be 7-10days after developed, even in the hands of the most experi- appliedonce the skin has healed, usually yourprocedure Do notuse these products until you have enced surgeons.The exceptions here are the eyelids beeninstructed to do so and the perioral region, which can be treated as "1"Oozrng of cear yellowor pinkfluid from the treated areas distinct cosmetic units, and in experienced hands the willoccur for 3 7 days lt maybe gentlypatted dry wtth a treatment of acne scarringin the malar regions rn cleangar:ze pad ll is a'socommon to seeareas of trappedblood under the Silon mask patients with type IV-VI skin. It is important to '? N/ildto moderateswelling is normaland may last 2 7 feather the edges carefully in these casesso as to days Occastonallythe eyes may swell c osedfor a dayor avoid distinct margins of change two to severeredness is expectedfor 1-2weeks, 2. Test out your equipment on a wet tongue blade prior * Moderate thenwill fade gradually over 8 12weeks or longer to beginning the procedure. Have a tongue blade ready "i. A mildburning sensation oJ the treated areas may occur on the operating table to test out different settings to and shouldresolve within a week Useyour prescribed ensure that the laser is functioning properly. Also pan mediationas directedto keepcomfortable during before starting resurfacing on the patient, it is thistirne {" lf you developa fever,rash, blisters, increased pain, important to ascertainthat the equipment is up and severeitching, or changein color of the weepingfluid, runnlng. call our office immediately,as these symptomsmay be a sign of infection Lasersand Lights Volume ll

Fig. 1.13 The 3 mm beam usedto targetpursed rhytides on the vermilionborder

handpiece should be used to make a single pass along the vermilion borders of the upper and lower lips, as this is the most common area of persistenceof wrinkles Beware of over-treating the vermilion 'under-privileged border, which is an zone' with a propensity to scarring.Treating up to the vermilion border will tend to evert the vermilion, emohasrze the vermilion border, and make the lips appear fuller. The lines that cross the vermilion border can also be individually traced with the 3 mm beam. Further- more, the 3 mm beam can be used to treat individual problematic lesions such as actinic or seborrheic keratoses,and can be used to sculpt individual scars or deep wrinkle lines. Fig. 1.12 (A) The 3 mm beam usedto tightenthe lowereyelid 5. Carefully obserue the laser-tissue interaction. Aiways (B) The 3 mm beam usedto tightenthe uppereyelid carefully observethe immediate tissue responsefor 'chamois' contraction and the so called yellow-brown discoloration, a sign of thermal damage.Also observe the excessivetissue contraction in the eyelids to 3. Start your first pass away from critical anatomic avoid excessivetightening of tissue and possibility of locations, for instance on the forehead. scleral show or ectropion. This is especiallytrue rn 4- Use the 3 mm beam sat'ely and et'fectiuely in appropri- patients with a prior history of blepharoplasty. ate areas. The 3 mm beam should be used for the 6. Know your endpoints The endpoint of treatment is treatment of specific problem areas.It is far safer to reached when one of the following conditions 1sseen: tighten the tissue of the eyelids using carefully placed (iJ the u'rinkle or scar is clinically effaced; (ii) yellow individual spots of the 3 mm beam for fine sculpting or brown discoloration indicating thermal damage is and inducing appropriate tissue contraction (Fig.r.rz). seen; (iii) no further skin tightening is observed. This can be done after a first passwith the appropri- There is no reason to continue treating an area when ate CPG settings.The 3 mm spot can be piaced at 3- any one of these phenomena is observed. 5 mm intervals to achieve tightening of the skin 7. Feather appropriately to blur lines of d.emarcation. without significant thermal risk. Concentric lines of Becausemost types of problematic healing occur at these spots shouid be placed so that the laser beam is the periphery of the face, reducing the pulse energy moving away from the site to be tightened. Another and leaving the epidermal debris intact in these areas area where the 3 mm beam has a sisnificant role is results in better healing with fewer problems. In fact, the upperand lower lips (Fig.r.r3). The 3 mm the areasof tissue tightening for more aggressive 73 LaserSkin Resurfacing

therapy may be preselected for two or three passes SIDEEFFECTS, COMPLICATIONS, AND of the CO2 laser, with the remainder of the face ALTERNATIVEAPPROACH E5 receiving only a single pass.The epidermal debns of the single pass areas may be left intact so as to The incidence of complications of resurfacingprocedures enhance wound healing in these areasand to give an is generally related to the depth of ablation and the area of transition with the non-treated skin (Fig.r.r4). patient'sgenetic pigmentary phenotype. The targeted areas thus receive full and effective treatment, while those of less concern receive more . Postoperativeswelling superficial therapy reducing risk and healing time Postoperative swelling is generally mild to moderate, while maintaining efficacy. peaks on days2-3, and resolvesby days 5-7. However, at 8. Do not ouerlap passes.When using a pattern-scanning times, dramatic swelling may occur and be frightening and device or pattern generator, the patterns should not uncomfortable for the patient Although we do not rou- be overlapped.Also the individual laser impacts tinely use steroids in the postoperative course, the use of within the pattern should have minimal overlap. Such oral prednisone (40-60 mg per day for 3-5 days) or IM overlap may cause excessivethermal necrosisleading betamethasone(6-9 mg) may be valuablein isolated cases. to deep wounds, which may ultimately lead to Patients are also advised to apply cold compresses of scarring. When performing resurfacing with the 3 mm vinegar soaks in addition to utilizing ice packs or bags of collimated beam, it is critical to move the handpiece frozen peasto reduce post-treatment swelling. Be careful at a rate that allows single pulse laser-tissue interac- not to induce frostbite in these areasl tion, with minimal or no overlapping (generally a rate of 4-10 Hz). This beam can literally coagulatethe skin if kept in a constant position for a few seconds. . Erythema Erythema after CO2 laser resurfacing occurs in 1000/oof patients (Fig. r.rf). The erythema is proportional to the depth of laser resurfacing: deeper peels and multiple passesare associatedwith a higher degree and more persistent erythema. The erythema can persist for a period of l-8 months with an averageof 3.5 months. The lower eyelids are particularly prone to persistent erythema, possibly because of the thinness of the tissue. The clinical perception of erythema can also persist longer in those

Fig. 1.14 The epidermaldebris of the first pass is left intactin the jawlineto give a more smoothtransition, enhance healing time, as well as decreasingpotential complications in this sensitiveanatomic Fig. 1.15 Typicalerythema seen 7-10 days afterCO, laser resurfacing r4 Lasersand Lights Volume ll

Fig.1.16 Petechia on thecheek of a patientappearing in thefirst 2 weekspost-treatment These were most likely caused by scratching

patients undergoing resurfacing in a localized area as opposed to the entire face [4 versus 2.5 months). There is usually no significant erythema observed after I year. After complete re-epithelialization at t0-14 days, most patients are able to camouflagethe erythema with appropriate make-up. COz lasers with short pulse duration appear to produce less residual thermal damage, which translates into decreasedpostoperative erythema

o Petechiae Although of almost no long term significance,the appearance of small petechiae is often a source of much concern to the patient (Fig. r.16) They appear jusr as re-epithelialization is complete, thus conflicting with the patient's desire to return to the public view Petechiae may continue for several weeks after the procedure but clear quickly without treatment

o Hypopigmentation Fig. 1.17 (A) Hypopigmentedpatches present in the mandibleof a patientas a resultof CO, laserresurfacing This anatomicarea is The risk for pigmentary aiterations is an important issue particularlyprone to this operativecomplication (B) True hypopigmen- that needs to be discussed with patients carefully tationon the upperlip of a patientas a resultof CO, laserresurfacing Hypopigmentation associatedwith laser resurfacing has been estimated to occur with an incidence of 6-200/0.It appearsto be a delayed phenomenon that usually becomes apparent only after 6 months in most patients. It may not become visible in some patients for as long as I year or The incidence of hypopigmentation is approximately more after treatment. There is some confusion about this 5-20o/oand curiously is more common in skin types I and subject stemming from the lack of clear distinction II than in the darker skin types. There appearsto be no between two commonly observed forms of pigment loss difference in rates of hypopigmentation using short pulse associatedwith this procedure: delayed-onsetpermanent (90 ms) versus longer dwell time [950 ms) CO2 lasers hypopigmentation and pseudohypopigmentation associ- devices, but the incidence with erbium lasers is signifi- ated with rejuvenation of actinic bronzing A third type of cantly less This problem appearsto be related to depth hypopigmentation is associated with focal scarring, an of injury and thickness of thermal necrosis,or as a conse- uncommon but reported phenomenon. This is apparent quence of other complications such asinfection or contact much earlier than the delayed-onsetpermanent hypoprg- dermatitis. These patients generally have long-lastingery- mentation/ is related to aggressivelocal resurfacing with thema (Fig. r.r7). There is some evidence that use of greater depth of vaporization and thermal injury, and is EM[A topical anesthetic can reduce the incidence more obvious. of delayed onset permanent hypopigmentation as a result LaserSkin Resurfacing ofbetter hydration (and protection) oftreated skin. Free- epidermal treatment of the neck and/or upper chest in hand techniques allowing pulse stacking or CPG patterns patients with significant solar bronzing of the neck and having greater than 500/ooverlap may contribute to this chest may also be necessary. complication. This type of pigment loss is difficult to treat. However one can blend the depigmented areas into ' the surrounding skin by decreasing the pigmentation in HyPerPigmentation those areasto effectivelv reduce the contrast. either via Hyperpigmentation occurs as a consequence of skin type repeat CO2 resurfacing, or using vascular and pigment and is more commonly seen in Fitzpatrick skin types III lasers.The excimer laserhas had limited successin reduc- and higher. Patients with skin type II with green or brown ing true hypopigmentation, and may be related to inducing eyes may also be at some risk during the healing phase. 'tan' a in the treated skin. Any benefit gained seemsto be This phenomenon occurs irrespective of the laser system reversed after cessationof therapy with this modality. used (Fig. r.r8). The incidence has been estimated to be Pseudohypopigmentationrefers to the relative hypo- in the range of 25-1000/0.In a study of 22 patients with pigmentation of the resurfaced skin compared with the Fitzpatrick type IV skin, the incidence of hyperpigmenta- actinicallybronzed and photodamagednonresurfaced skin. tion was 680/0.Hyperpigmentation started I month after This, however, cannot be considered true hypopigmenta- treatment and lasted 3.8 months with therapy. tion, as the pigment loss reflects only a return to the \A/hether pretreatment reduces the incidence of natural skin color prior to sun damage.This is a phenom- hyperpigmentation has been the subject of controversy. enon that can be demonstrated to the patient by examin- However, two recent studies seem to indicate that pre- ing the color of a non-sun-exposedarea such as the inner treatment with topical agents does not influence the arm. This type of hypopigmentation is an inevitable con- incidence of postresurfacing hyperpigmentation. In the sequenceof skin resurfacingirrespective ofthe methodol- above mentioned study of 22 patients, there was no dif- ogy It merely reflects elimination of the photodamaged ference in the group pretreated with hydroquinone, tret- dyspigmented skin and its replacement with non-sun- inoin and topical vitamin C. Similarly, a study of 100 exposed pigment. One obvious way to minimize this con- patients with skin types I-III dlvided into three groups trast is to treat the entire face as a complete cosmetic unit randomized to receive for a minimum of 2 weeks so that any perceptible change in color can be hidden in either 100/oglycolic acid alone, 40lohydroquinone plus the transition zone of the skin at the angle of the man- 0.025ok tretinoin, or no pretreatment prior to CO2 dlble and the neck. lVhen this is done, superficial intra- laser resurfacing, no significant difference in the rates of

Fig. 1.18 Postresurfacinghyperpigmentation in a patientwith type lV skin. (A) Beforetreatment. (B) 3 monthspost-treatment. (C) One year afterthe procedurethe pigmentarychange is clearedwith the aid of bleachingcream. 76 Lasersand Lights Votume ll

hyperpigmentation was detected. The average rate of ter cloacae,Escherichia coli, Proteusmirabilis, Corynebac- hyperpigmentation was 31% in all skin types but there terium sp.,andSerratia marcescens, although it is uncertain were no patients with skin types IV or V. One of us is if some of these isolates are colonizers or contamlnants. simply not concerned about postlaserhyperpigmentation; In general,the types of organism identified are similar to we guaranteeitl But starting 40lohydroquinone cream at those isolated in burn patients. The majority of infections about 3.5 weeks post laser resurfacingwill abort the com- occur during days 2-10 postoperation. Delayed infection mencement of hyperpigmentation in most cases. following full face CO2 laser resurfacing appearing 3-5 weeks after the completion of oral antibiotics has been o Infection reported and may be related to exogenous sources of infection, such as contaminated emollients, possibly sec- CO2 laser resurfacing of the face produces a large, open ondary to the practice of'double dipping' with fingers or superficial second degree burn with subsequent copious other instruments. drainage and extensive crusting during the early heaiing Pain is by far the most common complaint in infected phase Given the localized immunosuppressed milieu of patients, reported by nearly 50% of the patients. This is burnt tissue, a fertile environment is produced for various followed by burning and itching (29%). patnogens. sensations Other signs include excessive erythema, yellow crust or exu- There are three categoriesof infections that can occur dates,pustules, and erosions However, an active infection following resurfacing.These include bacterial, fungal, and should be suspected when a patient complains of new viral infections. The most common and the most Doten- onset, persistent, or increasing pain, beyond the mild tially significant infections are caused by bacteria. The sunburnlike stinging, burning or itching experienced by incidence of bacterial infections without antibiotrc oro- most patients in the first 3 days. In such an event, infec- phylaxis was 7.60/0.This number is reduced to 4.3% in tion should be strongly suspected,irrespective of a pos- those patients who receivedprophylactic PO ciprofloxacin sible lack of findings on physical examination. It is in one study. The use of intranasal mupirocin has not important to note that one can not identify the type of proved to be efficacious in reducing the risk of bacterial infection based on symptoms and clinical signs Culture infections. Other reports have indicated much lower identification and sensitivitv is reouired. infection rates. The rates of infection appear to be higher Among fungal infections in postresurfacing patients, in full face procedures compared with localized resurfac- candida species are the most commonly found culprits. ing (i e., eyelids, perioral areaJ. Typical clinical findings of candidiasissuch as beefy ery- The most common bacterial agent is coagulase-positive thema and pustule formation, although helpful in early S. aureus (Fig.r.r9). This infection can lead to scarring of clinical diagnosis, are rarely encountered Instead, the the infected areas.The most clinically significant conse- symptoms appear to be similar to bacterial infections and quence of this infection is toxic shock syndrome, which include intense pain, burning or pruritus. The incidence can occur in a subset of patients regardlessof the severity of cutaneous candidiasisis approximately 1-30lobased on of the infection. The secondmost common bacterial infec- several published reports. Fungal organisms, especiaily tion is causedby gram-negativeorganisms, the most prev- candida, may be less likely to be cultured than bacteria. alent of which is pseudomonas.Similarly, these infections Cutaneous candidal infections prevent re-epithelialization are associated with localized scarring. Other reported and result in prolonged wound healing.Prophylactic treat- pathogens include Staphylococcusepidermidis, Enterobac- ment with fluconazoledecreases, and may entirely elimi, nate the risk of, postresurfacing candidal infections. In one study, comparing the prophylaxis with antibiotics alone versus antibiotics and fluconazole,patients treated with fluconazole re-epithelialized somewhat faster. We routinely administer prophylaxis with fluconazole 100 mg daily, typically started the evening prior to surgery and continued for a total of 5 days. Among viral infections that can occur postresurfacing, reactivation of latent herpes simpiex virus IHSVJ is of most concern as it can result in scarring (Fig. r.zo). The trauma to the skin can trigger the multiplication of HSV virions, which can quickly spread to the entire raw skin The true incidence of this phenomenon is unknown, but without HSV prophylaxis the incidence of HSV reactlva- tion after Baker'sphenol peels has been reported to be up to 50o/oin patients with a positive history of prior herpes labialis. HSV infection postresurfacinghas been reported Fig. 1.19 Erosionsand crustson the chin causedby Staphyloccus despite prophylaxis with acyclovir.We have also observed aureus poslresurfacing severalcases of postresurfacingHSV reactivation despite 11

LaserSkin Resurfacing

thrombocytopenic events We have adopted the use of valacyclovir for COz laser resurfacing procedures over famciclovir. We use valacyclovir 500 mg twice daily starting the day before surgery for patients without prior history of HSV, but increasethe dosageto 500 mg three times daily for those patients with a prior history of HSV. Among other rare adverseinfections are those caused by atypical mycobacteria Symmetrical non-tender nodules developing I month after full-face laser skin resurfacing and blepharoplasty discovered to be Mycobacterium fortuitum rpon surgical debridement and culture have been reported. These resolved uneventfully after appropriate antimicrobial therapy. Another unusual viral complication reported is the development of multiple warts on day 20 after COz laser resurfacing. These spontaneously invo- luted 5 days later.

RECOMMENDATIONSFOR PROPHYLAXIS We find that broad prophylactic antimicrobial coverageis extremely useful in our practice to minimize the risk of infection. As such,we routinely treat patients with dicloxacillin [500 mg b.i.d.) and ciprofloxacin (500 mg b.i.d.] for l0 days. We have found it necessaryto provide full coverage against both S aureus and pseudomonas. We have not been satisfied with the prophylactic coverage of a single antibiotic and consequently have decided to provide dual coverage Patients are instructed to start both agentsthe evening prior to surgery. Patients also receive Fig. 1.20 (A) Cultureproven HSV afterCO2 resurfacing (100 mg q.d.) for 5 days irrespective of (B) DisseminatedHSV in a patientafter COz resurfacing which fluconazoie resultedin significantscarring prior history of candidal infections. Valacyclovir is used as prophylaxis against HSV infection (500 mg b.i.d. without history of prior HSV started I day and 500 mg t.i.d. for patients with prior history of HSV started 3 days prior to procedure). This is continued for a total of l0 famciclovir prophylaxis. In a study of 99 laser resurfacing oays patients randomized into two groups receiving famciclovir In order to reduce the overall bacterial count, we 250 mg or 500 mg twice daily, starting the day before the instruct patients to wash the area to be resurfaced along procedure and continuing for 10 days, the investigators with their hands with an antiseptic at least once daily reported a t0.10/obreakthrough rate with no significant starting 3 days prior to the procedure' Patients are difference between the two dosing groups. instructed to soak the resurfaced area with I teaspoon of The efficacy of valacyclovir as a preventative agent white vinegar in I cup of water (20loacetic acid) at least againstHSV outbreaks post resurfacinghas recently been every 2 hours for 10-15 minutes This practice is espe- established in a clinical trial. Valacyclovir, the L-valine cially stressedin the first few days while the patients are ester prodrug of acyclovir, is rapidly and completely con- wearing the Silon mask. verted to acyclovir with a three- to fivefold increasein oral bioavailability compared with oral acyclovir itself. In a o study of 84 patients who underwent resurfacing with Contactdermatitis either chemical peels, dermabrasion, or COz/Er:YAG The incidence of contact dermatitis is estimated to be lasers,patients were randomly assignedto start valacyclo- 5-l0o/0, although this number may be lower nowadays vir 500 mg twice daily either the morning before or the compared with when the original reports were published. morning of the procedure for 14 days.Viral cultures were This reduction in incidence predominantly stems fiom the performed at suspicion of an outbreak and at the end of fact that we have learned not to utilize topical antibiotics 14 days Patients were followed clinically for a period and other sensitizingemollients postresurfacing.The cuta- of 21 days. The infection rate was 00/oin both groups It neous surface devoid of the epidermal barrier will provide is important to note that caution should be exercised a more effective environment for the interaction of various when administering valacyclovirto immunocompromised sensitizerssuch as fragrance,preservatives, or antibiotics hosts due to concern about the ootential associationwith with the cutaneous immune system, thereby causing a Lasersand Lights Volume ll type IV allergic contact dermatitis Hence, the use of . Complicationsin resurfacingof the skin of topicals, except what is required to serve as tne open the eyelids dressing, should be avoided until the skin is fully re- epithelialized. We recommend that patients avoid using Ectropion is a rare complication that can be seenas a result make-up and other emollients for up to 2 weeks after CO2 of overaggressivetissue tightening of the lower eyelids. laserresurfacrng. It may alsobe that the thin re-epithelial- Contraction of scarred tissue leads to exposure of the ized layer is simply more susceptible to the irritating conjunctiva Considerable care should be given to resur- effects of various topical agentswithout the presence of facing the lower eyelids of patients over 50 yearswho have a true allergicdermatitis. lax lids or a history of transcutaneouslower lid blepharoplasty without stabilization of the lateral canthai tendon. o Pruritus Mild ectropion of the iower lids associatedwith CO2 laser resurfacingis usually reversible. Patients' frustration Pruritus is a common sequel of laser resurfacing. Some with excessive tearing, dryness, photophobia, and con- reports indicate that up to 910/oof patients expenence junctivitis needs to be managed. Severe ectropion is a some degree of pruritus during the healing process. This rare and serious complication that requires surgical symptom can last from 3 to 2l days. A variety of factors correction. may contribute to this phenomenon, including patchy Synechiarefers to the attachment of the re-epithelial- dryness,irritation induced by topical emollients and med- ized surfacesof the skin during the healing processresult- ications, and physiologic sensationsthat are associated ing in unnatural webbing (Fig. r.zr) It is generally with epithelial healing. The itch experienced by most encountered in the first few days postresurfacing. The patients secondaryto wound healingis particularly norice- most common location is the lower eyelids It is crucial able in the f rst 2 weeks to examine the skin of the eyelids carefully postresurfac- Another etiology of pruritus may be infection. The ing as early intervention can completeiy resoivethis com- sensationof itch may signalbacterial, fungal or viral infec- plication. If synechiais detected, the areashouid be locally tions of the healingepithelium. Persistentand severecom- infiitrated with lidocaine With the help of a 30 gauge plaints of pruritus should therefore be investigated needle, the webbed surfacesshould be gently teased away thoroughly with appropriate tests and cultures. Some have from each other completely separatingthem (Fig. t.zz) speculated that fungal organisms may be more closely An Uitrathin Duoderm patch can then be appiied for related to postresurfacing pruritus than other infectious 3-4 days to expedite the healing process in the area agents. (Fig.r.z3) Once infection and contact or irritant dermatitis are excluded, postresurfacingpruritus generallyresponds well . Scars to antihistamines such as diphenhydramine (Benadryl l0 or 25 mg) or cetirizine (Zyrtec, 10 mg). Cool soaks can Scarringis a much reported but, with properly performed also contribute to the amelioration of this sensation. laserresurfacing, fortunately a rare complication following Finally, the initiation of topical steroids can also produce CO2 laser resurfacing (Fig. t.z+) The true incidence is significant relief.

. Acneand milia Investigators have reported differing rates of acne and milia formation postresurfacing.It is our estimate that this side effect occurs in l0-l5o/o of our patients. Reported figures of l0-l l0loby Nanni and Alster are in agreement with our estimates. However. Bernstein et al reoorted an incidence of 860/0.These lesionsusually became apparent 3-6 weeks post-therapy, often lasting 4-8 weeks. The use of petrolatum-based ointments is certainly a contributing factor in these patients. It is possible that the incidence of this side effect may parallel the degreeof thermal inlury to the tissue. By way of explanation, thermal injury will probably lead to a disruptive effect on sebaceousglands causingtheir aberrant behavior, or paradoxicallyto stimu- lating increased sebum production Treatment of this complication includes the institution of oral antibiotics, alpha-hydroxyacids, and manual extraction. It may be beneficialto place those patients with prior history of acne on an appropriate prophylactic regimen in anticipation of Fig. 1.21 Synechiadetected at day 3 in the lowereyelid of patient postresurfacingflare. afterCO, laserresurfacing 19 LaserSkin Resurfacing

Fig. 1.22 The synechiais teasedapart with the aid of a 30 gauge needleafter localinfiltration with lidocaine(lignocaine)

Fig. 1.23 Duodermpatch placed tor optimalhealing

probably less than l0l0. Scars may be both hypertrophic and atrophic. The risk of scarring is increased by overly Fig.1.24 (A) White scars on the lateral aspects of theupper lip aggressivetreatments, poor treatment technique, or exten- (B) In orderto eradicatethe deep lines and blend scarring, more COrlaser resurfacing was attempted which also caused sion of the wound depth by infection or contact dermati- aggressive 'off' furtherscarring. (C) Postoperative appearance of theupper lip tis Incorrect times, high scanner densities (greater demonstratingthe eradication of thedeep lines, healing of thenew than 400/o),and failure to keep the handpiece moving redscar, as wellas blendingof theprevious scars on theupper lip during resurfacing are some of the issues that lead to 'stacking' inadvertent overlap or of pulses with the resultant accumulation of heat and residual thermal damage. A patient's past medical history such as recent or dibular region is particularly prone to this side effect and, current history of isotretinoin use, personal or family as such, extreme care should be devoted to this area with history ofkeloids or hypertrophic scarring,and other prior partrcular attention to laser settings while attempting to cosmetic procedures or superficial radiation may be rele- minimize the number of passes.However, there exists a vant and should be given seriousconsideration. The man- subset of patients who develop scarring due to as yet Lasersand Lights Volume ll unidentifiable factors. Re-epithelialization for these ADVANCEDTOPICS patients is prolonged and can be in the order of months rather than weeks. Longer durations for spontaneous o Erbiumlaser rejuvenation of the wound healing correlates with increased risk of scarrrng photodamagedneck Intrinsically poor wound healing with underlying medical problems may be a factor in these patients Resurfacingof the face alone often leavesa line of demar- The earliest evidence for the develooment of scars rs cation between the sun-damagedskin of the submandibu- usually erythema and pruritus. At this point, the affected lar area and the neck, and the new skin of the face that is area should be cultured to rule out infection, and the use relatively free of sun damage.Although this line of transi- of high-potency topical steroids should be initiated If the tion can usually be well hidden in the submandibular area affected area begins to thicken, intralesional injection of to detract attention, it can still be visible. In addition, l0 mg/ml triamcinolone with fluorouracil (50mg/ml) many patients are interested in reducing the overall should be given every week until resolution. Treatment appearance of photodamage on their neck. Even when with the pulse dye laser should also be considered. only mild photodamage is present on the neck, such changesfrequently appear accentuated after laser resur- o facing of the face As an increased risk profile including Timeline for occurrenceof sideeffects scarring and pigmentary changesis associatedwith CO2 It is important to keep in mind the various stages of laser resurfacingof the neck, the more appropriate choice wound healing following CO2 laser resurfacing and the of a laseris the Er:YAG. possible time frame within which various complications Various explanationslie behind the poor wound healing can occur during each specific phase of recovery so that on the neck. There is a significantdecrease in the number long term sequelaecan be minimized. During the first l0 of terminal hair follicles on the neck, the main source of days it is crucial to observe closely for signs of infection epidermal regeneration.There is also a relative decrease and lack of re-epithelialization. Areas that do not re- in adnexal structures of the neck compared with the face epithelialize, exhibit excessiveerythema, or have become A thinner epidermis and decreasedvascularity may also painful should be cultured, as these are not normal post- contribute to the differential healing. The average thick- operative signsand symptoms. If the cultures are negative, ness of facial epidermis is 122 pm, whereas it is only and the areasdo not re-epithelialize rapidly, they should 87 pm for the neck. The papillary dermis of the neck is be covered with a thin oatch of Duoderm and then also thinner averaging8l pm compared with the average recheckedin 2-3 days thickness of I 13 pm on the face. Lastly, increasedsurface At weeks 4-6, postinflammatory hyperpigmentation stress factors related to mobility of the neck may play a can start to appear. This should be aggressivelytreated role, as well as the skin's attachment to the underlying with a bleaching agent (such as 4% hydroquinone cream), platysma muscle. and complete sun protection with judicious use of com- In resurfacingof the neck, patients need to be educated plete blocking agentscontaining zinc or titanium. Consid- to have realistic goals and expectations of improvement. eration should alsobe given to the use of a topical retinoid Complete elimination of the wrinkling of the neck cannot and Vitamin C. be achieved with resurfacing procedures A modest At 6-12 weeks, observationfor signsof incipient scar- improvement of the texture of the skin of the neck can ring or excessiveskin tightening is important. Incipient be realized, but elimination of the crepeJike textural scarring is indicated by persistent localized erythema and changes of the lower neck is extremely difficult Also possible induration. If these signs are evident, a strong becauseof the need to remain superficialin resurfacingof topical steroid such as clobetasol propionate [Temovate] the neck, the survival of some sun-damagedpigment cells should be instituted. Ifthese poorly healing areasbegin to intermixed with the new epidermis may result in less develop cords of fibrosis or induration with skin elevation, improvement than desired. they should be injected with a combination of intralesional The specificbenefit ofthe Er:YAG laserin resurfacing S-fluorouracil (50mg/ml) and triamcinolone l0 mg/mL the neck derives from the fact that it has an increased in a I :9 dilution. Manual massageof the tight areasmay ability to ablate tissue while producing markedly lessnon- also be beneficial and should be performed for 10-15 specificthermal damagethan the CO2 laser.Also this laser minutes three to four times daily. Treatment with the has the ability to vaporize epidermis in a more superficial pulse dye laser should also be strongly considered, using manner per pass. low fluence at weekly intervals The typical treatment protocol involves treating the At 6 months, other pigmentary changesmay become entire neck with a single pass of the Er:YAG laser (Fig. visible Residualareas of hyperpigmentation can be treated t.z5). The V-neck of the chest can be treated in this with the Q-switched Alexandrite laser. We have recently manner if desired. A second passat identical settings can had good successin treating this complication with frac- be made on the upper half of the neck. A more defocused tional photothermolysis [Fraxel lasertreatment). Hypopig- pass should be employed for the lower half of the neck mented areascan be treated with glycolic acid peels and and chest. Care should be taken not to wipe the epidermal the excimer laser. debris. Leaving this layer of desiccated epidermis intact LaserSkin Resurfacing

Fig. 1.26 The use of the pulsedye laser(V-beam) betore laser resurfacing.More aggressiveis acceptabletreatment as the purpura will resolvebv the time full re-eoithelializationis achieved Fig.1.25 Erbium resurfacing of theneck The debris is leftintact on theneck to minimizecomplications and enhance wound healing

results in a biologic dressing that prevents excessive drying of the dermis and markedly reducesdermal inflammation. orbital hyperpigmentation, and other skin surface rrregu- Furthermore, wiping after the completion of the laser larities. Although CO2 laser resurfacing can improve treatment may remove some remaining viable cells that superficial pigmentation and surface irregularities, other can aid wound healing from nonadnexal structures. In an mentioned complaints cannot solely be addressedwith the area with poor wound healing reserve/ those remaining routine use of the CO2 laser. viable cel1scan be of critical value in boosting the regen- Nevertheless, many of the above problems can be erative process. Postoperative care is similar to that of treated with more specific lasers during the same treat- CO2 resurfacing and includes dilute vinegar soaks and ment session with favorable results without an increased application of white petrolatum. Prophylaxis against infec- risk of side effects. We routinely use the pulse dye laser tion is similar, as outlined in the previous section on this for the treatment of facial telangiectasias immediately topic. It is very important that resurfacing of the neck prior to resurfacing. Such treatments can be rendered remains intraepidermal. Removal of the epidermts com- more aggressivelyin this manner as damage to epidermal pletely exposes the patient to risks of hypopigmentation skin is no longer a concern asthe removal of the epidermis and scarring,even if done in small areas. will be immediately achievedwith the COz laser. In fact, The risks with this procedure are similar to those out- a more efficacious outcome with the pulse dye laser can lined in the complication section of COz laser resurfacing. be achievedwith a singletreatment session.The resultant Having used the Er:YAG laserroutinely in resurfacingthe purpura induced by the pulse dye laser generally resolves neck in this manner for the past 8 years,we have seenfew within 7-10 days the time it takes for re-epithelialization permanent adverse effects. The risk of scarring is assocr- of the denuded skin postresurfacing(Fig. t.z5). ated with poor treatment technique, infection, and contact The pulsed dye laser (or more specifically the V-beam) dermatitis, all of which are significantly increased with is also very useful in decreasingthe contrast of the resur- complete epidermal removal. All patients generally heal faced facial tissue with the sun damaged skin of the neck. within 7-10 days with the resolution of the erythema Very commonly, a significant component of the color con- within 2 weeks. One reported caseof prolonged erythema trast is caused by dilated capillaries, typical of poikilo- was associated with the development of Pseudomonas derma of Civatte, that are most prominent on the upper aerugtnosa infection during the second postoperative lateral neck and the upper mid chest. These vesselsare treated with the V-beam (6 ms, 7.5 J/cm2, l0 mm, 30 ms cryogen, 30 ms delay), using single or stacked pulses to . Useof multiplelasers in thesame achieve intravascular coagulation of the vesselsprior to erbium resurfacing. treatmentsession For the treatment of pigmentary alterations which are Many patients who desire COz laser resurfacing due to confined to the epidermis, CO2 laser resurfacing will photodamagealso express concern about a variety of other usually suffice. However, the concomitant use of a findings including facial telangiectasias, lentigos, peri- pigment-specific laser can result in more effective Lasersand Lights Volume ll

Fig. 1.27 The O-switchedalexandrite laser is usedto treat dyschromiaand lentiginesprior to a resurfacingprocedure

treatment of deeper dermal pigment when compared with use of either laser alone. For example, in treating dark circles around the eyes,which are often causedby dermal pigment, we have discovered that ablating the epidermis using the pulsed CO2 laser prior to the use of the Q- switched alexandrite produces better results In fact, resurfacing of the epidermal layer not only will make the Fig.1.28 (A) The erbium laser is usedat a 30 degreeangle for fine dermal pigment more obvious, but also will eliminate the sculptingof deeperrhytides (B) Capillary bleeding after erbium laser competing epidermal melanin, thereby reducing the scat- lreatmentis routinelyseen tering of the pigment specific laser. This dermal pigment will fade slowly following a period of weeks to months similar to the disappearanceof the dermal pigment seen a 30 degree angie to the skin surfaceto selectivelyvapor- in nevus of Ota The alexandrite laser is also very useful ize the edges of acne scars and high points of residual in treating dyschromia of the neck, lentigines, seborrheic wrinkle lines, as using this laser at a 90 degree angletends (Fig.te). keratoses,and solar bronzing \4/hen the erbium to drill holes and result rn an uneven contour. The 30 laser is used alone, in an intraepidermal manner/ many degreeangle allows selectiveablation of the high points of of these lesions will recur with healine. Treatment of tissue irregularity. these lesions prior to Er:YAG resurfacing results in much greater successin complete elimination of these lesions The Er:YAG laser intraepidermal resurfacing FURTHERREADING blends the transition from lesions to surroundins skin Alster TS 1996 Comparisonof two high-energypulsed carbon imperceptibly dioxide lasersin the treatment of periorbitalrhytides Careful sculpting of the edgesof sharply defined acne DermatologicSurgery 22:541 scars,chicken pox scars,or deep wrinkle lines can be aided Alster T, Hirsch R 2003 Single-passCO2 laserskin resurfacingof with the use of the Er:YAG laser in the same trearmenr light and dark skin: extendedexperience with 52 patients Journalof Cosmetic LaserTherapy session The depth of vaporization of the CO2 laser is 5:39-42 Alster TS, Nanni CA 1999 Famcyclovirprophylaxis of herpes limited to 200-300 prm after three to four passes.The simplex virus reactivationafter laserskin resurfacingDermato- Er : YAG laserhas the ability to ablate 10-40 pm of tissue logic Surgery25:242-246 per pass at an approximate fluence of 14J/cmz. For the Atiyeh BS, Dham R, CostagliolaM, et al 2004 Moist exposed treatment of abovementioned irregularities,the use of the therapy: an effective and valid alternative to occlusive dressings Er:YAG iaser ailows the deeper penetration and the fine for post laserresurfacing wound care DermatologicSurgery 30:18 25, discussion25 sculpting needed to ameliorate such lesions (Fig.r.z8). As FitzpatrickRE 2000 COz and Er:YAG laserresurfacing: practrcal the beam of this laser is noncollimated, the desired effect approachesDermatologic Therapy 13:102 113 can be achieved by moving the handpiece away from the Fitzpatrick RE 2002 Maximizing benefits and minimizing risk with target area.Also we find it useful to use the handpiece at COz laserresurfacing Dermatologic Clinics 20:77-86 23

Laser Skin Resurfacing

Fitzpatrick RE, Goldman MP 2000 Carbon dioxide resurfacingof Khosh MM, LarrabeeWF, Smoller B 1999 Safety and efficacy of the face. In: Fitzpatrick RE, Goldman MP [eds) Cosmetic laser high fluence COz laser skin resurfacingwith a single pass. surgery. Mosby, St Louis, pp 45-145 Journal of Cutaneous Laser Therapy l:3740 Fitzpatrick RE, Rostan EF, Marchell N 2000 Collagen tightening Lowe NJ, Lask G, Griffin ME, et al 1995 Skin resurfacingwith the induced by carbon dioxide laser versus erbium:YAG laser. UltraPulse carbon dioxide laser: observationson 100 patients. Lasersin Surgery and Medicine 27:395-403 DermatologicSurgery 2l :1025 Fulton JE 1997 Complications of laser resurfacing. Dermatologic Manuskiatti W, Fitzpatrick RE, Goldman MP, et al 1999 Prophy- Surgery23:9I-99 lactic antibiotics in patients undergoing laser resurfacingof the Gilber S, McBurney E 2000 Use of valacyclovir for herpes simplex skin. Journal of the American Academy of Dermatology 40:77- virus-l (HSV-I) prophylaxis after facial resurfacing:a 84 randomized clinical trial of dosing regimens. Dermatologic Nanni CA, Alster TS 1998 Complications of carbon dioxide laser Surgery26:50-54 resurfacing:an evaluation of 500 patients. Dermatologic Surgery Goldberg D 1998 Treatment of photodamagedneck skin with 24:315-320 the pulsed erbium:YAc laser. Dermatologic Surgery 24:619- RossEV, Barnette DJ, Glatter RD, et al 1999 Effects ofoverlap 621 and passnumber in CO2 laser skin resurfacing: a study of Goldman MP, Fitzpatrick RE 1995 Laser treatment of scars. residual thermal damage,cell death, and wound healing Lasers DermatologicSurgery 21 :685-687 in Surgeryand Medicine 24:103-l l3 Goldman MP, Rostan EF, Fitzpatrick RE 2002 Laser rejuvenation RossEV, Miller C, Meehan K, et al 2001 One-passCO2 versus of the photodamagedneck. American Journal of Cosmetic multiple-pass Er:YAG laser resurfacingin the treatment of Surgery19:21-28 rhytides: a comparison side-by-sidestudy of pulsed CO2 and Surgery 27 :709-7 I 5 Grimes PE, Bhawan J, Kim J, et al 2001 Laser resurfacing-induced Er :YAG lasers.Dermatologic hypopigmentation: histologic alterations and repigmentation Schwartz RI, Burns AJ, Rohrich RI, et al 1999 Long term with topical photochemotherapy. Dermatologic Surgery 27 :515- assessmentof COz facial resurfacing:aesthetic results and 520 complications. Plastic and Reconstructive Surgery I03:592-601 Grossman PH, Grossman AR 2002 Treatment of thermal injuries Waldorf HA, Kauvar ANB, Geronemus RG 1995 Skin resurfacing from COz laser resurfacing.Plastic and Reconstructive Surgery of fine to deep rhytides using char-free carbon &oxide laser in 109:1435-1442 47 patients. Dermatologic Surgery 2l:940 Kannon GA, Garrett AB 1995 Moist wound healing with occlusive Weinstein C 1998 Carbon dioxide laser resurfacing:long-term dressings:a clinical review. Dermatologic Surgery 21:583 follow-up in 2123 patients. Clinics in Plastic Surgery 25:109

INTRODUCTION tive dual mode, or a pure coagulative mode' The ablative mode is characterized by a short 200 ps suprathreshold Once upon a time, the world of facial rejuvenation was pulse. The dual-mode ablation/coagulation is achieved by rather simple. But so much has changed, with the develop- an ablative pulse immediately followed by a relatively long ment of a host of new laser, broad-band light, and radio- subablative pulse. The coagulative mode, according to frequency systems. If only it was possible to predict the Sapijaszko ind Zachary, consists simply of a series of long-term efficacy of some of these newer devices. But, subablative pulses. fortunately there is still laser resurfacing, one of the most With this device, it is possible to control with a wide predictable procedures available for facial rejuvenation. the depth of ablation and thermal 'king' degree of flexibility The CO2 laser is still considered by some for injury, in micrometers. This is a departure from any other facial tightening. But for a time, there was a degree of system, and makes the operator consider the tissue effects irrational exuberance concerning the first generation carefully and in clinically relevant units. Other features on erbium:yttrium-aluminum-garnet (Er:YAG) lasers. A1- the touch-sensitive screen include the fluence, scanpattern though according to Teikemeier and Goldberg, these are and size, repetition rate and degree of overlap. Changing excellent for microlaser fvery superficial) peels, the origi- the latter is automatically associated with a change in the nal Er:YAG lasersdid not induce sufficient thermal dena- declared fluence delivered to the tissue. These are useful turation to cause significant tightening comparable to the and intuitive additions that add to the safety of the laser, CO2 lasers. However, as stated by Kaufmann and Hibst, particularly when it is considered that Er:YAG laser the second generation Er:YAG laserswere both ablative tissue vaporizationis almost linear with each pass,and has 'chamois' and coagulative (hence the term dual mode), which no color changesassociated with thermal necro- allowed much deeper vaporization with significant control sis. This is in contrast to the COz laser that has a plateau 'colors of hemostasis. \44ri1e the author has used many of the of ablation and characteristic of depth'. In desic- Er:YAG laser systems,he will focus mainly on the device cated tissue, the ablation rate is very low when using the made by Sciton, namely the dual-mode Contour COz laser at 10.6 pm, and thus the ablation processtypi- ET:YAG cally all but ceasesafter three passeswith standard param- absorption of the Based on the high coefficient of eters. At 2.94 trtm (with the Er:YAG), the ablation rate 2.94 Stmwavelength by water, the vaporization threshold of desiccated tissue is also moderated, but still significant, of the Er:YAG laser has been calculated to be between at roughly two thirds the rate for hydrated tissue, that is joule/cmz 0.5 and 1.5 J/cm2. According to Zachary, each approximately2-2.5 Stm/I / cmz. will instantly vaporize 2-4 1trrrof tissue, leaving minimal thermal injury. The Contour Er:YAG contains not one TECHNIQUES but two Er:YAG lasers providing 45 W of power. The engineers use a technology called optical multiplexing to Standardpreoperative resurfacing measures are employed. 'macropulses' generate multiple variable length to gener- Surgery is generally performed under local anesthesia, ate high tissue fluence. Perez et al report that at 50% though some surgeonsprefer general anesthetic. Kilmer overlap, fluencesof up to 100 J/cmz can be generatedfor has sho*tt that superficial anesthesia can be adequately aggressive vaporization. In contrast to the earlier low- powered Er:YAG lasers, sufficient energy can be delivered with this device to remove the epidermis in one pass. The optical multiplexing also allows the laser to be used either in an ablative mode, a combined ablative/coagula- Lasersand Lights Volume ll

50-75 mg and hydroxyzine 25 mg IM are also frequently are employed to blend the perimeter of any treated area used. It should be remembered that the natural tendency of the 'collimated' Each anatomic area of the face needs to be assessed Er:YAG beam is to be diversent at a distance separatelywith regardto depth of vaporization.The eyelid of greater than approximately 5 inches By pulling back epidermal thickness is approximately 50-70 pm The the handpiece,a very significantreduction in fluencesfor normal parametersrn this area would be a first passusing feathering purposes can be achieved. As always, careful ablation 60-80pm (15-20Jlcm2J to remove the entire observationof tissue responseis indicated to assessappro- epidermis in one pass. A 500/opulse overlap is used to priateness of parameters. Postoperatively, patients are prevent any irregularity of vaporization depth associated treated with standard postlaser resurfacing dressings 'occluded' with suboptimal overlapping puises. Unlike CO2 laser Generally closed techniques are advisedfor the resurfacing,residual laser debris need not be wiped away first 48 hours since the Er:YAG laser will remove this on subseouent The technique for microlaserpeels should be addressed passes.Indeed one of the real benefits of Er: YAG laser is here, for they are very popular. They go by various names, 'arctic the hands-off nature of this technique, with very little including the peel'. These are generally performed tissuemanipulation. A secondpass would normallv include under topical anesthesia,and can be applied to the full both ablative and coagulativemodes at 60/25 pm \Arhen face, neck, chest, and upper limbs. But great care must be necessary,a third pass with similar parameters could be taken to perform only an intraepidermal vaporization on glven. any areabut the face, otherwise scarringmight occur. Any By contrast the upper lip generally requires more Er: YAG laser can be used for these procedures, since the aggressiveresurfacing. The first pass might be at 90- object is to provide only superficial vaporization. Many l00pm of ablation,the secondpass at 90/50pm abla- laser surgeons use a single pulse freehand approach, tion/coagulation, a third at 90/100pm, and so forth without the scanner, with low fluences inducing about depending on the degree of rhytides and elastosis There l0-30 pm ablation, and a repetition rate of approximately is no obvious clinical endpoint with this laser.Novice users l0-15 pulses/s. Patients generally heal within 3-5 days need to be cautious about the depth of vaoorization. and can be back at work with minimal residual signs of Visible contraction is evident in second and zubsequent laserpeeling. The procedure is repeated at l-month inter- using the combined ablative and coagulative vals four to six times, until a satisfactory outcome ls ffj:"":*n"" achieved.The improvements between each treatment are Those physicians who are used to working in a com- not awesome,but the final outcome, when compared with pletely dry field will be in for a slight surprise. Some the preoperative images,is generally quite obvious. Post- patients are just more vascularthan others. Bleeding is a operatively frequent and simple superficialmoisturization function of many factors including rosaceous change, is all that is required. anxiety level, and venous pressure. There is a trade-off between absolute hemostasisand reduced thermal iniurv when comparing the CO2 lasers with the dual mode OUTCOMES Contour Er: YAG laser. For this reason the ooerator can be relatively aggressivewith the coagulatingmode of the Patientswith significantphotodamage, thick wrinkles, and Contour, though this might delay healing and prolong elastosisrequire deeper vaporizationcompared with those 'contraction' erythema However, most patients do not need more than with more superficialdamage. Tissue is seen 50 pm of coagulation to control hemostasis,and on the on secondand subsequentpasses, though it was lessappar- eyelids 25 pm is sufficient. ent for Hughes than with the CO2 laser. This is presum- Some experienced Er:YAG lasersurgeons like to work ably related to the increased desiccation induced by the freehand becauseconventional Er: YAG lasersIl 5-20 \4f latter as experienced by Zachary. are relatively underpowered and the scanners can be The majority of patients undergoing standard Er:YAG rather pedestrian.This is a perfectly reasonabletechnique, laser resurfacingre-eprtheli alize by day 5-7 . Deeper areas though the uniformity of the scanningdevice is preferable. of vaporization take relatively longer to heal. Persistent At 45 W, the Contour Er:YAG is a high-powered system erythema is noted in those who undergo any significant enabling the scannerto run at a usefully fast rate. There depth of vaporization This may last for up to 3 months is a noticeable reduction in scanningspeed when using the or longer in some cases.In comparisonwith the CO2 laser, dual mode as opposed to the single ablation-only mode, erythema does clear somewhat faster, though as the pro- There are times when a single collimated spot is more cedure becomesmore aggressive,so too will the erythema useful than a scan pattern. The single spot is either 2 or persist longer. Minor scarring has been seen in a small 4 mm in diameter. The 2 mm diameter spot is capableof number of patients where laser surgery was more aggres- delivering extremely high fluences, and may be used for sive, and the author would caution that this complication local sculpting of elevated lesionssuch as epidermal nevi, might certainly occur without careful technique. Fortu- angiofibromas,other benign tumors, scars, warts, rhino- nately, with the use of the pulsed-dye laser, topical and phyma, and superficial skin cancers.For generalresurfac- intralesional steroids, and some handholding, these prob- ing purposesthe 4 mm spot is used. Featheringtechnrques lems can generallybe ameliorated satisfactorily. LaserSkin Resurfacing

Postinflammatory hyperpigmentation is almost guaran- mainly depth related, and this author regularly has patients teed in those with darker skin types, but is never persis- whose skin is still pink at 3 months, and in rare caseseven tent when appropriately treated, according to Polnikorn up to 9 months. Patients undergoing superficial laser et al Hydroquinone cream 40lois started at 3-4 weeks abrasion heal very quickly with only minimal erythema. postoperatively, and continued for approximately 6-8 However, these results were very comparable to those weeks. The current author has seen delayed-onsetpersis- patients undergoing very superficial laser abrasion with the tent hypopigmentation in three patients In one case,the CO2 laser systems.There are many excellent indications loss of pigmentation was quite linear and appearedto be for Er:YAG lasers,and it would be difficult for this indi- related to depth of vaporizatron. This very common sequel vidual to practice dermatoplastic surgery without one of traditional CO2 laser resurfacing is less of a problem V/hen compared with the new nonablative rejuvenation with the Er:YAG laser,but patients should be warned of treatments, this author believes there is no contest its occurrence,as mentioned by Bassand Weinstein. Con- between the results: ablative remains the kingl trary to popular belief, this is a problem for those with skin types I and II, and is rarely seenin those with darker skin types. FURTHERREADING Complications with infection including bacterial, viral, BassLS 1998 Erbium:YAG laserskin resurfacing:preliminary and candidal can all be seen,and vigilanceis required, both clinicalevaluation. Annals of PlasticSurgery 40:328-334 with prophylaxis and early treatment. Herne KB, Zachary CB 2000 New facial rejuvenation techniques 19:221-731 The long-term improvement in color, texture and tone Seminarsin CutaneousMedical Surgery PS 1998 Skin contractionfollowing Erbium:YAG laser have all been long lived, but the degree of improvement Hughes resurfacingDermatologic Surgery 24:109-1 I I depends on the aggressivenessof treatment. On the one KaufmannR, Hibst R 1996 PulsedErbium:YAG laserablation hand, significant tightening and wrinkle reduction compa- in cutaneoussurgery Lasersin Surgery and Medicine rable to that with the COz laser can be achieved with I 9:324-330 multiple passesusing significantcoagulation, leaving up to PerezMI, Bank DE, SilversD 1998 Skin resurfacingof the 50-100 pm of thermal necrosis. Conversely, the newer face with the Erbium:YAG laser Dermatologic Surgery 24:653-658 microlaser peels, wherein just 10-30pm of epidermis PolnikornN, Goldberg DJ, SuwanchindaA, Ng SW 1998 peel are removed, while providing a nice superficial will Erbium:YAG laser resurfacingin Asians Dermatologic Surgery result in more minor benefits. but with verv minimal 24:1303-l 307 downtime SapijaszkoMJ, Zachary CB 2002 ER:YAG laser skin resurfacing DermatologyClinics 20:87-96 TeikemeierG, GoldbergDJ 1997 Skin resurfacingwith the SUMMARY Erbium:YAG laser DermatologicSurgery 23:685-687 WeinsteinC 1999 Erbium laserresurfacing: current concepts There are many myths about the Er:YAG lasers such as Plasticand ReconstructiveSurgery 103:602-6I6 an absence of prolonged redness and less scarring- Zachary CB 2000 Modulating the ER:YAG laser Lasersin Surgery concepts that are simply untrue. These complicattons are and Medicine 26:223-226

AbtativeLaser Resurfacing ll

Zakia Rahman,Melissa Bogel

INTRODUCTION heat the dermis, hence producing no resurfacing effect. Intact, undamaged skin around each treated area theo- The aging of the global population combined with fast- retically acts as a barrier to infection and a reservoir for paced lifestyles have necessitatedefficacious treatments rapid healing through migration of surrounding epidermal for skin senescenceand photodamage that carry minimal cells and division of transient amplifying cells from the downtime There is a myriad of research supporting the basallayer. importance of physical attractiveness as an indicator of The FraxelrMlaser was the first laser that utilized frac- teacher judgment of student intelligence (futts et al tional technology at a wavelength of I 5 50 nm to coagulate 1992), juror's judgment in simulated trials [Mazzella and the epidermis and dermis. Subsequently, a number of Feingold1994), predictedjob success,and compensation other lasers and intense pulsed light (lPL) sources have levels (Morrow et al 1990) Attractive peopie expenence utilized fractional technology, including Palomar Lux IR greater professional and personal successcompared with FractionalrMInfrared handpiece (850-1350 nmJ, Palomar their less attractive counterparts (Langlois et al 2000) Lux 1540 FractionalrMhandpiece (l540nm), Cynosure Long gone are the days when wrinkles, lax skin, and AffirmrM and Alma Harmony Pixel@ Device specifica- pigment spots, such asthose seenin many of Rembrandt's tions and FDA approvalsare summarized in Table z.r. masterpiecesare socially acceptable There are currently four major modalities for ablative skin resurfacing. These are the carbon dioxide [COr) . Fractionaldevice descriptions laser, erbium : yttrium-aluminum-garnet (Er :YAG) laser, FRAXELSR'" AND FRAXELSR 15OOTMLASER microablative or fractional photothermolysis, and plasma regeneration. Although fractional photothermolysis The first fractional resurfacing laser launched in 2004 achievesresurfacing, tissue is coagulated,not ablated The (FraxelrM,Reliant TechnologiesInc., Mountain Mew, CA) COz and Er:YAG lasersare effective in the treatment of usesa diode pumped erbium fiber laser,which emits light sun-induced wrinkles, brown spots, acne scars, and skin at a wavelength of 1550 nm with a variable spot size that laxrty, but have a disadvantagein that they require a high is determined by the telescoping lens, targeting water as level of operator skill to avoid complications such as scar- its chromophore in the skin (Box z.r). The beam is deliv- ring, dyspigmentation, and lines of demarcation between ered through an optically tracked, microprocessor- treated and untreated areas.They also require meticulous controlled handpieceto produce an affay of microthermal postoperative care by the patient and have downtime zones (MTZs), each approximately 100 pm in diameter, periods of a week or more with oozing and denuded skin. or about the size of a human hair. The depth of an MTZ The side effect profile has decreasedthe number of COz variesbetween 300 and 1200 pm deep. and Er:YAG laser treatments that are performed, as The energy varies from 4lo 40 mJ/cm2. During each patients demand iow or no downtime procedures treatment, 125 or 250 columns for the Fraxel SRrMdevice in 2004 Manstein et al introduced the concept of frac- of MTZs are created per cm2 per pass, depending on tional photothermolysis usrngthe FraxelrMlaser by Reliant operator settings. The density of MTZs per pass in the device varies from 9 to 4000 MTZs/ technologies [Mountain View, CA) in an attempt to Fraxel SR l500rM dehver results approachingthat of traditional ablativelaser pass. The laser incorporates variable densities for each resurfacing, without the associated risks and lengthy energy and coveragesetting. The energy settings are opti- recovery period \{Ihereas traditional laser resurfacing mized to prevent bulk heating at each energy setting while removes the entire top layer of the skin surface, creating maximizing coverageand depth of tissue coagulationper a visible wound and loss of the skin's protective function, pass. A water-soluble dye applied in a thin layer to the 'fraction' fractional laser resurfacing treats a small of the treatment area allows the laser's optical tracking system skin at each session This also differs from other nonabla- to detect contact and movement with the skin and adjust tive lasers, which require epidermal cooiing whiie they the laser repetition rate depending on hand velocity' This Lasersand Lights Volume ll

Company Device Energy FractionaItechnology: Ctearedindications source characteristics

AlmaLasers, Pixel@ 2940nm Er:YAG Delivery:Stamping method tor deliveryof "$ Ablalionof softtissue Inc. preprogrammedfractional pattern .:. Skinresurfacing Caesarea, Spotsize: | 1 x 11 mm treatmentarea .:. Treatmentof wrinkles lsrael Patterndensity: Two settings:49 pixelsor .1.Epidermal nevi 81 pixelsper 121 mm'?spot set .1.Spider veins Maximumfluence: 1400 mJ/oulse "l' Keratoses MaximumreD. rclei 2Hz Cynosure, Affirm 1440nm Delivery:Stamping method for delivery %t-Ablation and coagulation Inc. 1440rM Nd:YAG throughmultilensed handpiece to of soft tissue Westford,MA createcolumns of highfluence S Periorbitaland periocular USA interspersedwith uniform low-fluence wrinkles backgroundirradiation. ,1"Pigmented lesions Spotsize: 10 mm treatmentarea Maximumfluence: 8 J/cm2 Maximumrco. 'ate'.2Hz AffirmrM Xenonpulsed Delivery:Stamping method {or delivery .:. Ablationand coagulation light throughmultilensed handpiece to of softtissue 560-950 nm createcolumns of highlluence .1"Periorbital and periocular interspersedwith uniform low{luence wrinkles backgroundinadiation. * Pigmentedlesions Spotsize: 11 x 55 mm (6 cm'?) Maximumfluence: 20 Jlcm2 Maximumreo. rate:0.33 Hz Palomar Lux 1540rM 1540nm Delivery:Stamping method for deliveryof "i' Dermatologicprocedures Medical preprogrammedfractional pattern requiringthe coagulation Technologies, throughmultilensed handpiece of soft tissue Inc. Spotsize: 10 mm or 15mm treatment Burlington, MA USA Patterndensity: Two settings:100 or 320 spotsper cm' Cooling:Contact cooling LuxlR .:, Infrared Delivery:Pulsed delivery for energy .3 Dermatologicprocedures FractionalrM noncoherent fractionationof hyperthermicbeams. requiringthe coagulation light Spotsize: 12-28mm treatment area ot softtissue, including d,,Wavelength Patterndensity: Thermal pulses delivers treatmentof wart and rangingfrom an arrayof variabledensity tattoos 850-1350 nm Cooling:Contact cooling & 1700- 2500nm Reliant FraxelSR 1550 nm Delivery:Scanning and focusing ""rDermatologic procedures Technologies, 75OTM diode-pumped, continuousmotion handDiece requiringthe coagulation Inc. erbiumfiber Spotsize: 140pm of soft tissue Mountain Patterndensity: Up to 4000microthermal 4" Skinresurfacing View,CA USA treatmentzones oer cmz proceoures Energysettings 6-40 mJ/MTZ * Pigmentedlesions, Maximumhandsoeed: 6 cm/s includinglentigos, solar lentigos,melasma and dyschromia $ Periorbitalwrinkles {. Acnescars and surgical scars FraxelSR 1550 nm Delivery:Scanning and focusing ri Dermatologicprocedures 1500rM diode-pumped, continuousmotion handoiece with requiringthe coagulation erbiumfiber autozoomteChnology of soft tissue Spotsize: Adjustable, ranging from "3 Skinresurfacing 50-300 pm procedures PatternDensity: Up to 4000microthermal {' Pigmentedlesions, treatmentzones oer cm2 includinglentigos, solar EnergySettings: 4-4O \J|MTZ lentigos,melasma and Maximumhandsoeed: 6cm/s dyschromia * Periorbitalwrinkles )r AbtativeLaser Resurfacing ll

Fractionalphotothermolysis was developedto approach rA^ ^ t^ ^^t ^+{i^^^., ^{ +"^!i+ ^^^t t^^^. ,^,i+A I Y Urr I u4r gr iluduy ut U dutt ur at rdSY I"^^ gJur "{^^i^^rdur/ rg vvru I locc ronn'roni r'ma and an imnrnrrari c do offont nrnf lo Earlyc nical evldencereveals fractional resurfac ng lo be parlicularlyusefu in the treatmentof photoagng, mi dlo- moderaterhytides, acne scarring,and superficial pigrnentarydisorders including melasma The dev ce ls safe for treatrnentof nonfacial areas such aS lhe nech,chesl, bacr..a-d exl,emlies The energysetting controls the depth of inlury,while the dens ty settng co.trorsthe percentageof skin that is -reatcd Hin^trrtrntrrn\/ strt-i^os th'rs have 2 ora2te.trffcat in the treatmentof rhytidesand scarrng, while low-energ, settingsare sufficient for superficial p gmentarydisorders

is very similar to an optical mouse for computers When the handpiece moves more quickly, the laser repetition rate is higher, and when the handpiecemoves more slowly, Microthermalzone the laser repetition rate is lower. This assuresa uniform, Fig.2.1 A schematicof fractionalphotothermolysis treatment oi the reproducible pattern of microthermal treatment columns skin Noteconical shaped zones of tissuecoagulation (microthermal independent of operator velocity. The ability of the laser zones)surrounded by normaltissue. to adapt to the operator's preferred speed makes treatment with the device simple to master. Treatment columns are approximateiy 300 to 1200 pm coliagen change and deep, in contrast to the typical 200 to 300 pm depth of to heat the deep dermis to induce Palomar multiple pass CO2 resurfacing (Laubach et al 2005). A skin tightening (Starlux LuxlR FractionalrM, MAJ. The third zone of normal skin surroundseach microscopic treatment Medical Technologies, Inc., Burlington, the company, but column, leaving the barrier function of the epidermis approach is not defined as fractional by interspersed with intact and no visible woundins. The stratum corneum incorporates columns of high fluence irradiation This is labeled remains intact during and after laser firing. Patients can uniform low-fluencebackground (CAP) technology by the maker often apply make-up or sunscreen following treatment Combined Apex PulserM including a frac- (Fig. z.r) The normal intervening tissue allows for rapid of the device [Cynosure) Other devices, re-epithelializationby keratinocyte migration and divislon tional COz laser, are rn development. of transient amplifying cells into the treatment column After 2-3 days, the tops of the wounded areasare shed PALOMARLUX IR FRACTIONALTMINFRARED as microscopic epidermal necrotic debris (MENDs; HANDPrECE(ASO-rrSO NIl\ ) Tannous et al 2005). \44ren there is disruption of the a handpiece attachment in basement membrane, dermal as well as epidermal con- Palomar Medical introduced is FDA approved for the coagulation tents are expelled in the MENDs This has clinical impli- 2005: Lux IR, which employs an IPL noncoherent light in cations in the treatment of dermal pigmentary disorders of soft tissue. This to the StarluxrM system. Further collagen remodeling continues in the MTZ over the handpiece attachment the next 3 to 6 months. On average,each sessiontreats about 20% of the skin surface, so four to six treatments PALOMARLUX 1540 FRACTIONALTM are needed for optimal results HANDPTECE(rS+O r'rnn) Severalcompanies are now incorporating the fractional Palomar introduced the LUX 1540 handpiece in 2006 concept into laser technology. Presentiy three different Zelickson et al presented a clinical comparison of approachesare being taken. The first approach delivers [2006) the FraxelrMlaser to the Palomar Lux 1540 FractionalrM columns of laser light to the skin to fractionally heat and handpiece.This is a 1540nm Er:YAG laser delivered irreversibly damage the epidermis and hlgh dermis using through a multilensed circular aperture that is either 10 an Er:YAG laser delivered through a multilensed hand- or 15 mm in diameter The handpiece lays down 100 or piece Fractional Er:YAG, Palomar Medical ) [540nm JIU spotsper cm-. TechnologiesInc , Burlington, MA and 1440 nm Nd:YAG laser,AffirmtM, Cynosure Inc , Westford MA). The second approach uses a fractional infrared handpiece to deliver AFFIRMTM, AFFI RMTM 1440 noncoherentlight in the 825-1350 nm rangeas a regular The Cynosure AffirmrM comes in two different heads,the array of small hyperthermic beams with contact cooling AffirmrM, which is a xenon pulsed light, and the AffirmrM Lasersand Lights Volume ll

1440, which is a l440nm neodymium [Nd):YAG laser. molysis to target water-containing tissue and effect con- The AffirmrM also distinguishes itself as not being frac- trolled tissue vaporization. Rather, ionized inert nitrogen tional, but having a CAP technology The Cynosure gas (plasma) is emitted in a millisecond pulse to deliver AffirmrM has FDA approval for the ablative and coagula- heat energy to tissue directly upon contact. tion of soft tissue, periorbital and periocular wrinkles and The plasmaskin regenerationdevice consistsof an ultra pigmented lesions.In 2006, Weiss et al published the use high frequency (UHF) radiofrequency generator which of the AffirmrM device for the treatment of photodamage excites a tuned resonator and imparts energy to a flow of and scars.Twenty subjectsunderwent treatment with the inert nitrogen gas within the hand piece (Fig. z.z). The l0 mm diameter tip at fluences of 3-7 J/cm2 at a repeti- activated, ionized gas is termed plasma. Nitrogen is used tion rate of 7-2Hz with a stamping handpiece.Histologic for the gaseoussource becauseit is able to purge oxygen evaluation demonstrated depth of penetration to 300 pm, from the surfaceof the skin, minimizing the risk of unpre- which is believed to limit the depth of penetration to dictable hot spots and charring. Upon formation, the the epidermis and papillary dermis. The majority of sub- plasma appears as a characteristic lilac glow that transi- jects underwent five treatment sessionsand 760loof the tions to a yellowish light ca11ed a Lewis-Raleigh subjects were graded as having 26-500/oimprovement by afterglow. investigators. Plasma is directed through a qrartz nozzle out of the tip of the handpiece and onto the skin. Energy is rapidly HARMONYPIXEL@ transferred to the skin surface upon contact, causing instantaneous heating in a controiled, uniform manner, The Harmony Pixel@ (Alma LasersLtd, Ceasarea,Israel) without an explosiveeffect on tissueor epidermal removal. device is a 2940 nm attachable module for the Harmony The depth and area of thermal effect are determined by base platform device or a dedicated Harmony Pixel the energy setting and spot size of the handpiece. The system. The Pixel@ device ablates the tissue, unlike the energy can be adjusted from I to 4 J per pulse. The other devicesthat coagulatetissue fractionally There have intended spot size of 6 mm is reached when the device is been no clinical reports of this device to date held approximately 5 mm from the surface of the skin, o however the thermal effect can be increasedor decreased Plasmatechnology by defocusingthe handpiece either closer or farther away Plasmaskin regeneration(PSR) technology was developed from the skin surface. High temperatures during each at roughly the same time as fractional photothermolysis. puise erode the tungsten resonator in the handprece/ so Although high-temperature plasmas have been used in the handpiece must be replaced after each use. Because surgery for over a decade,plasma has been used primarily the nitrogen gas flushes oxygen from the treatment area, as a conduction medium for electric current With PSR, there is no charring, and the skin remains in place to act the plasma itself produces controlled thermal damage to as a biologic dressing on the treated area. This simplifies the skin surface. The technology can be used at varying postoperativecare and decreasesthe risk of adverseeffects energies for different depths of effect, from superficial such as infection and scarrins epidermai sloughingto deeper dermal heating (Box z.z). Plasmaskin regenerationis unique in that it usesenergy PATIENT delivered from plasmarather than light or radiofrequency. SELECTION Plasmais the fourth state of matter in which electrons are As with any procedure, the treating physician must have stripped from atoms to form an ionized gas.Unlike lasers, a complete understanding of the indications and limita- it does not rely on the principles of selective photother- tions of a given technique for cutaneousresurfacing. The

Ultrahigh frequency Plasmaformation (UHFJenergy in Plasmaskin regeneration uses nitrogen plasma energy to heatthe skin without reliance on chromophores,causing tissueremodeling and newcollagen formation plasma skinregeneration technology can be usedat varying energiesfor differentdepths of effect,from superficial epidermalsloughing to deeperdermal heating Threelow-energy treatments can givesimilar results to onehigh-energy treatment in termsof finelines, Plasmaout dyspigmentation,and overall texture with less recovery PulsedN, in time Hign-snglgytreatments are preferred 'for tne improvementof deeprhytides and skin tightening Fig,2,2 A schematicof the plasmaskin regenerationhandpiece A seriesof low-energytreatments can improve Pulsednitrogen gas is ionizedby ultrahigh frequency(UHF) energy prgmentationand textural irregularities on theneck, chest insidethe hand pieceto form plasma.The plasmais directedthrough and hands the quartznozzle al the tip, causinginstantaneous heating upon impactwith the skin . ' '. \ : t':: :' ,' :,t' :.: ::':.1::'':: AblativeLaser Resurfacing ll major indications for ablative and microablative resurfac- improvement in 72o/oof patients, noticeable improvement ing are the improvement of moderate-to-deep rhytides, in 300/0,and moderate-to-significantimprovement in 54o/o dyspigmentation, textural anomalies, and atrophic scars. I month after four treatments. Rokhsar and Fitzpatrick Other conditions that may respond favorably include [2005J treated l0 casesof resistant melasma with frac- sebaceoushyperplasia, xanthelasma, syringomas, actinic tional photothermolysis at 6-12mJ/MTZ with 2000 to cheilitis, and diffuse actinic keratoses, and dyschromras 3500 MTZlcm2 at I to 2 week intervals After four to six such as melasma treatment sessions,600/o of patients achieved 75-1000/o The COz laser is still the gold standard for the treat- clearing and 300/ohad less than 25o/oimprovement. Anec- ment of severelyphotodamaged facial skin, however it has dotal evidence has demonstrated fractional photother- an extended re-epithelialization period with prolonged molysis to be useful in the treatment of solar lentigines, erythema that may persist for severalmonths and has the overall skin texture, and dilated pores following a serles potential for significant side effects Both fractional pho- of three to five treatment sessions.The device appearsto tothermolysis and PSR are prudent alternatives to tradi- work better on fine-to-moderate rhytides than it does on tional resurfacing and, in some cases/may be preferred. deeper lines. Perioral vertical rhytides are particularly Fractional photothermolysis can be used for the treat- resistant. As with other lower recovery time procedures, ment of photodamaged skin, facial rhytides, acne scars, rhytides are not improved to the same degree as tradi- surgical scars, melasma, and photodamaged skin Anec- tional ablative resurfacing. dotai reports suggestthat it may be beneficial in the treat- Fractional photothermolysis has also been studied in ment of senile purpura on the forearms, striae distensae, the treatment of acne scars. Rahman et al presented 53 and telangiectatic matting. There have also been reports atrophic scars, including acne scars, surgical scars, trau- of the treatment of hypopigmentation utilizing fractional matic scars,and striae that were treated at low and high technology (Friedman et al 2006). Fractional resurfacing energies.Ninety-two percent of subjectssustained at least has the advantage of ease of treatment with minimal some clinical improvement and 660/oof subjectssustained downtime and the disadvantage of requiring multiple 50-1000/o improvement of their scars (Rahman et al treatments for optimal results 2006a). Geronemus and colleaguestreated 17 subjects Indications for PSR include mild-to-severe rhytides, with ice-pick, boxcar, and rolling-type acne scarswith five sun-damaged skin, acne scarring, and superficial benign treatments at one- to three-week intervals fGeronemus skin lesions Multiple low-energy treatments appear to 2006; Kim et al 2005). Mean improvement in acne scar- approximate the results of treatments at higher energies, ring measuredby topographic imaging was found tobe 22 with improvement in dyspigmentation, texture, and fine to 61"/o(f lg. 2.3J. lines. High-energy treatments may have better results in Zelickson et al evaluated the Palomar Luxl540 Frac- terms of skin tightening, but will also have 3-5 days more tionalrMdevice compared with the Reliant FraxelrMdevice recovery tlme. and found both to be effective in the delivery of patterns Advancements of fractional photothermolysis and PSR of highly controlled, limited islands of thermal damagein over traditional resurfacingare their relatively safe use rn superficial tissue and the treatment of superficial pig- darker skin types (IV-VI) and in the treatment of non- mented lesions,solar elastosis,and wrinkle reduction. The facial skin such as the neck, chest, and extremities (Chan Palomar device has two spot size heads [10 and l5 mm] 2005J Carbon dioxide resurfacingis limited mainly to the that deliver a uniform array of microbeams, rather than face becausepost-treatment skin regenerationrelies upon the presence of skin appendagesto serve as sources of epithelium that can migrate upward to form the new 'r\hile epidermis. CO2 treatment of the hands, neck, and chest may be successful,a much greater risk for scarnng exists becauseof their lower density of skin appendages. ment of superficialrhytides, scars,and photoaging.Eighty- Fractional resurfacing or a series of low-energy plasma two percent of subjects exhibited mild-to-moderate rejuvenation treatments are a much safer option. improvement, and 72o/oexhibited good improvement. Side effects were minimal and included mild post- and edema resolvingwithin 24 hours. BENEFITS treatment erythema EXPECTED Pain during treatment was judged minimal to moderate. In all resurfacing techniques, the potential for improve- Postauricularhistology showed areasof thermal injury up ment is related to the depth and degree of the injury, to 250 pm deep and 150 Pm wide. regardlessof the method used Since both fractional pho- Pilot studies evaluatingPSR have resulted in the devel- tothermolysis and PSR are relatively new techniques that opment of three main treatment protocols including have been in use for 2 years, few studies have been pub- single- and double-passhigh-energy procedures and low- lished evaluating their results, optimal treatment param- energy treatments performed in a series for rhytides and eters, and long-term benefits and side effects. acne scarring (Kilmer et al 2005). A single,full-facial PSR Preliminary studies on fractional photothermolysis treatment at high energy (3-4 Jl demonstrated a mean for the treatment of periorbital rhytides revealed mild improvement in overall faciai rejuvenation of 500/oby I Lasersand Lights Volume ll

Fig. 2.3 Resultsafter a seriesof four FraxelSR 1500rM skin-resurfacing treatments at 40 mJ spacedone monthapart for acne scarring The patienthas achievedsignificant improvement (Photos courtesy ol Dr ZakiaRahman)

month. Potter and colleaguesused silicone molding to OVERVIEWOF TREATMENTSTRATEGY demonstrate a 390/odecrease in fine line deoth 6 months after one high-energy, full-face rreatment (Potter et al o Treatmentapproach 200sJ. The first step in evaluating a candidate for ablative or Bogle et al (in pressJ evaluated a series of three low microablative resurfacing is to determine the patient's energy plasma [1.2-1.8 J) treatments for facial rejuvena- motivation for correction and what their ultimate soal is. tion and found a 370loimprovement in facial rhvtides at This should include some discussionon the Datient's life- 3-months follow-up (Fig. z.L).In the same study, partici- style and the degree of recovery time he o. rh" ir able to pants rated themselves as having a 68% improvement in tolerate overall facial rejuvenation at 3-months follow-up. Histo- After obtaining an accurate understanding of the logic analysis of post-treatment samples revealed a patient's goals, a comprehensive physical examination of decreasein solarelastosis with significantnew interdigitat- the suggestedtreatment areashould be performed. Careful ing collagen and thickening of the collagen band at the attention should be paid to the quality ofthe skin (texture, dermal-epidermal junction. The mean depth of new col- scarring,rhytides, telangiectasias,dyschromia) and degree lagen formation was 72.3 pm. of skin laxity. A well-trained eye will be able to tailor a Alster and Tanzi (2006) evaluated the efficacy of the plan for facial rejuvenation that will give the greatest plasma regenerationon moderately photodamagedskin on benefit with the least risk. A variety of treatments and the neck, chest, and dorsal hands. The treatment was proceduresshould be discussedwith the patient, outlining found to give significant improvement in all three area, the risks, side effects, costs, invasiveness,recovery time, with the neck and chest respondingbetter than the dorsal and anticipated outcomes The importance of good quality hands. As with facial treatments, higher energy settings photographscannot be overstated.Photographs are useful resulted in greater clinical benefit but longer tissue not only in evaluation of patient progressionand market- healins. ing of one's practice, but also to protect against unwar- 35 AblativeLaser Resurfacing ll

Fig. 2.4 Patientbefore (A) and after(B) a seriesof three low-energyplasma skin regeneration(PSR) treatments with good improvemenlin dyspigmentationand overallskin tone (Photoscourtesy ol Dr. MelissaBogle)

ranted lawsuits A designated person who is skilled in temples appearto do particularly well with fractional resur- taking consistent photographs should be assignedin any facing. Simiiarly, fractional photothermolysis appearsto be esthetic practice the lasertreatment of choice for therapy resistantmelasma Fractional photothermolysis is an excellent choice (Tannous and Astner 2005J. Neither current fractional for patients with mild-to-moderate rhytides, lentigines, technologiesnor PSR can really compare with traditional scarring, textural abnormalities, or dyschromias such as CO2 resurfacing in the treatment of severe rhytides and melasma (Rahmanet al 2005). Fractionaltreatments carry excessivesolar elastosis,but they both can offer consider- 1ittle to no downtime for the patient. Low-energy PSR is able improvement with a superior safety profile and more a good choice for patients with mild photodamage or comfortable healingtime for the patient. patients who cannot tolerate a significantrecovery period. Both fractional photothermolysis and plasma regenera- The healing time for the PSRI protocol is typically 3-4 tion are indicated for the treatment of nonfacial condi- days, but the intensity is quite mild, consisting of ery- trons such as photodamageor scarringon the chest, neck, thema and minor peeling. Patients with more extensive arms or dorsai hands (Tanzi, and Alster 2005). In addition, photodamage or scarringmay u'ant to consider the PSRZ both techniques work well with segmental treatment protocol, and patients who desire skin tightening effects areasand do not appear to have significantproblems with may want to consider the PSR3 protocol (see Table lines of demarcation between treated and untreated skin. 2.31. None of the resurfacingtechniques work particularly well for telangiectasiasand vascular conditions, although they can offer some improvement through nonspecificdestruc- . Maiordeterminants tion of superficialvessels There are few major determinants favoring one strategy Lastly, patients undergoing fractionai resurfacing and over the other. Rolling type acne scarson the cheeks and low-energy PSR must be able to fit multiple treatment 36 Lasersand Lights Volume ll

sessionsinto their schedule. Some patients may prefer . Preoperativeconsiderations recovery period, versus 2 or 3 days every few Ablative resurfacing procedures can be uncomfortable for n:i:* the patient, depending on the device and energy used. Patients with skin types IV-VI are more safely treated Topical anesthesiawith a lipid-based anesthetic applied with fractional photothermolysis Patients with lighter 45-90 minutes before the procedure appearsto be suffi- skin types (l-lll) are good candidates for both plasma as cient for fractional photothermolysis with the FraxelrM well as fractional treatments device. To date, our clinical experience has the best pain o management wlth 7o/o lidocaine/7o/o tetracaine (com- Patientinterviews pounded by Central Avenue Pharmacy 133 15'h Street During the initial consultation, a complete medical and PacificGrove, CA 93950 www.caprx com 831-373-1225). surgical history should be obtained from the patient. It is Zelickson and Weiss' studiesof the Palomarand Cynosure particularly important to establish any contraindications devices state that no topical anesthetic is required for to laser resurfacing including isotretinoin use within 12 these treatments. Contact cooling with the Palomardevice months, a tendency toward keloid or hypertrophic scar and forced air cooling with the Cynosure device are used formation, and any condition that may causean abnormal concurrently with treatment. healing response, such as scleroderma, burn scars, or a Some patients may require additional oral analgesiaor history of ionizing radiation to the skin Patients undergo- regional nerve blocks Additional analgesiafor fractional ing fractional treatment should also have a washout for resurfacingtreatments is obtained from forced air cooling topical retinoids asthese can blunt the heat shock response with the Zimmer device (Zimmer MedizinSysteme, Ulm, that is needed in surroundins normal tissue. Germany) at the time of treatment fFisher et al 2005; The benefits, risks, and limitations of the varioustypes Rahman et al 2006b) Histologic analysisrevealed a slight of ablative and microablative resurfacing should be dis- decreasein thermal damage zone width, but no statisti- cussedwith the patient in detail, including a mention of cally significant change in lesion depth when combining alternative therapies so that the patient can make an fractional resurfacingwith forced cool air. For this reason, informed decision. the Ztmmer should be used at the lowest possiblesetting to minimize alteration in the microthermal zones.\Mhen TREATMENTTECHNIQUES treating superficial indications such as pigmentation and melasma, Zrmmer settings should be 1-2. \Mhen treating o Patients deeper indications such as deep rhytides or scars,higher Ztrnmer settingsin combination with higher laser settings Proper patient selection is essentialto any cosmetic pro- can be used. The second generation Reliant FraxelrM cedure, including abiative and microablative resurfacing. device has incorporated forced air cooling into the baseof An examination of the proposed treatment area should be the laser, relieving the need for a stand-aloneunit. performed with particular attention to skin type, texture, Low-energypiasma treatments can be performed under rhytides, and dyschromia. Patients desiring periorbital topical anesthesiawith a variety of agents. High-energy treatment with the high-energy PSR protocol should be treatments are more uncomfortable and require adjunc- examined for scleral show, lid lag, and ectropion. Active tive oral sedationor pain medication Particularly sensitive cutaneousbacterial or viral infections in or near the treat- areas such as the forehead and around the mouth may ment area should be cleared before the procedure. require local infiltrative anesthesia or regional nerve Darker skinnedparients have the higlest risk o[ post- blocks. procedure hyperpigmentation. Some physicianschoose to pretreat at-risk patients with topical retinoic acids,hydroquinone bleaching agents, and alpha-hydroxyacids for TREATMENTALGORITHM severalweeks to reduce the risk of postoperative hyperpigmentation. The usefulnessof such regimens is debat- o Fractionalphotothermolysis able, and studieshave not shown them to havea sisnificant To prepare a patient for fractional photothermolysis with effect in traditional ablative resurfacing Hydroqurnone the FraxelrMlaser (Reliant Technologies,Mountain View, inhibits tyrosinase and decreasesmelanosome formation, CA), the skin should be washed with cleanser A lipid- but it does not reach the deeper melanocytesresponsible based topical anesthetic (e.g. 7o/o ltdo caine/ 7o/o te tracainel for hyperpigmentation. Therefore, treating hyperpigmen- is then applied for 45 minutes to I hour. Before laser tation if it appears after treatment is a more effective treatment, the anesthetic is removed and a water-soluble approach. blue dye (OptiGuiderM Blue, Reliant Technologies,Moun- Patients with a history of herpes simplex should be tain View, CA) is applied in a thin layer to allow the laser's prescribed antiviral prophylaxis before high-energy full- optical tracking system to detect contact and movement face or perioral resurfacing treatments with either the with the skin and adjust the pattern of microthermal fractional or plasmadevices. Trauma from thermal damage treatment columns with respect to hand velocity The can cause a reactivation of the virus or predispose the blue dye does not need to be applied in a uniform manner patient to a primary infection during re-epithelialization as the optical mouse detects differences in density of the 37 AblativeLaser Resurfacing ll blue dye on the skin's dermatogliphs. The blue dye is Treatment parameterscan be adjusted accordingto the also detected at the center of the laser handpiece,which desired depth of injury The energy setting controls the makes application close to the eyelid unnecessary depth of injury, while the density setting controls the Another layer of either topical anesthetic ointment or percentageof skin that is treated (Fig. 2.6J. Therefore, for petrolatum-based ointment is applied to help the hand- the treatment of superficial targets such as pigment, a piece glide along the skin's surface Once the handpiece typical course might consist of three to five treatments at comes into contact n'ith the skin, it should be moved in low energies (8-10 mJ) and higher densities (2000- a straight line consistingof one stroke until the end of the 3000 MTZlcm2) spaced 2-4 weeks apart For the treat- cosmetic unit is reached (Fig.z.l) The hand piece should ment of deeper lesionssuch as acne scars,a typical course then be retraced back over the same row to return to the might consist of four to six treatments at higher energies starting point, completing two passes.Concomitant forced [16-20 mJ with the Fraxel SR'M and 30-40 mJ with the air cooling with the Zimmer device is useful to prevent FraxelSR l500rM) and lower densities[1000-1500 MTZI bulk heating and achieve a greater degree of analgesra cm2J spaced 2-4 weeks apart (Table z.z; Rahman et al The handpiece tip has markings that help guide the 2006c1 'targeted' position of successivepasses The first stroke of the third A treatment algorithm can be employed passshould be positroned either by overlappingthe prior where higher energiesare used in areasof deeper rhytides passby 500/oor with no overlap. Again, when the end of such as the perioral region and lower energies can be the cosmetic unit is reached, the handpiece should be employed on the forehead and nose. This also increases retraced back over the same row A 7 mm tio is available patient comfort significantly during treatment Off-face for use in the treatment of small areassuch as the nasal resurfacing, except when treating for acne scars, should bridgeor periocularskin. be treated at lower energiesas well. After a cosmetic unit has been treated entirely with Treatment algorithms can be tailored to patients A 'lighter' overlappingstrokes from side to side, the direction of the treatment with less downtime requiring a great rou.s should change by 90 degrees, and the process number of total treatments (five or more) can be used in 'high- repeated from top to bottom. Each square centimeter of patients who cannot tolerate any edema while a skin should end up with eight passes.If the 500/ooverlap leve1'treatment with greater downtime and fewer total technique is used, then four to-and-fro motions are per- treatments (approximately four) can be used in those formed If the no-overlap technique is used, a total of six patients who can tolerate a few days of edema and ery- to-and-fro motions are performed. Thus, if the laser was thema fRahman et al 2006dJ set at 250 MTZ/clr'z, the end treatment density would be Some comparative high- versus low-energy data with 2000MTZ/cm2 with approximately 5-8kJ of energy the FraxelrM laser shows improved results with higher delivered over a ful1-face treatment. When the 500/o energy treatments This is believed to be based on the overlap technique is used, the edgesof the treatment area concept of a largervolume of tissuetreated at higher ener- will receive fewer passesbecause of the stroke pattern, gies allowing for deeper collagenremodeling providing a built-in feathering effect. Treatments with the fractional Er:YAG lasers (1540nm Fractional Er:YAG, Palomar Medical Tech- nologies Inc., Burlington, MA and 1440 nm YAG laser, Af{rrmrM, Cynosure Inc., Westford MA) have been more recently described. Each appears to be somewhat less involved than FraxelrM treatments. Optical tracking is avoided, so the need for a skin colorant applied before the procedure is ehminated. In addition, topical anesthesiais only occasionallyrequired, with reports ofthe procedures being more comfortable compared with the Fraxelrt laser resurfacing treatment. There have been no split-faced reports of pain scores comparing the various fractional devices at comparable energies

o Plasmaskin regeneration Patients undergoing PSR should arrive at least I hour beforehand so that a topical anesthetic cream can be applied to the treatment area. Patients undergoing high- Fig. 2.5 Fractionalphotothermolysis treatment-the area is lightly energy treatments will require adjunctive oral analgesia coatedwith a water-solubleblue dye (OptiGuiderMBlue, Relianl and/or sedation Technologres,Mountain View, whichallows the laser'soptical CA), Generally, it is a good idea to work in esthetic seg- trackingsystem to detectcontact and movemenlo{ the handpiece chin, etc with the skin and adjustthe patterno{ microthermaltreatmenl ments of the face [i e , forehead, nose, cheek, ), columnswith respectto hand velocity removing the anesthetic cream for each area immediately 38 Lasersand Lights Volume ll

Application Energy(mf) Treatmentdensity Passdensity Numberof Coverage (MTZIcm') (MTZIcm') passes (%)

Melasma 6 1000 250 4 1500 250 o 2000 250 8 10 8 1500 250 6 10 2000 250 8 14 3000 250 12 22 Off-faceresufacing 8-10 1500 250 6 10-14 2000 250 8 14-19 3000 250 12 22-29

Mild-to-moderate 8-10 1500 z5u o 10-14 't4-19 rhytides.and 2000 250 8 pigmentation 2s00 250 10 20-24 (Glogaull-lll) 12 1250 125 10 IJ 1500 zau o 18 2000 250 8 24

Severerhytides. t3 1000 tzJ 8 15 and pigmentation 1250 tzJ 10 19 (GlogaulV); scars- 1500 125 12 ZJ

zv-z? t5u 125 o 14-16 1000 125 8 19-22 1250 125 10 24-27 *Fraxel laseris FDAapproved for periorbitalrhytides, acne scars, and surgicalscars.

before treating that area rather than removing the cream for the entire face at once Hvdration of the eoidermis hasbeen found to influencethe amount of energyatsorbed, CoverageChart T@tmant Density so the physician should develop a protocol to standardize 35 MfZl

There are three recommended treatment guidelines, rows when performing the procedure to avoid unnecessary termed PSRI, PSR2, and PSR3 (Tablez.l) The PSRI heat buildup. The handpiece should glide lightly over the protocol uses a series of 1ow-energytreatments spaced 3 skin. Too much pressureduring a passcan causeabrasions weeks apart The first treatment is performed at 7.0-7.2 J, or excessiveerythema on fragile skin. In addition, patients and energies are increased as tolerated at subsequent should be instructed to avoid scrubbing and harsh cleans- visits Recovery time is 3-4 days. The PSRI protocol is a ers to remove the blue optical dye post-procedure The good choice for those with mild-to-moderate photodam- blue dye is best removed with a foaming cleanser ustng age or those who cannot tolerate more than a few days of gentle rubbing of the skin. healing time The PSR2 protocol uses one hlgh-energy With the Palomar and Cynosure devices, the laser pass(3 0-4.0 J) with a recovery time of 5-7 days, and the operator should be careful not to pulse stack during treat- PSR3 protocol uses two high-energypasses (3.0-4.0J) ments as this can cause erythema or excessivethermal with a recovery time of 6-10 days. The PSRZ protocol is damage. a good choice for those with moderate photooamage, Wth the PSR device, mid-energy (1.6-3.0J) treat- while the PSR3 protocol is a good choice for those with ments do not offer significantly better improvement than moderate-to-severephotodamage and those who desire a low-energy treatments, but have deveraldays more recov- greater degree of skin tightening. A series of treatments ery time. For this reason,most physiciansprefer the use in the mid-energy group (1.5-3.0J) has good results in of low- or high-energyprotocols. Similar to the fractional improving skin texture and discoloration, but has only devices, care must be taken to avoid excessivethermal slightly less recovery time than a singlehigh-energy treat- damage Treatments should be performed in rows all right ment. Therefore, most practitioners prefer to use the to left or all left to right Alternating (zig-zaggingJdirec- suggestedPSRl, 2, or 3 protocols. tions can cause excessive heat buildup at the corners To avoid lines of demarcation with the high-energy High-energy settingsabove 3 J shouldbe used with caution protocols, the borders of the treatment area should be in the infraorbital area to avoid ectropion formation feathered by increasing the distance of the nozzle from Patients should be told not to pick the skin or try to the surface of the skin to approximately I cm. Feathering remove any brown flakes post-treatment as this can cause can also be achieved by holding the handpiece nozzle at prolonged redness,open sores,and potentially scarring. an angle with respect to the skin surface or reducing the power setting There is no need for feathering in the 1ow- energyPSRI protocol. SIDEEFFECTS, COMPLICATIONS, AND ALTERNATIVE APPROACH ES TROUBLESHOOTING Recoverytime after fractional laser resurfacingis minimal in comparison to traditional ablative resurfacing lasers Fractional resurfacing is a relatively straightforward, fFisher and Geronemus 2005). Rednesslasts an average unproblematic procedure; however, it is important to of 3-5 days. Swelling is less common and when present keep in mind possibletreatment pitfalls. The main source may lasts l-5 days. Immediately after treatment, the blue of unwanted side effects such as excessiveerythema, ero- dye is gently washed off with a mild soap.Harsh scrubbing sions,or scarringcomes from either excessiveheat buildup may result in abrasions or excessive erythema Small during the treatment or excessivetrauma to the skin fol- amounts of the dye may remain in the pores for several lowing the procedure. With the Reliant device, careful days. This can be prevented with the application of a attention should be paid to the positioning of treatment dimethicone-based sealant to the skin prior to blue dye

Protocol Visits Energy(J) Recoverytime lndication (days)

Seriesof 3 treatments(3 1.O-1.2,single pass 3-4 (erythemaand Mildto-moderatephotodamage or weeksapart) exloliation) patientcannot tolerate more than a lew dayshealing time PSR2 Singletreatment 3.0-4.0,single pass 5-7 Moderatephotodamage, acne scarnng PSR3 Singletreatment 1.0-1.2, double pass 6-10 Moderate-to-severephotodamage, acnescarring, significant skin laxity Lasersand Lights Volume ll

Microthermalzone (MTZ):Thermal lesion created by one pulseof energy Pulseenergy (mJ): Energyin a singlelaser pulse Factorof laseroower and pulseduration Passdensity: # MfZslcm2per pass Treatmentdensity: # MTZs/cm'zforthe treatment Percentagecoverage: Percentage of totaltreatment surface areacovered with MTZs in onesession Treatmentlevel: Treatment aooressiveness Based on % coverage

ing, virtually eliminating oozing or crust formation. Imme- diately after treatment, a thin layer of bland ointment is applied, and cool compressesare used to minimize swell- Fig. 2.7 Plasmaskin regeneration(PSR) treatment. The handpieceis ing. Patients should be instructed to avoid sun-exposure held approximately5 mm from the skin surface There is no char and apply a bland ointment to the face at frequent inter- formationand the epidermisis left intactpost procedure vals while the skin is healing. Low-energy PSRI treatments may causeonly erythema for 2-3 days. High-energy treatments generally have 'dirty' greater erythema and the skin develops a look as application. Discomfort is generally mild, similar to a the damagedepidermis and upper dermis slough off. This sunburn, and easily relieved by cool compressesor acet- resolvesin 5-10 days Patients should be instructed not aminophen. Elevation of the treated area on the evening to pick at the peeling skin as it can causeprolonged ery- of treatment will help keep edema to a minimum. thema or scarring. Within the first few days after treatment, the skin may There have been no major side effects associatedwith develop a bronzed appearance due to the presence of plasma skin regenerationin studies to date. As in all pro- melanin-containing MENDs, which form beneath the ceduresutilizing heat energy,possible side effects include intact stratum corneum in each MTZ and gradually slough erythema, edema, epidermal de-epithelialization, and off within the first week. The MENDs may take longer to post-treatment hyperpigmentation. Erythema and edema exfoliate off the face. Other than the application of a light are common post procedure/ usually resolving in several moisturizer, postoperative skin care is generally not days. Edema can be decreasedby the application of cool required and most patients can return to normal activities compresses post procedure. Epidermal de-epithelializa- immediately. tion is a risk at higher energiesand should be treated with Immediate and short-term side effects of fractional appropriate wound care and liberal application of a bland photothermolysis in patients undergoingtreatment on the ointment. Temporary hyperpigmentation has been face, neck, chest, and hands include transient post-treat- reported at mid- to high-energy treatments. There have ment erythema !00%), xerosis (870/o), facial edema been no reported instances of scarring, infection, or o/o), (82%J, fl aking (600/o),superficial scratches (47 pruritrs hypopigmentation in clinical trials to date. (3 70/o), and bro nzing (27 0/o). Reactivation of herpes simplex virus can occasionallybe seenand may require prophylaxis in at-risk patients ADVANCEDTOPICS: TREATMENT TIPS FOR Bulk heating can result from treating too large a frac- EXPERIENCED PRACTITION ERS tion of the skin at one time when a small amount of skin is treated in a rapid fashion by passingthe laser back and Rolling-type acne scarsrespond dramatically to forth over the same area. Even at lower energies,treating fractional photothermolysis. A combination approach over a small area without allowins the skin to cool can can improve results with ice-pick or boxcar-type lead to bulk heating. For adequaie prevention of bulk scarring.Combination approachesinclude selected heating, each treatment should cover lessthan or equal to punch excisionsor subcision,which may be per- 30-350/o of the skin per session. Blistering should be formed at the same visit as the laser procedure treated with appropriate wound care and ftequent appli- Both fractional photothermolysis and plasma treat- cation of a bland ointment. Long-term adverse events ments can be titrated from low to hish levels. including hypopigmentation and scarring have not been Fractional photothermolysis carries the least amount reported. of downtime. Recovery after PSR is unique because the desiccated Fractional photothermolysis is the treatment of 'biologic' outer layer of skin is left intact to act as a dress- choice for skin tvoes IV-VI. 47 Ablative Laser Resurfacingll

{. During PSR treatments, selected double passingover remodeling using microscopic Patterns of thermal injury Lasers and Medicine 34:426-438 deep scarsor wrinkles can give additional benefit and in Surgery Mazzella R, Feingold A 1994 The effects of physical attractiveness, improve results with single-passfull-face treatments. race,socioeconomic status, and genderof defendantsand * Plasmatreatment energiescan be adjusted according victims on judgmentsof mock jurors:A meta-analysis.Journal to the facial unit for the best results with the least of Applied SocialPsychology 24:1315-I344 overall recovery time The use of higher energiesis Morrow PC, McElroy JC, StamperBG, Wilson MA 1990 The physical attractivenessand other demographic tolerated quite well in the perioral area and will allow effects of characteristicson promotion decisionsJournal of Management greater improvement in vertical lip lines. l6:723-736 Potter M, Harrison R, RamsdenA, Andrews P, Gault D 2005 Facial acne and fine lines: Transforming patient outcomes with FURTHERREADING plasmaskin resurfacingLasers in Surgeryand Medicine 36:23 Rahman Z, Rokhsar CK, Tse Y, Lee S, Fitzpatrick R 2005 The Alster T, Tanzi E 2006 Plasmaskin resurfacingfor rejuvenation of treatment of photodamageand facial rhytides with fractional the neck, chest, and hands: Investigation of a novel device photothermolysisLasers in Surgeryand Medicine 36:32 Lasersin Surgeryand Medicine 38:20 RahmanZ, Tanner H, JiangK 2006aTreatment of Atrophic Scars Bogle MA, Arndt KA, Dover JS 2007 Evaluation of plasma skin with the 1550nm Erbium-FiberFractional Laser' Lasers in regenerationtechnology in low fluence full-facial rejuvenation Surgeryand Medicine 38:24 Archivesof DermatologyI 43:168-1 74 RahmanZ, Tanner H, Chan KF, JiangK 2006b Histologicand Chan H 2005 Effectiveand safeuse of lasers,light sources,and Clinical Evaluation of the Use of Forced Cool Air With radiofrequencydevices in the clinicalmanagement of Asian Fractional Laser Resurfacing Lasersin Surgery and Medicine patients with selected dermatoses Lasersin Surgery anc 38:62 Medicine37:l 79-185 RahmanZ, Tanner H, Herron S, JiangK 2006c Comparisonof FisherGH, GeronemusRG 2005 Short-term side effects of High Energy Versus Low Energy Treatment for Resurfacing fractionalphotothermolysis Dermatologic Surgery 31:1245- with the 1550nm Erbium-FiberFractional Laser' Lasers in 1749 Surgeryand Medicine 38:62 FisherGH, Kim KH, BernsteinLI, GeronemusRG 2005 RahmanZ, Alam M, Dover JS 2006d Fractionallaser treatment for Concurrentuse of a handheldforced cold air deviceminimizes pigmentation and texture improvement Skin Therapy Letters patient discomfort during fractional photothermolysis l1:7-ll Dermatologic Surgery 3I :1242-1244 Ritts V, PattersonML, Thubbs ME 1992 Expectations,impressions, FriedmanPM, Glaich A, RahmanZ, Goldberg L 2006 Fractional and judgments of physically attractive students: A review Photothermolysis for the Treatment of Hypopigmented Scars Reviewof EducationalResearch 67:413-426 American Societyfor DermatologicSurgery Annual Meeting Rokhsar CK, Fitzpatrick RE 2005 The treatment of melasmawith PresentationOctober 2006 fractional photothermolysis: A pilot study Dermatologic Geronemus RG 2006 Fractional ohotothermolvsis: Current and Surgery31:1645-1650 future applicationsLasers in burgeryand Medicine 38:169-176 Tannous ZS, Astner S 2005 Utilizing fractional resurfacing in the Kilmer S, FitzpatrickR, BernsteinE, Brown D 2005 Long term treatment of therapy-resistantmelasma Journalof Cosmetic follow-up on the use of plasmaskin regeneration(PSRJ in full LaserTherapy 7:39-43 facialrejuvenation procedures Lasersin Surgeryand Medicine Tannous Z, Lalbach HJ, Anderson RR, Manstein D 2005 Changes 36:22 of epidermal pigment distribution after fractional resurfacing: a Kim KH, FisherGH, BernsteinlJ, BangeshS, SkoverG, clinicopathologiccorrelation. Lasers in Surgeryand Medicine GeronemusR 2005 Treatment of acneiformscars with 36:37 fractional photothermolysis Lasersin Surgery and Medicine Tanzi, EL, Alster, TS 2005 Fractionalphotothermolysis: Treatment 36:31 of non-facialphotodamage with a 1550 nm erbium-dopedfiber LangloisJH, KalakanisL, RubensteinAT, LarsonA, Hallam M, laser Lasersin Surgeryand Medicine 36:31 Smoot M 2000 Maxims or myths of beauty?A meta-analytic Weiss RA, Gold M, BeneN, et al 2006 Prospectiveclinica- and theoretical revrew PsychologicalBulletin 126:390-423 evaluation of 1440-nm laser delivered by microarray for the LaubachH, TannousZ, AndersonRR, MansteinD 2005 A treatment of photoagingand scars.Journal of Drugs Dermatol- histological evaluation of the dermal effects after fractional ogy5:740-744 photothermolysistreatment Lasersin Surgeryand Medicine Zelickson B, Altshuler G, Eroffev A, et al 2006 Comparative 26:86 evaluationof PalomarStarlux and ReliantFraxel devices for H, AndersonRR 2004 MansteinD, Herron GS, Sink RK, Tanner treatment of photodamagedskin fabstract] Lasersin Surgery Fractionalphotothermolysis: a new conceptfor cutaneous and Medicine 38:27

NonablativeSkin Resurfacing

Ellen S. Marmur, David J. Goldberg

ing triggersa wound healingresponse to restore the normal INTRODUCTION architecture of collagenin the dermis Associatedvascular At the forefront of laser and nonlaser light source damagerecruits inflammatory mediators that lead to fibro- technology, dermasurgeonscontinue to lead the way to plasia and homogenizationof the col1agen. remarkable innovations in the field of nonablative laser Clinical photodamageis classifiedinto three types (Box resurfacing. This technically diverse group of systems 3.r) Type I photodamage includes telangiectasias,solar includesthe potassiumtitanyl phosphate (KTP) (532 nm), lentigines, increased skin coarseness,and symptoms of Type II photodamage includes rhytides, derma- pulsed dye [585 nm, 595 nm), neodymium:yttrium-alu- rosacea. minum-garnet (Nd:YAG; i064-nm Q-switched, 1064- tochalasis, comedones, and skin laxlty. Type III photo- nm long pulse, 1320 nm), diode [450 nm), erbium:glass damage includes actinic keratoses, nonmelanoma skin cancers,and melanoma Standard nonablative skin resur- [1540nm) lasers,intense pulsed light (500-1200nm), and light-emitting diode devices (FiS.f.1) Photodynamic facing is successfulin patients with types I and II photo- therapy is a recent innovation utilizing aminolevulinic acid damage Generally photorejuvenation treatments are to enhancethe effects of light and laserbased technology. undertaken on the sun-exposed areas of the face, neck, Radiofrequency technology also used for nonablative upper chest, and hands. 'nonablative treatments is describedin Chapter 4 Historically, abiative The term skin resurfacing' includes the laserswere the optimal treatment for photodamagedskin. terrns subsurf acing, noninuasiu e resurf acing, sbin t on i ng, Ablative skin resurfacinghas become increasinglyunpopu- and wrinh.le reduction This process involves dermal neo- lar with both patients and physiciansdue to the significant collagenesis,and photorejuuenation due to both epidermal risks of prolonged recovery time, possible permanent improvement and dermal coliagenremodeling. Each group hypopigmentation, and/or scarring. Nonablative skin of nonablativedevices will be discussedalong with clinical resurfacing has become the treatment of choice for pho- pearls to ensure optimal treatment outcomes, realistic torejuvenation It offers an elegant,highly effective, non- expectationsfor the patient, and managementof potential invasivetreatment for problems related to photodamage complications. and aging. This chapter will focus on the use of non- Nonablative skin resurfacingtechnology can be catego- ablative skin resurfacing to treat patients with mild-to- rized into five different generalmodalities: vascularlasers, moderate photodamage mid-infrared lasers, intense pulsed light systems, radio- Ultraviolet-induced photodamageaccelerates and mag- frequency devices and the recently developed light emit- nifies the physiologic changesof the normal agingprocess ting diode (LED) techniques (Box 3.2) Photodynamic Ultraviolet exposure produces a myriad of changesin the therapy utilizes aminolevulinic acid in conjunction with skin including free radical formation, apoptosis,angiogen- photoactivation from a light or laser source to enhance esis,melanogenesis, DNA mutations, oncogenesis,tmmu- photorejuvenation. nosuppression,matrix metalloproteinase induction, and Nonablative skin resurfacing is ideally used for the degradation of connective tissue The histologic manifes- patient with mild-to-moderate photodamage and signsof tations of photodamagedskin include loss of collagenand skin aging This approachis not meant for the patient who abnormal clumping of elastic fibers in the superficial r,vantsthe degree of improvement, and is willing to accept dermis. In addition, ultrastructural analysisshows a thin the added risks, associatedwith more aggressivesurgical epidermis, flattened rete, increased vasculature, chronic options. Nonablative technologiesstimulate collagenfiber inflammation, elastotic changesincluding the accumula- synthesisto reduce wrinkles and lax skin The fina1effect tion of large amounts of elastic material, wide spaces is clearly more subtle than that seenwith more aggressive between the collagenbundies, and random deposition of surgicaland lasercosmetic treatments However, nonabla- collagenfibers. These histologic and ultrastructural changes tive skin resurfacingrequires essentiallyno recovery time. are clinically correlated with rhytides, laxity, yellow dis- With nonablativetreatments, one avoidsthe risk of general coloration, and telangiectasias.Nonablative skin resurfac- anesthesia,with most treatments accomplishedwith little Lasersand Lights Volume ll

Invisible Invisible

40Omm 700mm 10600mm UV Infrared Vascular IPL Mid infrared 532 500- 1320 585 1200 1450 595 1540

'/-i f !n I t2v Bloodvessels Fig. 3.1 Electromagneticspectrum and targetchromophores

often choose to begin with nonablative skin resurfacing treatments. Invasive dermatologic laser procedures such TypeI as laser blepharoplasty and ablative laser resurfacing will Lentigenes,telangiectasias, increased coarseness, be covered elsewhere in this text. symptomsof rosacea

Typell PATIENTSELECTION Rhytides.laxity. derr.ratochalasis Patient selection for nonablative skin resurfacins is based on an evaluation Typelll of the individual's degree of plotodam- age and aging. The ideal patient years Actinickeratoses, nonmelanoma skin cancers is 35-55 old with moderate signs of photodamage and aging (Fig. 3.2) Younger patients with mild photodamage may also show improved skin texture after nonablative skin resurfacing; however the results will be subtle. Conversely, patients with deep rhytides and severe laxity may show minimal to no response. Such patients may be better candidates for ablative resurfacing or other more invasive cosmetic Vascularlasers techniques Assessment of the patient's expectations Mid-infraredlasers during the consultation is critical in patient selection for Intensepulsed light systems nonablative skin resurfacrng. Radiofrequency systems Darker skin types may preclude the use of certain types LED of nonablative skin resurfacing In such patients light sourcesand lasersthat target pigment must be used with caution and at settings to minimize thermal damage. Side effects such as blisters, scars, focal atrophy, textural change,and hyper- or hypopigmentation are all more likely to be seen in darker complected individuals. Mid-infrared or no topical anesthesia.Such treatments also avoid the laserswith emitted wavelengthsvarying between 1320 and risk of infection, a leading causeof morbidity and compli- 1540 nm target water in the dermis and theoretically can cation seen after invasive cosmetic surgery. Nonablative be used safelyin darker skin types. However, when irradi- skin resurfacing treatments are easily and expeditiously ated at high-fluencesnonspecific laser energy absorptron achieved in an outpatient setting. They have become by melanin can lead 'lunch-time' to thermal damage and side effects known as laser procedures. The results from even in darker skin types. The most common albeit rare these procedures are not as dramatic as those seen after side effect experienced by patients with darker skin color standard surgical procedures. In fact, patients who ulti- after nonablative skin resurfacing is transient hyperpig- mately plan to have more extensive cosmetic surgery mentation. This is usually seen with those nonablative 45 NonablativeSkin Resurfacing devices that utilize cryogen epidermal cooling. The hyper- VASCULARLASERS (slz-ro6+ NM) pigmentation may be due to cryoinjury and can be avoided pulsed dye laser (FLPDL) was the by reducing the amount of cryogen delivered with each The flashlamp-pumped laser (Table that was developed based pulse. A detailed discussion of laser and nonlaser light first vascular 3.r) principle of selective photothermolysis. It was sourcesin the treatment of darker skin phototypes may be on the specifically designed to treat port-wine stains. Although found elsewhere in this text. (See Chapter 5 ) a 577-nm wavelength (a hemoglobin There are some individuals who are not appropriate initially used with peak) and a 450-ps pulse duration candidates for nonablative resurfacing. Although clearly absorption fshorter relaxation time of targeted cutaneous controversial, these may include those patients who have than the thermal currently availablepulsed dye lasersemit taken oral retinoids (for 6 months) prior to nonablative vascularlesions), 585 nm and 595 nm with pulse treatment, who have had recent ablative resurfacing with wavelenghs between between 350 and 40 ms. Variable wave- either lasersor deeper chemical peels, and/or have active durations us lengths and pulse durations lead to the targeting of a skin diseasewithin the treatment area (Box 3.3). Finally, vessel sizes. in the rare patient reactivation of herpetic eruptions may variety of different FLPDL usesa high-power flashlampto excite elec- occur. Pre-medication in these Datients is indicated. The trons in an organic dye (rhodamine). Originally, this led to emission of yellow light at 577 nrn. The dye has been modified to emit photons at different wavelengths cor- responding with the absorption peaks of hemoglobin in its various states of oxygenation. Longer wavelengths in theory target larger and deeper blood vesselsin the skin. Enhanced safety cooling systems include cryogen-spray cooling delivered in millisecond bursts prior to laser pulsing or air cooling delivering chilled air to skrn con- tinuously throughout laser pulsing. Most recently, elon- gated pulse duration laser systems known as variable-pulse Jye lar.rs [V-Beam@,Candela, Wayland, MA; V Star@and Cynergy@, Cynosure, Chelmsford, MA) have been designed to allow for effective yet gentle, uniform heating of vesselswithout resultant purpura. Over the past decade, dermasurgeonswho have used the FLPDL for treatment of vascularlesions have noticed anecdotal improvement in skin elasticity, dyschromia, and Fig. 3.2 ldeal nonablativepatient for photorejuvenation texture. Some physicianshave alsoreported improvement of skin striae with vascular lasers. Finally treatment of hypertrophic scarsand keloids with pulsed dye lasershas been shown to produce both clinical and histopathologic improvement of dermal collagen.With FLPDL treatment Oralretinoids-6 months the absorbing chromophore would appear to be dermal Ablativeresurfacing 6 months vasculaturecontaining hemoglobin. The exact mechanism Chemicalpeels-medium or deep,6 months of action of pulsed-dye laser induced collagen formation Activeskin disease within the treatment area-herpes, is unclear. Theoretically, laserinduced damageto vascular impetigo,autoimmune disease endothelium produces cytokines that lead to dermal

Tradename Wavetength(nm) Spotsize (mm) Putseduration (ms)

V Star 585,595 7, 10,12 0.5-40 V Beam 7, 10 0.45-40 N Lite 350 Aura 532 1,2,4 1-50 Versapulse 532 2-6 1-50 Diolite 532 5, 7, 10,14 1-100 46 Lasersand Lights Volume ll

remodeling of collagen and improvement in the appearance of rhytides Traditional pulsed-dye lasertreatment is often compli- cated by purpura. This lack of cosmetic elegance with older FLPDLs limited the usefulness of this device for nonablative resurfacing Current pulsed-dye lasers that play a role in nonablative resurfacing include the previously describedV-star@ series from Cynosure (air cooling, varying wavelengths between 585 nm and 600 nm and varyrng pulse durations), V-beam@series from Candela (cryogen cooling, 595 nm .rvavelength,and varying pulse durations), the Nlite@laser from USA Photonics (585 nm, 350 tr^ts,3 J system), and the new Cynergy@laser from Cynosure (air cooling, combined 595 and 1064-nm wavelengths with varying pulse durations). Several studies have shown that increased collaeen production can occur with a lower fluence, purpura free puised dye laser treatment. Zelickson et al showed improvement in dermal collagen after one pass usrng the 585-nm FLPDL (450 msJ Multiple passes of the FLPDL (either the 585 nm or the 595 nm) at sub- purpuric fluenceswere not shown to be superior in creating dermal collagen as compared to the results from a single pass In one study, Goldberg and Sarradet analyzed both clinical rhytid improvement and electron microscopic evidence of ultrastructural changes after treatment with a nonablative 595-nm, flashlamp pulsed-dye laser. At 6 Fig.3.3 FLPDLpatient: (A) pre-treatment; (B) post-treatment months after two laser treatments, 400/oof the treated subjects noted mild improvement in rhytid appearance Non-treating physician evaluation revealed some degree Thus, it would appear that vascularlaser treatment for of improvement in 50% of the treated subjects. Mild nonablative photorejuvenation is appropriate for patients improvement in quality and texture of the skin was also with one or more components of types I or II photodam- reported by 50% of the subjects. Electron microscopic age (Fig. 3.4) Patients with dyschromia, skin coarseness, evaluation showed ultrastructural chaneesconsistent with redness,or rhytides may benefit. Uncommon side effects new collagenformation (Fig.f .f). include purpura, dyschromia, blistering, or scarring (Fig. In addition, other types of vascularlaser systems such 3.5). Darker skin types may be treated more safely at as the 532-nm KTP, 755-nm alexandrite,81O-nm diode appropriate fluences with the 1064-nm Nd:YAG laser. and 1064-nm Nd:YAG lasershave been shown to be Due to the potential side effect profile, especially in effective in nonablative resurfacing. The absorbing chro- darker skin types, with the current vascularlaser systems, mophores for the 1064-nm laser may include melanin, other modalities may still be preferable for the treatment hemoglobin, and water contained within the skin. of rhytides. One study by Lee evaluatedusing the long-pulsedKTP 532-nm and long-pulsedNd:YAG 1064-nm laserssepa- rately and combined for nonablative resurfacing (Lee MID-INFRAREDLASERS (r3zo NM, 2003). After a series of three to six treatments, patients 1450NM,1540 NM) treated with a combination of 532-nm and 1064-nm lasers showed the greatest improvement in both types I and II A substantialnumber of studies have examined the clini- photodamage.The KTP laser used alone showed superior cal and histologic effects following treatment with mid- results compared with when the Nd:YAG laser was used infrared lasers.The group of mid-infrared lasersincludes alone. However, both lasers when used alone produced the 1320-nm Nd:YAG (CoolTouch@;CoolTouch Corp, inferior results when compared with the observedfindings Auburn, CA), 1319-nm Nd:YAG (Profile, Sciton, Palo when patients receivedtreatment with both lasers.Similar Alto, CA), the 1450-nm diode fsmoothbeam@;Candela to studies evaluatingintense pulsed light sourcesthat emit Corp., Wayland, MA), and the 1540-nm erbium:glass polychromatic wavelengths and addressmultiple signs of (Aramis@,Quantel Medical, Clermond-Ferrand, France) photodamage, this was the first study to use two lasersrn lasers(Table 3.2). combination to address both the epidermal and dermal The first specifically nonablative laser to be solely elements of photoaging marketed to the physician community was the 1320-nm NonablativeSkin Resurfacing

Nd:YAG laser.The goal of this system, similar to that of all nonablative resurfacing devices, is improvement of rhytides without the creation of an epidermal wound. The 1320-nm wavelength is advantageousbecause of its high scattering coefficient. Thus, the emitted laser irradiation scatters throughout the treated dermis after nonspecific absorption of dermal water. The ensuing thermal injury theoretically triggers vascular damage and a cascadeof events leading to remodeling of dermal collagen and clinical improvement of rhytides (Fig.f .6) The currently availablemodel of the I320-nm Nd:YAG laser is accompanied by a unique handpiece with three portals. One portal contains the cryogen spray that coois the epidermis prior to, during, and after treatment, one Fig. 3.5 FLPDLcomplication: purpura

Fig. 3.4 FLPDLpatient: (A) pre-treatment;(B) post-treatment Fig. 3.6 Pre (A) and post (B) Mid-infraredlaser treatmenl

Tradename Wavelength(nm) Spotsize (mm) Pulseduration (ms)

Cooltouch 1320 10 200

Smoothbeam 1450 4,6 250 Aramis 1540 4 48 Lasersand Lights Volume ll

portal emits the 1320-nm Nd:YAG laser irradiation, and As with all mid-infrared lasers, selective vaporization of one portal contains a thermal sensor. Emitted 1320-nm water-containing dermis tissue leads to subsequentcolla- Nd:YAG laser fluenceslead to peak measured epidermal gen remodeling and reduction of rhytides This laser pen- temperatures of 42-48'C. An epidermal surface tem- etrates up to a depth of 2 mm. Theoretically, this depth perature of 40-48'C correlates with a dermal tempera- correlateswith the depth of maximum solarelastosis This ture of 70"C. This is the required dermal temperature system differs from the 1320-nm and 1450-nm lasers in for collagen denaturation and the subsequent wound several ways. Instead of a three phase cryogen cooling healing response.The handpiece thermal sensorcaptures system/ the 1450-nm erbium:glass handpiece delivers the surface T-,* after the initial test spot allowing the continuous contact cooling with a sapphire lens cooled to clinician to adjust the fluence accordingly. For example, 5"C. The efficacy ofthe 1540-nm laser has been demon- T-,* after an initial test spot at the setting of l4J/crrrz strated by photography, profilometry, and ultrasound may be 37'C. For optimal results, the clinician should imaging showing a 400/oreduction in wrinkles and a 17o/o increase the fluence by 7J/cm2 increments until the increasein epidermal thickness at 6 weeks after the fourth surface T-"* is between 42-48'C. treatment. In another study, histologic evidence of sig- Multiple studies have shown photodamaged skin nificant dermal remodeling, clinical satisfaction, and few treated with the 1320-nm laser results in laser induced side effects were noted after treatment with the I540-nm neocollagenesis.It has been shown by Fatemi et al (2002] laser. that three passesare better than a single pass in causing Side effects common to the use of all mid-infrared the early 1320-nm Nd:YAG laser induced histologic lasersinclude transient pain, edema, and erythema of the changes such as vascular damage, apoptosis, and edema treatment areasthat resolvewithin 48 hours. Uncommon that are thought to lead to a cascade of inflammatory side effects include reactivation of herpes simplex infec- mediators and subsequentneocollagenesis. tions, pigmentary alteration, or scarring (Figsl.Z and 3.8). The 1450-nm diode laser is quite similar in its effect to the 1320-nm Nd:YAG laser. This mid-infrared wavelength laser also vaporizeswater in the dermis, createsan imperceptible wound, and subsequentneocollagenesis for the treatment of rhytides and atrophic acne scars. The 1450-nm diode and 1320-nm Nd:YAG lasersystems are often used interchangeablywith similar efficacy.However, it remains to be seen whether more specific trearmenr parameterswill show one to be superior lo the other. One study by Tanzi and Alster (2004) did suggest that the 1450-nm diode to be superior in the recontouring of atrophic scars when used at fluences ranging from 9-74 J/cm2. Another study by Friedman et al (2004) found the 1450-nm diode laser damagessebaceous glands selectively and is effective for the treatment of inflammatory acne on the back. Finally, a study compared the effect of the cryogen alone to the 1450-nm laser with cryogen cooling Fig. 3.7 Mid-infraredcomplication: blister formation and found the laser effect led to significantly more collagenin the papillary dermis. The 1450-nm diode laser utilizes an integrated cooling device that delivers cryogen pre-, during, and post- irradiation in a manner similar to that seenwith the 1320- nm Nd:YAG laser.This laserhas a slightly longer emitted pulse duration of 250 ms compared with the 200-ms pulse duration seenwith the 1320-nm Nd:YAG laser. There is no thermal sensorin the 1450-nm diode laser handpiece but generally treatment fluences range between 9 and 74 J/crrr2. Theoretically, there shoulJ be no epidermal absorption by melanin when this laser is used in darker skin types. However, there is still a risk of post-treatment hypopigmentation when this laser is used with skin types IV, V, or VI. This may be secondaryto cryoinjury and/or nonspecific energy absorption. The 1540-nm erbium:glass laser is widely used in Europe for the treatment of mild-to-moderate rhvtides. Fig. 3.8 Mid-infraredcomplication: hyperpigmentation NonablativeSkin Resurfacing

Despite fairly consistent ultrastructural evidence of with a time interval between individual pulses. This delay dermal collagen remodeling with new type I collagen, allows the epidermis and superficial, small-calibervessels clinical improvement does not always correlate with the to cool while thermal energy accumulatesin the deeper, degree of histologic fibroplasia. Advances in technology largervessels or hair follicles. Most systemsuse some form and establishment of optimal treatment parameters will of protective skin cooling. With earlier IPL systems,many undoubtedly lead to more consistent improvement in oDerators found it difficult to understand the numerous clinical outcomes with a continuinq low side effect parameters that could be changed to optimize each treat- profile. ment. Some newer IPL systemshave preprogrammed settings based on both clinical indications and treated skin equipment more user-friendly INTENSEPULSED LIGHT types making the IPL has been used for virtually all of the same indica- Polychromatic light devices were first developed to tions as laser systems. These systems are successfulfor thermocoagulatevascular malformations in the 1970s In the treatment of essentialtelangiectasias of the face, mild the mid 1990s, the first high-intensity intense pulsed dyschromia, and poikiloderma of Civatte. Other success- lights sources (lPL) were marketed to physicians. Since ful applications of IPL are in therapy-resistant port-wine then, multiple IPL and combinations of IPL with laser stains,venous malformations, hemangiomas,treatment of and/or radiofrequency sourceshave become availablefor idiopathic cutaneous hyperchromia of the orbital region, nonablative resurfacing. pilonidal cysts, hair removal, acne therapy, sebaceous IPL systems are high intensity polychromatic light hyperplasia reduction, and correction of soft-tissue filler sources that emit pulsed light in a broad band of wave- complications. lengths between 400 nm and 1200 nm. Cut-off filters are Most major laser centers provide multiple treatment available to narrow the bandwidth of emitted wavelengths options for the patient with photodamaged skin. IPL or in order to selectively target variable structures at differ- long-pulsed nonpurpuric FLPDL are excellent treatments ent depths in the skin. For example, filters may be changed for those patients with confluent networks of telangiecta- to correspond to vesselsof different depths and caliber, sias on the forehead, glabella, nose, cheeks, chin, neck, the hair follicle, or pigmented cells. High cut-off filters and upper chest. IPL is also excellent for the patient with can be used to reduce melanin absorption and protect the multiple types of photodamage including lentigines, mild epidermis in patients with darker skin types. In addition, rhytides, and mild-to-moderate poikiloderma. higher cut-off filters emit longer wavelengthsfor nonspe- One benefit of IPL compared with more aggressive cific absorption of dermal water. This results in wide- laser systems used for photorejuvenation is that newer spread dermal heating that causescollagen damage and IPLs are more user friendly and cause very few major subsequentremodeling. adverseside effects. Yet, if used too aggressively,scarring Similar to lasers, IPL systems produce their effect can occur (Fig. f .g). \Arhereasolder short-pulsed FLPDL based on the principle of selective photothermolysis. treatment often results in purpura, IPL most commonly Hemoglobin's absorptionpeaks are approximately 418 nm, leads to transient erythema that resolves within hours and 542nrn, and 580nm, whereas melanin absorbs energy can be covered with makeup. Similarly, Q-switched lasers throughout the entire visible spectrum (400-700 nm) used for epidermal hyperpigmentation often result in with a lower absorption coefficient occurring in the infra- immediate crusting where IPL, when used for this condi- red spectrum (1200 nm). Unlike lasers,which treat one tion, may causeonly transient, deepened hyperpigmenta- chromophore with monochromatic light, IPL systemscan tion and eventual exfoliation. However, it should be noted be used to simultaneously treat both pigmented and vascular lesions. In addition, polychromatic light irradiates these chromophores with both major and minor absorption peaks theoretically allowing for greater selective energy absorption. More recently, IPL has been used for treating rhytides. The mechanism of action is thought to be light induced thermal denaturation of dermal collagenleading to a reac- tive cascadeof inflammatory mediators and subsequent collagen synthesis.Several studies have shown successful clinical improvement in rhytides after IPL treatment. Some have also shown good results in treating large pore size and telangiectasias. There are numerous commercial IPL systemsavailable. They differ in emitted light spectrum (nmi, optical filters (nm), fluence (Jlcrr'2), pulse sequence, pulse duration [ms), pulse delay (ms), cooling systems, and spot size (--t). Some IPL systems also allow for stacked pulses Fig. 3.9 IPL complication:scar Lasersand Lights Volume ll

that, in general, when IPL is used for the trearment PHOTODYNAMICTHERAPY of superficial epidermal pigmentation, more sesslons Photodynamic therapy (PDT) are required when compared with Q-switched laser was introduced in the treatment. beginning of the 20th century as an experimental treatment that combines a photosensitizing dntg, a photoacti- vating light, and phototoxic oxygento destroy cancercells. LIGHT.EMITTINGDIODES It was first used in the treatment of tumors of the bladder, bronchus, esophagus,and the skin The PDT mechanism Light-emitting diode (LED) sources represent a new of action involve the biosynthetic pathway for heme where group of light based devices originally developed for the precursor compounds are metabolized phototoxic National Aeronautics and SpaceAdministration (NASA) into compounds such as protoporphyrin IX (PpIX). Although plant growth experiments in space.NASA researchfounj effective, early treatment applications of PDT using that LEDs deliver light deep into human tissue and systemic photosensitizing drugs, were severely limited promote wound healing and human tissue growth. LEDs by prolonged phototoxicity. In 1990, the field of PDT was are now used for the treatment of a wide range of derma- revitalized with the introduction of S-aminolevulinic tologic conditions including acne,photodamale, nonmela- acid a potent topical photosensitizer. noma skin cancers,skin rejuvenation, dyschromia, vitiligo, [AtA), Topical AtA is a precursor of PpIX in the and wound healing. LED devices often have detachable heme bio- synthesis pathway. AIA ls preferentially treatment heads that can deliver painless, nonthermal, absorbed by rapidly dividing cells in the epidermis and the superficial incoherent wavelengths of narrowband light via a matrix dermis. PplX has maximum absorption of small LEDs set into a larger treatment panel (Fig. at 470,630, and 690 nm. With light activation, PpIX produces 3.10). free radicals that cause cellular destruction. process The LED mechanism of action involves immunomodu- This is called photodynamic therapy and has been FDA-cleared Iation of mast cells, macrophages,T cells, and fibroblasts for the treatment of actinic keratoses. leading to accelerated neocollagenesis.This mechanism Currently, topical A[,A, used in PDT, is being studied may include the inhibition of matrix metalloprorernase for the treatment of photorejuvenation, actinic photodamage, activity, the enzyme responsiblefor collagenbieakdown. nonmelanoma skin cancer, mycoses fungoides, warts, and moderate-to- LEDs in the blue and red light spectra are effective against severeacne using 560-1200 nm light sources Propionibacterium acnes via bactericidal and anti-infl am- ALA-PDT has a well established role in the matory mechanisms.LED photomodulation mav be used trearmenr of type III photodamage.Ultrastructurai evidence alone for skin rejuvenation but also has been effective in shows robust, new collagen formation in the skin after augmentation of results in patients receiving concomitant treatment with ALA-IPL compared with that seen after nonablative thermal and vasculartreatments such as IPL, IPL treatment alone. Current light activators pulsed dye laser, KTP and infrared lasers,radiofrequency include IPL, PDL, and LEDs. energy/ and ablative lasers. The most common adverse events reported with Patient selection for LED therapy is expansivedue to AtA- PDT are transient pain, irritation, and edema its excellent safety profile and its extensive list of applica- during and directly after treatment. Patients are potentially tions Patients who are contraindicated for LED treat, photo- sensitive for 24-48 hours and ments are those with photosensitivity due to medications should wear appropriate sun protection. Dyschromia and scarringmay also such as antibiotics or systemic diseasessuch as lupus occur. One erythematosus. Iimitation to topical photosensitizers is their minimal depth of penetration. Prior microdermabrasion or topical acetone application may enhance penetration. New and promising topical medications and penetration enhancers such as ethylenediaminetetraacetic acid (EDTA) and dimethylsulfoxide (DMSO) are in development.

OVERVIEWOFTREATMENT STRATEGY . Treatmentapproach The treatment approach for nonablative skin resurfacing starts with a consultation. The most important information to obtain during the consultation is a determination of patient goals. If the patient complains of erythema or rosacea, the IPL, FLPDL, or KTP lasers are the best choices. If the patient is concerned about skin textural changes,such as large pores or acne, IPL or LED are good Fig. 3.10 CaptainLED device choices. If the patient is concerned only about wrinkles, NonablativeSkin Resurfacing either the 1320-nm Nd:YAG. 1450-nm diode, 1540-nm eye protection must be worn by all personspresent in the erbium: glass lasers or radiofrequency devices are the laser room. The patient's eyes are covered by clean, dry treatments of choice For any combination of concerns gauze,or opaque goggles.For treatment of eyelid vessels, such as erythema, rosacea,hyperpigmentation, acne, or intraorbital eye shieldsmust be used. As with all laser and poor skin texture, the IPL with possible adjunctive LED light systems, any reflective surface in the room must be treatments may provide the best treatment option. covered. The outside door of the laser room should hold Once the problem is defined by the patient, the con- a warning sign prohibiting personswithout eye protection sultation can focus on the appropriate treatment options from enteringthe areaduring treatment. It is helpful to explain to a patient that lasers and light Vascularlaser devices employ different coolingmethods sources use computers that generate light to target an from cryogen spray, to air cooling, to contact cooling, to undesired aspect of aging skin. IPL and LED therapy no cooling. Full-face treatment without overlappingpulses entails a series of treatments depending on the desired is recommended. The handpieceswith cryogen spray or clinical effect. Caution the patient that initial changesmay air cooling should be placed at a preset distanceaway from be subtle and therefore invisible for at ieast one or two the skin to prevent injury. Each system provides an attach- treatments. Final clinical results often require 6 months ment for the handpiece to ensure proper focal distance to I year to appreciate The risks of nonablative resurfac- Contact cooling handpieces are placed directly onto the ing must be addressed.These include transient erythema skin surface \4rhen the pulse is fired, the patient will and pain during the procedure. In addition, the rare risk experience a brief hot snap comparable to a rubber band of scarringand pigmentary changesafter treatment should snap against the skin. The patient may still see a bright be discussed The consultation should conclude with the flash of light, but as long as they have properly fitted eye patient having the opportunity to ask questions protection covering the orbit, they are safe. Erythema, edema, blanching of the vessels,and tran- o Treatmenttechniques sient hyperpigmentation or dyschromia may be seen immediately or shortly after the treatment. If purpura rs VASCULARLASERS (532-595 NM) noted, the utilized fluence is generally too high. Patients Treatment with the FLPDL or KTP lasers begins with a may choose to apply cool gel packs when the treatment consultation. Vascular lasersare used primarily for telan- is completed to alleviate discomfort. No wound care ts giectasias,and less commonly for dyschromia and rhyt- usually required. ides. The consent form and discussionshould focus on the Pearls and pitfalls when using the vascular lasers are risks of purpura, dyschromia, crusting, possible scarring, numerous. Patients with darker skin types (Fitzpatrick and the probable need for a seriesof treatments. Param- IV-VIJ are at a greater risk of developing hypopigmenta- eters are then chosenbased on skin type, degree of laxity, tion. These patients might consider a laser patch test size and depth of vessels,or type of dyschromia to be in an inconspicuous area prior to full-face treatment. treated For examples of general treatment settings see However, such test patches are not foolproof. Topical Table3.3 retinoids, glycolic acid cream, and ascorbicacid have been The area is cleansedprior to treatment. Al1 make-up is used successfullyfor a course of 4-6 weeks prior to and removed and preoperativephotographs are taken. Usually, during treatment in patients with darker skin types to no topical anesthesiais required. However, such anesthe- prevent hypopigmentation No overlap of pulsesis recom- sia may be applied for I hour prior to treatment especially mended to prevent FLPDL-induced purpura. It may be if higher laser fluences are to be used or if the patient helpful to decreasethe repetition rate of each pulse (Hz) requests pain control in order to space out each pulse accordingly. Energy set- The patient is placed in a supine position in caseof the tings should be changedbased on the anatomy of the treat- rare event of a vasovagalreaction. Appropriate external ment area. The periorbital area is particularly prone to

Tradename Fluence(l/cm') Pulseduration (ms) Spotsize (mm)

V Star 5-l 6-1 0 10

V Beam 5-7 o-lu 10 N Lite 350ms Aura 10 10 1

Versapulse 10 IJ + Diolite 253 10-20 0.5 Lasersand Lights Volume ll

developing purpura whereas the paranasalarea requires The cheeks,chin, and upper lip are generallytreated with higher fluences,larger spot sizes,and longerpulse durations between two and five passes. compared with the cheeks.Precooling the skin permits the No wound care is required after treatment. A common use of higher laserfluences without damagingthe skin, but side effect is transient erythema and mild edema. Patients cryoinjury to the epidermis must be avoided especiallyin may wish to apply cool packs for a short period of time darker skin types Persistentblanching is a danger sign for until the pain subsides. the potential development of blistering. If a burn or blister- Treatment pearls and pitfalls are relatively few coming is suspected,the patient should apply topical antibiotics pared with the other nonablative laser modalities. When for 2 weeks and avoid sun exposure. It is wise to offer treated with conservative fluences for the initial treat- frequent follow-up visits for these patients. ment, it is rare to incur seriousside effects with the mid- infrared devices Before currently used safe treatment MrD-TNFRAREDLASERS (1054-1540 NM) parameterswere defined, atrophic and hypertrophrc scarring was fairly commonly seenwith these devices.Because Treatment with the mid-infrared devices begins with a mid-infrared devices are used with some form of cooling, consultation. Mid-infrared lasers are used for improve- cryoinjury of the skin must be a consideration. This is ment of overall skin texture, laxity, and mild rhytides. more commonly seen in darker skin types Today, when Consent is signed outlining the risks of dyschromia, scar- rare atrophic scarringdoes occur, it is unpredictable. Post- ring, pain, erythema, or crusting. Initial parametersare set laser induced hyperpigmentation generally requtres no according to skin type and treatment area. Suggested treatment and will fade over the courseof I year. Hypopig- starting treatment parameters for the three mid-infrared mentation is an unfortunate and permanent side effect, systems are seen in Tabte 3.4. albeit very rare. The skin is cleansed to remove oil, make-up, or sub- stances that will impede the laser light delivery to the dermis and to minimize the possibility of infection. There INTENSEPULSED LIGHT is some controversy as to whether topical anesthesracan IPL treatment begins with a consultation to define the be used. It hasbeen postulated that sincetopical anesthet- patient's goals. The IPL may provide the best treatment ics increase the epidermal water content, the target of option for any combination of concerns such as essential mid-infrared lasers,they might decreasethe ensuinglaser- telangiectasias,solar lentigines, rosacea,hyperpigmenta- delivered thermal damage. This is unproven and many tion, acne, poor skin texture, and early rhytides. Param- patients will require topical anesthesiawhen treated with eters are selectedbased on skin type and target tissue For higher fluences. example, for facial telangiectasiasin patients with type Appropriate eye protection in the form of clear plastic I-III skin the initial setting might be 500-560 nm filter, or glassesis worn by all present in the room. The patient's ).5-20 J/cm2, with singleor double varying pulse duration eyes may be protected with clean dry gauze or opaque delivered pulses. Due to the extensive list of available goggles The patient is placed comfortably in a suprne devices, see each manufacturer's literature for suggested position. parameters Follow the guidelines for consultation estab- Al1 currently availablemid-infrared lasersutilize either lished in the vascularlaser section epidermal-sparing cryogen spray or sapphire-tip contact The skin is cleansedto remove make-up or any material cooling The 1320-nm laser handpiece has a thermal that may interfere or absorb the IPL energy. No topical sensorthat provides feedback readingsof the peak epider- anesthesiais necessaryin most patients unless high flu- mal temperature that correspondsto the temperature of ences are to be used. Urticarial plaques may occur at the dermis. The fluence is increased incrementally until higher fluences especially without adequate intraoperative the thermal sensor reads between 42 and 48"C. The cooling. Be sure to test higher fluences prior to fu11-face 1450-nm and the 1540-nm devices do not offer this treatment even in a well-known patient. In patients with option One pass is given over the forehead where the a lower pain threshold, l5-30 minutes of pre-treatment dermis is thinnest and the intensity of pain the greatest. topical anesthetic cream may be sufficient.

Tradename Fluence(llcm') Pulseduration (ms) Spotsize (mm)

Cooltouch 16-20 200 10 Profile 12-18 200 6 (scanne0 Smoothbeam 10-13 250

Aramis 10 J.C 4 NonablativeSkin Resurfacing

Appropriate eye protection in the form of dark lenses Immediately after treatment, the patient may apply is required for the surgeonand staff present. An assistant make-up. If the treatment involved PDT, sun protection places gauze or opaque gogglesover the patient's eyes. is essentialfor 24 hours Some operators wear light-colored lensesto enable them to see the treatment site clearly. After placing the hand- PHOTODYNAMICTHERAPY piece in the desired location, these operators close their For nonablative photorejuvenation, PDT may be used in eyes for further eye protection when they fire the IPL. conjunction with other techniques discussedwithin this The IPL emits a bright flash of light that may be seen by chapter. Treatment plans vary based on each patient's the patient even with eye protection. Ifthe eye is covered, requirements. For optimum penetration of the topical this incidental light is not harmful. ALA, cleansethe skin with alcohol or acetonefollowed by The skin is generally covered with a layer of cool a gentle soap cleanser.Microdermabrasion prior to AIA coupling gel such as ultrasound gel. The handpiece is incubation is excellent as well. The ALA is applied using piaced on the skin with uniform contact. \Mhen the pulse a brush or a spongeapplicator to the clean, dry skin ofthe is fired the patient will experience a brief sensation of entire treatment area. Some cliniciansplace their patients pain and heat. At low fluences, multiple passesover the in a dimly lit room (to avoid photoactivation of the ALA) chin, nose, and cheeks may be used. At higher fluences, for 30 minutes to 3 hours depending on the practitioner's non-overlapping pulses with single or double passesare discretion. The ALA is not washed off prior to light acti- generally successful. vation Proper eye protection is selectedbased on the laser Side effects are uncommon. Transient erythema or light sourceto be used A11treatment areasare covered occurs in nearly all patients This is due to the cooling using one passof the light source,or multiple passesbased gel, the mechanical pressure of the handpiece, plus the on endpoint and parametersand patient tolerance. Ideally, IPL effect Blistering and scarringare extremely rare fsee the ALA is completely photobleached by the treatment Fig 3 9). Some patients develop slight swelling post- but there may be residual ALA that can lead to photosen- operatively. Topical steroid cream applied once is usually sitivity in sunlight for 24 hours postoperatively. Gently sufficient. wash the treatment areaand apply nonirritating sunscreen Pitfalls to avoid during IPL treatment are multiple. to the treatment area before the patient leavesthe office. When treating the skin of the forehead, care must be Ifthe patient has experiencedpain, cool packs and topical taken to avoid vaporizing the eyebrow hair. Place the steroids may be applied judiciously. handpiece at least I mm away from hair-bearing areas (unless photoepilation is a desired endpoint.) Lipstick and all cosmetics must be completely removed, other- ADVANCEDTOPICS: TREATMENT TIPS FOR wise the patient may suffer an unintentional burn due to EXPERIENCED PRACTITION ERS energy absorption by the pigment in the cosmetics. It is also reasonableto start with conservativelylow fluences Future applications of nonablative resurfacingpromise to when treating patients with moderate-to-severesigns of significantly advance the fieid of dermasurgery. Indeed, rosaceain order to prevent unexpected side effects such the nonablativeresurfacing fie1d is quite new. At this time as intensified pain, prolonged erythema, or second-degree there are many well-respecteddermasurgeons who suggest burns. that nonablativetechnology does not reliably provide consistent clinical results. It is also true that histologic proof of neocollagenesisdoes not always correlate with clinical LIGHT-EMITTINGDIODES improvement. Most do believe that nonablative dermal After the initial consultation, LED treatment may be used remodeling does play a substantialrole in the noninvasrve alone or as multitherapy in conjunction with other light cosmetic treatment of patients. With continued improve- and laser devices It is also safe to use after injectabies ment of technology, standardizationof critical studies,and The number of treatments depends on the indication. establishment of optimal treatment parameters, greater Many patients receive monthly treatments to maintain results will be seen the beneficial effects of their anti-aging or anti-acne Some newer nonablativeinnovations combine laser and treatments. nonlaser technologies. For example, the combination of The vast majority of patients report LED treatment to IPL and radiofrequency is being studied for the treatment be painless,even relaxing.Make-up is removed completely for photodamageas well as for white hair photoepilation. prior to treatment If LED is to be used with PDT, prior IPL combined with an 810-nm diode laser is being evalu- microdermabrasion for at least 5 minutes to each side of ated for the treatment of wrinkles. the face followed by application of ALA for 30 minutes A more advancedapproach to nonablative laser resur- to 3 hours is recommended by some clinicians.The patient facing combines the use of more than one nonablative is positioned in front of the LED panel and opaque eye device in the samesetting. This should be done judiciously protective gogglesare worn for 20 minutes of treatment. and at a minimum risk to the patient. It is wise to Blue light versus red light versus combination therapy is explain to the patient that although no epidermal wound predeterminedby the physician is created with nonablativetechnologies, these systemsdo 54 Lasersand Lights Votume ll

intentionally create a closed wound in the dermis. Many Goldberg DJ, RogachefskyAS, SilapuntS 2002 Non-ablativelaser of these devices may be used safely on the same day as treatment of facialrhytides: a comparisonof 1450nm diode lasertreatment with dynamiccooling as opposedto treatment other nonablative devices and injectables. Similarly, IPL with dynamiccooling alone. Lasers in Surgeryand Medrcrne treatments for small networks of vesselsmay be used in 30:79-8I conjunction with KTP or FLPDL for larger, discrete Lupton JR, Williams CM, Alster TS 2002 Nonablative laser skin vesselsin the paranasalcrease. Conservative parameters resurfacingusing a I 50 nm erbium glasslaser: a clinicaland should be used when more than one treatment is orovided histologicanalysis Dermatologic Surgery 28:833-835 at the same time. Tanzi EL, Alster TS 2004 Comparisonof a 1450-nm diode laser and a 1320-nmNd:YAG laserin the treatment of atroohic facialscars: a prospectiveclinical and histologicstudy FURTHERREADING Dermatologicsurgery 30:152-l 57 Intensepulsed [ight devices Further reading of key articles and seminal texts are listed below by subject: Raulin C, Greve B, Grema H 2003 IPL technology:A review Lasersin Surgeryand Medicine 32:78-87 Vascularlasers LED BjerringP, Clement M, Heickendorff L, et al 2000 Selectivenon- ablativewrinkle reductionby laser Jounalof CutaneousLaser Goldberg DJ, RussellBA 2006 Combinationblue (415 nm) and red Therapy 2:9-l 5 (633 nm) LED phototherapyin the treatment of mild to severe Min-Wei C Lee 2003 Combination532-nm and 1064-nmlasers for acnevulgaris Jouornalof CosmeticLaser Therapy 8:71-75 noninvasiveskin rejuvenation and toning Archives of Dermatol- Goldberg DJ, Amin S, RussellBA, Phelps R, Kellett N, Reilly tA ogy139:1265-1276 2006 Combined 633-nm and 830-nm led treatment of Tanghetti EA, Sherr EA, Alvarado SL 2003 Multipass treatment of photoagingskin Journalof Drugs Dermatolology5:748-753 photodamageusing the pulse dye laser Dermatologic Surgery Weiss RA, McDaniel DH, GeronemusRG, et al 2005 Clinical 29:686-69I experience with light-emitting diode [LED) photomodulation ZelicksonBD, Kilmer SI, BernsteinE, et al 1999 Pulseddye laser DermatologicSurgery 3l:l 199-1205 therapy for sun damagedskin. Lasersin Surgeryand Medicine 25:229-236 Photodynamictherapy Marmur ES, PhelpsR, Goldberg DJ 2005 Ultrastructuralchanges Mid-infraredlasers seen after AIA-IPL photorejuvenation: a pilot study Journal of FatemiA, WeissMA, Weiss RA 2002 Short-term histological Cosmetic LaserTherapy 7:21.-24 effects of nonablative resurfacing:Results with a dynamically Marmur ES, SchmultsCD, Goldberg DJ 2004 A review of laser cooledmillisecond-domain 1320 nm Nd:YAG laser and photodynamic therapy for the treatment of nonmelanoma DermatologicSurgery 28:t 72-176 skin cancer DermatologicSurgery 30:264-271 FournierN, Dahan S, BarneonG, et al 2002 Nonablative remodeling:a 14-month clinicalultrasound imaging and Reviewsand editorials profilometricevaluation of a 1540 nm Er:Glasslaser. Dermatol Alam M, Hsu T, Dover JS, et al 2003 Nonablativelaser and light Surg; 28:926-931 treatments: histology and tissue effects-a review. Lasersin FriedmanPM, Jih MH, Kimyai-AsadiA, Goldberg LH 2004 Surgeryand Medicine 33:30-39 Treatment of inflammatory facial acne vulgaris with the Goldberg DJ 7002 Nonablative dermal remodeling: Does it really 1450-nm diode laser:a pilot study DermatologicSurgery work? Archivesof Dermatology138:1366-1368 30:147-l 5I Lefell DJ 2002 Clinical efficacy of devices for nonablative Goldberg DJ 2000 Full-facenonablative dermal remodelingwith a photorejuvenationArchives in Dermatology20:97-l I l 1320 nm Nd:YAG laser DermatologicSurgery 26:91 5-918 SkinTightening with Radiofrequency MacreneR. Alexiades-Armenakas,Michael S. Kaminer

INTRODUCTION Chapter X. In contrast, nonablative devices target the dermis without epidermal injury, and include the near- The skin rejuvenation field has advanced rapidly with infrared lasers, intense pulsed light, and radiofrequency patient demand and improved technology driving the technologies. While resulting in more modest clinical development of laser and light treatments that requrre improvement, this approach involves minimal risk and little or no recovery time The concept of the nonsurgical extremely rapid recovery Non-skin tightening, nonabla- alternative to the facehft inspired efforts to increase tive devicesare describedin Chapter 2. Within this nonab- penetration depth, and target skin laxity, with the use of lative category,radiofrequency devices produce electrical longer radiofrequency wavelengths. These devices heat energy that volumetrically heats the dermis, inducing co1- the dermis and potentially the subdermaltissues, resulting lagen contracture and clinical improvement in skin laxity. in clinical findings of skin tightening The first devrce rn this areawas a monopolar radiofrequency (RF) device that was FDA approved for the noninvasivetightening of peri- RADIOFREQUENCY TECH NOLOGI ES orbital rhytides using this proven mechanism of tissue tightening Disadvantagesof that first generation device . Background included inconsistency of clinical results and significant The first radiofrequency energy source for skin rejuvena- discomfort during treatment Since then, protocol and tion n'as the monopolar radiofrequency device, Therma- technical modifications have been impiemented, and Cool (Thermage, Hayward, CA, USAJ, which was shown ner'verbipolar and monopolar RF devices and treatment to be safe and effective in treating skin laxity. In 2002, tips have been developed to increase efficacy and mini- this device received FDA approval for the reduction of mize discomfort In addition, wavelengthsin the infrared periorbitai rhytides, and has been used for skin tightening region, and most recently ultrasound, have been devel- on other areasofthe face,neck, extremities, and abdomen. oped to induce volumetric heating and improve skin laxity The technology delivers a uniform volumetric heating In this chapter we will outline radiofrequency skin tight- effect into the deep dermis, generated by the tissue's ening technologies and explore their role in the field of resistanceto the current flow, while protecting the epi- cosmetic enhancement. dermis through contact cooling. The electric field polarity The lasers,RF, and light devicesused for skin reluvena- is changed6 million times per second,causing the charged tion fal1 into three general categories:ablative, fractional, particles within the electric field to changeorientation at and nonablative. Ablative lasers included carbon dioxide that frequency; tissue resistanceto the movement of the (COr) and erbium:yttrium-aluminum-garnet (Er:YAGJ particles generatesheat. Advantagesinclude the minimal lasers,which rejuvenate skin through controlled thermal erythema postoperatively that typically resolves within ablation of epidermis and upper dermis \\4ri1e highly hours, and a lack of significant risk of side effects. Initial effective, ablative laser resurfacing requires 5-10 days of drsadvantagesof that system were inconsistent results: epidermal healing and may cause erythema lasting weeks dramatic improvement in a minority of patients and to months. These technologies are amply described in minimal changesin the majority. A study of this system Chapter l. Recently, fractional laser resurfacinghas been used to treat the lower face of 16 patients demonstrated developed,which employs a 1540 nm erbium-doped mid- that only one third of patients considered the results infrared fiber laserto causemicroscopic cylindrical epider- satisfactoryand photographic analysisdid not yield statis- mal and dermal areasof thermal damage spaced at 2000 tically significant results Recent technological and tech- treatment zonesper cm2 or approximately 20% of the skin nique modifications have dramatically improved the surface This intermediate approach increases efficacy consistencyand extent of improvement with ThermaCool compared with nonablative,but with faster recovery com- treatments by increasingthe tip size and repeatedly treat- pared with ablative resurfacing Now a variety of devices ing over the indicated area as many as five times at lower are available for fractionated resurfacine as described in energy settlngs. 5o Lasersand Lights Volume ll

A new development has been the combination of electrical and optical energy that has been developed in order to augment the nonablative effects achieved with either Energy(joules) = 12x Zx t modality alone The combination of infrared laser at / = current(amps) 900 nm and bipolar radiofrequency (Polaris, Syneron, Z= rmpedance(ohms) Yokneam, Israel), and of intense pulsed light (500- t = time(seconds) 1200 nm) with bipolar radiofrequency (Aurora, Syneron, Yokneam, Israel) has been evaluated for the reduction of rhytides, laxity, and photoaging. The combination of RF with diode laser or with pulsed light has been shown to Radiofrequency energy production follows the princi- induce tissue contraction and effects on laxity, rhytides, ple of Ohm's law (Box 4.1), which states that the imped- and other aspectsof photodamage Combination RF and anceZ fohms) to the movement of electrons createsheat infrared light (Veiasmooth, Syneron) has been assessed relative to the amount of current I [amps) and time t for striae and cellulite Most recently, an RF-only hand- (seconds). piece has been developed IST Refirme, Syneron], which may be fitted to this company's Galaxy system, though published data are not yet available A paired comparison THERMACOOI (rH ennnnCe) control study of the laser or pulsed light with and without For the monopolar Thermage unit, the RF generator sup- RF is lacking. Until such data becomesavailable, clinicians plies a 6 MHz alternating current acrossa specially modi- have no way of testing the hypothesis regarding a syner- fied monopolar electrode to deliver volumetric heat to gistic effect of the RF and laser/light on outcome tissue in a targeted manner. A disposablereturn pad con- Newer RF technologiesare continually being developed nected to the patient's flank creates a path of travel for to promote the degree of skin tightening in fewer treat- the radiofrequency signal.The generator is regulated by a ments A recent advent is the Accent device (Alma lasers), PentiumrM chip-based internal computer that processes which offers alternatively bipolar and unipolar RF modes. feedback, including temperature of the tip interface with This RF technology [40.68 MHzJ is delivered through one the skin, applicatron force, amount of tissue surface area of two different handpieces. The first delivers bipolar contact, and real-time impedance of the skin. This infor- energy with a penetration depth of between 2 and 6 mm, mation is gathered by a microprocessorin the handpiece while the second delivers unipolar energy with a potential and relayed to the generator via a high-speed fiber optic for a 20 mm penetration depth. This device was recently link (Fig.+.rA). approved for rhytides reduction on and off face. The A unique capacitively coupled electrode disperses unipolar mode employs RF electromagneticradiation, not energy uniformly acrossthe very thin (1/1000 of an inch; current, targets the deep dermis and subcutaneousjunc- 25 pm) dielectric material on the treatment tip, thereby tion, whereas the bipolar mode employing RF current creating a uniform electric field (Fig. 4 lBJ The RF gen- targets superficial and mid-dermis, thereby theoretically erator operates at 6 MHz, which changesthe polarity of improving both laxity and fine lines through a combined an electrical field in biological tissue 6 million times per approach The results of the trials conducted in the United second. The charged particles of the tissue within the States are pending electric field change orientation at that same frequency, Most recently, ultrasound deviceshave been developed and the dermal tissue's natural resistance fexpressed in in an effort to further increasepenetration depth for the Ohms law as Q to the movement of electrons generates treatment of cellulite and deep tissue tightening, though heat This friction from electron movement createsvolu- the outcome from this pilot study is pending. metrically distributed deep dermal heating.Before, during, and after delivery of the monopolar RF energy, a cryogen o Mechanismof action spray delivered onto the inner surface of the treatment tip membrane provides cooling to protect the dermis from GENERAL overheating and subsequent damage The treatment tip The ThermaCool RF device has four key components: an continually monitors heat transmission from the skin via RF generator, a handpiece, a cooling module, and dispos- thermisters mounted on the inside of the dielectric mem- able treatment tips The Galaxy (Polaris and Aurora) brane. The cryogen spray also provides cooling of the device, has two handpieces,one for diode laser combined upper portion of the dermis. This createsa reversethermal with bipolar RF, the other for pulsed light combined with gradient through the dermis and results in volumetric bipolar RF. Both handpieces have associated contact heating and tightening of deep dermal and even subdermal cooling. As described above, the ST Refirme handpiece tissues (Fig.+.2). The depth of this heating is dependent may be fitted to the Galaxy system The Accent device upon the treatment tip geometry and the duration of has two handpieces, one for unipolar RF and the other cooling. for bipolar RF both with contact cooling. The latter Each treatment cycle consistsof three phases:precool- two systemsdo not have disposableparts associatedwith ing; cooling and treatment; and postcooling. A treatment their use cycle was about 6 secondswith the initial generation of SkinTightening with Radiofrequency

::==

tr Fig. 4.1 A. ThermageThermaoool device B. Capacitivelycoupled electrode treatment tip. (Photographscourtesy of Thermage)

'fast' treatment tips, and about 2 secondswith treatment generatedin the tissue can be customized by changingthe 'fast' tips. With the newer treatment tips, the handpiece size and geometry of the tip electrode, the amount of microprocessor aborts the treatment pulse to protect energy delivered (which is directly correlated to tissue against burning if a1l four corners of the tip are not in impedance), and the cooling parameters designatedfor a complete contact with the skin. given energy setting. These heating, cooling, and energy The initial feasibility study of this RF device coupled parameters are programmed into a small eprom chip with a concurrent epidermal cooling system utilized a located within each disposabietreatment tip, with manu- three-dimensional Monte Carlo simulation mathematical facturer-optimized parameters automatically upg_raded model to gauge the theoretical temperature distribution without active user intervention or generator sottware within human skin. The results showed that this treat- upgrade. ment tip design produces volumetric heating deep within the dermis yet protects the superficial skin layers from GALAXY(RURONR, POLARIS, ST REFIRME)AND thermal injury This creates a much greater temperature rise below the surface than in the epidermis. The depth vELASMOOTn(SvruenOru) of the RF field in tissue varies with the surface area of For the bipolar RF device, Galaxy, there is no need for the treatment tip electrode design The larger the tip grounding the patient. The distance between electrodes electrode surfacearea, the deeper the heat produced. The determines the depth of penetration; RF energy penetra- amount of heat generated depends on the impedance of tion is approximately equal to half the inter-electrode the tissue being treated with each pulse and on the distance For example, a distance of 8 mm yields an selected treatment setting. The depth of the protected approximate penetration depth of 4 mm. Good contact tissue zone at the surfaceis controlled by the cooling time needs to be maintained to prevent arcing. For coupling, and intensity. Therefore, the degree and depth of heat an aqueous gel is used. A theoretic synergistic effect of 58 Lasersand Lights Votume ll

Reversethermal gradienl

Oo+45=45o

20o+45=65o 30o+45=75o

Fig. 4.2 Reversethermal gradient createdvia simultaneouscooling of the epidermisand heatingof the dermis

the RF on the pulsed light and diode laser tissue interac- Primary changesto collagenoccur as heat disrupts hydro- tion has not been proven. gen bonds, altering the molecular structure of the triple The bipolar RF device VelaSmooth, which is FDA- helix collagenmolecule and resulting in collagencontrac- approved for cellulite, delivers a maximum power of 20 W tion. Secondaryto the immediate thermal contraction of (or 20Jls) with a depth of heating of 5-10mm The collagen,a more gradualcontraction due to wound healing skin surface is hydrated for coupling with a conductive is predicted to occur over time as collagen regenerates, solution, not gel. Broad-spectrum infrared light [700- leading to a thicker remodeled dermis. Animal studies 20000nm) is emitted at 20W (or J/s) with a depth of have demonstrated dermal collagen heating as shallow as optical heatingof 5 mm. This device alsoincludes mechan- the papillary dermis or as deep as the subcutaneousfat ical rollers and 750 mmHg negative-pressurevacuum Additional animal studies examined I cm2 treatment tros 'fast' Recently, the ST Refirme handpiece application of bipolar with 2- and 6-second cycle times, described as and 'standard' RF alone hasbeen developed for attachment to the Galaxy treatment tips, respectively. Lactate dehydro- base system. This applicator is mobile and painless,but genase (LDH) and heat shock protein [HSP) stainings published data are lacking. were used to determine the depth of action for these two treatment tips. Results showed that the depth of treat- 'fast' 'standard' ACCENT(nWA) ment was the same for both the and the treatment tips. This was observed histochemically when The Accent system contains both bipolar and unipolar the enzyme or protein (HSP) was inactivated. Of technologies in one device. The base system generates ILDHJ note from this experiment was that the LDH enzyme was 40.84 MHz of RF energy.In the unipolar mode, RF energy deactivated at approximately the same treatment levels is applied as electromagnetic radiation, not electrical for both tips even though the cooling and heating times current from a single electrode tip without a grounding and intensities were different (personal communication, plate. The energy is delivered to a penetration depth ofup Karl Pope, Thermage, Inc.) to 20 mm In the bipolar mode, the RF current is applied These reliable LDH and HSP heating depth results between two points on the tip ofthe probe, to a penetration confirm the heating profile postulated by Zelickson et al depth of 2 to 6 mm. In addition, since this is not a station- (2006) who used transmission electron microscopy to ary energy delivery device, but rather energy is delivered evaluate ex-vivo bovine tendon immediately after treat- in a mobile fashion, pain control is not needed. Mineral oil ment with monopolar RF at various energy and cooling is used to decreasefriction ofthe handpieceacross the skin. settings Results showed collagen fibrils with increased Skin surface temperature monitoring is performed and a diameter and loss of distinct borders as deep as 6 mm peak temperature of 40-42"C is maintained. Higher energy settings produced deeper and more exten- o sive collagenchanges. Histochemicaland microscopicfindings In a clinical study involving in-vivo human skin, a In-vivo studies have shown that volumetric RF tissue- similar pattern of immediate collagen fibril contraction heating produced with monopolar RF createsa dual effect. was observed,an acute effect that has not been associated SkinTightening with Radiofrequency with nonablative lasers. In this same study of intact neck should be clearly demarcated and excluded from abdominal tissue, northern blot analysis demonstrated treatment. All skin types can be treated effectively, as increasedsteady-state expression of collagentype I mRNA dermal heating while simultaneously cooling the epider- in treated tissue, evidence that wound healing is initiated mis with RF has not been reported to cause hypo- or by the single ThermaCool TC treatment. The secondary hyperpigmentation. Patients with advanced photoaging or collagen synthesis in response to collagen injury is pur- more severe skin saggingmay still benefit from RF treat- ported to occur over several (2-6) months. Kilmer et al ment, but possibly to a lesserextent. Adjuvant or combi- [2005) noted fibroplasia and signs of increased collagen nation treatment, such as incorporation of infrared or formation in the papillary dermis and less frequently in pulsed light is of additional benefit to photoagingpatients, the reticular dermis. Histology specimenstaken 4 months making the Galaxy system a viable option. A comprehen- after treatment demonstrate epidermal and papillary sive grading scale of laxity, rhytides, and all categoriesof dermal thickening aswell as shrinkageof sebaceousglands photoaginghas been devised,which may be used to predict (Fig.+.r). and select which technology or combination of technologies will most benefit the patient (Tabte+.r). Patients with mild, moderate, and severe rhytides and CLINICALAPPLICATION photodamage are candidates for nonablative technology; o however, patient expectations must be handled directly. Patientselection Patients who are concerned about risk and recovery and Guidelines should include treating a broad surface area at are willing to accept minimal efficacy in exchange for appropriate fluences and carefully selecting patients in minimal risk are the ideal candidates for nonablative their 30s to 70s, who have medium quality skin thickness approaches.Dark-skinned and tanned patients should be and mild-to-moderate jawline and neck laxity. Treating cautioned of the risk of post-treatment dyspigmentation areas on and adjacent to the described laxity may also when nonablative lasers, and light sources/ are used in improve responserate. The thyroid region of the anterior combination with RF. A test spot may be performed on a

Fig. 4.3 Humanskin: before (A) and 4 monthsafter (B) treatmentwith the ThermacoolTC, showingepidermal thickening and increaseddermal density.(Photograph courtesy of Thermage) D o

D f o Categoriesof skin ageingand photodamage @ 5 Grading Descriptive Rytides Elastosis Dyschromia Erythema Keratoses Texture scate parameter telangietasia - 3 o 0 None None None None None None None None 1 Mitd Wrinklesin motion, Localizedto nasolabial Early, Few (1-3) discrete PinkE or few T Few Subtle few,superficial (nl) folds minimal, small(<5 mm) localizedto irregularity yellowhue lentigines singlesite

Mitd Wrinklesin motion, Localized nl and early Yellowhue or Several(3-6) discrete PinkE or several Several Mitd multiple,superficial metalabial (ml) folds eafly smalllentigines T localizedto 2 irregularityin localized sites few areas periorbital (po) elastotic beads(eb) Moderate Wrinklesat rest, Localizednl/ml folds, early Yellowhue, Multiple(7-10) small Red E or Roughin few few,localized, jowls,early submental/ localizedpo lentigines multipleT localized supedicial submandibular(sm) and eb localizedto 2 sites SitES Moderate Wrinklesat rest, Localizedprominent nl/ml Yellowhue, Multiplesmall and {ew Red E or Multiple, Roughin multiple,localized, folds,jowls and sm po and malar largelentigines multipleT rarge several superficial eo localizedto 3 localized sites areas Advanced Wrinklesat rest, Prominentnl/ml folds, Yellowhue, Many(10-20) small ViolaceousE or Many Roughin multiple,forehead, jowlsand sm, earlyneck eb involving and largelentigines manyT, multiple multiple periorbitaland strands po, malarand sites localized perioralsites, other sites sites superficial 3.5 Advanced Wrinklesat rest, Deepnl/ml folds, Deepyellow Numerous(>20) or ViolaceousE, Little Mostlyrough, multiple,general- prominentiowls and sm, nue, multiplelarge numerousT, little uninvolved little ized,superficial; prominentneck strands extensiveeb lentigineswith little uninvolvedskin skin uninvolved few,deep with little uninvolvedskin skin uninvolved skin Wrinkles Markednl/ml folds, iowls Deepyellow Numerous,extensive, Deepviolaceous No uninvolved Rough throughout, and sm, neckredundancy hue,eb no uninvolvedskin E, numerousT skin throughout numerous and strands throughout, throughout e)densively comeoones distributed,deep

Reproducedwith permission from Alexiades-Armenakas MR Rhytides,laxity, and photodamagetreated with a combinationof radiofrequency,diode laser, and pulsedlight and assessedwith a comprehensivegrading scale. J DrugsDermatol 2006; 5 (8):731-8 6r SkinTightening with Radiofrequency high-risk patient prior to the first treatment sessionand areas AdditionaIIy, 14.3o/ctQ'7/)J'9) of treated areashad patients should be instructed as to sun avoidance and no change, and 25'k (3/t19) worsened. Photographic sunscreen use following treatments. These lasers are analysis revealed an eyebrow lift of at least 0.5 mm rn avoided in the caseof a patient u,ho has received systemic 61.570[40/65) of patientsafter 6 months (FiS.+.+). Fifty isotretinoin within the preceding 6 months due to the percent (4I/82) of subjectswere satisfiedor very satisfied reported increasedrisk of impaired."voundhealing in these with their treatment outcome. Incidence of side effects individuals Pregnant women are best not treated until was lou, and consistedof edema (13.90/oimmediately) and after delivery and breastfeeding. erythema (360i immediately) By I month, no subject had signs of edema, and only 3 (3.970) had lingering signs of . Ctinicalfindings erythema Rare second-degreeburns occurred in 2l firings of 5858 RF exposures,indicating a burn risk of 0 360/oper THERMACOOL application.Three patients had sma1lareas of residualscar- To obtain FDA clearance for the esthetic application of ring 6 months after treatment The authors concluded that the monopolar radiofrequency device, ThermaCool TCrNI a singletreatment with monopolar RF reduced periorbital researchersundertook a 6-month study to evaluate the rvrinkles, produced lasting brow elevation, and improved device's efficacy and safety Eighty-six subjectsreceived a eyelid esthetics The authorsalso concludedthat the safety single treatment on the forehead and temple area with profile of this device, used by physicianswith no previous 68 cm2 of tissue'"vith a singlepass at settingsranging from experiencer'vith its operation, was impressive. 6q-qi T/.-2 T*rantr,-t.rspatients received a nerveblock In another study, Hsu and Kaminer evaluated 16 just superior to the eyebrows immediately prior to or patients treated with a single passon the cheeks,jawline, shortly after initiation of treatment. Independent scoring and/or upper neck. Treatment levels averagedll3 8J/ of blinded photographs taken 6 months after treatment cm2 on the cheeks,decreasing to 99.7 J/cm2onthe neck. resulted in Fitzpatrick wrlnkle score improvement of at In post-treatment follow-up phone interviews, 3601,of least I point in 83.20lo(99/ll9) of treated periorbital patients rvho r'r,ere treated at all three sites reported

Fig. 4.4 Eyebrowlift following Thermage treatment, Photographic example of patlentprior to treatment(A) and 4 weeks post-treatment(B)' with a mean li'ftof 3 42 mm (right)and 3 41 mm (left).(Photograph courtesy of Thermage) Lasersand Lights Volume ll

satisfactory results compared with 25o/oof patients who red laser,and pulsed iight assessedusing a comprehensive, were treated at only one or two sites. Also, satisfied quantitative grading scale for the treatment of rhytides, patients were those treated with higher energies. This laxity, and the various aspectsof photoaging.Among 28 study had three important findings: patients treated, a mean improvement of 10.90/oper category of skin agingper treatment and 260looverall improve- I Higher treatment fluencesgenerally 1edto improved ment following a mean of 2 6 treatments was observed. or more consistentresults. Patient satisfaction on a yes/no scale revealed 71.40lo 2 The greater the surface area treated, the better the satisfactionrate results. Clinical studies of the Velasmooth for the treatment 3. Younger age is a predictor of rncreasedefficacy with of cellulite demonstrated a decreasein thish circumfer- the Thermage procedure. ence of I cm and a mean clinical improvement of 500/oI These findings have direct implications for refining treat- month after 8 twice-weekly treatments at 1-month follow ment algorithm guidelines. Guidelines should include up. treating a broad surface area and carefully selecting patients who have medium-quality skin thickness and ACCENT mild-to-moderate jawline and neck laxity Treating areas The Accent bipolar and unipolar RF device was recently on and adjacent to the described laxity may also rmprove FDA-approved for the treatment of rhytides both on face responserate. Patients with advancedphotoaging or more and body A pilot study of 26 patients with cellulite on severe skin saggingmay still benefit from ThermaCool the thighs and buttocks were treated with two sessionsof TCrM treatment, but possibly to a lesser extent. unipolar RF with the Accent device. In this report, 680/o Tanzi and Alster [2005) evaluated cheek laxity in 30 of the patients achievedvolume contraction, as measured patients and neck laxity in 20 patients after one treatment by ultrasound from dermoepidermal junction to Camper's with the ThermaCool TCrM Patients were pretreated fascia. The limitations of the study included large stan- with 5-10 mg of oral diazepam as well as topical anes- dards of deviation for the measurements and a lack of thetic cream (LMX-506 cream, Ferndale Laboratories, clinical evaluation of improvement, though photographic Inc., Fernadale,MI) The cheek treatment area extended data demonstrated significant improvement. It will be from the nasolabialfolds to the preauricular margin and interesting and informative to observe the results of the down to the mandibular ridge Treatment of the neck clinical trials in the U.S. In another recently completed extended from the mandibular ridee to the mid-neck. study, 30 female subjectswith upper thigh cellulite were Fluencesranged from 97 to 144 J/cmt on the cheeks and treated with the Accent unipolar device.A11 subjects were frorn 74 to 134 J/cm2 on the neck. Mild oost-trearmenr treated six times over the course of l2 weeks. The mean erythema was seen in all patients and periisted up to 12 decrease in thigh circumference was 2.45 cm. Of note hours after the procedure. Fifty-six percent of subjects there were no changes noted with magnetic resonance complained of sorenessat the treated sites; the soreness imaging (MRI) evaluationsand blood lipid analysis His- resolvedwith oral nonsteroidal anti-inflammatory medica- tologic analysisdid show fibrosis in the deep dermrs, con- tions. Erythematous papules that resolved over 24 hours sistent with the clinicai findings of skin tightening (David were observed in 3 patients. One patient developed dys- J. Goldberg, MD, Personal CommunicationJ. Recently esthesiaalong the mandible that resolved over 5 days. No Alexiades-Armenakascompleted two randomised,blinded, blistering or scarring was observed A quartile grading split-design,controlled trials employing the Accent for the system was used and independent assessment noted treatment of rhytides and laxity on the face and for the improvement in 28 of 30 patients who were treated on treatment of cellulite on the thishs. the cheeksand I 7 of 20 patients who were treated on the On the face, a 4.4-7.3o/orJuction in rhytides and neck. The 5 subjects who demonstrated no clinical laxity was detected in blinded evaluationsof randomised, improvement were all older than 62 years. At 6 months, split photographsusing the comprehensivegrading system the mean clinical improvement score was 1.53 on the following four treatments. In the cellulite study, an 80/o cheeks = and L27 on the neck fscaleof I 25-50% inrprove- quantitative improvement was detected following a mean = ment, 2 51-75o/oimprovement). On a scaleof l-10, the of 4 treatments by blinded evaluations of randomised, averagepatient satisfaction score was 6.3 for cheek treat- controlled, split-design photographs. ment and 5 4 for neck treatment. OVERVIEWOF TREATMENT STRATEGY GALAXYAND VELASMOOTH ' The combination of bipolar RF and optical or infrared Treatment approach energy was assessedin several studies for the treatment \A4rentreating the face, the physician can essentiallylook of skin^aging._lnone study, the combination of bipolar RF at the face as two distinct areas:upper and lo*ei f".e and infrared laser demonstrated improvement in rhytides There may be some benefit to treating the entire face in and laxity among 108 patients. Recently, Alexiades- one session,but it is possibleto treat Iither the forehead Armenakas utilized the combination of bipolar RF, infra- region or the cheek/jawline region alone. Both treatment 6j SkinTightening with Radiofrequency zones include treatment of the periorbital area (crow's 1200 nmJ of the Aurora handpiece should be applied at a feet) Radiofrequency devices are capable of tightening starting fluence of 20 J/cmz and increased by 2-4 l/cmz skin and improving contours. The physician must per treatment, while maintaining concomitant RF energy analyze the three-dimensional facial structure of the it a starting fluence of I 8 J/cm2 and increments of 2 J/ cm2 patient to assessthose areasthat would benefit most from to a maximum of 22 J/cmz. Two passeswith the combina- tightening. Typically, this would include the forehead/ tion of RF and pulsed light should be applied. For the brow area, as well as the lower cheek, jawline, and sub- Accent system, tentative parameters for cellulite reduc- mental region tion include a starting fluence with the unipolar RF hand- Patients with a combination of photoaging as well as piece of 150 J/cm2 to a peak temperature as measured on rhytides and laxity may benefit from a combined approach the skin surface using an infrared thermometer of 40- treatment. In these patients, treatment with the Galaxy 43 " C (Alexiades,manuscript in preparation). On the face fSyneron) system, using bipolar RF and infrared laser to and neck, the unipolar handpiece should be applied with target laxity and rhytides, and pulsed light to target vascu- a starting fluence of 100J/cm2. The bipolar handpiece larity and dyspigmentation,may havea theoretical although is applied to the face and neck at a starting fluence of unproven advantage.This would yield modest but consis- 70 I/crn2. A peak temperature of 40'C is attained in this tent improvement in all categoriesof skin aging location as well Once the peak temperature is achieved, Once this analysishas been done and the treatment plan three successivemaintenance passes should be applied created, therapy can be initiated. By varying the fluences with a decreaseof 10 J/cm2 per pass. used and the number of passesin each areaof the face, the Patients scheduled for treatment must be in general physician can preferentially tighten some areas/ reduce good health, and must not have a pacemaker.It is recom- the prominence of others (i.e., jowls), and overall improve mended that pregnant women not be treated. It is also the shape and appearanceof the face. A grading system, important to assessthe following pretreatment: such as that published for use in evaluating RF and other ,1" Do you have a low pain tolerance?The measure of nonablative devices, should be employed to rate the heat felt during the procedure is important in patient's degree of severity in the various categories of determining treatment levels. Patients with a very rhytides, laxity and photoagingprior to and following each low pain tolerance and no supplemental anesthesia treatment. Photographic analyses at each visit are also may not be able to reach appropriate treatment essentialto monitoring the patient's level of response levels, and may not achieve maximum benefit from their treatment. . Maiordeterminants .$ Do you have any important social events coming up? The three variables that seem to determrne how much Rarely, patients will have edema lasting for several benefit a patient will obtain from the ThermaCool TCrM days. It is important they schedule the procedure at a time when they have no important social obligations .5 \Mhat are your expectations? Patients expecting I individual patient extent of photoaging,as well as age facelift or browlift quality results need to be carefully 2. treatment fluences assessedand counseledpre-treatment. Although in 3. number of passes. many patients the results are remarkable, that is not Early data suggestthat younger patients (under the age of always the case.Patients who have lofty expectations 60-65 years) will do best, as will those with mild-to- may end up disappointed, and this should be moderate amounts of skin laxity Moderate fluences discussedwith the patient before treatment is begun. (titrated to patient comfort) covering a broad surface area of skin also appear to promote better results, as does the use of multiple (5-10) carefully placed passes TREATMENTPROTOCOLS The roie of multiple treatments is not yet adequately understood. . Patients In using the Galaxy system, the number of passes Men and women aged 30 to 80 years. should be maximized at 6-10. The RF setting should be increasedas tolerated to the maximum fluence within one to three treatment sessions.Employing the Polaris hand- . Equipment piece first, an initial setting of RF of 80 J/cm2 should be device-return patient pad, coupling increased to a maximum of 100J/cm2 with subsequent ThermaCool TCrM grid, individual treatment tip, treatments to the face and neck. The RF setting should fluid, treatment if desired (lorazepam, be maintained at 50 J/cm2 to the forehead. The infrared supplemental anesthesia (900 nm diode) laser component should be commenced meperidine/hydroxyzineJ at 20 J/cmz, increasingby 2-4 l/cm2 per treatment to a Galaxy device-aqueous gel, EMLA or LMX cream. maximum of 36 J/cm2 in type I skin The clinical endpoint Alma Accent device-mineral oil, cotton rounds, of erythema should be achieved. The pulsed light (500- infrared skin-surfacethermometer. 64 Lasersand Lights Volume ll

. Preoperativesetup become the current recommendation The challengewith pain control while heating areas of deep dermis, and GENERAL potentially subdermal structures, is that topical anesthet- Preoperative photographs are taken. For the Galaxy ics do not typically penetrate to that depth Therefore, system, all areas to be treated are covered with a thick adjunctive measureshave been utilized to enhancepatient layer of anesthetic cream (LMX 50/ocream, Ferndale Lab- comfort and to relieve anxiety causedby the deep heating oratories, Inc , Ferndale, MI) with or without occlusion sensatlon. with plastic wrap to create mild epidermal anesthesiaand Nerve blocks are theoretically useful, particularly on hydration Some physicians also apply anesthetic cream the forehead. However, usersare cautioned that complete prior to Thermacool After approximately t hour the elimination of pain feedback from the patient as a data cream is removed, and the area is cleansedwith alcohol point for energy adjustment may put the patient at risk wipes, moist gauze, as well as dry gauze. It is essential of thermal injury. Since pain perception can help the to remove all of the topical anesthetic cream The newer physician understand when thermal injury is hign, nerve RF device Accent (Alma lasers) does not require topical blocks are not recommended. Rather, patient feedback of anesthetic. pain perception on a l-10 scale is used Treatment is titrated to a maximum pain of 5 out of 10. Although THERMACOOL injectable local anesthesiacan eliminate pain, it also adds a conductive fluid to the subdermal environment, For the ThermaCool system, the treatment grid is then which in turn reduces tissue impedance. This iatrogenic applied with the ink side on the skin and the use of alcohol alteration in tissue impedance can have negative swabsto the back side ofthe grid paper,thoroughly wetting effects on both patient outcomes and predictability. Until further the paper. This allows transfer of the ink to the areato be study is undertaken to predict its effects, it is not recommended treated The grid is used to ensure even placement of the as a form of anesthesia. treatment pulsesand to prevent overlap,which could lead For these reasons, physicians have to excessiveheat and epidermal or dermal injury The turned to various forms of sedation to improve patient comfort. adhesivereturn pad is applied to the patient's left flank to Complete generalanesthesia or intravenous conscious ensure a travel conduit for the RF energy and to complete sedation completely take patient pain feedback the circuit It is important that the return pad be placed out of the equation and are not recommended. Rather, pain in this same location on all patients since impedance read- control options using oral and intramuscular medications ingscan change when the pad is movedto other locations seem to dramatically improve patient comfort during procedure, yet (personal communication, Thermage, Inc.). The return the still enable some patient feedback. In practice, physicians pad is attached to the machine, and a new treatment tip use is placed into the handpiece various combinations of medicatrons includins oraLdiaz- epam, lorazepam, triazolam, oxycodone, ut *"11 as intramuscular meperidine, hydroxyzine, and butorphanol The GALAXY authors have developed a combination approach that has For the Galaxy system, no grounding pad is needed, as substantiallyimproved patient tolerance of the procedure. this is a bipolar system.Aqueous gel is applied. The Polaris Patients are given I mg of lorazepam oraily upon arrival. handpiece is applied in successivepasses that are perpen- Fifteen minutes before the procedure is to begin, patients dicularly oriented to each other The first pass is applied are given meperidine 75 mg and hydroxyzine 25 mg intra- in parallel adjacent pulses acrossthe skin surface at the muscularly A second I -mg dose of lorazepam is given parameters aforementioned The next pass is applied subiingually at the start of the procedure if patients are perpendicular to the first pass, across the entire skin stil1uncomfortable. surface.For the subsequentpass, the first passorientation Performing the first 20-30 caseswithout oral, intra- is repeated. The clinical endpoint of erythema rs muscular, or topical anesthesiais a useful iearning tool. achieved This approach teaches the physician how to manage different areasof the face, as well as different pain percep- ACCENT tions from patient to patient while strictly adhenng to the 5 out of 10 pain guidelines For the Accent system, mineral oil is applied. The hand- Once the doctor is experienced in using piece is kept mobile throughout the treatment. The hand- the ThermaCool system, pain controi can be expanded by piece is moved acrossthe patient's skin in regular,uniform, utilizing sedating medications. The combination or circular movements, spanningthe entire surface area. RF and diode or intense pulsed light system (Galaxy, The clinical endpoint of erythema and a surfacetempera- flPL) Syneron) doesnot require systemic ture of 40-42'C is attained analgesiaas the discomfort is well controlled with topical anesthetic creams Topical lidocaine and prilocaine cream (EMt-{) o Anesthesiaalternatives is applied for I hour prior to treatment and is adequate for pain control. Due to the discomfort with the Thermage procedure at An advantageof the newer mobile RF device Accent higher settings, multiple passes at lower settings have fAlma) is that it is painlessand no anesthesiais required. 65 SkinTightening with Radiofrequency

The tip provides cooling and the mobile nature of energy . Periorbitalrejuvenation delivery precludes the need for pain control. THERMACOOL o Genera[treatment principles Treatment for periorbital improvement should extend acrossthe entire forehead, down to the temples and the 'fine THERMACOOL crow's feet area. Initially, a tune' seriesof 2-3 treat- Eariy treatments [2001-2002) with the Thermage device ment firings is performed with the ThermaCool to tune the were done with a single pass at relatively low fluences deviceto the patient's skin. A generousamount of coupling 'slow using the so-called tip.' As the understanding of RF gel is applied to ensure complete contact between the tissue physics improved, so did the physician comfort treatment tip and the skin. The gel can be added or reap- level with increasing both fluence per pulse and the plied asneeded during the treatment sessionAfter the fine number of passesover the same tissue area.A key break- tuning, actual treatment firings may begin after choosing through seemsto haveoccurred with the addition of selec- the energylevel. With the 3-cm2treatment tip and a typical tively placed second,third, and even fourth through length setringof 354.0-355 5, an initial singlepass is delivered passesto the treatment algorithm. \A4ren a single pass is across the forehead. The temples and crow's feet are used, many patients will benefit from treatment Adding treatedat levels352.5-353.0 in this first pass.lt is critical multiple passes in selected lax areas appears to yield to reduce treatment fluences over the temporal region greater benefit, sometimes visible at the time of treat- (lateral to the frontalis muscle) since there may be an ment. Rarely are any immediate benefits seen after one increasein side effects (subcutaneousdepressions or super- pass, but they are almost routinely seen when multiple ficial burning) when settingsover 353.0 are usedin this thin passesare employed (Box+.2). tissue area. Extending treatment to the lateral periorbital A second key breakthrough has been the use of lower region can have a significantimpact on periorbital rhytides fluenceswith multiple passesto minimize discomfort and and can provide substantial local rejuvenation and tissue maximize clinical results Lower fluences correlate with tightening that can affect adjacent areas(Fig. 4.5). lesspain, but by delivering multiple passesto a given area, Pain sensation is a crescendo of warmth ending in a 'spike' total energy delivered actually increases.This has resulted brief of heat. Differing patient tolerances to this in both rmproved results, and importantly, increasedpre- sensationmay inhibit higher treatment levels. The sensa- dictability. Thus, the population of patients who might tion appearsto be stronger over the temporal area,where benefit from the Thermage procedure has expanded the frontaiis muscle is absent, and this is yet another considerably with these additions to the treatment reasonthe treatment setting should be dropped to 352.5- algorithm 353.0. Levels in all areas are adjusted to patient comfort the newer treatment tips, rapid cooling may allow GALAXY With for lower fluences to achieve a higher degree of dermal For the Galaxy [SyneronJ system, topical anesthesiais heating than with the standard original 1-cm2 slow tip. adequate. Topical EMIA for I hour with or without The rapid cooling cycle may also give less protection to provides pain occiusion acceptable control in the vast the epidermis than with the slow tip Therefore, lower majority of patients. fluences are needed to avoid overheating the epidermis and creating a superficial injury, burn, or blister. It is also ACCENT essentialnot to overlap treatment areas,as the Z-second a For the Accent (Alma) system, no pain control is neces- pulse with the fast tip allows the physician to move at sary as the procedure is painless. quicker pace. This can increasethe chance of accidental 'double pulsing' at the edge of the treated area, and possible epidermal overheatingand blistering. Newer treatment recommendations utilize multiple passes(4 to 8) on the forehead over the brows. Multiple passesare performed only over the central two-thirds of the forehead where there is frontalis muscle deep to the .F FirstPass treatment tip. Placement of subsequentpasses is critical 3530 3555 centralforehead 'lifting 3530-355 5 cheeksand neck over points,' from the medial to lateral portion of 35253530temples the brow extending up to the hairline. \A4renthis is per- .i" SecondPass formed, the entire first pass should be completed before 3530-355 5 centralforehead returning to begin the second pass,thereby allowing time 3530-355 5 cheeks,jawline and neck pass to dissipate * ThirdPass for residual dermal heat from the first 3530-354 5 centralforehead, cheeks, submental, and before retreating the same area. jawline It is important to know that patient tolerance is an * Fourthand FifthPass indicator of treatment levels, and treatment levels should 3530-354 5 jawline,jowls, and submental not exceed 355.5 on the forehead. Typically 75-150 Lasersand Lights Volume ll

Fig. 4'5 Periorbitalrejuvenation following Thermage treatment Clinical example of patientprior to treatment(A), 2 monthspost-treatment (B) and 4 monthspost-treatment (C) (Photographscourtesy ot Thermage)

treatment pulsesare required to cover the entire forehead a 20-30 second pass. Three successivepasses in decre- and temples. This number may vary based on the size of ments of l0 J/cm2 per passare administered(Fig. 4.7). the patient's forehead (men tend to have larger foreheads) and on the number of passesused o Treatmentof the lowerface

GALAXY THERMACOOL With the Galaxy system, the Polaris handpiece is applied With ThermaCool, it is currently recommended to treat jawline, for periorbital wrinkle reduction Employing the Polaris, the entire cheek, and neck area as one cosmetic an initial setting of radiofrequency of 50 J/cm2 to the unit, beginning at the malar prominence and periorbital/ forehead and 80 J/cm2 to the lateral and inferior peri- crow's feet area,extending medially toward the nasolabial folds, orbital regions and a diode setting of 20 J/cm2 should be laterally toward the preauricular area,and inferiorly jawline, used. The RF component should be increasedby l0 J/cm2 to the mandible. The upper one third of the neck, (Fig. per treatment to a maximum of 100 J/cm2 for the lateral and submental region are included as well +.8) One and inferior periorbital region with subsequent treat- or two pulseson each side of the cutaneousupper lip may also ments, whereas the fluence should be maintained at 50- be of benefit, but should be approachedwith caution and 60J/cm2 to the forehead. The infrared (900 nm dtodeJ at very low fluences. It is recommended that treat- pulses laser component should be increased by 2-4 J/cmz per ment be placed lateral and inferior to the bony treatment to a maximum of 36 J/cm2 in type I skin. The orbital rim The initial pass of the lower face should be clinical endpoint of erythema should be achieved. The set at 353.0-355 5. However, results have improved sub- number of passesper treatment should be in the range of stantially when two, three, or as many as five passesare (see 6-10. A rangeof one to five treatment sessionsat monthly used Box 4.2) The skin is made taut, creating a trampoline-1ike effect, by putting tension on the skin to intervals may be administered (Fig.+.6). be treated with the nontreating hand. It is important for the treatment tip to meet some resistance when it is ACCENT placed on the skin to allow equal contact throughout the For the Accent system, the unipolar handpiece is applied surface of the electrode. It can also be useful to gently first at a starting fluence of l00J/cm2. One-to-three pull the skin off of the jawline and neck superiorly to passesof 20-30 s each are applied to the entire periorbital move this skin offthe sensitivefand challenginglyconvex] region until a peak temperature of 40 " C is attained. Three mandibular region. successivemaintenance passes in decrements of 10 J/cm2 Treatment settings for the first pass are usually in the should be applied. This is followed by the bipolar hand- 353 0-355.5 rangefor the entire lower face.A secondand piece with a starting fluence of 70 J/crnz administered in third passat similar settingsis performed in the sameareas 67 SkinTightening with Radiofrequency

Fig. 4.6 Periorbitalrejuvenation following treatment with Galaxy.Clinical example of a patientprior to (A) and following(B) threetreatments

Fig. 4.7 Periorbitalrejuvenation followrng Accent treatment Clinical example of a patientprior to (A) and 3 monthsfollowing (B) four treatments (Photographscourtesy Dr. Alexiades-Armenakas)

as the first. This can be followed by a fourth (approxi- "t" compaction of fat and tissue tightening in the z-axis mately 353.0-355.0), fifth, or even more passesin areas perpendicular to the skin, which pu1lstissue in that require maximum contraction. There are differing toward the bony underlying structures fvia tightening theories asto the mechanism of action of the third throueh and contraction of fibrous septaein fat) fifth passes,and they include: 'i- a combination of the two.

* tissue tightening in the x [horizontal) and y (vertical) This z-axis effect appearsto be an important element plane along the cutaneous surface of the improved results seen recently in treatment of the 58 Lasersand Lights Volume ll

Fig. 4.8 Lowerface treatmentwith Thermage Patientprior to (A) and 6 monthsfollowing (B) one pass at 15 0 J

lower face \A4retherthis comes from additional tightening GALAXY in the x (horizontal) and y (verticalJplane or from a dlrect The Galaxy system's Polaris component provides the vast third-dimension effect on subdermal fat and collagen of majority of skin tightening to this anatomic location. The the {rbrous septaeremains to be determined Polaris handpiece is applied to the lower face and neck at However, treating physicians can use these z-axis an initial setting of at least 80 J/cm2 and a diode setting changesto their advantage.Multiple passescan therefore of 20 I/cm2 should be used. The thyroid region is to be be carefully placed in areasrvhere maximal z-axisimprove- avoided. The RF component should be increasedby 10 J/ ment is needed This would include the jowl and submen- cm2 per treatment to a maximum of 100 J/cm2 The infra- tal region. Additionally, further x- and y-axis changescan red (900 nm diode) laser component should be increased be produced with these passes,and should include the 'vector' by 2-4 J/cm2 per treatment to a maximum of 36 J/cm2 in preauricular region to create a of pull laterally. type I skin. The clinical endpoint of erythema should be The fourth, fifth, and more passesare used to augment achieved. The number of passesper treatment should the results of the third pass,and in many casesto achieve he in the ranpe'_ of 6-]0. A ranpeof one to fire rrear- visible tissue tightening and contour changesat the time b' "' ment sessionsat monthly intervals mav be administered of the procedure (Fig. After treatment, the ink grid is gently wiped off +.s). with the aid of coupling gel or a gentle cleanser.Alcohol swabs should be avoided as thev mav cause irritation ACCENT to the newly treated skin. The patieni is counseled to The Accent system is applied to the lower face and upper use sunblock containing a UVA block, such as zlnc neck, avoidingthe thyroid area.The unipolar handpiece is oxide or titanium dioxide, for 7-10 days and to avoid applied first at a starting fluence of 100-l 10 J/cm2 in one direct sun exposure as UV rays can increase metallo- to three passesof 20-30 s each. Once a peak skin surface proteinasesleading to potential collagenand elastic tissue temperature of 40-43'C is attained, three successive degradation. passesare administered in decrements of 10 J/cm2 each. 69 SkinTightening with Radiofrequency

Fig. 4.9 Treatmentof lowerface with Galaxy.Patient prior to (A) and immediatelyfollowing (B) a singletreatment

This is followed by the bipolar handpiece with a starting Fig. 4.10 Treatmentof neck with the Accent Patientprior to (A) and (B) (Photographcourtesy of fluence of 70J/cm2 in a 20-30 second pass, and three immediatelyfollowing a singetreatment Dr Alexiades-Armenakas) successivepasses in decrements of l0J/cm2 each (Fig. 4.ro)

TROUBLESHOOTING SIDEEFFECTS, COMPLICATIONS, AND The ThermaCool device is equipped with sensors and ALTERNATIVEAPPROACH ES mechanismsto detect if excessiveor inadequate pressure is being applied during treatment pulses.The machine also Adverse effects from the ThermaCool device include but aborts any treatment pulse if all four corners of the treat- are not limited to: discomfort during treatment and after, ment tip are not in contact with the skin (when using the mild-to-moderate edema lasting severaldays, depressions fast treatment tip). Sensors also alert the physician to from very aggressivetreatment at high fluences, blistering, excesstemperature in the skin, aswell as give information scarring, and no improvement in the treated patient. about the status of the cryogen module. Treatment of the lower face can lead to mild-to-moderate It is also essentialto observe the impedance readings edema of the jawline and neck, which usually resolves while treating different areas.Any site with an impedance in 7-14 days, and occasionaltenderness along the pre- less than 100 ohms should not receive further passes,as auricular or mandibular area, which can be managed the risk for overheating and possible blister formation is by ibuprofen. increased. It is important to know that patient tolerance is an The main concern with the Galaxy system is the bipolar indicator of treatment levels, and treatment levels should nature of the handpiece. Good contact must be main- not exceed 355.5 on the forehead due to the rare occur- tained with adequate aqueous gel in order to prevent rence of temporary indentations on the forehead skin. arcing. Arcing is the primary cause of crusting. This is thought to be due to over heating of the adipose \A/hen using the Accent system, it is imperative that (Fig.zr.u). In addition, small 0.5-1 cm nodules have been the physician maintain mobility of the handpiece through- observed and usually resolve without treatment or sequelae out the procedure. The handpiece should not remain wlthin 2-4 weeks (Fig.4.rz) stationary on the skin in order to avert pain or thermal For the Galaxy system, adverse events among 28 lnJury. patients treated in one study included I case of crusting 7o Lasersand Lights Volume ll

that healed rvithout scarring One case of transient hair be made with the skin surface and aqueous gel in order loss to the beard area of a man occurred; the hair regre\v that arcingbe averted; arcing is the primary causeof crust- completely One case of acneiform eruption r,vasalso ing or blistering and is very rare when proper technique observed The bipolar handpiecerequires that level contact is used

ADVANCEDTOPICS: TREATMENT TIPS FOR EXPERIENCED PRACTITION ER5 o Othersites Off-the-face treatment sites have become increasingly popular targets for monopolar RF treatment and studies, and include the lower abdomen for skin laxity (agerelated, post-pregnancy,or post-liposuction; Fig.4.9), tissue areas adjacentto the breastsfor tightening and lifting, arms, and others Currently there are no validated treatment algorithms for these off-the-face sites, but typically multiple passes(600-900 pulsesJare used at moderate treatment settings (352 0-354.5J. Skin tightening and celluiite improvement are two FDA approved indications off the face with ThermaCool TC. Alexiades-Armenakas and Goldberg have completed FDA trials employing the Accent for the treatment Fig. 4.11 Atrophysecondary to Thermage Subtleindentations 4 of weeks after high-energytreatment on lateralforehead, which resolved skin laxity and cellulite on the body. It has been granted over 5 months approval for body rhytides to date (Fig.4.t4)

'1 Fig' 4'12 Nodulessecondary to treatmentwith Thermage Temporarynodules (A) and cheekswelling (B) week followingtreatment SkinTightening with Radiofrequency

DTSCUSStON

Radiofrequency devices for tissue tightening are the latest and perhaps most distinctive treatment option in the quest for nonablative rejuvenation. Studies show that these devices can lead to substantialimprovement in skin laxity and rhytides, with newer devices and treatment algorithmsproviding greaterconsistency in results.Because the treatment risks are extremely low, this is a relatively simple alternative for patients who do not want major surgery or who have moderate skin laxity that does not warrant an invasivesurgical procedure. One of the central questionsis what the role of RF will be in the future of facial rejuvenation. It is clear that RF tissue tightening produces effects that are not achievable with other devrcescurrently on the market. And although a facelift may be an option for some, many patients are reluctant to go through the expenseand recovery of such a procedure. For these and other reasons, the RF skin tightening procedure is likely to become a central part of facial rejuvenation. In exploring the mechanismsand effects of photoaging, there are two basic components: (il superficial (epidermal) and (ii) deeper (dermal, subcutaneous) structural changes(sagging). Although the RF procedure may yet be determined to have some benefit on superficialepidermal changes,that would be a secondaryeffect. But it is clear that the technique has a direct and at times profound effect on dermal and subdermal tissues.This is where the uniquenessof the RF becomes its greatest utility Fig. 4.13 Tighteningof abdominalskin with ThermaCoolTC Patient Other devices exist for treatment of epidermal changes priorto (A) year (B) pass and 1 following one at 15.5 Iablative resurfacing, chemical peels, pigment lasers, photorejuvenation), and dermal remodeling can be achievedwith severalof the non-ablative lasers.Yet none of these techniques or devices is capable of producing nonablativetissue tightening, and that is clearly the niche for radiofrequency to fill. Since sagging of tissues ts a fundamental part of the aging process,nearly all patients who are candidates for other forms of facial rejuvenation are also candidates for the radiofrequency procedures. Radiofrequency tissue tightening is not a substitute for the wide array of nonablative lasers,but rather a companion to them. There may be some overlap, for example, in remodeling of the dermis achieved by nonablative lasers and the radiofrequency wavelengths. However, only RF can produce tightening of dermal collagenin the x and y axes,and the z-axis changesdiscussed earlier are not seen with any of the other nonablative options available. Recently, a new infrared device emitting wavelengths Fig.4.14Cellulite treatment with Accent Right leg following five from I 100 to 1800 nm has been introduced for the treat- treatmentswith left leg as untreatedcontrol. (Photographs courtesy of Dr.Alexiades-Armenakas) ment of skin laxity (Titan, Cutera). This technology is postulated to function by causing broad-based heating of the dermis, which is followed by tissue contraction. To The VelaSmooth [Syneron] system has been approved date, early data, which has not been peer-reviewed, for the treatment of cellulite. As aforementioned, it com- suggestits safety and moderate degreeof efficacy in treat- bines RF with broad-spectrum infrared light and suction. ing rhytides and laxity. In one preliminary study of 25 It is currently undergoing FDA trials for the treatment of patients, fluences of 20-30 J/cm2 produced immediate striae distensae. changes and moderate improvement in rhytides of facial 72 Lasersand Lights Volume ll

skin In a preliminary split-face design study comparing Dover JS, ZelicksonB, Atkin D, et al 2005 A multi-specialty gurdelines this modality to RF, discussedbelow, a more mild improve- review and ratification of standardizedtreatment for optimizing tissue tightening and contouring with a non-invasrve ment was reported using the infrared device It will be monopolarradiofrequency device American Societyof interesting to monitor the efficacy of this device as the DermatologicSurgery Abstracts Atlanta, GA, October 28 final reports become available. Further studies will be Fitzpatrick R, Geronemus R, Goldberg D, Kaminer M, Kilmer S, needed to better determine the effectiveness of this Ruiz-EsparzaJ 2003 Multicenter study of noninvasive device compared with RF in the skin tightening arena. radiofrequency for periorbital tissue tightening Lasersin Surgeryand Medicine 33:237-242 Radiofrequencydevices are continually being advanced Hsu TS, Kaminer MS 2003 The use of non-ablativeradiofrequency for the treatment of rhytides, laxity, and cellulite. Physi- technology to tighten the lower face and neck Seminarsin cians now have a nonsurgical alternative to the facelift CutaneousMedicrne and Surgery22:II5-l'23 utilizing these technologies,provided that proper patient JacobsonLG, Alexiades-ArmenakasMR, BernsteinL, Geronemus selection and management of expectations are achieved. RG 2003 Treatment of nasolabialfolds and jowls with a non- invasiveradiofrequency device Archives of Dermatology It is most useful for those oatients who would benefit I 39:13 I 3-l 320 from dermal remodeling, as well as from tissue tightening Lee M-W C 2005 Comparisonof radiofrequencyvs 1100-1800 nm of the forehead, cheeks, jawhne, and neck. \A/hen RF infrared light for skin laxity American Society of Dermatologic techniques are combined with other procedures that SurgeryAbstracts, Atlanta, GA, October 28 improve the more superficial changes associated with Ruiz-EsparzaJ 2005 New infrared devicecan produceimmediate photoaging, patients are likeiy to experience results that and long-termskin contractionby painlesslow fluence irradiation American Society of Dermatologic Surgery were previously in the absenceof impossible to achieve Abstracts,Atlanta, GA, October 28 more aggresslve,lnvaslve surgery. Ruiz-EsparzaJ, Gomez JB 2003 Nonablativeradiofrequency for active acne vulgaris: The use of deep dermal heat in the treatment of moderate to severeactive acne vulgaris (Thermo- therapy):A report of 22 patients DermatologicSurgery 29:333339 FURTHERREADING Sadick N, Alexiades-ArmenakasM, Bitter P, Hntza G, Mulholland S 2005 Enhancedfull-face skin rejuvenationusing synchronous Alexiades-ArmenakasMR 2006 Rhytides,laxity and photoaging intensepulsed optical and conducted,bipolar radiofrequency treated with a combinationof radiofrequency,diode laser,and energy (ELOS) : introducing selective radiophotothermolysis pulsedlight and assessedwith a comprehensivegrading scale Journalof Drugs Dermatology4:l8l-186 Journalof Drugs Dermatology5:609-616 ZelicksonBD, Kist D, BernsteinE, et al 2004 Histologicaland Doshi SN, Alster TS 2005 Combinationradiofrequency and diode ultrastructural evaluation of the effects of a radio-frequency- laser for treatment of facial rhytides and skin laxity Journal of based non-ablative dermal remodeling device: A pilot study. CosmeticLaser Therapy 7:l 1-15 Archives of Dermatoloev 1 40.204-709 LaserTreatment of EthnicSkin

Henry H.L. Chan, Taro Kono

INTRODUCTION Acquired bilateralnevus of Ota-like maculesIABNOM), or Hori's macules, affects about 0.8% of the population Dark-skinned patients have significantlyhigher epidermal in Asia. C1inica1ly,it presents as a bluish hyperpigmenta- melanin content than their lighter-skinned counterparts. tion that usually affects the bilateral malar regions Other This melanin can act as a competing chromophobe Thus, areascan alsobe involved, including the temples, the root the use of lasersfor the treatment of vascularlesions, such of the nose, the alae nasi, the eyelids, and the forehead as facial telangiectasia,or hair removal in darker skinned In contrast to nevus of Ota, in ABNOM the pigmentation individuals is more likely to give rise to adverse effects. occurs in a symmetrical bilateral fashion, has a late onset These adverse events lnclude blistering, crusting, dyspig- in adulthood, and does not involve the mucosa Laser mentation, and even scarring In addition, becauseepider- treatments can now be used to improve this pigmentary ma1 melanin acts as a competing chromophore, the light alteration, r'vhichtends to be more resistant to treatment dosagethat reachesthe targeted blood vesselsis reduced, than nevus of Ota. RoshanKetab 02I-66950639 and higher fluences may be necessaryto produce a suffi- In terms of photoaging, as described above, dark- cient effect Indeed, clinicians u'ho are less familiar r'vith skinned Datients tend to have fewer wrinkles than the treatment of dark-skinned patients are often con- Caucasians.Laser resurfacing is not as commonly used in cerned about their perception of lessenedclinical outcome darker skin types Conversely,the possibleadverse effects and the increasedrisk of adverseeffects of laser resurfacing,such as erythema and PIH, are more Darker skinned individuals have an increased risk of common u'ith dark-skinned patients Nonetheless, laser laser-induced complications. However they, like lighter resurfacingis sti11performed, mainly in patients with acne skinned individuals, also may present signs of photoaging scarring. Fractional resurfacing has gained much popular- rvith pigmentary conditions such as lentigines and sebor- ity in Asia due to its potentially lower risk of complica- rheic keratosis, and even mild wrinkling Chung et al tions and downtime It is particularly effective for acne (2001Jlooked at 407 Koreansbetween the agesof 30 and scarring and rejuvenation for those with more significant 92 years and assessedthe cutaneous manifestation of degreesof photoaging. photoaging. Their findings revealed that pigmentary The most common complication in dark-skinned changes are common features of photoaging in patients patients, after laser surgery, is PIH. Although this is tran- r,vithskin types III and IV. Seborrheickeratosis is the main sient, it can last for severalmonths and is poorly tolerated pigmentary lesion in men, whereas lentigines are common by most patients. Recent advances in skin cooling and among women. longer laser rvavelengths and pulse durations, have Conditions such as Hori's macules, while uncommon improved treatment outcomes in laser hair removal and in Caucasians,are frequently encountered in dark-skinned the treatment of telangiectasiain dark-skinned patients. patients, especiallyAsians This chapter addressesthe cosmetic use of laser and intense pulsed light sourceon dark- skinned patients, with the aim of obtaining optimal results PATIENTSELECTION nhile reducing the risk of complications.The logic behind Due to the higher risk of postoperative complications, our approach aswell asthe managementof postinflamma- especiallyPIH, and lesswrinkling in dark-skinnedpatients, tory hyperpigmentation (PIH) are also discussed. nonablative skin rejuvenation procedures, using lasers, intense pulsed light sources (lPL), and radiofrequency (RF) devices are presently the first line of treatment . The problembeing treated for dark-skinned patients r,r'ho request treatment for This chapter will also review particular aspects of non- photoaging. ablative skin rejuvenation, ablative skin rejuvenation, the Although nonablative skin rejuvenation has been used treatment of telangiectasia,and hair removal, with refer- for acne scarring,the degree of improvement rangesfrom ence to their effects on dark-skinned oatients. mild to moderaleat best As a result,laser resurfacing or Lasersand LightsVolume ll fractional resurfacing, in combination with other surgical procedures such as subcision and punch biopsy, remains the therapeutic option that offers the optimal clinical outcome. Dark-skinned patients also seek laser- and light-based hair removal. Such individuals often present with fine black hair and tend to have a poorer responsethan lighter skinned individuals who have thicker hairs. Nevertheless, laser hair removal often delivers particularly good results, coupled with a low risk of complication in the removal of hair from areas that are not normally exposed to the sun, such as the armpit. Finally, darker skinned individuals may present with telangiectasias.Facial telangiectasiacan be effectively removed with IPL and/or a long pulse width laser equipped with cooling. For larger vesselleg telangiectasia(>2 mm), sclerotherapyremains the treatment of choice. r Exclusioncriteria Patients with acne scarring who have been treated with isotretinoin within the last 6 months should be excluded from laser resurfacing. For laser hair removal, recent hair bleaching and plucking are best avoided a short period of time before laser/light based treatment. Recent suntan predisposesdark-skinned patients to a higher risk of PIH after all laser and IPL treatments. Hence, sun protection and avoidance is necessaryfor at least 2 weeks before any such treatment. The use of topical bleaching agents 2 weeks before the treatment may also be helpful. Photosensitizingdrugs, such as tetracycline, can also increase the risk of PIH, and are best avoided for 2 weeks before and after any laser/IPl procedure.

EXPECTEDBENEFITS In combination with subcision and punch biopsy, laser resurfacing or fractional resurfacing for acne scarring can lead to significant improvement (>700/o)in some individuals (Fig. 5.:.). For patients with photoaging,that have not responded to a nonablative procedure, fractional resurfacing or laser resurfacing can also lead to substantial improvement. Fractionalresurfacing has been shown to be effective Fig.5.1 Acnescarring improved after fractional resurfacing (20 mJ, for the treatment of melasma, but in one of the authors' 500MTZ, 8 treatmentsessions) (parallel polarized view) (HC) experience only some melasma patients respond well to it (approximately 50-600/oexperience some degree of clearing; Fig. S.z). This is in line with a previous publi- multiple different devices. The initially described method cation that suggested 60% of patients experience signifi- involves the use of a scanning device that delivers a laser cant improvement, 30o/o experience a mild degree of injury when the device moves across the skin surface lightening, and 10% ofpatients experience a worsening of fscanning mode). Other devices involve the placement of their melasma. Postinflammatory hyperpigmentation can the laser handpiece on the skin's surface in a stamping occur with fractional resurfacing, but the risk is signifi- fashion (stamping mode). Some stamping devices are cantly less compared with that seen with laser resurfacing. associated with multiplatform devices that can also By reducing the energy and density of laser treatments, deliver IPL and/or other laser treatments. Newer frac- the risk of PIH following the treatment for acne scarring tional resurfacing scanning technology also allows for and wrinkle reduction can be reduced to less than 30/0. alteration in spot size with different fluences. By rncreas- Fractional resurfacing can now be performed with ing the spot size with higher fluence, the depth of penetra- 75 LaserTreatment of EthnicSkin

[Nd:YAG]). Four to eight treatment sessionsat intervals of 4-6 weeks are necessary to achieve a significant to complete degree of clearing. PIH occurs in 72-730k of treated patients, and topical bleaching agents should be used. Hypopigmentation can occur in up to 50% of patients, and the possibility of such a complication should be discussedwith each patient in advance (Fig.S'+). Vascular lasers, when used to treat telangiectasia and in the area of nonablative skin rejuvenation, induce vessel injury with the aim of creating healing and subsequent collagen production. Facial telangiectasia can be effectively treated with a variety of long pulsed dye, variable pulse 532 nm Nd:YAG, long pulsed alexandrite, and long pulsed 1064-nm Nd:YAG lasers, all equipped with different types of cooling devices. Complete, or near complete, resolution with minimal adverse effect can be expected aker 2-4 treatment sessions.Leg telangiectasia, with larger vessel diameters, are more resistant, and generally require more sessions.In some cases,leg telangiectasia are treated with a combination of modalities including sclerotherapy. In terms of using cooling for vascularlesion laser treatments/ cryogen cooling with the pulsed dye laser was examined in the treatment of port-wine stains in skin types III and IV, and was found to be highly effective. However, for skin types V and VI, epidermal protection could not be achieved even at the lowest radiant laser exposure (8 J/cm'z). A variable pulsed 532 nm Nd:YAG laser, equipped with contact cooling with a water glass chamber, was also comparatively ineffective when used in the treatment of port-wine stains in skin types III and IV, but could be used effectively for the treatment of facial telangiectasia. There is only limited data on the optimal Fig.5.2 Epidermalmelasma improved after fractional resurfacing cooling parameters and efficacy of other cooling devices (6-14mJ 1000-1500MTZ, 6 treatmentsessions) (cross polarized the treatment of vascular lesions when used in dark- view) for skinned patients. tion increases, which reduces the risk of bulk tissue As described above,vascular lasers have alsobeen used heating-an issue of particular concern in ethnic skin to induce vessel injury, with the subsequent healing Reduction in bulk heating will reduce PIH in dark-skinned process producing collagen. Although considerable data patients. Bulk heating induced PIH is also lessenedwith has been collected on the use of vascular lasers on Cauca- the use of appropriate cooling. Air cooling is currently sians, data on dark-skinned patients is limited. Further- used with fractional resurfacing with the scanning mode more, studies looking at the use of these devices for the device; contact cooling is incorporated into some of the treatment of port-wine stains in dark-skinned patients stamping mode devices. have shown a higher risk of complication. Issuessuch as Photoaging in dark-skinned patients often presents the optimal fluence, clinical efficacy, and possible adverse with an increase in pigmentation. The use of lasers and effects when such lasers are used for nonablative skin IPL sourcescan lead to a 90-1000/odegree of improvement rejuvenation for dark-skinned patients have not yet been in epidermal pigmentation. Although fewer treatment investigated. sessionsare necessarywhen a laser is used (l-2 sessrons, Lasers with wavelengths in the near infrared spectrum compared with 5-6 when IPL is used), PIH is a greater have also been used for wrinkle improvement. With such risk in the laser-treated group and can occur in l0-150/o devices, the goal is to heat the dermis, thereby increasing of laser-treated patients, depending upon factors such as the amount of collagen by eliciting an increase in fibro- the type of device used, the skill of the operator, and blastic activity. Although many devices are now used for patient factors such as recent sun exposure (Fig.f.:). IPL such purposes, data on their effects on dark-skinned has the advantage of no downtime, improvement in other patients remains limited. A millisecond-domain 1064-nm parameters of aging, and a lower risk of PIH. Nd:YAG laser, used in conjunction with a long-pulsed (KTP) has ABNOM can be treated with QS lasers (ruby, alexan- 532-nm potassium titanyl phosphate laser, drite and 1064-nm neodymium : yttrium-aluminum-garnet been successfully used for nonablative skin rejuvenation /o Lasersand Lights Volume ll

Fig. 5.3 (A) Beforetreatment (B) Hyperpigmentationafter O-switched laser

Fig. 5.4 (A) Acquiredbilateral nevus of Ota-likemacules before treatmenl (B) Clearingwith hypopigmentationafter nine QS Alex laser treatments(8 J/cm'?) LaserTreatment of EthnicSkin in dark-skinned patients. A mild-to-moderate degree of improvement in telangiectasia,and over 600/oexperienced improvement in wrinkling, a moderate degreeof improve- an improvement in texture after 2-6 treatment sessions ment in skin toning and texture, and a significant degree (Figs S.S and 5.6). Devices with better cooling systems of improvement in redness and pigmentation can be have better safety margins but require more treatment achieved using these combined laser therapies. sessionsto improve pigmentation, as the photothermal Trelles et al investigatedthe use of a 1320 nm laser on effect of IPL is reduced. Newer pulsed light source dark-skinned Spanish patients, and found histologic evi- systems with better filtering technology can potentially dence of new collagenformation despite a limited degree of post-treatment patient satisfaction. However, their sample size was quite small. In addition treatment intervals may have been too short (2 treatments/week for 4 weeks) with a shortened follow up period (2 and 6 weeks after the final treatment). Indeed, Trelles later pointed out that there was fair to significant clinical improvement 4 to 6 months after treatment. Another study on the use of a 1320 nm Nd:YAG laser indicated that it was well tolerated in skin types III and IV, and produced a moderate degree of improvement that was both subjectively apparent to the patient and objectively confirmed by histologic and Cutometer assessment.Despite this, assessment by blinded observersdid not reveal any significant changes.Complications, such as PIH, were observed in only I .80/oof the treatment sessions[3 out of I 62) . A 1450-nm diode laser has alsobeen used for nonablative skin rejuvenation Although this laser can be of theoretical advantagefor dark-skinned patients, given its long wavelength (not absorbedby pigment), PIH is surprisingly common after treatment. Hardaway et al [2002) found that 6 out of 9 light-skinned patients (skin types I-III) developedpost-laser treatment PIH This finding was confirmed by Tanzt et al [2003), who investigatedthe use of this laser for the treatment of facial rhytides in 25 light- skinned patients (skin types I-III) The incidence of PIH, even in these lighter skinned individuals, was 180/0. Although all casesresolved with the use oftopical bleaching agents,the averageduration even in this light-skinned group was l4 weeks As most casestend to develop after the second treatment, and the total duration of cryogen spray was 60 ms, it has been suggestedthat the cooling, in itself, led to such a high rate of PIH. Hence, the duration of cryogen spray has been decreasedto 40 ms for dark-skinnedpatients However, even at a shorter cryogen delivery duration, a recent study looking at the use of cryogen spray associatedlaser treatment for the treatment of atrophic acne scar found that the risk of PIH in skin types III and IV was 50/0.To addressthis issue, we have treated acne patients with a 1450-nm diode laser using a multiple pass,low fluence approach [three passes,fluence at 70 J/cmz , dynamic cooling). Our preliminary data have indicated a significant reduction of post-treatment PIH, which means that this laser can be used on dark-skinned patients A I 540-nm erbium : glasslaser has alsobeen used for nonablative skin rejuvenation, but data on its effects on dark-skinned patients is limited. Studies on the use of IPL sourceshave shown that they can produce a significant degree of improvement in pho- Fig. 5.5 (A) Lentiginesbefore treatment (B) After seventreatments todamage. Sixty to ninety percent ofpatients experienced with the VascuLight(590-645 nm filter;energy of 45-€0J/cm'z; a reduction in pigmentation, 60-830/o experienced an durationof 2 5-4 ms for T1-T3; pulsedelay of 20 ms) 78 Lasersand Lights Volume ll

achieve better results when used for the removal of lentigines (Figs 5.2 and 5.8) Recently, \\''e compared the effectivenessoftwo different IPLs (lPL Quantum and IPL Estelux) for nonablativeskin rejuvenation in patients with skin types III and IV Twenty-one females received IPL Quantum treatment (12 with a 560-nm filter and 9 with a 640-nm filterJ, rvhile 11 were treated with Estelux. Our preliminary data indicated that there was a greater degree of improvement in pigmentation in the group that was treated with Estelux brand IPL [450/owith a moderate-to- significantsubjective degree of improvement in pigmentation) than in the group that was treated with Quntum IPL (13-330/o with a moderate-to-significant subjective improvement) The difference is likely to be due to the greater coohngeffect seenwith Quantum IPL Hence, the optimal cooling parameters for use on dark-skinned patients need to be determined. Monopolar RF has recently been introduced for nonablative skin rejuvenation in dark-skinned patients In one of the authors' (HCJ experience, good results can be achievedwith this technique in some, but not all, patients. Bipolar RF, in combination with IPL, has also been used. In our experience it appearsto be as effective as IPL in terms of pigment reduction. However, it has not yet been established whether the bipolar RF effect has any significant extra benefit for skin texture Some investigators have suggested that a combination of bipolar RF and IPL is better than IPL alone, but there has been no drrect comparison study. Recently, one of the authors (HC) performed a study looking at the effectiveness of bipolar RF in combination with an infrared light source for skin reluvenation in dark-skinned patients. Preliminary data indicated a high degree of patient satisfaction (over 800/o),but the objectrve degree of improvement \,\rasless impressive (on1y 3070 of patients were found to have significant tightening) Adverse effects were miid, with transient crust formation in the forehead being seen in some patients It lasted no more than a few days Photomodulation, using a light-emitting diode (LEO) 1ow-leve1energy light sources, is a recently reported development These treatments can be used in conlunc- tion with other nonablative technologiesto improve the clinical response.Data on the effects of its use on dark- skinned patients is limited. We have looked at the photomodulatory effect of yellow, blue, and red light in Asians Our data indicated that while subjectiveimprove- ment was significant, objective improvement was unlm- pressive There are severalpossible reasons for this. Most importantly, dark-skinned patients have much lower Fig. 5.6 (A) Beforetreatment, (B) After6 treatmentswith IPL degrees of wrinkling than Caucasianpatients, and a sig- Quantum (560-nmfilter; energy of 22-27 Jlcm2iduration of 2,4 and 4 0 ms forT1 andT2; pulsedelay of 15 ms) nilicant degree of improvement is therefore less likely to be detected. Another issue is the higher epidermal melanin context of dark-skinned patients, which may influence the effect of these systems As a result, these devices are best used as adiunctive theraov for dark- skinned Datients. LaserTreatment of EthnicSkin

Fig. 5.8 (A) Beforetreatment (B) Aftersixth treatment with IPL Fig. 5.7 (A) Beforetreatment (B) Afterfirst treatmentwith IPL DDD PalomerEstelux (Lux G-6 500-670nm and 870-1400nm filter; Ellipse(400-nm filter, pulse time of 2.5ms,delay of 10ms, 8J/cm'z) energyof 30J/cm'?;pulse delay of 20 ms) Lasersand Lights Volume ll

. Laserand intensepulsed light sourcefor pigmentation in 80/0.A larger-scalestudy of dark-skinned hair removal patients will be necessaryto establish the efficacy and safety of this device when used on dark-skinned Many devicescan be used for hair removal, including long patlents. pulsed ruby, alexandrite, diode, and Nd:YAG lasers, a well as IPL Optimal cooling, longer wavelengths, and long pulse widths are essential to improve efficacy and OVERVIEWOF TREATMENT STRATEGY reduce adverse effects. These devices are used not only for cosmetic hair removal but also for the treatment of . Maiordeterminants hair follicular disorders, including pseudofolliculitis Patient selection and the determination of a patient's barbae. Long-pulsed ruby laser have been used in darker treatment objective are the most important consider- skin types, but adverse effects, including eschar and ations The main reasonsfor poor patient satisfaction are hypopigmentation, can occur. A study that investigated unrealistic expectations, a lack of understanding about the efficacy and complication rate of long-pulsed diode postoperative skin care, and short-term complications, and long-pulsed Nd:YAG lasers in hair removal, from especiallyPIH. A11patients should use sun protection and skin type III and IV patients, showed that long-pulsed avoid sun exposurefor at least 2 weeks before laseror IPL Nd:YAG laser treatments took longer and were associ- surgery The use of topical bleaching agents can further ated with significantly greater pain. Transient adverse reduce the risk of PIH. Although in one study of ablative effects were erythema and perifollicular edema One iaserresurfacing, preoperative topical bleachingagents did patient developed hypopigmentation at week 6, which not reduce the incidence of postlaserPIH, it might be best resolved by week 36. These findings were further con- if these topical agentsare started preoperatively and confirmed by Alster et al (2001), who examined 20 dark- tinued postoperatively Such an approach may reduce the skinned patients who were safely and effectively treated severity of PIH. with long-pulsed Nd:YAG lasers. Another study followed l0l Japanesepatients who were treated with a . diode laser. The average number of treatment sesslons Treatmentapproach was 2 4 [range: l-8J. Although all of the patienrs expe- Dark-skinned patients with photoagingtend to have more rienced temporary hair loss, only half of them experi- pigmentary problems but less wrinkling than Caucasrans. enced 600/ohair reduction 6 months after their last Therefore, it is important to clarify the patient's objective treatment. Another study using a long-pulsed diode laser in a detailed interview before choosing the appropriate in the treatment of pseudofolliculitis and hair removal laser device and treatment regimen. Postoperativedown- from skin type V and VI patients also confirmed its effec- time and cost effectivenessare two issuesthat should be tiveness with a low risk of complication. Battle et al discussed with the patient. Between 80% and 900/oof (2000) suggested that for effective hair removal from patients with pigmentary problems respond well to laser dark-skinned patients, including those with skin types V treatment, and test areas may assist in identifying poor and VI, very long pulses (20-200 ms) are necessaryto responders.Test areaswith different lasers (the types of improve clinical efficacy without a significant increase in which will depend upon the clinic setup) also allow the risk of adverseeffects. Using a very long pulsed diode patients to experiencethe processof laser treatment, the laser, they found that transient pigment changes, the appearanceof the crust [downtime associatedwith laser most common side effect, were significantly reduced. A surgery) and postoperative skin care. For those who feel long-pulsed Nd:YAG laser can achieve similar clinical that downtime is not an option/ a combination of intense outcomes in dark skinned patients. Another study that pulsed light source, infrared spectrum laser, and light- compared the clinical outcomes of long pulsed alexan- emitting diode treatments is a good alternative drite, diode, and Nd:YAG iasers for patients with skin For patients with acne scarringwho opt for laser resur- types IV-VI found no difference between the three treat- facing, a 2-mm punch biopsy and subcision is performed ment gfoups. 2 weeks before laser surgery. For laser resurfacing, all IPL treatments have also been found to be effective patients are given an anti-viral ffamciclovir IFamvir] for hair removal in patients of various skin types (I-V), 250 mg t.i.d ) and an antibiotic (cefuroxime 750 mg t.i.d.l with hair reduction of 87o/oseen after a mean of 8 treat- from 2 days before surgery untii complete re-epitheliza- ments (range of 2 to 23) followed for a mean period of tion, which is usually approximately 10-14 days It is 27.3 months A recent study that looked at 28 Koreans, important for patients to understand what to expect after who were treated with four sessionsof IPL, noted minimal laser resurfacing,including the timeframe for healing and adverse effects with a clearance rate of up to 800/0.A PIH, which can last up to 3-6 months. Serial photographs combination of bipoiar RF and IPL has also been used of other patients who have undergone the treatment are effectively for hair removal. Six months after 4 treatment useful. Fractional resurfacing,which can achieveexcellent sessions;the clearancerate ranged from 400/oto 85%. The results for acne scarring, is now the treatment of choice results did not vary based on actual skin color. Mild for many patients. Oral antibiotic prophylaxis is not gener- erythema was observed in 20o/oof patients, and hyper- ally necessary,but patients with a previous history of 8r LaserTreatment of EthnicSkin herpes simplex should be treated r'vith oral antivlral agents dermal melanln content of dark-skinned patients is such immediately before and for 5 days after treatment. Since that relatively nonspecific devrceslike IPL have a greater the introduction of monopolar RF, the treatment approach risk of complication Hence, IPL should not be considered to nonablative skin rejuvenation has changed. For those as the {irst choice unless factors such as cost effecttveness lr,'ho rvant to improve their pigmentation, skin texture, or lack of availability of other vascular lasers are impor- and pore size, a combrnation of laser (vascular,pigment tant Under such circumstances,especially for a lessexpe- and infrared spectrum laser) and IPL can be effective For rienced operator, a test area should be performed and a those who want to improve their skin laxity, deepen the consistent treatment technique, especially skin cooling, nasolabial fold and treat rvrinkles, monopolar RF treat- should be used to lessenthe incidence of complications. ment is offered. In all cases.other adiunctive treatments Short and long pulse width pulsed dye and 532-nm such as topical therapy, LED, botulinum toxin, and fillers Nd:YAG laserswith cooling can be particularly effective should alsobe considered. in the treatment of facial telangiectasia(Fig. l.S). Patients IPL can be used effectively for the removal of vascular should be warned that recanalizationcan occur after 4-6 lesions, including telangiectasia Horvever, the high epi- r,r''eeks,and repeat treatment is necessary.A recent study

Fig. 5.9 lmprovementol rosaceaafter seventh lreatment with long pulseddye laser(595 nm, 10 ms, 7 5 Jlcm2, 10-mm spot size) 82 Lasersand Lights Volume ll

resurfacing,we adopt the combination approach in which three passeswith a COz laser are followed immediately by one passwith an Er:YAG laser In our experience,such a combination can reduce the degree of erythema and PIH More recently, long-pulsedEr:YAG lasershave been used to achieve better hemostasis and some degree of collagen contraction. Jeong and Kye (2001J studied the use of such a system among skin type III and IV patients with pitted acne scars. They found a good-to-excellent response in 930/oof patients, but erythema lasting more than 3 months was seenin 54o/oSingle pass CO2 laser skin resurfacing has recently been shown to be effective in the treatment of acne scar and wrinkle reduction in dark-skinned patlents, with reductions in the severity and duration of laser-associatedcomplications. As mentioned earlier, fractional resurfacingcan now be performed by multiple methods either through the use of scanningor stamping modes. In the initial scanningmode, the typical setting for the treatment of acne scarring and wrinkle reduction is l6-20 rr'J, 125 microthermal zones (MTZsl per pass for 4-8 passes.In one of the authors' (HC) experience,reducing the number of passesper treatment sessionreduces the pain and risk of PIH. The disadvantage of this approach is that more treatments are generallynecessary to obtain the optimal clinicai outcome. A new version ofthe scanningdevice allows greater depth of penetration by automatic adjustment of the spot size when higher energy is used In one of the authors' (HC) experience,the pain that is associatedwith the procedure hasdecreased significantly despite the use ofhigher energy. Fig.5.10 Leg veinin a malewith type lll skinbefore laser treatment For this device, much higher energy can be used for the (A)and 2 monthsafter (B) Hyperpigmentationwas observed treatment of acne scarring and wrinkle reduction (30- 40 mJ, treatment level 8-9]. The typicai treatment interval for acne scarring and wrinkle reduction is 4-6 weeks. These delayed intervals between treatments allow the indicated that pulse stacking can be useful to achieve a inflammation at the epidermal-dermal junction to settle, better clinical outcome, and should be considered Long- thus further reducing the risk of PIH. The specific risk of pulsed 1064-nm Nd:YAG and long-pulsed alexandrite PIH, with this new scanningdevice, is not known but is lasers,equipped with cooling, are best used for leg telan- likely to be less than the initial scanning model due to giectasia,but PIH can still occur (Fig. 5.ro). reduction in bulk tissue heating. For melasma, lower For hair removal, recent sun exposureis a contraindica- energy but higher density should be used (6-7 mJ, tion in dark-skinned patients. Patients with recent sun 250MTZ, 6-10 passes) The use of topical bleaching exposure may expect treatment induced delayed ery- agents, as adjunctive therapy for melasma treatment, is thema (24-48 h) followed by PIH. This is particularly important to further enhance the result. For resistant common when IPL is used for hair removal. A test area cases,one of the authors (HC) has used a large spot size of treatment may be appropriate for lessexperienced IPL 1064-nm operators. QS Nd:YAG [7-mm spot size, 1.6 l/cmz) immediately before fractional resurfacing to further enhance the result. This approach has been successfulin TREATMENTTECHNIQUES SOME CASCS, For nonablative skin rejuvenation, using a 1320-nm . Treatmentalgorithm Nd:YAG laser, a spot size of 10 mm is used with three passesperformed (2 precooling and I postcoolingJ ABLATIVEAND NONABLATTVESKIN REJUVENATION Using real time temperature monitoring, the fluence is adjusted AND TELANGIECTASIA so that the skin temperature reaches 42-45'C immedi- It hasbeen suggestedthat the erbium:yttrium-aluminum- ately after laser exposure for the precooling passesand garnet [Er:YAG) laser is associatedwith less erythema less than 40"C for the postcooling pass. Patients should and a lower risk of hyperpigmentation and, therefore, is receivemonthly treatment for 5-6 treatment sessions,and particularly useful for dark-skinned patients. For laser should be followed up 4-6 weeks after their last treatment 8l

LaserTreatment of EthnicSkin for final assessment.For nonablative skin rejuvenation, be lower (4-5 J/cn'? for both lasers), and the repetition using a 1540-nm erbium:glass laser,we tend to use higher rate should be reduced (to no more than 3 Hz) in order fluencesthan previously documented, and treat the perr- to reduce the risk of adverseeffects. Nonetheless,a tran- orbital area with three stack oulses of l0J/cm2 and the sitory post-treatment pigmentary alteration is not uncom- rest of the Facewith five staclipulses of l0 J/cmz. mon, and patients should be warned about this before For IPl-induced nonablative skin rejuvenation, the their treatment. main clinical end point is mild erythema. If significant In principle, the clinical end point for IPL and long- erythema persistsafter IPL treatment/ especiallyin a non- pulsed laser treatment of facial and leg telangiectasiais pigmented area, we apply a moderate-potency topical immediate vesseldisappearance or darkening of the vessel steroid immediately after treatment. The use of an icepack hyperemia For the shorter pulse width lasers,purpura is after treatment can reduce the IPl-induced ohotothermal the end point \A/hen such lasers/lPl are used for the effect and is best avoided. treatment of vascular lesions in dark-skinned patients, it For the treatment of lentigines in ethnic skin, test areas is important to achieveoptimal cooling to ensureadequate using different lasers might be considered. When usrng a epidermal protection. The high epidermal melanin context variablepulse 532-nm Nd:YAG laser,without cooling,the is such that inadequate cooling can lead to a higher risk of suggestedparameters are aZ-mmspot sizeand 6.5-8 J/cm2, complications. However, overcooling can lessen efficacy with an ashen gray appearanceas the clinical endpoint If by reducing the photothermal effect on the dermal vessels. the variable pulse 532-nm Nd:YAG laser is attached to a Furthermore, cold-induced injury can also occur, leading cooling glasswater chamber, then the fluence should be to blister formation and pigmentary disturbances Although increasedto 1,2-14J/cmz to compensatefor the reduction many devices are used for cooling, data on dark-skinned in photothermal effect. Recently, a pulsed dye laser patients are limited. Cold air hasbeen used in conjunction attached to a compressionhandpiece has been developed with pulsed dye lasers for the treatment of port-wine to allow the laser to be used effectively for pigment stains in light-skinned patients, but there is no published removal. The intention is to press and empty the blood data on the efficacy of cold air as a cooling device when vesselsand, in doing so, remove the competing hemogiobin usedwith a vascularlaser in dark-skinnedpatients. Contact chromophore. A recent study compared the efficacy and cooling can offer good epidermal protection, but in areas complications of the QS ruby laser with those of a long- such as the alar folds good contact is difficult and addi- pulsed 595-nm pulsed dye iaser, with an attached com- tional cold gel is necessary.It is also important, when pression window, for the removal of lentigines among contact cooling is used, to reduce the laser repetition rate Japanesepatients. The group treated with the compressron to ensure adequate time for pre-, parallel, and post- technique was associatedwith a lower risk of PIH than the cooling It is also undesirableto press the contact cooling group treated with QS laser, while the degree of efficacy glasschamber too firmly againstthe skin, as this empties was the same in both groups. The typical parameters for the vessel and reduces efficacy. For cold gel, adequate such long-pulseddye laserswith compressionwindows are uniform cooling is difficult and can only be achievedifthe 7-mm spot size, I .5-ms pulse durations, and I l-13 J/cmz , gel is applied to a small area. Cold gel should be kept in wrth an ashengray appearanceas the end point an ice bucket between applications so that the gel tem- \A4ren using a QS laser, the clinician should use the perature remains cold. Cryogen spray has also been used lowest fluence and the smallest possible spot size (and with IPL handpieces,and as with cold gel a repeat spray therefore spare the surrounding normal epidermis) to is necessaryto maintain adequatecooling. Of these cooling obtain immediate whitening For example, for the QS 532- devices,dynamic cooling with cryogen spray hasbeen best nm Nd:YAG laser, a 2-mm spot size with 0.9-l J/cm2 studied in dark-skinned patients. For pulsed dye laser should be used In some devices, that are only available treatments/ the optimal parameter in our own unpub- with larger spot size handpieces,such an approach is not lished data for skin types III and IV appearsto be 40-ms possible for mechanical reasons,and it is best to use the spray time followed by a 20-ms delay. For skin types V lowest possible fluence. In all cases,a moderate-potency and VI, a study indicated that the high epidermal melanin steroid mix with antibiotic is applied once immediately concentration can reduce the protective effect of cryogen after the treatment to reduce the risk of PIH. spray cooling More recently, multiple intermittent ABNOM tends to be more resistant to therapy, and cryogen spurts and laser pulses have been proposed to such patients should be treated more frequently, with the provide adequate epidermal protection while permitting laser procedures repeated every 4 weeks The idea behind PWS photocoagulation for darker-skinned patients [Fitz- such an aggressiveapproach is to treat the area before patrick skin type III-VI). This has now been studied using epidermal repigmentation. In doing so/ more laser energy heat diffusion, light distribution, and thermal damage can reach the dermal target chromophore through a computational models. hypopigmented epidermis without the competitive The combined approach for skin rejuvenation involves absorption of epidermal melanin. For resistant cases the use of severaldevices in the same treatment session, (failure to improve after 4 treatment sessions),QS alex- with the intention of optimizing the clinical outcome. To andrite laser treatment is followed immediately bV QS reduce the possibility of adverse effects, lower fluences 1064-nm Nd:YAG laser treatment. The fluence should should be used. In one of the authors' (HC) experrence, d4 Lasersand Lights Votume ll

this approach can be verv cffcctive fbr nonablative skin greaterdcgrcc of epidermalprotection, is more appropri- reluvenation Typically, a r.ascularlaser and an infrarecl ate rvhen used rn dark-skinned patients Adequate cooling laser are used, follor'r.cd b.v selective treatment r,r.ith a is once againimportant for laser/lPl hair removal Fur- pigmented laser/lPL For erarlple, the lr'hole facc is thermore, for dark-skinned patients a lor'r.fluence ."r,.ith treated rvith either a largc spot size 532-nm Nd:YAG long pulse duration can reducethe risk of comphcations laser (10-mnr spot sizc, 7 J/cm2,20 ms for I pass),or When using a diode laser equipped u'ith contact cooling, pulsed dye laser [595 nm, 1O-mmspot sizc, 7 5-9 J/cm2, the adhesronof burned hair to the chill tip can be a Dvnamic Coohng Device (DCDI 40ms/20ms delayJ, problem This ar.oidablecomplication can causeburns and fbllor'r.edby either long-pulsedl064-nm Nd:YAG lascr subsequentPIH (Fig.5.t3). (10-mm spotsize, 40 J/ctn1,45-mspulses), or a 1540-nnr Er:YAG laser fl0J/crnr,3 stack pulses.).Immediatclr, . Theprevention and management of afteru.ard, prgrnentcd a laseris used to remo\,eindividual postinflammatory hyperpigmentation lentigincs(Figs 5.rr and 5.rz) For laserhair removal, long-pulscpulsed diode, alex- Postinflammatoryhyperpigmentation is the most common andrite, and 1064-nm Nd:YAG laserscan all be uscd complicatron in dark-skinned patients, and effectire pre- Detailed treatment parametersare drscussedin anl' hair vention and subsequent management is important All removal textbook A longer u.avelength 1aser,offcring .r patlents should use sun protection and avordsun exposure before laser or IPL surgery It is not uncommon for patlents to misunderstand the meaning of sun avoidance, and to onl1,avoid sunbathing.It is important to emphasize

Fig.5.11 Nonablativeskin rejuvenation using a combinationof Fig.5.12 Non-ablativeskin rejuvenation using a combinationof devicesto improvepigmentation (cross polarized view) devicesto improvepore size (parallelpolarized view) 85 LaserTreatment of EthnicSkin

is far too big to be effective when treating smaller subjects where bony areas such as rib cages and pelvis limit the coveragearea. Plasma skin resurfacing involves the production of plasma by activation of nitrogen from ultra high frequency energy.Plasma skin resurfacinghas been successfullyused for the treatment of wrinkles in light-skinned patients. Preliminary data has suggestedthat this nonlaserapproach can be successfullyused for dark-skinned patients using lower energy fl-1.5 J per pulse) with multiple treatment sessionsat 4 weekly interval Further study is necessary to determine the risk of PIH with this approach.Ablative fractional resurfacing is being explored as a new modality for skin rejuvenation,with the risk of PIH in dark-skinned patients, at present, unknown. Fig. 5.13 Cleaningthe adhesionof burnedhair off the chilltip

FURTHERREADING patients to all that they should apply sun block (preferably Aguilar G, Diaz SH, Lavernia EJ, Nelson JS 7002 Cryogen spray containing titanium dioxide and zinc oxide) every day for cool:ingefficiency: improvement of port wine stain laser therapy 2 weeks before laser/lPl surgery, whether or not they through multiple-intermittent cryogen spurts and laser pulses engage in any outdoor activities. Ultraviolet light pro- Lasersin Surgeryand Medicine 31:77-35 2001 Long-pulsedNd:YAG tected clothing is also useful. The application of moder- Alster TS, BryanH, Williams CM laser-assistedhair removal in pigmented skin Archives of ate-potency topical steroid immediately after laser and Dermatology;I 37:88 5-889 IPL surgery may also reduce the risk of PIH. Alster T, Hirsch R 2003 Single-passCOz laserskin resurfacingof The use of topical bleaching agents before and after light and dark skin: extended experience with 52 patients treatment may also be important. Many different combi- Journalof Cosmetic LaserTherapy 5:39-42 nation topical agents,containing tretinoin, hydroquinone, Battle EF Jr, Hobbs LM 2004 Laser-assistedhair removalfor darker Dermatologyand Therapeutics17:177-183 topical steroid, alpha-hydroxy acid (AHAJ, kojic acid, skin types Battle Jr EF, Suthamjariya KK, Alora MB, Palli K, Anderson RR and/or azelaic acid, have been advocated In practice, our 2000 Very long-pulsed (20-200 ms) diode laser for hair removal all patients are given a combination of azelaicacid mixed on all skin types Lasersin Surgeryand Medicine Sl2:85 with 40lohydroquinone and a moderate-potency steroid Chan HH 2005 Effective and safe use of lasers,light sources,and one day before treatment and then for 4 weeks after treat- radiofrequency devices in the clinical managementof Asran ment. Tretinoin is added if the patient experiences no patientswith selecteddermatoses Lasers in Surgeryand Medicine37:179-185 irritation If PIH developsdespite the use of such agents, Chan HH, Chan E, Kono T, Ying SY, Ho WS 2000 The use of we add 50/oglycolic acid in the morning to further reduce variable pulse width frequency double neodymium:YAG 532 nm the hyperpigmentation. Depending on the degreeof irrita- laser in the treatment of port wine stain in Chinese Dermato- tion, we add other bleaching agents,including vitamins C logic Surgery26:657-661 and E, and kojic acid. If PIH persists,then we perform a Chan HH, Fung WKK, Ying SY, et al 2000 An in vivo trial of different types of 532 nm Neodymium: mild glycolic acid peel (20-35%J about 6 to 8 weeks after comparingthe use Yttrium-Aluminum-Garnet (Nd:YAGJ lasersin the treatment of the treatment The use of microdermabrasionmay alsobe facial lentigines in oriental patients Dermatologic Surgery effective as an adjunctive means to improve superficial 26:743-749 niomentafinn Chan HH, Lam LK, Wong DS, Kono T, Trend-Smith N 2004 Use of 1320nm Nd:YAG laserfor wrinkle reduction and the treatment of atrophic acnescarring Lasersin Surgeryand FUTURESTUDY Medicine34:98-103 Chan HH, Shek S, Yu CY, Yeung CK, Kono T, MainsteinD 2006 The use of high-intensity focused ultrasound has recently Prevalenceand risk factor of post-inflammatory hyperpigmenta- been introduced in cosmetic dermatologyfor body contour tion in Chinese patients treated with fractional resurfacing Lasersin Surgeryand Medicine SI8:77 and skin tightening. The effect of these devicesappear to Chan HH, Ying SY, Ho WS, Wong DS, Lam LK 2001 An in vivo be skin-type independent; potential risk the of complica- study comparing the efficacy and complications of Diode laser tions should be much lower than those of laser or light and long-pulsed Neodynium: Yttrium-Aluminum-Garnet [Nd: source. In one of the authors' (HC) experience, the use YAG) laser in hair removal among Chinese patients Dermato- of high-intensity focused ultrasound for localized fat logic Surgery2l :950-954 reduction is effective among large and hear,y subjects. Chiu CH, Chan HH, Ho WS, YeungCK, Nelson JS 2003 Prospective study of pulsed dye laser in conjunction with However, the is for degree of improvement not significant cryogen spray cooling for treatment of port wine stains in smaller people with less fat.. This is likely to be due to Chinesepatients. Dermatologic Surgery 29:909-91 5; discussion the focusedultrasound technology'stransducer size, which 915 85

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Chung JH, Lee SH, Youn CS, et al 2001 Cutaneousphotodamage Rohrer TE, Chatrath V, Iyengar V Does pulse stacking improve the in Koreans:influence of sex, sun exposurersmoking, and skin resultsof treatment with variable-pulsepulsed-dye lasers? color lu-chivesof DermatologyI 37:I043-l 05 I DermatologicSurgery 2004; 30:163-167; discussion167 Elman M, Klein A, SlatkineM 2000 Dark skin tissuereaction in RokhsarCK and FitzoatrickRE 2005 The treatment of melasma laserassisted hair removalwith a long-pulseruby laser.Journal with fractional photothermolysis: a pilot study Dermatologic ol Cutaneou5Laser lherapl 2:17-20 Surgery3l:1645-1650 GaladariI 2003 Comparativeevaluation of different hair removal Ruiz-EsparzaJ, Gomez JB 2003 The medicalface lift: a nontnva- lasersin skin types IV, V, and VI InternationalJournal of sive, nonsurgicalapproach to tissue tightening in facial skin using Dermatology42:68-70 nonablativeradiofrequency Dermatologic Surgery 29:325-332; Goh CL, Chua SH, Ang P, Khoo L 2004 Efficacyof smoothbeam discussion332 l,450nm laserfor treatment of acnescars in Asian skin Lasers Ruiz-EsparzaJ, BarbaGomez JM, Gomez de la Torre OL, Huerta in Surgeryand Medicine Sl6:76 FrancoB, PargaYazquezEG 1998 UltraPulselaser skin Goldman MP 2000 The use of hvdroquinonewith faciallaser resurfacingin Hispanic patients A prospective study of 36 resurtacingJournal ol CutaneousLaser Therapy 2:73-77 individuals DermatologicSurgery 24:59-62 Greppi I 2001 Diode laserhair removalof the black patient Lasers SadickNS, Makino Y 2004 Selectiveelectro-thermolysis in in Surgeryand Medicine28:150-155 aestheticmedicine: a review Lasersin Surgeryand Medicine -97 Hardaway CA, RossEV, Paithankar DY 2002 Non-ablative 34:91 cutaneousremodeling with a I 45 microm mid-infrared SchroeterCA, GroenewegenJS, ReinekeT, Neumann HA 2004 diode laser:phase II Journalof Cosmetic LaserTherapy Hair reductionusing intense pulsed light source Dermatologic 4:9-14 Surgery30: 1 68-1 73 JeongJT, Kye YC 2001 Resurfacingof pitted facialacne scars Shek SY, Yu CS, Yeung CK, Kono T, Chan HH 2006 A study of with a long-pulsedEr:YAG laser DermatologicSurgery 27:1,07- non-thermal non-ablative LED photomodulation device for Ir0 reversal of photoaging in Asians Lasersin Surgery and Medicine Kono T, Chan HH, MansteinD, SesovaIP, Nozaki M 2006 S18:108 Comparisonstudy of the down time and complicationsof Shim EK, BarnetteD, HughesK, GreenwayHT 2001 Microderm- fraxel laserskin rejuvenation,Lasers in Surgeryand Medicine abrasion:a clinicaland histopathologicstudy Dermatologic S18:220 Surgery27:524-530 Kono T, MansteinD, Chan HH, Nozaki M, AndersonRR 2006 Tanzi EL, Alster TS 2004 Long-pulsed1064-nm Nd:YAG laser- Q-switched Ruby vs Long-pulsedDye Laserdelivered with assistedhair removal in all skin types Dermatologic Surgery compressionfor treatment of faciallentigines in Asians,Lasers 30:I 3-l 7 in Surgeryand Medicine 38:94-97 Tanzi EL, Williams CM, Alster TS 2003 Treatment of facial Kono T, Nozaki M, Chan HH 2001 Diode laserassisted harr rhytideswith a nonablative1,450-nm diode laser:a controlled removalin Asians:a retrospectivestudy of 101 Japanese clinical and histologic study Dermatologic Surgery 29:724-128 patients.Lasers in Surgeryand Medicine Sl3:245 Trelles MA 2001 Short and long-termfollow-up of non-ablative Lee MW 2002 Combination visible and infrared lasersfor skin 1320 nm Nd:YAG laserfacial rejuvenation Dermatologic rejuvenation Seminarsin CutaneousMedicine and Surgery Svrgery27:781-782 2t:288-300 TrellesMA, Allones I, Luna R 2001 Facialrejuvenation with a non- Lee JH, Huh CH, Yoon HJ, Cho KH, Chung JH 2006 Photoepila- ablative1320 nm Nd:YAG laser:a preliminaryclinical and tion resultsof axillaryhair in dark-skinnedpatients by IPL: a histologicevaluation DermatologicSurgery 27:1 I t-l l6 comparison between different wavelength and pulse width Tunnell JW, Chang DW, Johnston C, et al 2003 Effects of cryogen Dermatologic Surgery 32:734-24\ spraycooling and high radiantexposures on selectivevascular Nanni CA 1999 Laserassisted hair removal:side effects of Q- injury during laser irradiation of human skin Archives of switched Nd:YAG, long-pulsed ruby, and alexandrite lasers Dermatology139:7 43-7 50 Journalof the AmericanAcademy of Dermatology4I :165-171 West TB, Alster TS 1999 Effect of pretreatmenton the incidence Negishi K, Tezuka Y, Kudshikata N, Wakamatsu S 2001 Photoreju- of hyperpigmentation following cutaneous C02 laser resurfacing venation for Asian skin by intense pulsed llght Dermatologic DermatologicSurgery 25:15-l 7 Swgery 27:677-632 .r4trite WM, Laubauch H, Makin IR, Slayton MH, Barthe PG, PandolfinoT, LaubachH, GagnonD, MansteinD 2006 CO2 laser Gliklich R 2006 Selectivetrancutaneous delivery of energyto induced ablativemicropatterns in skin Lasersin Surgeryand facial subdermal tissues using the ultrasound delivery system Medicine 37:5279 Lasersin Surgeryand Medicine 37:Sl 13 LaserTreatment of Cetlutite

Adam M. Rotunda,Jaggi Rao, Mitchel P. Gotrdman

INTRODUCTION what is already known and speculated,we may be better equipped to appraise the newer technologies and tech- Just as apparently inevitable r,r.rinklingis with aging, so niques that have arisen to treat it. For a complete discus- apparently inevitable is ceilulite on a woman's thigh or sion of the pathophysiologyand treatment of cellulite, the buttock. The characteristic cutaneous irregularity and interested reader is referred to a complete textbook on dimpling on the buttocks, and upper outer or posterior this subject. thighs on more than 850/oof post-pubertal women could quahfy cellulite as a secondary female sex characteristic o Predisposingfactors The condition leaves many women feeling unattractive to a patient's pre- It would appear that a topical, surgical, light-based, or There are many factors that contribute mechanical treatment that cures cellulite would be to disposition for cellulite: women what penicillin was to the world of infectious 'i, Gender: due to underlying structure of fat and disease-akin to a miraclel Although this chapter does not connective tissue described above, women are more describemiracles, it aims to elaborateon studiesthat have likely to develop cellulite investigatedcellulite and describethe increasinglypopular "i, Heredity: empirically, it has been found that the treatments that may improve the appearance of this degree and presenceof cellulite, as with body medically benign, but cosmetically disturbing condition. habitus, is often similar between females within the same famiiy . Definition * women are more iikely to develop 'Celluiite' Race: Caucasian was described over 150 years ago in France, cellulite than Asian or African-American women and has since been referred to as adiposis edematosa, t, Increasedsubcutaneous fat: due to the unique dermopannniculosis deformans, status protrusus cutis, 'orange 'cottage histology of skin with cel1u1ite,it is evident that and gynoid lipodystrophy, and peel' or greater adiposetissue in the subcutaneouslayer cheese' dimpling. It has been proposed that clinicians enhancesthe appearanceof cellulite on the skin substitute the single term cellulite with incipient cellulite surface and cellulite Incipient cellulite is identified by t'ull-blown ,i' Age: women begin to develop cellulite after puberty the mattressphenomenon, a gender-specificfeature of the as part of normal anatomic and physiologicaldevelop- skin that is demonstrated by the pinch test, apparent even ment, combined with hormonal influences in a female infant (Fig.6.r) Pinching the skin tethers the dermis to a deeper layer of connective tissue and forces Unfortunately, these predisposing factors are difficult if clusters of adipose tissue into the overlying skin. Full- not impossible to alter. However, based on our under- blown cellulite is characterizedby permanent (asopposed standing of the etiology and nature of this condition, to induced), grosscutaneous irregularity. A cellulite clini- severaltreatment modalities have been developed cal grading system that accountsfor this clinical spectrum Hormones, specificallyestrogens, are thought to influ- has been described fsee Table 6 1) ence the formation of cellulite. Estrogen is known to Despite its prevalence and unsightly presence, there stimulate lipogenesisand inhibit lipolysis, resulting in adi- has only been a modest amount of scientific investigation pocyte hypertrophy (Rossi and Vergnanini, 2000). This into cellulite Scant research leads to innumerable pur- may explain the onset of full-blown cellulite at puberty, ported treatments, misconceptions, and controversy the condition being more prevalent in females, and the There are no unrversallyaccepted causes, no gold-standard exacerbation of cellulite with pregnancy, nursing, men- treatments, nor preventive strategies for the condition. struation, and estrogen therapy (oral contraceptive use Thankfully, there is no apparent morbidity or mortality and hormone replacement). The opposite seemstrue for associatedwith the condition. With an appreciation of men. From the limited number of studies involving men, 88 Lasersand Lights Volume ll

Fig.6.2 A schematicdiagram of skinstructure showing five zones Thegray layer is theepidermis Zone 1 is thedermis Zone 2 is the extrusionof thehypodermis into the dermis Zones 3-5 arethe upper, middle,and lower parts of thehypodermis, (Reprinted by permission of Blackwell{rom Mirrashed F,Sharp JC, Krause V, Morgan., TomanekB Pilotstudy of dermaland subculaneous fat structures by MRIin individualswho differ in gender, BMl, and cellulite grading SkinRes Technol 2004;10:161-8)

posed areaswhen circulation and lymphatic drainagehave been compromised. In responseto impairment of microvascularcirculation, it is proposedthat microedema within the subcutaneousfat layer causesfurther pressureon surrounding connective tissue fibers and accentuationof skin irregularities.A number of the more novel cellulite therapies attempt to augment lymphatic drainage and mrcro- vascularcirculation.

ANATOMYAN D PATHOPHYSIOLOGY It stands to reason that a discussion of cellulite should start with a review of the anatomy of adipose tissue. A schematicview of typical extremity adiposetissue is ilius- trated in Fig. 6.2 based upon high-resolution in-vivo magnetic resonance(MR) microimaging (Fig.6.3). Further, minimally invasive imaging techniques have proved useful in advancing our understanding of gender differences that account for the relative absenceof cellulite in males [except for certain androgen deficient states like Kleinfelter's syndrome, post castration, prostate cancer treatments). Although cellulite is correlated with increasing body mass index (BMI = person's weight in kilograms divided by the square of their height in metersj, thigh Fig.6.1 Upper-thighskin before (A) and after (B) the pinch test, circumference, and body fat, it is not necessarilycorre- whichdemonstrates the'mattress phenomenon.' The changes lated with obesity. A number of local structural compo- observed,apparent here in a s-month-oldfemale infant, strongly nents in adiposetissue can account for the appearanceof suggeststructural rather than acquired or environmentalfactors contributeto cellulite cellulite in women. The conventional concept of adipose tissue anatomy originates from Nrirnberger and Muller, who analyzed adipose samplesfrom'normal' fno cellulite) men, normal it is hypothesizedthat the combination of gender-specific women, and women with cellulite. Their observations soft-tissue histology at the cellulite-prone anatomic sites, hold that predominately perpendicularly oriented septae with a relatively lower circulating estrogen level, may be [connectivetissue formed by elasticand collagen)between responsiblefor the lower incidence of cellulite in males. fat lobules of women, in contrast to the criss-crosspattern Adipose tissue is relatively vascular, ieading to the for men, account for the surface undulations in women theory that cellulite may appear and worsen in predis- with cellulite (Fig.6.4) 89 LaserTreatment of Cetlulite

Recent in-vivo magnetic resonanceimaging (MRI) has confirmed differencesin fibrous septaestructures between the genders For women with cellulite, there is a higher proportion of fibrous septaeperpendicular to the skin, and a smaller proportion of septae parallel to the skin (Fig. 5.5), findings validating to some extent the initial work of Nurnberger and Muller. However, MR studies reveal that these units are in fact pillarJike columns (Fig.6.6), rather than paral1e1septae perpendicularly oriented as previously proposed.Thus, the variability seenbetween women with cellulite, women without celiulite, and men suggestthat modeling the septae as either criss-crossin men or perpendicular in women is an oversimplification. Nurnberger and Muller also described deep fatty indentations into the dermis in women but not in men Others authors have confirmed that the thigh skin of females, regardlessof clinical signs and severity of cellulite, was invariably associatedwith a characteristiclumpy appearance of fat into the dermis, known as papillae adiposae. Men, on the other hand, had a smooth der- mohypodermal interface. High-frequency ultrasound (FiS.6.) as well as wedge biopsies of thigh cellulite, have confirmed an undulating dermo-hypodermal interface and extrusion of fat into the reticular dermis fsee Figs 6.3 and 6.7) MRI has further revealedthat cellulite overlies a thick, deep inner adipose layer, iocated below the Camper's fascia (Fig. 6.8) Large, heary patients (BMI >30) with Fig. 5.3 TypicalMRI ol thighskin To the rightis the surfaceof the cellulite as well as smaller patients (BMI 18-25) with skinand to the leftis musclewith a planeresolution ol 273x273pm cellulite have a thicker fat layer, larger fat lobules, and From right:the surfaceof the skin; 1, dermislayer; 2 the brightpixels more fat inclusion into the dermis, than smaller patients shownin the box are extrusionof hypodermictissue inside the (Fig. thicker fibrous dermis;3-5, the upper,middle, and lowerparts of the hypodermis, without cellulite 6.g). Men have respectivelyDark fibrousslreaks separating fat lobulesinside the septae and more obliquely oriented fibrous planes than hypodermis(tibrous septa) and fascia;the linearconnective tissue women (Fig.6.ro) It may therefore be that heavierpatients connectingthe deep fat layerof the skin to muscleis clearlyvisible in are more susceptibleto cellulite than thinner women and the image (Reprintedby permissionof Blackwellfrom MirrashedF, to larger fat 1obules,less fibrous tissue, greater SharpJC, KrauseV, l\/organJ, TomanekB Pilotstudy of dermaland men due subcutaneousfal structuresby MRI in individualswho differin gender, fat-dermal herniation, and thicker fat layer, which places BMl,and cellulitegrading Skin Res Technol 2004;10:161-8) great pressure on these overlying structures.

Epidermis coflum

upperzone of subcutis

Fig. 6.4 Orientationof subcutaneousfibers extending from dermisto fasciain malesand females (Reprintedby permissionof Blackwellfrom NurnbergerF, and MullerG So-calledcellulite: An inventeddisease J DermatolSurg Oncol 1978i4:2211 9o Lasersand Lights Votume ll

80 f--l Womenwith cellulite l---l Womenwith no cellulite 70 I---l Men O S60 o c) q-^ ocU l o c+u 3O 20

Directionsperpendicu ar Directionst lted at 45'' Directons parallel to theskin +/- 15' to theskin +/- 30' to the skin+/- 15'

Fig. 6.5 Structuredpatterns of the fibrousseptae network according to sex and presenceof celluliteOur quantitativefindings give more evidenceabout the heterogeneityin the directionsof the septae,and highlysuggest that modelingthe 3D architectureof fibrousseptae as a perpendicularpattern in womenbut tiltedat 45 degreesin men wouldbe an oversimplification(Reprinted by permissionof Blackwellfrom QuerleuxB, CornillonC, JolivetO, BittounJ Anatomyand physiologyof subcutaneousadipose tissue by in vivomagnetic resonance imaging and spectroscopy:relationships with sex and presenceof celluliteSkin Res Technol 2002;8:1 18-24)

Fig. 6.6 Visualizationof the 3D architectureof fibrousseptae in subcutaneousadipose tissue (A) Womanwith cellulite;(B) normalwoman; (C) man (Reprintedby permissionof Blackwellfrom QuerleuxB, CornillonC, JolivetO, BittounJ Anatomyand physiologyol subcutaneousadipose tissueby in vivo magneticresonance imaging and spectroscopy:relationships with sex and presenceof celluliteSkin Res Technol2002;8:118- 24)

The measurement of T1 and T2 relaxation values for after isoproterenol infusion into fat) or regional blood water in cellulite versusnon-cellulite-affected limbs ln 67 flou,' betrveen affected and unaffected sites has been subjects suggest that therc are no differences in lr,'ater confirmed [ar.erage, 7 4Vr u,'ater) or degree of lipid distribution [about 7 3%r unsaturated and 85 3(/o saturatedl These EVALUATION findings contrast rvith theories proposed by some authors that cellulite is causedby circulation disturbancesand There is a broad spectrum of tools availableto evaluate edema of affected sites No signilicant differences in lipo- cellulite, rangingfrom simple observationto tissue biopsy. lytic responses[by measuring glycerol using microdialysis Some such methods are given belou.. 91 LaserTreatment of Cellulite

<*- *l,la1i:ftllr1: n Womenwith celluliie 40 o Womenwith no cellulite <- dfrrTllS 35 E 30 AI-I-ECTED E 25 FEr\'1ALE 0) 20 C5

C) tc C +"* JrlllJ(]gc tr{:$Ll{j C 10 5 0 468 Outerlayer (mm)

UNAI.f:FCTED Fig. 6.8 New characteristicmarker of cellulite.MR imagingshows Ff l'r,lALE that womenwith cellulitehave a much greaterincrease in the thicknessof the deep inneradipose layer compared with normal womenor men (Reprintedby permissionof Blackwellfrom Querleux B, CornillonC, JolivetO, BittounJ Anatomyand physiologyof subculaneousadipose tissue by in vivo magneticresonance imaging and spectroscopy:relationships with sex and presenceof cellulite. Skin Res Technol2002;8:118-24)

UNAFFECTED fIIALE

Fig. 6.7 Color sonographsof the thighof an affectedwoman, an unatfectedwoman, and an unaffectedman. Note the extrusionof adiposetissue into the dermisof the affectedindividual (Reprinted by permissionof Pierard-FranchiemontC, PierandGE, HenryF, et al 2000 A randomized,placebo controlled trial of topicalretinal in the treatmentof celluliteAm J Clin Dermatol1:369-74.)

OBSERVATION Direct or photographic visualization of the skin with Fig.6.9 Skinof twofemales both from low BMI group. (A) Cellulite further assessmentof puckering, dimpling, and nodulari- grade= 2 5, hypodermis16 2 mm.(B) Cellulite grade = 1, hypodermis ties is a relatively simple and inexpensive tool. Further 11.3mm (Reprintedby permissionof Blackwellfrom Mirrashed F, assessmentis performed by manual palpation and gently SharpJC, Krause V, MorganJ, TomanekB. Pilotstudy of dermaland whodiffer in gender, squeezing the skin under tangential lighting that can subcutaneousfat structuresby MRIin individuals BMl,and cellulite grading Skin Res Technol 2004;10:161-8) accentuateskin tethering.

PATIENT SELF-ASSESSMENT Although prone to scientifically inaccurate and inconsis- ANTHROPOMETRY tencies as a measureof outcome after treatment, patients' 8"' BMI is a simple calculation. Although useful in the self-assessmentsare an important tool. It is usually con- evaluating obesity, this tool is not effective in the ducted with a questionnaire and self-rate visual analog assessmentof cellulite as it does not directly corre- scalesthat evaluatethe extent of signsand symptoms. late with cellulite distribution or severity. Lasersand Lights Volume ll

Fig.6.10 Examplesof sagittalimages of normalskin (i.e.cellulite grade = 0) of men (A, B) and women (C, D); all subjectsare from the high BMI group (Reprintedby permissionof Blackwellfrom MirrashedF, SharpJC, KrauseV, MorganJ, TomanekB Pilotstudy of dermaland subcutaneousfat structuresby MRI in individualswho differin gender,BMl, and cellulitegrading. Skin Res Technol2004;10:161-8

* Body circumt'erence,especially thigh circumference, is HISTOLOGICALANALYSIS an indirect measure of cellulite. It should be noted This method is the most specificmethod of evaluatingthe that there are a number of factors that can cause underlying microanatomy, but it is invasive and may not measurement inaccuracies,including inter- and intra- correlate with clinical appearance It is performed using a evaluator variability, and changesin body fluid and deep skin biopsy of the affected site and can be further weight between measurement periods. analyzedwith tissue specific staining. ."* Skinfold thickness involves measuring subcutaneous fat indirectly by using a caliper; the validity of usrng skinfold thickness as a tool in celiulite assessment ELECTRICALCON DUCTIVITY remains to be validated by further studies. This method allows assessment of body composition ,ts Skin elasticity involves measuring skin tension with a (including muscle, fat and water) by measuring tissue suction elastometer to determine resilience of the resrstanceto electron flow. Clinically useful results of dermis and gaugethe extent of cellulite. In a similar celiulite examination remain to be seen. manner to skinfold thickness, it may not necessarily be a valid tool for grading cellulite. FLOWMETRYOF THE SKIN PERFUSION NONINVASIVEIMAGING TECHNIQUES "'* Laser doppler flowmetry ts a tool to measure irregularities in the distribution of the microcirculatory ,"""Uhrasound (USJ is a readily available imaging blood flow. technique that allows visualization of the dermal- * Anode hypodermal tissue interface. Some of the disadvan- thermograplry is a method of assessingskin surface temperature producing tages of this technique include inability to visualize and a thermal map of colors that are indicative of deep adipose tissue planes, as well as being subject to certain temperatures on operator error. the skin surface. The thermal maD can be further analyzedto determine the grade of cellulite severity. * Magnetic resonance imaging is an expensive [MRI] It should be noted that interpretation of the results imaging technique, but provides the best visuaiization are affected by certain factors, including sun/heat of dermal-hypodermal interface and underlying soft exposure, smoking and ovulation. tissue. It is not subject to operator error and appears to be the most accurate objective tool available. Of all methods discussed, observation with tangential Unfortunately, it not a practical option for most lighting and anthropometric measurements are the most investigatorsin large cohort trials, given the time and common due to their relatively fair reproducibility and resourcesrequired for imaging. accuracv,ease and cost effectiveness LaserTreatment of Cetlulite

CLASSIFICATION antioxidants and vasodilators, are included to increase microvascular flow and lymphatic drainage.Other agents The attempt to classifycellulite is as historic asits original may promote lipolysis, with the goal of reducing the size descriptions. This is related in part to the difficulty in and volume of adipocytes, thereby decreasingtension on establishing an accepted definition of the condition and surrounding connective tissue and decrease the clinical a sensiblepathophysiologic correlation Classificationsof appearanceof puckering. Some topical ingredients, such cellulite have varied from functional aspectsthat involve asvitamin C, are proposed to strengthen existing collagen oxygenation and vascularization, to structural schemes and/or stimulate collagen deposition. Topical retinoic invoiving obesity and histology On practical terms, it may acid and related vitamin A derivatives have been used to be best to classify cellulite based on clinical observation, stimulate circulation, decreasethe size of adipocytes,and given the lack of external equipment and minimal time augment dermal collagen In reality however, whether and resourcesrequired to do so A simple, low requrre- these agents penetrate the skin, let alone have a potent ment four-grade classificationscheme for cellulite is illus- physiologic effect in their target tissue that actually yields trated in Table6.r. a clinical change,is debatable. Aminophylline, a methylxanthine, has been proposed as TREATMENT/MANAGEMENT a useful agent in the treatment of cellulite. It was predicted that amrnophyliine's effect on the inhibition of Although there hasbeen an increasinginterest in the treat- phosphodiesterase,an enzyme responsible for breaking ment of cellulite over the recent years/ no single method down cyclic adenosine monophosphate would 'the [cAMP), has been universally proven to be best.' Presently increase cAMP concentrations and lead to increased there are four basic categoriesof cellulite treatment that regionallipolysis via activation of hormone-sensitivelipase include conservative management, topical management, Preliminary studies, despite showing improvement, have systemic and localized therapy, and physical therapy. either lacked controls or showed small, clinically insignifi- cant changes in thigh-girth measurements. A lZ-week, CONSERVATIVETHERAPY randomized controlled trial involving I 7 patients did not support the effectiveness of aminophylline in cellulite Conservative management inciudes the adoption of a treatment. At the present time, there is no evidence for healthy lifestyle. Unfortunately, despite the benefits of clinical use of aminophylline cream in cellulite treatment achieving cardiovascularhealth, there is 1ittle evidence to Topical retinolhasbeen suggestedto potentially restrict support significant cellulite reduction with the combina- the herniation of the fat tissue into the dermis by thicken- tion of diet and regular exercise Diet and exercisecannot ing the dermis through promoting glycosaminoglycansyn- alter the histologic structure of the perpendicular bands thesis and increasingthe collagendeposition. Two studies connecting the skin to the underlying fasciaand so cannot have so far investigatedthe effect of topical retinol in the eliminate cellulite entirely However, lifestyle modifica- treatment of cellulite, but their relevance remains to be tions may assistto reduce the appearanceof cellulite by seen, as both of the studies n'ere small. In a double blind decreasing adipocyte volume, thus placing less tenston study that involved 20 patients, Kligman et al investigated on surrounding connective tissue, resulting in decreased the effects of topical retinol and its vehicle that was puckering, but this has not been well documented. applied to opposite lateral thighs twice daily for a period of 6 months. The investigatorsdemonstrated that 12 of TOPICALMANAGEMENT the patients experienced clinical improvement Another, randomized,placebo-controlled study involving 15 women A number of different topical agentsin the form of gels, who applied topical retinol for 6 months daily did not ointments, foams, creams, and lotions are available for show any improvement in overt cellulite. The authors treatment of cellulite Most active ingredients, including were able to demonstrate a phenotypic changethat consisted of a 2- to 5-fo1d increasein the number of factor XIIIa+ dendrocytes in the dermis and in fibrous strands of the hypodermis, but no clinical improvement was patients with overt cellulite. No or minimalskin irregularity upon shown in standing,pinch test, or muscle A number of herbal treatmentscontaining specific mix- contraction tures of botanical extracts havebeen used in the treatment significance remalns No or minimalskin irregularity upon of cellulite, although their clinical standing.Dimpling becomes apparent by unclear (Table6.2). pinchingor musclecontraction Classicskin dimpling at restwith AND LOCALIZEDINJECTABLE THERAPY palpable,small subcutaneous nodularities SYSTEMIC Hormonal manipulation is not a popular treatment option GradelV Moresevere puckering and nodularity due to its many potential adversesequelae. This approach Lasersand Lights Volume ll

Herbalname Concentration Partsof the Mainconstituents Mechanismof action (%) plant

Bladdenrurack 1 Wholedried thallus Stimulatesvascular flow Butcher'sbroom 1-3 Rhizomeand Saponins,ruscogenin and floweringtops neororuscogenrn Ginkgo 1-3 lmprovesmicrocirculation Chofitolor artichoke Leaves,flower heads Enzymes,cynarin, ascorbic Reducesedema and roots acid,caffeoylquinine acid Promotesdiuresis derivativesand flavonoids Commonivy Driedleaves, stems Saponins(especially lmprovevenous and hederin) lymphaticdrainage Reduceedema Groundivy Flavonoids,triterpenoids, and phenolicacids Indianor horse Seeds,shells Triterpenoidsaponins and Reduceslysosomic chestnut flavones,coumarins and enzymeactivity and tannins reducescapillary permeability Sweetclover Flowersand leaves Coumarin Reduceslymphatic edema and reducescapillary permeability Centella asiatica Leavesand roots Asiaticoside,madecassic Anti-inflammatoryand acid,asiatic acid potenthealing effect Redgrapes Tannins,procianidins Antioxidantsthat decrease lipidperoxidation and increasepermeability of lymphaticand microarterial vessets Corynanthyohimbe, Leaves,shells, roots Yohimbe Stimulatemetabolism ot Pausinystalia fat cells youhimbe, and Rauwolfia serpentina Papaya Fruits,leaves Papainand bromelain Anti-inflammatoryand (proteolyticenzymes) decreaseedema

includes the avoidance of oral contraceptives and hormone PHYSICALTHERAPY replacement in females and the maintenance of proper androgen levels in males in attempt to counteract the Originally developed in France, Endermologie (LPG detrimental effect of these hormones on cellulite. Another Systems,Valence, France) is also known as skin kneading. option is the direct injection of pharmacologic agents Endermologie is a technique that involves a patented directly into the dermal-subcutaneous junction of the machine with two rollers that suctions the skin so that it skin. This is referred to as intradermotheravv or meso- is further compressed and rolled. This therapy increases therapy, and aims to reduce cellulite throu[h directly blood and lymphatic flow and thus purportedly improves acting on the adipocyte by promoting lipolysis. Despite underlying fat tissue architecture. anecdotal claims of efficacy, a comprehensive recent In a l-year study of 85 patients by Chang et al, patients review has not revealed any peer-reviewed literature that were separated into 2 groups so that 46 patients com- has evaluatedmesotherapy for cellulite. It should be noted pleted 7 treatment sessionsand 39 patients completed 14 that the mesotherapy technique is distinct technically, sessions.The former group showed a mean index reduc- mechanistically, and historically from a treatment called tion in body circumference of 1.34 cm, whereasthe latter injectable lipolysis, which uses detergents like bile salts group showed a reduction of 1.83 cm. The authorsclaimed (i.e., sodium deoxycholate) to chemically ablate adipose that 900/oof the patients reported favorable improvements tissue. in their cellulite-affected areas. :.":...:..:..::|::..::i]]:]:l']i;:ii;]]]],'::]ii]]l1::''!]].i'i::]l:i:::']:]:]]lilli:l::!,]::i]1:]]i 95 LaserTreatment of Cellulite

However, Coilis et al conducted a lZ-week prospec- benefits of deep tissue suction massageproduced by the tive, randomized, controlled trial, which included twice- LPG Endermologie machine by incorporating lasers,light weekly treatment with Endermologie in l7 patients and sources, and/or radiofrequency into their mechanism of a combination of aminophylline cream and Endermologie action. Unfortunately, there have not been any reported in l8 patients. The authors concluded that Endermologie clinical evaluations to determine which if any of these is not an effective treatment of cellulite, although l0 out additional treatment modalities increasethe efficacy and of 35 patients with Endermologie-treated legs reported by what extent. At times, it appearsthat each company that their cellulite appearanceimproved incorporates something new and patentable into their In our medical spa, Endermologie has been used since device more for sales and marketing than for scientific 1996 with great successin many patients. Our expenence advancement.This section will review the possiblebene- is that the more treatments a patient obtains, the better the fits from these advances and the cument peer-reviewed improvement of cellulite. Patients tend to lose any benefit literature comparing the Triactive and Velasmooth within a few months of treatment so that continued, main- systems. tenance treatments are recommended. To this end, LPG Low-energy lasers have been demonstrated to have 'at Systems has introduced the Well BoxrM as an home' beneficial effects on wound healing and biochemical Endermologie unit that the patient can use by herself as effects on endothelial cells, erythrocytes, and collagen. needed As of this writing, not one of the over 100 units We have evaluated a device with a low-fluence laser and we have sold since early 2006 has been returned, and suction massagethat was developedto reduce the appear- many patients report that the Well BoxrM meets their ance of cellulite. This device combines massagewith a expectatlons. dynamic suction action, a low-energy diode laser, and Subcision is a simple surgical procedure that has been contact cooling. The proposed mechanism of action con- noted to improve moderate-to-severecellulite. With the sistsof increasedtissue perfusion and mobilization of lym- use of local or tumescent anesthesia/this technique is phatic drainagedue to the combination of dynamic suction performed by inserting a notched catheter (such as a massagewith lowlevel laser irradiation, and reduction in NokorrM) needle into the subcutaneouslayer of the skin. tissue edema due to contact cooling. This study was The catheter is then manually moved in a repetitive designedto evaluatethe combination of active and passive motion parallel to the surfaceto physically break the con- mechanismsin the treatment of cellulite. nective tissue adhesionsthat tether the dermis to muscu- A11subjects Q000/o)exhibited observableimprovement lar fascia.Upon rupture of these adhesions,the tethering in cellulite following l0 treatments. Blinded evaluation of effect is diminished and cellulite improved. Although pre (T0) and post (Tl0) -treatment photos yielded an reported successful,it is unclear if these beneficial results averageimprovement of 1.67 on a 4-point scale,or mod- are long term and, if not, how long remission time lasts erate improvement (Fig.6.rr). We also observeda measur- Liposuction involvesthe removal of 1ocaladipose tissue able improvement in thigh and hip circumference. Average deposits to achieve a greater esthetic body contour. hip circumferencemeasured 100.62 cm at T0, 100.56cm Performed under general or local tumescent anesthesia, at T5, and 99.35 cm at Tl0, with an averagehip reduction this surgery usesa small tip suction cannulato remove fat of I .21 cm. Average thigh circumference measured from unwanted areas,without altering other skin tissues. 50.80 cm at T0, 50.53 cm at T5 and 49.97cm at Tl0, Adipose tissue is most commonly extracted from the with an averagethigh reduction of 0.83 cm. All subjects thighs, buttocks, abdomen, back, face, neck, and arms. found the treatment to be pleasant. Often, patients fell Liposuction may decreasethe appearanceof cellulite by asleep during the treatment sessions. There were no reducing local fat volume and by disrupting the fibrous adverseeffects reported throughout the study. bands that cause the dimpling appearance of the skin In short, we found that the Triactive device decreased surface, but cellulite reduction is not typically regarded as hip and thigh circumference. In addition, blinded evalua- a consistent outcome Further, the procedure will not tors found improvement in appearanceof cellulite in all permanently eliminate cellulite. It is possiblethat a com- subjects. Treatment was progressive,with an improve- bination of liposculpture with other modalities such as ment in cellulite over the course of the procedures. TriactiverM may work in synergy to prolong the effects of Improvements included reduction in the appearanceof cellulite reduction. Studies are currently being conducted skin dimpling, improvement in the overall contour of the to verify this speculation. limb, and improvement in overall skin texture Patients enjoyed the procedure and found it to be relaxing, with LASER/LIGHT/ENERGY TREATM ENTS no side effects. There was no significant change in either BMI or A wide variety of devicesare presently being evaluatedto percent body fat. This suggests that observed improve- help improve the appearanceof cellulite. As of this writing, ment were attributed to the Triactive, and suggeststhat two devices are clearedby the United StatesFDA for the the Triactive device provides localized treatment/ without treatment of cellulite-The Triactive fCynosure, Bedford, an apparent systemic effect on the body. MA) and the Velasmooth (Syneron, Israel). These units, Our next study evaluated Syneron'sVelaSmooth. This as well as many more under development, add to the technology is based on a combination of two different 96 Lasersand Lights Volume ll

ranges of electromagnetic energy, which produce heat (infrared light, and radiofrequency) combined with mechanical manipulation of the skin and also has been demonstrated to improve the appearance of cellulite The proposed mechanism of action of the Velasmooth is that heating subcutaneous tissue and fat leads to increased localized blood flow and lipolysis. Our study compared the Velasmooth with the Triac- tive on the same patient. Patients were treated twice a week for 6 weeks with the randomization of TriActive on one side and VelaSmooth on the other side. There were a total of l2 treatments per leg. We calculated a 280/oimprovement with Velasmooth versus a 300/oimprovement with Triactive in the upper thigh circumference measurements, while a 560/oversus 370loimprovement was observed, respectively, in lower thigh circumference measurements.These differences in treatment efficacy, using the thigh circumference measurements were nonsignificant (P > 0.05). Based on pre- and post-treatment photographs that were blindly evaluated, we found that 250/o[5 out of 19) of the subjects showed improvement in cellulite appearance for both TriActive and VelaSmooth. The averaqe percent lmprovement based on random photography grading from a scale of 1-5 (l representing no improvement and 5 representing most improvement) for the VelaSmooth versus TriActive are 7ok and 25010,respectively. This difference was also nonsignificant [P = 0.091). Perceived grade change was also calculated based on random side by side comparisonsofbefore and after photographs. Seventy-five percent (15 out of 19) subjects showed improvement in the VelaSmooth leg, while 55% (ll out of 19) subjects showed improvement in the Tri- Active leg. The average mean percent improvement was roughly the same for both treatments (22o/o and 200/0, respectively) and showed no statistically significant difference (P > 0.05) (FiS.6.tz). Some patients did have an increased benefit from one machine compared with the other, but overall, both systems were not statistically different. The only real difference between these two treatment modalities was adverse effects. Bruising incidence and intensity was 30% higher in the VelaSmooth leg than in the TriActive leg. Seven of 20 subjects reported bruising with VelaSmooth, whereas I subject reported bruising with TriActive, and 3 patients reported bruising with both VelaSmooth and TriActive. Extent of bruising ranged from minor purpura to larger and diffused bruises, which lasted for an average of a week with no intervention Fig. 6.11 Cellulitetreatment with Triactive Subjectbetore (A) and (Fig.5.13). following10 (B) treatments (Reproducedwith permissionfrom: Boyce A recent new study suggeststhat, aswould be expected, S, PabbyA, ChuchaltkarenP, BrazziniB, GotdmanMP 2OO5Clinical more diffuse deep radiofrequency, may have an evaluationof a devicefor the treatmentof cellulite:Triactive. Am J even Cosm Surg 22:233-237\ greater result on skin tightening of cellulitic skin. Gold- berg's group treated 30 female subjects with upper thigh cellulite using a unipolar radiofrequency device (Accent, Alma Lasers).Al1 subjects were treated 6 times over the course of l2 weeks. The mean decreasein thish 97 LaserTreatment of Cellulite

Fig. 6.12 Before(A) and after (B) photographsof the subjectseen in Fig 6 11 (Reproducedwith permission from: Nootheti PK, Magpantay A, YosowitzG, CalderonS, GoldmanlVlP: A singlecenter, randomized,comparative, prospeclive clinical study to determinethe ef{icacy Fig. 6.13 Purpuraafter treatment with the (A) Triactiveand of the Velasmoothsystem versus the Triactivesystem tor the (B) Velasmooth(Reproduced with permissionfrom: NoothetiPK, treatmentof celluliteLasers Suro Med 2006:38:908-912 ) MagpantayA, YosowitzG, CalderonS, GoldmanMP: A singlecenter, randomized,comparative, prospective clinical study to determinethe efficacyof the Velasmoothsystem versus the Triactivesystem for the treatmentol celluliteLasers Surg Med 2006;38:908-912) 98 Lasersand Lights Volume ll

circumference was2 45 cm. Of note there were no changes Hexsel DM, Mauuco R 2000 Subcision:a treatment for cellulite. noted with MRI evaluationsand blood lipid analysis His- InternationalJournal of Dermatology39: 5 39-544 tologic analysisdid show fibrosis in the deep dermrs, con- Hexsel D 2006 Socialimpact of cellulite and its impact on quality of life In: Cellulite: Pathophysiologyand Treatment Goldman sistent with the clinical findings of skin tightening. MP, Hexsel D, BacciPA, LeibaschoffGH, Angelini F, Eds Finally, new focused ultrasound emulsification tech- Taylor & Francis,London niques are being developed that may also impact on the KligmanAM, PagnoniA, StoudemayerT 1999 Topicalretinol 'fat' of cellu1ite. Further studies will determine the effi- improvescellulite Journalof DermatologicTreatment 10:l l9- cacy of this approach as a primary treatment modality or t25 Lotti T, in combination with other approaches. GhersetichI, GrapponeC, Dini G 1990 Proteoglycansin so-calledcellulite InternationalJournal of Dermatology29: z7z-274 MirrashedF, SharpJC, KrauseV, Morgan J, TomanekB 2004 SUMMARY Pilot study of dermal and subcutaneousfat structures by MRI in individualswho differ in gender,BMI, and cellulite grading Although 850/o of post-pubertal women have various Skin Researchand Technologyl0:161-168 degrees of cellulite, nearly all women think they do. Nootheti PK, MagpantayA, YosowitzG, CalderonS, Goldman MP Although cellulite is not a medically debilitating physical 2006 A single center, randomized, comparative, prospective defect, it does impact the psychological well-being of clinicalstudy to determinethe efficacyof the Velasmooth 'Madison many patients. Apparently, Avenue' is trans- system versus the Triactive system for the treatment of cellulite Lasersin Surgeryand Medicine 38:908-912 forming this normal female characteristic into a malor 'herd NurnbergerF, Muller G 1978 So-calledcellulite: an invented public health problem and mentality' provides a disease The Journal of Dermatologic Surgery and Oncology profit for industry It is expected that our role as physi- 4:221-229 cians is not to dictate public policy or public opinions, PierardGE, Nizet JL, Pierard-FranchimontC 2000 Cellulite: from rather, to it is to provide sound scientific reasoning.Our standing fat herniation to hypodermal stretch marks American hope is that this chapter provides a brief introduction into Journalof Dermatopathology22:34-37 the scientific pathophysiology of cellulite and an evalua- Pierard-FranchiemontC, PierandGE, Henry F, et al 2000 A randomized, placebo controlled trial of topical retinal in the tion of safe and effective treatments to temporarily treatment of cellulite.American Journal of Clinical Dermatology improve its appearance.Treatments are being developed; I 369-l 374 long-lastingresults are required. Querleux B, Cornillon C, Jolivet O, Bittoun J 2002 Anatomy and physiology of subcutaneousadipose tissue by in vivo magnetic resonanceimaging and spectroscopy:relationships with sex and FURTHERREADING presenceof cellulite Skin Researchand Technology8:118-124 RomanosGE, PelekanosS, Strub JR 1995 Effectsof Nd:YAG laser AgaibyAD, Ghali LR, Wilson R, Dyson M 2000 Lasermodulation on wound healingprocesses: clinical and immunohistochemical of angiogenicfactor production by T-lymphocytes Lasersin findingsin rat skin Lasersin Surgeryand Medicine 16:368-379 Surgervand Medicine 26:357-363 RosenbaumM, Prieto V, Hellmer J, et al 1998 An exploratory Alster i, Tanzi EL 2005 ExtendedexDerience with a novel investigationof the morphologyand biochemistryof cellulite combinationradiofrequency, infrared light and mechanicaltissue PlasticReconstructive Surgery I 0 I :I 934-1939 manipulation device for the treatment of cellulite Journal of RosenbaumM, Prieto V, Hellmer J, et al 1998 An exploratory CosmeticLaser Therapy 7:81-85 investigation of the morphology and biochemistry of cellulite Artz JS, Dinner MI 1995 Treatment of the cellulite deformitiesof PlasticReconstructive Surgery 101 :1934-1939 the thighs with topical aminophylline gel Canadian Journal of RossiABR, Vergnanini AL 2000 Cellulite: a review Journal of the PlasticSurgery 3: I 90-1 92 EuropeanAcademy of Dermatologyand Venereologyl4: Avram MM 2004 Cellulite: a review of its physiology and 251-262 treatment Journalof CosmeticLaser Therapy 6:181-185 RotundaAM, Avram MM, Avram AS 2005 Cellulite: Is there a BoyceS, PabbyA, ChuchaltkarenP,Brazzini B, Goldman MP 2005 role for injectables?Journal of CosmeticLaser Therapy 7: Clinical evaluation of a device for the treatment of cellulite: t 47-r54 Triactive AunericanJournal of Cosmetic Surgery 22:233-237 RotundaAM, KolodneyMS 2006 Mesotherapyand phosphatidyl- ChangP, WisemanJ, JacobyT, SalisburyAV, ErsekRA 1998 choline injections:historical clarification and review Dermato- Noninvasivemechanical body contouring:(Endermologie) a one- logic Surgery32:465-480 year clinicaloutcome study update.Aesthetic PlasticSurgery RyanTJ, Curri SB 1989 The developmentofadipose tissueand its 22:I45-I53 relationshipto the vascularsystem Clinical Dermatology7:1-8 Collis N, Elliot tA, SharpeC, SharpeDT 1999 Cellulite treat- SadickNS, Mulholland RS 2004 A prospectiveclinical study ment: a myth or reality: a randomized, controlled trial of two to evaluatethe efficacy and safety of cellulite treatment therapies,endermologie and aminophyllinecream Plastrc usingthe combinationof optical and RF energiesfor Reconstructive Surgery104:l 1l0-1 I 14 subcutaneoustissue heating JournalCosmetic Laser Therapy DraelosZD, MarenusKD 1997 Cellulite Etiologyand purported 6:187-l 90 treatment DermatologicSurgery 23:l I 77-1 18t SchindlA, SchindlM, SchindlL, JureckaW, HonigsmannH, Goldberg DJ, Hussain,M, Fazeli,Berlin A Analysisof cellulite Breier F 1999 Increaseddermal angiogenesisafter low-intensity treatment results after unipolar radiofrequency treatment laser therapy for a chronic radiation ulcer determined by a video Journalof CosmeticLaser Therapy Submitted for Publication measuringsystem Journal of the American Academy of Goldman MP 2002 Cellulite: A review of current treatmenrs. Dermatology 40:481-484 (-osmeticL)ermatoloev I 5:l 7-20 StadlerI, EvansR, Kolb B, et al 2000 In vitro effects of low-level Hamilton EC, G.een*"iFL, Bray GA 1993 Regionalfat lossfrom Iaserirradiation at 660 nm on peripheralblood lymphocytes the thigh in women using 2% aminophylline. Obesity Research Lasersin Surgeryand Medicine 27:255-256 1:95S Tran M, Odle TG 1998 Gellulite Meltdown? 5:7 Complicationsin Laser and LightSurgery Tina S. Alster, EhzabethL. Tanzi

INTRODUCTION patient receive consultation and counseling before treatment to assesshis or her specific risk of adversesequelae. Complications of cutaneous laser surgery can be under- Laser surgeons must spend time educating patients on stood by reviewing the evolution of laser technology over the realities of laser treatment and the potential side the past four decades. Lasers initially were designed to effects that may occur. During the consultation, clinical operatein a continuous-wav" (C\M) mode, which produced photographsand written material can enhancethe patient's a continuous beam of radiation that subsequentiy was understanding of the procedure, expected clinical absorbedby a tissuechromophore. Although particular skin outcome, and potentiai complications. It is alsoimportant structures could be destroyedusing these early lasers,their that patients understand the importance of good wound usewas limited becausethe energyemitted not only altered care after a laser procedure Preoperative laser evalua- the target, but alsoconducted heat into adjacentnonirradi- tion should include a basic medical history, including ated tissue. The nonselectivethermal injury produced in documentation of medications and allergies. A history adjacenttissue resulted in significantside effects and com- of smoking, abnormal scarring, excessive sun exposure, plications, namely, hypopigmentation and scarring allergic or inflammatory conditions, herpes simplex virus The safety and efficacy expected from modern laser (HSV] outbreaks,immune disorders,or previous cosmetic systemscan be attributed to the ground-breakingwork of procedures within the involved area should also be ascer- Anderson and Parrish in the 1980s Their theory of selec- tained Proper pretreatment education and closephysician tive photothermolysis outlined the mechanism for specific follow-up helps to reduce morbidity and al1owsfbr early tissue destruction through manipulation of the type of recognltion and management of potential problems. laser energy produced and the manner in which it was delivered Thus, a specific chromophore or target can be selectivelydestroyed with minimal thermal tissue damage when the laser wavelength matches that absorbedby the ABLATIVELASER SKIN RESURFACING chromophore and when the target is exposed to the laser Since the introduction of the high-energy,pulsed carbon energy for an interval shorter than its thermal reiaxation dioxide (COt and erbium:yttrium-aiuminum-garnet time (the time required for the target to cool to half its (Er:YAG) lasersin the mid 1990s, cutaneouslaser resur- peak temperature after laser irradiation) facing hasbecome an increasinglypopular method of facial Lasers designed based on the theory of selective skin rejuvenation. These ablative lasers enable the treat- photothermolysis are more specific and have a lower risk ment of photodamaged facial skin, specifically photo- profile in terms of scarring;however, they have their own induced facial rhytides, lentigines, and dermal elastosis. unique side effect profiles. Depending upon the wave- Although reported rates of serious complications assoct- length and puise durations delivered, dyspigmentation, ated with the use of these systemsare iow, adversereac- epidermal cell injury, textural changes,as well as crustrng tlons can occur even rn the hands of experienced laser and tissue splatter potentially can occur. It is important surgeons. Fortunately, most adverse reactions are tran- to remember that even the safestof laserscan causeinjury sient and, if detected early, are amenable to treatment if used inappropriately Application of stacked pulses,use without permanent sequelae.All iaser surgeonsshould be of excessive energy or power settings, and improper familiar with the signsof an impending problem and cog- patient selection potentially can result in a high rate of nizant of appropriate remedies when such a reaction does morbidity with any laser system. OCCUT The frequency and severity of adverse reactions asso- lasers depends on PATIENTSELECTION ciated with cutaneous resurfacing multiple factors, including the type of laser system being Becauseof the varied side effects and complications pos- used. Early laser technology consisted soiely of CW sible after cutaneouslaser surgery,it is essentialthat each laser systemsfor resurfacing,which were associatedwith Lasersand Lights Volume ll unacceptably high rates of scarring and permanent pig- CO2) laser systems.The single-passCO2 laser technique mentary alterations due to prolonged tissue exposure to involves application of a single set of non-overlapping laser energy. The newer COz and Er:YAG systemswere scans to the skin The partially desiccated tissue is left developed taking into account the principles of selective intact to serve as a biologic wound dressing.At standard photothermolysis, so that high laser energies and short treatment parameters,this method ablatesthe entire epi- pulse durations best effected tissue ablation with minimal dermis The modulated Er:YAG laser systemsemit light thermal injury of residual skin. with extended pulse durations [up to 500 ps) producing Other factors affecting the risk of adverse reactions larger zonesof thermal damagecompared with traditional with laser resurfacing include the number of laser passes short-pulsedEr:YAG lasersystems. In addition, increased performed, the energy densitiesused, the degree of pulse thermal coagulationof dermal vesselsis effected, permit- or scan overlap, the skin type and pretreatment condition ting deeper tissue penetration and improved intraopera- of the individual patient, the anatomic location to be tive field vrsualization. These larger zones of collateral resurfaced, and the individual expertise of the iaser tissue damage resuit in beneficial tissue effects that surgeon. True adverse reactions, however, are rare and approximate those of the CO2 laser The use of these must be differentiated from the normal Dost-trearmenr newer methods are associatedwith shorter and lesssevere morbidity that all patients experience after ablative laser erythema, edema, and postinflammatory hyperpigmenta- skin resurfacing,including erythema, edema, crusting, and tion compared with traditional, multiple-pass CO2 laser serous discharge skin resurfacing. A meticulous postoperativewound care regimen is the proper o Normalhealing process best measureto ensure healingand rapid resolution of symptoms during the recovery process.Two different After cutaneous laser resurfacing, all patients experience recovery regimens are availableto patients after resurfac- some degree of immediate post-treatment morbidity ing: the open and closed wound dressingtechniques. The Becauselaser ablation involves complete epidermal vapor- open technique involvesthe liberal application of a healing ization and upper papillary dermal destruction and re- ointment or plain petrolatum with cool wet compresses modeling, the most common immediate post-treatment every 2-3 hours for the first severaldays after the proce- reactions include intense erythema, edema, and copious dure. The open technique is labor intensive and may be serous discharge that persist until re-epithelialization is associatedwith increased patient discomfort but allows complete If a pulsed CO2 laseris used to deliver multiple excellent visibility of the resurfacedskin and permits early passesto the skin, re-epithelialization is complete in an detection of untoward side effects. The closed technioue averageof 7-9 days, compared with 4-5 days after short- involves the placement of a semiocclusive biosynthetic pulsed Er:YAG laser treatment The degree of erythema dressingover the irradiated skin in an attempt to decrease correlates directly with the number of laser passesdeliv- patient discomfort and speed re-epithelialization by ered due to the increasingdepth of penetration and degree limiting crusting The closed system is relatively easy for of residual thermal injury The pulsed CO2 laser ablates patients to use and so has greater compliance. However, tissue to a depth of 20-60 pm with each consecutivepass if wound dressingsare left in place for extended periods and produces zones of thermal damage ranging from 20 of time, potentially higher rates of infection may occur. to I 50 pm after a typical skin resurfacingprocedure, com- In addition, the use of semiocclusivedressings may con- pared with 20-50 pm of residualthermal damagewith the tribute to wound maceration and, if opaque,render direct short-pulsed Er:YAG laser Therefore, patients treated visualization of the resurfaced skin difficult. Some laser with a traditional multiple-passCO2 lasertechnique expe- surgeons are now using a combined open and closed rience more persistent and intense erythema, especiallyin wound care approach to maximize postoperative healing. the immediate postoperative period Maximum intensity The closed technique is used for the first 2 days post erythema after CO2 laser resurfacing occurs 8-0 days procedure when the edema, serousdrainage, and discom- postoperatively and lasts an averageof 3-6 months/ comfort are greatest, followed by an open technique for the pared with 2-4 weeks for short-pulsed Er:YAG laser remainder of the recovery period until re-epithelialization treated patients. Edema is another normal consequenceof is completed. Proper pretreatment education and close cutaneouslaser treatment and is most Dronouncedon the physician follow-up, in addition to a carefully executed second and third postoperative days with either laser. home recovery regimen, ensuresminimal post-treatment Application of cool compresses and ice alleviates the morbidity and allows for complicationsto be detected and edema, which resolvesafter severaldays. addressedexpeditiously. Newer trends in ablativefacial resurfacing have emerged that offer modest clinical improvement in rhvtides and . atrophic facial scarswith reduied postoperativemorbidity Complicationsof cutaneous and shorter recovery times than traditional, multi-pass laserresurfacing CO2 laser skin resurfacing. Less aggressivetechnrques Complications of cutaneous laser resurfacing can be cat- include single-passCO2 laser ablation and use of modu- egorizedaccording to severity (TabteZ.r) Mild side effects lated fvariable-pulsed Er:YAG or combined Er:YAG/ or complications include prolonged erythema and edema, Complicationsin Laser and Light Surgery

MiId Prolongederythema Acneand milia{ormation Allergic/irritantcontact dermatitis Petechiae Prurilus Moderate HSV reactivation Superficial cutaneous infection Post-inflammatory hyperpigmentation Delayed-onsethypopigmentation Severe Hypertrophicscarring Ectropionformation Disseminatedinfection

Fig.7.1 Erythemais an expectedconsequence of ablative CO, or Er:YAG laser skin resurfacing, but has a tendencylo be more acne or milia formation, irritant or allergic contact derma- prolongedin patientsafter multiple-pass CO, laser procedures. No titis, and persistent pruritus. Moderate complications specifictreatment is generallyindicated include reactivation of HSV, superficialbacterial or fungal infection, transient post-inflammatory hyperpigmentation, and permanent, delayed-onset hypopigmentation. The most serious complications of laser skin resurfacing healing and therefore should not be prescribed with the are rare and include hypertrophic scarring, ectropion intention of speeding resolution of erythema. However, formation, and disseminatedinfections. The risk of these focal areas of erythema with induration and tenderness untoward side effects are significantly reduced when may herald incipient scar formation and should be appropriatepretreatment patient selectionis made, proper promptly and aggressivelytreated with potent [class I) surgical technique is used, and when the post-treatment topical corticosteroid preparations or pulsed dye laser recovery period occurs under optimal healing conditions. irradiation

PROLONGEDERYTHEMA ACNEAND MILIA Post-treatment erythema is an expected consequenceof Acne flares and milia formation are relatively common laser skin resurfacing and occurs in every patient after side effects of cutaneous laser resurfacing due to the use treatment (Fig. Z.t). Erythema is most intense after CO2 of occlusive healing ointments and biosynthetic dressings laser resurfacing and may persist for 6 months or longer. during the acute recovery process. Aberrant follicular Short-pulsed, Er:YAG laser-inducederythema is usually epithelialization during healing may also contribute to less severe and of shorter duration, lasting severalweeks acne exacerbation within I to 2 weeks postoperatively. on average.The risk of prolonged erythema is increased Patients with a prior history of acne are at particular risk when multiple laserpasses or inadvertent stackingor over- of its development after resurfacing. lapping of laser pulses are performed, producing greater Acne has been reported to occur in as many as 800/o depths of tissue injury. It has also been proposed that of patients and milia in upwards of 140/owho undergo aggressivedebridement of the skin to remove partially laser skin resurfacing.Treatment is usually not necessary desiccated tissue during surgery may also contribute to for mild flares since spontaneousresolution is commonly excessiveerythema Postoperative wound infection and observed once use of the occlusive ointments and dress- dermatitis irritate the skin and may also result in persis- inss are discontinued Short courses of oral antibiotics tent erythema. Patients who have acne rosaceaor who ,rrih tetracycline or minocycline may be necessaryfor "r regularly use topical tretinoin prior to resurfacingmay be moderate-to-severeacne flares especiallyin patients with predisposedto intensified erythema. a strong acne predisposition. Once the skin has re-epithe- Topical ascorbic acid has been shown to decreasethe lialized, topical antibiotics (e.g., erythromycin, clindamy- severity and duration of postoperativeerythema. It is best cin) can be used without fear of allergic or irritant contact applied when re-epithelialization has been completed in dermatitis Milia typically resolve spontaneously during order to avoid irritation of the denuded skin surface, continuation of the re-epithelialization process, but can which could further aggravate the erythema. Application also be remedied with topical application of retinoic acid of topical corticosteroids will not reduce normal post- or manual extraction. Intralesional corticosteroids may be operative erythema and could potentially retard wound necessaryfor the rare inflamed cyst Lasersand Lights Volume ll

CONTACTDERMATITIS INFECTIO N Contact dermatitis after cutaneous laser resurfacing can Viral, bacterial, and fungal infections may complicate any occur in over 50(/oof patients and is usually irritant in ablative laser resurfacingprocedure with development of nature (Fig.7.2) Becauseof the de-epithelialized state of signs and symptoms during the first postoperative week newiy resurfaced skin, the normal protective epidermal before re-epithelialization is complete (Fig. 7.3). These barrier is impaired, rendering the skin more susceptibleto infections must be promptly identified and treated so as irritation. An allergic or irritant reaction to fragrances to avoid scarring, delayed wound healing, infection with or allergens contained within a wide variety of topical other opportunistic pathogens,or dissemination Reactiva- ointments, soaps,moisturizers, or cosmeticsmay develop tion of HSV is the most frequently occurring infectious Topical antibiotics (e g., Neosporin, Polysporin, or baci- sequelaof cutaneouslaser resurfacing. Because of the high tracin) are the most common offending agentsso their use rate of asymptomatic carriersof HSV infection, al1patients should be avoided during the re-epithelialization process. must be assumed to be carriers of the virus. Therefore, It is also imperative that patients refrain from application any patient, regardlessof prior HSV history, planning to of self-prescribed remedies during recovery since many undergo fu1l-face or perioral resurfacing should receive 'natural' herbal or other compounds may exacerbateirrita- prophylactic oral antiviral therapy. Despite adequateanti- tion and contribute to postoperative morbidity. viral prophylaxis, 2-70/oof laser-treated patients experi- Signsand symptoms suggestiveof an irritant or allergic ence HSV reactivation. contact dermatitis include diffuse and intense facial ery- Detection of a postoperativeherpetic infection may be thema and/or pruritus. The eczematouseruptions observed difficult becauseof the lack of intact eoithelium \\4rereas are not usually the result of a true type IV allergic reac- a herpetic infection on normal skin typically presents as tion, as patch tests fail to reveal allergy in the majority of intact vesicopustuleson an erythematous base, an out- cases.Since most reactionsare ofthe irritant variety, only break on laser-treatedskin may only appear as superficial the sole use of bland, non-fragrance-containingemollients erosions(FiS.l.d There may alsobe associatedsymptoms is necessaryduring recovery. \44ien an allergic or irritant of pruritus or dysesthesiawith delayed re-epithelializa- contact dermatitis is suspected, all potential inciting tion. Since dissemination of the herpes virus may result agentsmust be immediately discontinued Although most in atrophic scarring, suspected HSV infection shouid be reactionswill clear once the offending agentsare removed, treated aggressivelywith an appropriate antiviral agent. the use of strong corticosteroids and oral antihistamines Oral antiviral agents (e.g , acyclovir, famciclovir, vala- may speedthe resolution of the dermatitis and reduce the cyclovir) should be initiated l-2 days prior to the resur- risk of scarring. In severe cases,oral corticosteroids can facing procedure and continued for another 7-10 days be prescribed to decrease the inflammatory response until re-epithelialization is complete If a herpetic out- Frequent application of cool compressescan also alleviate break occurs despite adequate prophylaxis, drug dosages prurltus should be increasedto maximum zoster levels or a chanse

Fig. 7.2 Contactdermatitis is a relativelycommon side effectof laser skin resurfacingbecause of the impairmentof the protective epidermalbarrier that occurswith skin ablation Topicalantibiotics and other irritantsshould be avoidedin the immediatepostoperative perioduntil re-epithelializationis completed Oral antihistaminesand Fig. 7.3 Excessivecrusting, discharge, and slow wound healingare applicationof cool compressesand topicalcorticosteroids speed its signsof infectionAppropriate bacterial, viral, and fungalcultures resolutionand reducethe risk of scarrinoin severecases shouldbe obtainedprior to olacementon oral antibiotics 103 Complicationsin Laser and Light Surgery to a different antiviral should be made, as viral resistance sensitivitiesare obtained. Although antibiotic prophyiaxis to the initially prescribed drug may have occurred. For the remains standard practice for those patients at increased rare case of herpetic dissemination, intravenous ad- risk of infection [e.g., immunosuppression, mitral va]ve ministration of acyclovir with hospitalization becomes prolapse with regurgitation, valvular heart disease), its necessary routine use is controversial, with large scale prospective Superficial cutaneous bacterial and fungal infections and controlled studies indicated to determine if anti- may also complicate recovery from cutaneouslaser resur- microbial coverageis warranted in all patients. facing Bacterial infections are often due to excessive wound occlusion during the initial postoperativerecovery ALTERATION period and therefore are more commonly seen when a PIGMENTARY closed wound technique is used. The moist environment Transient postinflammatory hyperpigmentation is one of of newly resurfaced skin provides an ideal medium for the most common complications of cutaneouslaser resur- overgrowth of opportunistic pathogens Staphylococcus facing occurring in one third of all treated patients regard- aureus and Pseudomonas aeruginosa are the most com- less of skin tone (Fig. Z.S). Individuals with darker skin monly isolated bacteria whereas Candida albicans is the phototypes fFitzpatrick IV-VI) almost universally hyper- most commonly isolated fungus, although many wounds pigment after cutaneousablative resurfacingand must be havemultiple contaminatingorganisms on culture. Patients warned of this reaction prior to the procedure Hyper- with nasalcolonization of staphylococcimay be more sus- pigmentation usually develops 3-4 weeks postoperatively ceptible to infection; however, it has not been proven that and can persist for severalmonths without intervention. prophylactic topical antibiotic ointment decreasesthis Nthough postinflammatory hyperpigmentation following risk. variable-pulsed Er: YAG laser skin resurfacing can last Signs and symptoms of an acute bacterial process longer than that seen after treatment with a short-pulsed include focal areas of increased erythema, purulent dis- Er: YAG laser,it is not as persistent asthat observedafter charge, pain, delayed healing, and erosionswith crusting. multiple-passCO2 laserskin resurfacing(average: variable- A meticulous postoperativewound care regimen is essen- pulsed Er:YAG laser,10.4 weeks; CO2 laser,l6 weeks). tial to decreasethe risk of bacterial infection. Patients Becausethe cutaneousdyspigmentation is so conspicuous, should be advised to wash their hands with antibacterial most patients seek treatment to hasten its resolution. soapbefore dressingor ointment application. Washcloths Treatment options for hyperpigmentation include topical and other linens should not be reused during the recovery bleaching agents [hydroquinone, kojic acid), retinoic, process Frequent dressingchanges and dilute acetic acid azelaic,ascorbic, and glycolic acid compounds, as well as compressesare additional measuresthat keep the wound broad-spectrum sunscreensto prevent further ultraviolet clean and free of infection If an infection is suspected, light-induced melanin synthesis.Mild glycolic acid peels patients should be given broad-spectrum antibiotics [e g., (30-40%J may also hasten pigment resolution and can be semisynthetic penicillins or first generation cephalospo- reoeated at 2-4 week intervals for more efficient results rins) until results of bacterial cultures with antibiotic (FiS 2.6). Since any of these topical remedies has the

Fig. 7.4 Erosions,ralher than vesicopustules,indicate HSV Fig. 7.5 Postinflammatoryhypopigmentation is most commonin infectionin laser-treated(de-epithelialized) skin Aggressive patientswith darkerskin tones and is initiallyobserved 3-4 weeks treatmentwith high-doseoral antiviralagents should be initiated afterlaser skin resudacinglt occurswith equalfrequency in patients and continuedfor 7-'10 days (untilre-epithelialization has been treatedwith COzor Er:YAG lasers,bul tendsto persistlonger after achieved) CO, laserand/or multiple-pass procedures 704 Lasersand Lights Volume ll

Fig.7.7 Hypopigmentationbecomes more apparent as postoperative erythemaJades, olten taking several months to observelt is relatedto increasedthermal injury to skinduring laser trealment, destructiveprior procedures (such as phenolpeels or dermabrasion), or incompletetreatment within a cosmeticunit (relative hypopigmentation )

Although many laser surgeonsrecommend pretreating patients with topical bleaching agentsand retinoic or glycolic acid compounds prior to cutaneouslaser resurfacing, no studies to date have demonstrated any reduction in the rate of postinflammatory hyperpigmentation with this practice In fact, a prospective study that examined the effects of application of either glycolic acid, hydroquinone with tretinoin, or no treatment at all in 100 patients prior to CO2 laser resurfacing showed equivocal incidence of postinflammatory hyperpigmentation Fig. 7.6 Dailyuse of topicalbleaching agents and in-officeglycolic between the three groups, giving further evidence that acid (30-40%)peels at 2- to 4-weekintervals hasten resolution of pretreatment is unnecessary. Topical agents primarily postinflammatoryhyperpigmentation Hyperpigmentation observed exert their effects on the superficial epithelium and do 1 monthafter laserskin resurfacing(A) was effectivelycleared after not reach the deeply situated melanocyteslocated within a seriesof glycolicacid peels (B). hair follic1es or adnexai structures that potentiate the hyperpigmentation. Hypopigmentation is an uncommon complication of cutaneouslaser resurfacing and does not usually manifest potential to irritate the skin and thus further contribute until 6-12 months after the procedure Once residual to the abnormal pigmentation, their use should be avoided erythema and hyperpigmentation have faded, conspicuous during the first postoperative month. skin lightening becomesmore apparent (FiS.l.) The risk Careful preoperative screening is necessaryto deter- of hypopigmentation post resurfacing appears to be mine which patients are at greatest risk of developing directly related to the depth of penetration and degree of hyperpigmentation after laser resurfacing Patients should thermal injury imparted on the tissue. True hypopigmen- regularly use sunscreenswith a sun protection factor of tation is rare; most cases of skin lightening represent 'relative 15 or higher for a minimum of 4 weeks preoperatively in hypopigmentation' due to the removal of photo- preparation for the procedure. Patients with a suntan damaged skin (appearing paler than that of adjacent should not be resurfaced since they have a much higher nontreated dyspigmented skinJ. In order to reduce the risk of postoperative hyperpigmentation due to stimula- appearance of postoperative hypopigmentation, it is tion of their melanocytes It is also important for patients important to treat within appropriate cosmetic units to get into the practice of reguiar sunscreenuse prior to \Arhenmore than one facial arearequires treatment/ it may laser resurfacing since it will be necessaryto limit their be best to resurface the entire face in order to minimize ultraviolet exposure postoperatively Daily sunscreenuse obvious lines of demarcation. True hypopigmentation is alsobecomes important so that the benefits obtained with more common in patients who have had previous derm- the laser procedure can be maintained. abrasionor phenol peeling, as fibrosis from the prior pro- 105 Complicationsin Laser and Light Surgery ceduresmay become unmasked.Treatment for relative or scars (Fig. 2.9) Numerous reports in the literature have true hypopigmentation involves the use of chemical peels demonstrated its ability to improve scar color, pliability, (glycolic acid or trichloroacetic acid) to help blend lines texture, and bulk. Pulsed dye laserirradiation of scarsalso of demarcation. The application of topical methoxsalen alleviatesassociated symptoms of pruritus or dysesthesia (Oxsoralen) and limited exposure of the skin to ultra- Treatment sessionsare repeated at 6-8 week intervals violet light has also been used to induce melanogenesisin with laser parameters similar to those used for benign these areas. vascularlesions.

HYPERTROPHICSCARRING ECTROPIONFORMATION Hypertrophic scarring and textural changesare rare but Ectropion of the eyelids is another potentially serious serious complications of cutaneous laser resurfacing and, complication following cutaneous laser resurfacing,often although there are individual differences with respect to requiring surgicalcorrection (Fig.Z.ro). Patients who have scar propensity, most scars seen after laser resurfacing undergoneprevious lower blepharoplastyor other surgical appearto be a result ofpoor intraoperativetechnique. The manipulation of the eyelids are at increased risk. A pre- 'snap' use of excessivelyhigh energy densities, stacking or over- operative evaluation of each patient with a manual lapping of pulsesor scans,or failing to completely remove test of the lower eyelid should be performed in order to desiccated tissue between laser passesare known causes determine their risk of lid eversion \4/hi1e application of of excessiveresidual thermal necrosisin treated tissuethat lower energy densities and fewer laser passesare advo- may eventuate in scar formation. Patientswho experrence cated for infraorbital treatment in order to reduce the risk postoperative wound infection or contact dermatitis or of scar formatron and/or potential compromise of the those with a history of radiation therapy, isotretinoin use within the previous 6 months, or keloid tendency are also at increased risk of scarring Additionally, certain anatomic locations are more prone to scarformation including the mandible, neck, and periorbital areas and should, therefore, be treated conservatively with fewer laser passes(Fig.7.8). Focal areasof increasederythema or induration are the first signs of impending scar formation. The skin may be tender in these locations and the prompt initiation of treatment is warranted. Application of potent topical corticosteroids or siliconegel products, aswell asintralesional corticosteroid injections, can halt or slow scarprogression. A vascular-specific585-nm pulsed dye laser (PDLJ can also be used to treat erythematous and hypertrophic

Fig. 7.9 Pulseddye laser(585 nm) irradiationcan be appliedat 6- to 8-weekintervals to improvescar color,pliabilility, texture, and bulk. Fig. 7.8 The mandibularand neck regionsare more proneto scarring Hypertrophicscarring, while rare afterlaser skin resurfacing,is seen and should,therefore, be carefullytreated. Multiple laser passes and as earlyas 1 monthpostoperatively (A). Significantimprovement atter excessivefluences should be avoidedin these areas lwo sessionsusing a 585 nm PDL systemis typical(B) 106 Lasersand Lights Volume ll

Fig. 7.10 Patientswho have had prioreyelid surgery or thosewith Fig. 7.11 [/ild transienterythema and edemais typicalafter limitedpreoperative infraorbital skin elasticityare panicularlyprone to nonablativelaser skin lreatment ectropionformation after periocular ablative laser skin resudacinq

eyelid margin, it is important to also observe laser-tissue following abiative laser skin proceduresand may be attrib- interaction intraoperatively, in order to detect excesslve uted to excessivecryogen cooling of the epidermis during collagencontraction that could potentiate lid eversron. treatment Becausereactivation of HSV is possible with perioral nonablative laser treatment, propiylactic oral antiviral medication is appropriate for patients with a NONABLATIVESKIN RESURFACING strong history of herpes labialis Atrophic, pitted scarsdue to nonablative laser skin resurfacing are rare and can be To address the limitations associatedwith ablative laser minimized by proper functioning of the equipment (par- skin resurfacing, nonablative laser systems for rhytides, ticularly the epidermal cooling deviceJ and the careful atrophic scars,and acne vulgaris with minimal morbidity placement of non-overlappinglaser pulses and recovery time were developed.Most current nonablative laser systemsemit light within the infrared portion of the electromagnetic (1000-1500 spectrum nm). At these FRACTIONALPHOTOTH ERMOLYSIS wavelengths, absorption by superficial water-containing tissue is relatively weak, thereby effecting deeper tissue A novel skin resurfacingtechnique termed fractional pho- penetration. Nonablative laser skin resurfacing induces tothermolysis was developed in 2003 to addressthe limi- collagen remodeling by creation of a dermal wound tations of currently availablephotorejuvenation lasersand without disruption of the epidermis. Contact and dynamic light sources.Although dramatic clinical improvement can cooling devicesare used simultaneouslywith laser irradia- be achieved with ablative laser resurfacing, patients are tion to ensure epidermal preservation.Although nonabla- often hesitant to pursue this treatment option becauseof tive lasersare not capableof results comparablewith those the extended postoperative recovery period and inherent of ablativelaser systems, they havebeen shown to improve risks of the procedure. On the other hand, nonablative mild-to-moderate atrophic scars, rhytides, and acne vul, mid-infrared laser and light sources have demonstrated gariswith virtually no external wound Therefore, nonab- modest efficacy in the noninvasivetreatment of mild facial lative laserresurfacing is ideal for patients with either mild rhytides and atrophic scarring with minimal side effects cutaneous pathology, or in those who are unwilling or However, disadvantagesof these nonablative procedures unable to undergo a labor-intensive procedure associated include the necessity for multiple treatments, delayed with considerablepostoperative morbidity such asablative clinical response,and inconsistent clinical results. laser skin resurfacing Fractional photothermolysis is based on the creation of Becauseof the minimal postoperativerecovery and few microscopic thermal wounds with sparing of the sur- associatedside-effects, nonablative laser skin resurfacing rounding tissue. Fractional resurfacingis performed using is an attractive procedure to patients and physiciansalike a 1550-nm fiber laser (Fraxel, Reliant Technologies,CA) The most common side-effectsof treatment include oost- to photocoagulatenarrow columns of tissue (microscopic operative erythema and mild edema, typically lasting less thermal zonesor MTZs) in the epidermis and dermis with than 24 hours (Fig. 7.rr). Transient postinflammatory a depth of 200-500 pm at interuals of approximately hyperpigmentation is observed far less commonlv than 200-300 pm. The depth of penetration of each MTZ is 707 Complicationsin Laser and Light Surgery energy dependent and can be tailored to the characteristics of the treatment area (i e, facial vs nonfacial skin). Exfoiiation of microscopic epidermal necrotic debris (MEND], occurs over several days following treatment, giving the treated skin a bronzed appearance.The wound healingresponse differs from that seenwith ablativetech- niques because the spared epidermal tissue present between treatment zones contains viable transient amplifying cells capable of rapid re-epithelialization. Further- more, since the stratum corneum has nominal water content, rt remains intact immediately after treatment Therefore, the wound created by fractional resurfacrngis unique; this is not simply an ablative laser used to make 'holes' in the skin. In addition, fractional resurfacing can provide an advantageover purely nonablative laser treatments due to the gradualexfoliation of the epidermis with resultant improvement in superficial dyspigmentation. Becauseonly a fraction of the skin is affected during one session, several fractional resurfacing treatments are required to yield the best clinical improvement Investigatorshave shown fractional skin resurfacing to be safe and effective for a variety of indications Side effects of fractional lasertreatment are typically mild and include short-term erythema (average2-3 days), periocu- 1aredema, and a slight darkening of the skin (bronzing) as the MEND desquamate. Transient acneiform eruptions that resolveswithin 1-2 weeks are seen in up to 50/oof patients with a history of recent acne, but can be avoided when a short course of oral doxycycline is administered concomitant with further laser treatments. Erosions are uncommon and can be managed by liberal application of a petrolatum-based healing ointment and with cool water compressesevery 2-3 hours (Fig.7.rz) Aithough the incidence of postinflammatory hyperpigmentation is lower Fig-7.12 Aggressivefractional resurfacing techniques can resultin than that seen after ablative laser skin resurfacing,topical erosionsdue to the dense placementof microthermaltreatment zones bleaching agents and mild glycolic acid peels can hasten (A) Erosionscan be managedwith an open wound technique healingointment several its resoiution. Permanent pigmentary alteration and involvingapplication of cool compressesand timesdaily until re-epithelializationis complete (B) scarring have not yet been reported; however, the use of aggressivetreatment protocol with high MTZ density, increasesthe risk of complete epidermal ablation, along with the associatedside effects and complications of an ablative laser process has been used in the past for a variety of vascularlesions, severalhistologic studies have shown that the tissue effect VASCULAR-SPECI FIC LASERS of the argon laser is due to nonspecific thermal injury resulting from exposure intervals exceeding the thermal Vascular-specific laser systems target intravascular oxy- relaxation time of the vessels.Consequently, the risk of hemoglobin in order to effect destruction of varrous scarringand dyspigmentationis increasedand is the reason congenital and acquired vascularlesions Lasersand light that the argon laser is no longer in common use sources that have been used to treat vascular lesions Quasi-continuoussystems such as the APTD, krypton, include the argon (488/514 nm), argon-pumped tunable copper vapor/bromide, and KTP lasersare CW lasersthat dye IAPTD, 577/585nm), potassium-titanyl-phosphate can be mechanicaliy shuttered to deliver puises as short (KTP, 532 nm), krypton (568 nm), copper vapor/bromide as 20 ns to treat facial telangiectasias However, their 'quasi-CW' [578 nm), pulsed dye laser (PDL, 585-595 nm), and nature is often associatedwith higher risk of neodymium; yttrium-aluminum-garnet [Nd:YAG, hypertrophic scarring and textural changesthan ts seen 532/1064 nm) lasers and the intense pulsed hght (IPL) rvith pulsed laser systems. source(515-1200 nmJ. KTP lasersemit light at 532 nm and are used to treat The argon laser emits a continuous blue-green beam a variety of vascular and pigmented lesions. As with the with wavelength peaks at 488 and 514 nm Although it argon-pumpedtunable dye laser,the KTP laser handpiece Lasersand Lights Volume ll

is used in a quasi-continuousmode at varying repetition dermal penetration is achieved. Lesions with smaller rates to trace individual blood vesselsor a scannercan be caliber vessels are best treated with low cutoff filters employed to facilitate faster treatment of large skin areas. (515 or 550 nm), while iesionswith largervessels respond Side effects are generallylimited to linear crusting of skin best to longer wavelengths(570 or 590nm). Because overlying treated blood vessels, transient pigmentary shorter wavelength light also interacts more readily with changes,and mild fibrosis,which usually improve without epidermal melanin, the lower cutoff filters should only be any specificintervention (Fig.Z.r:). Postoperativehypoprg- used for patients with fair skin phototypes. With longer mentation is a particular risk due to the 532-nm pigment- pulse durations, the IPL source can slowly heat more specific wavelength and so should be used cautiously in deeply located vessels/thus improving treatment efficacy patients with recent sun exposure or in those with natu- and decreasing the risk of postoperative purpura and rally darker skin tones. RoshanKetab 02l-66950639 hyperpigmentation. The PDL was developed specificallyfor the treatment Although sclerotherapyremains the cornerstoneof leg- of cutaneousvascular lesions employing the principles of vein treatment by most practitioners, it can be associated selectivephotothermoiysis. With its ability to target blood with side effects including ulceration, allergic reactions, vesselswith minimal risk of collateral thermal injury and and telangiectatic matting. As such, interest in the laser subsequentscar formation, it has proved to be the safest treatment of 1eg veins remains high Early attempts to vascular-specificlaser availableto date and is widely used treat leg veins with the argon, APTD, or CO2 lasershave to treat congenital and acquired vascular lesions in chil- been largely unsuccessful. Despite successin the treat- dren and adults, including port-wine stains and heman- ment of facial telangiectasia,the KTP and PDL are less giomas. The most common side effect of traditional effective in the treatment of leg veins and are hindered [0.45-1.5 ms) PDL treatment includes transient purpura by significant postoperative crusting and prolonged and dyspigmentation (FiS. lr+). Vesiculation, crusting, purpura, respectively. textural change,and scarringare rarely seen.Isolated cases Most recently, based upon a small but significant of hypertrophic and keloid scar development after PDL absorptionpeak of hemoglobin in the near-infraredportion irradiation have been reported in patients concomitantly of the electromagnetic spectrum, long-wavelengthpulsed taking isotretinoin or with application of excessiveenergy lasers have been used to treat moderately deep, larger densities and/or pulse overlapping. More recent pulsed caiiber spider and reticular veins. Since high fluences are dye lasers with longer wavelengths (590, 595, 600 nm) often necessaryto adequately damage the vessel, con- and pulse durations (up to 40 ms) retain their vascular- comitant cooling systemsare used to limit unwanted col- specificity, but produce little, if any, postoperative lateral thermal injury The long-pulsed alexandrite laser purpura. has been shown to improve large caliber reticular verns; The IPL source emits noncoherent lisht within the however, patients are subject to transient pigmentary 515-1200nm portion of the electromagneticspectrum alteration due to the pigment-specificity of the 755 nm and has been used successfully for a variety of vascular wavelength. Several clinical trials have demonstrated lesions Filters are used to eliminate shorter wavelengths, encouragingresults with long-pulsedNd : YAG (1064 nmJ thereby concentrating light energy so that improved lasertreatment of lower-extremity small to medium-sized

Fig. 7.13 Transienthyperpigmentation is often observedalong the Fig. 7.14 Shod-pulsed(0 45-1 5 ms) dye laserirradiation often courseof leg veinstreated with KTP or PDL lasers resultsin purpurathat persistsfor severaldays. The use of longer- pulsesystems (up to 40 ms) minimizesthe risk of this side ettect Complicationsin Laser and Light Surgery veins. In addition, Nd:YAG lasers with extended pulse durations have been deveioped to treat leg veins up to 3 mm in diameter Side effects are usually minimal and include purpura/ vesiculation, superficial thrombosis, transient hyperpigmentation, and telangiectatic matting

PIGMENT-SPECI FIC LAsER5

Melanin-specific, high-energy, Q-switched (QS) laser systems can successfullylighten or eradicate a variety of benign epidermal and dermal pigmented iesrons and tattoos with minimal risk of untoward effects. Eoidermal lesions (solar lentigines, ephelides, caf6-au-lait macules, and seborrheic keratoses),dermal and mixed epidermal/ dermal lesions (melanocytic nevi, blue nevi, nevi of Ota/lto, infraorbital hyperpigmentation, drug-induced hyperpigmentation, Becker's nevi, and nevus spilus), and Fig. 7.15 Hypopigmentationmay occur more readilyin darker-skinned amateur, professional,and traumatic tattoos have all been patientswho receivepigmenfspecific laser treatment lt tends to shown to be amenableto lasertreatment. Utilizing Ander- resolvesoontaneouslv over time son and Parrish'sprinciples of selectivephotothermolysis, Q-switched laser systemsreplaced earlier CW lasers,due to their ability to induce thermal necrosis that remains largely confined to the melanosomeswith limited coagulative necrosis of surrounding structures, thus decreasing the risk of untoward side effects The continuous and quasi-CW laser systemsthat have been used for pigment and tattoo destruction include the 488/514nm argon,5ll nm copper vapor, 520nm krypton, 532 nm KTP, and 10,600nm CO2 lasers.These laserstypically emit light with pulse durations longer than the thermal relaxation time of a melanosome (l ms) and therefore may result in scarring or textural irregularities due to excessivethermal damage of surrounding tissue during laser irradiation Use of CW lasers is therefore generally reserved for removal of epidermal lesions srnce treatment of deeper, dermal lesions is often associated with significanttissue scarring.Treatment with a CW laser removes pigment by epidermal ablation and destruction of the epidermal-dermal junction. Potential postoperative Fig.7.16 Q-switched (QS) laser irradiation of ironor titaniumoxide tattooinks, commonly found in cosmetictattoos, can lead to tattooink sequelaeinclude persistent pigmentary erythema, altera- darkening.Surgical excision or CO2laser ablation is oftennecessary tion, and skin texture irregularities. to eliminatethe darkened pigment The ruby laser with a wavelength of 694 nm is used in the treatment of epidermal and dermal pigment. This laser operates in a Q-switched mode, which produces high-energy light in nanosecond pulses An ultrashort epidermal atrophy has been reported in as many as 500/o tissue dwell time is ideal for treating melanocytic lesions of patients following ruby irradiation; however, perma- and dermal pigment and minimizes the risk of unwanted nent textural changesor scarringoccur in fewer than 50/o collateral thermal damage However, during ruby laser of patients. treatment, side effects include tissue splatter, punctate Immediate and irreversible pigment darkening of cos- bleeding, edema, pruritus/ vesiculation, and purpura. metic tattoos (particularly white, pink, and flesh-colored Like all of the Q-switched pigment-specific lasers, the inks) has been reported after ruby laser irradiation, pre- ruby produces an immediate ash-white epidermal tissue sumably due to chemical reduction of the iron-containing response on impact. Becausenormal epidermal melanin tattoo pigment from ferric oxide to the ferrous oxide form rv\rhile may also absorb ruby light, transient hypopigmentation (FiS. l.t6) continued ruby laser treatment may may be seenin 25-500/oof patients (Fig.Z.tf). Postinflam- eventually fade the darkened pigment, results are not matory hyperpigmentation, hair whitening, and hair loss predictable and additional procedures such as surgical have also been observed in ruby laser-treated areas Skin excision or CO2 laser ablation may be necessaryfor its crusting commonly develops locally after treatment and effective elimination. Lasersand Lights VoLume ll

Fig, 7.17 Granulomatousallergic reactions and hypertrophicscarring can occurupon QS pigment-specificlaser irradiation of tattoosdue to Fig. 7.18 Hypopigmentationafter QS pigment-specificlaser treatment liberationof antigenicintracellular ink particlesTreatment with of tattoosis more oftenobserved in patientswith darkerskin tones, intralesionalcorticosteroids mav be reouired after multiolelreatmenl sessions. and/or with the use of hioh treatmentfluences

Type IV cutaneous allergic reactions to laser tattoo darkening of cosmetic, white, flesh-tone, and pink tattoos removal have also been reported. It is hypothesized that has been observed after laser treatment with any of the laser treatment liberates intracellular pigment into the QS systems,including the alexandrite laser. extracellular spacewhere it becomes antigenic Both gen- The QS Nd:YAG laser emits a wavelength of 1064 nm eralized and localized urticarial, pruritic, and eczematous with a pulse duration as short as l0 ns. It has been used reactions may develop and can be treated with oral or to effectively treat primarily dermal pigment such as blue mid-potency topical corticosteroids and oral antihista- and black tattoos, melanocytic nevi, and nevi of Ota and mines. Rarely, a granulomatousallergic reaction can occur Ito. An immediate ash-white tissue response occurs at with subsequent hypertrophic scar formation {FiS.1.til. laser treatment sites with a subsequent wheal-and-flare Intralesional steroid injections or occlusion/pressure reaction. Other significant side effects of QS Nd:YAG therapy can be used to reduce the bulky nature of such laser treatment include tissue splatter and bleeding, lesions without further worsening of the inciting allergic textural changes,hypo- and hyperpigmentation. Textural reactron. changesmay occur in up to 8% of patients but are gener- Like the ruby laser, the alexandrite laser also operates ally transient and are only evident when patients are by a Q-switched mechanism and emits red light [755 nm) examined earlier than 4-weeks post treatment. Hypopig- to effectively treat a variety of pigmented lesions and mentation may also develop after severaltreatments. tattoos. Hypo- and hyperpigmentation havebeen reported Generalized cutaneousallergic reactionsto tattoo laser following treatment with the alexandrite iaser. Upwards removal have been reported with this laser as well as with of 500/oof patients being treated for tattoos may expen- the ruby and alexandrite lasers.As describedwith the QS ence postoperative hypopigmentation for 3-6 months systems above, immediate and irreversible ink darkening Skin lightening tends to occur more commonly in darker of white, flesh-tone, and pink cosmetic tattoos can also skin types and is also related to the total number of laser occur with QS Nd:YAG irradiation. treatments, with an averageof seventreatments necessary The frequency-doubled QS Nd:YAG laser is utilized to induce significant hypopigmentation (Fig.7.r8). for the treatment of epidermal pigment as well as red, Punctate bleeding and tissue splatter may occur with orange,and yellow tattoos. By passing1064-nm Nd:YAG the alexandrite laser especially at high fluences but is light through a potassium diphosphate crystal, the fre- generally less common than that observed upon QS quency is doubled, producing a 532 nm wavelength. The Nd:YAG laser irradiation. Older faded tattoos tend to resultant green light targets epidermal pigment due to show a milder tissue response in terms of bleeding and its marked absorption by melanin. Complications experi- epidermal erosions. However, when tattoos (especially enced with this laser include transient erythema, which those of the distal lower extremitv) are treated with the may persist for up to 6 weeks and appearsto be fluence- alexandrite or any of the other QS i"r". systems,hemor- dependent, purpura for up to I week, pigmentary altera- rhagic bullae may form. Rarely, scarringand tissue fibrosis tion, textural changes, and blistering. Postinflammatory can occur with the alexandrite laser as a result of poor hyperpigmentation occurs in upwards of 80/oof patients wound management. Immediate irreversible pigment and occurs more often in patients with darker skin tones Complicationsin Laser and Light Surgery

Painand postoperative bleeding have been reported to be greaterwith the frequency-doubledNd:YAG than with the ruby laserand is more commonwith the useof higher fluences.

PHOTOEPII*ATION

Systems currently approved by the FDA for the reduction of hair include the long-pulsed [LP) ruby [694 nm), LP alexandrite (755 nm), LP diode [800 nmJ, QS and LP Nd:YAG (1064nm) lasers, and IPL (515-1200nm) sources. These systems are used most often for hair removal because they can target melanin in the hair shaft and follicle and penetrate to the appropriate dermal depth to effect selective follicular destruction. Although the goal of laser-assistedhair removal is per- Fig. 7.19 Patientswith tannedskin or with intrinsicallydarker skin manent follicular damage, there also is a risk of epidermal tones are proneto hypopigmentationafter long-pulsed(LP) pigment- injury during the hair removal process. Any melanin- specifichair removaltreatment. The use of a LP Nd:YAG laser containing structure, such as a melanocyte, keratinocyte, reducesthe risk of this side effect or nevus/ also may sustain thermal injury when irradiated by red and infrared light. Although hair shafts are often darker in color than the surrounding skin, partial absorption of applied laser energy may occur by epidermal chromophores. Methods to protect the epidermis during laser-assistedhair removal have included contact cooling tips, cryogen sprays,and topical application of cooling gel. Epidermal cooling serves to reduce the amount of superficial thermal injury sustained upon laser impact Despite all efforts to protect the epidermis from injury, photoepilation may result in clinically significant adverse reactions. Complications after photoepilation are influ- enced by skin type, body location, seasonalvariations, and patient history of recent sun exposure. The extremities tend to suffer the most side effects and sun-orotected areas,such as the axillary and inguinal regions, iuffer the least. Side effects of laser-assistedhair removal using LP lasersare usually minor and transient. The most common adverse reactions include pain during treatment, transient erythema, and perifollicular edema; however, vesicle Fig. 7.2OTransient hyperpigmentation after laser-assisted hair formation, pigmentary alteration, and scarring have also removalis also more commonin patientswith darkerskin. The use of been documented (Figs7.ry and 7.zo) Most of the latter highfluences and/or inadvertent sun exposureincreases the complications have occurred in individuals who are either likelihoodof ils occurrence tanned or have darker skin phototypes (SPT IV-VD after the use of a LP ruby, LP alexandrite, LP diode, or IPL source. Becausethe 1064-nm wavelength is less effi- ciently absorbed by endogenous melanin, significantly a susceptiblepatient, triggering hair induction rather than fewer incidences of blistering, crusting and dyspigmenta- follicular destruction. Although laser-induced paradoxical tion occur after treatment of oatients with darker or hair growth responds well to subsequent LP laser treat- tanned skin. ments at moderate-to-high fluences, all female patients Paradoxical hair growh is a rare side effect of photo- undergoing laser-assistedhair removal shouid be clearly epilation occurring in selected patient populations and informed of the possibility of hair induction. body areas.Hair induction occurs predominantly on the face and neck of women of Mediterranean ancestry with SUMMARY darker skin phototypes. The border of the treated area and the immediately adjacent untreated skin are most Modern lasers and hght-based sources that were devel- commonly affected. The phenomenon is observed more oped based on the theory of selective photothermolysis often when low (sub-threshold) fluences are delivered to are capable of destroying specific tissue targets while Lasersand Lights VoLume ll minimizing the risk of scarring and pigmentary changes. BoixedaP, Nunez M, PerezB, de las Heras ME, Hilara Y, Leda A This is accomplishedthrough the use of a wavelength and 1997 Complicationsof 585-nm pulseddye lasertherapy InternationalJournal of Dermatology36:393-397 pulse duration that is best absorbedby a specific chromo- Demas PN, BridenstineJB 1999 Diagnosisand treatment of phore such as melanin or hemoglobin However, not all postoperativecomplications after skin resurfacingJournal of lasersand light-sourcesadhere to this principle. CW lasers Oral and MaxillofacialSurgery 57:837-841 are least selective and tend to produce unwanted tissue FisherGH, GeronemusRG 2005 Short-term side effectsof damage and scarring through heat conduction to normal fractionalphotothermolysis Dermatologic Surgery 3 I :I 245- 1249 skin. Quasi-CW laserslimit excessivethermal destruction Fitzpatrick RE 2002 Maximizing benefits and minimizing risk with by delivery of a series of brief iaser pulses, but still pose COz laserresurfacing Dermatologic Clinics 20:777-786 a higher risk of nonspecific tissue damage and thermal Gilbert S, McBurney E 2000 Use of valacyclovirfor herpessimplex injury. The pulsed and QS systems adhere most closely virus-l (HSV-l) prophylaxisafter facialresurfacing: a to the principles of selective photothermolysis and result randomizedclinical trial of dosingregimes Dermatologic in the most selective destruction with the lowest risk of Surgery26:50 54 scarringand excessthermal diffusion Certainly, any laser Goldberg DJ (ed) 2004 Complicationsin cutaneouslaser surgery Taylor & Francis,London system potentially can result in scarringand tissue damage Kimming W 2003 Lasersurgery in dermatology,risk and chances when used incorrectly; therefore, adequate operator edu- Hautarzt 54:583-593 Availableonline: Epub May l5 2003 cation and ski1l are essential.Side effects and complica- KontoesP, \4achos S, KonstantinosM, AnastasiaL, Myrto S 2006 tions that occur as a conseouenceof laser treatment can Hair induction after laser-assistedhair removaland its be significantly reduced if diagnosed and treated in an treatment Journalof the AmericanAcademy of Dermatology expeditious manner. 54:64-67 Nanni CA, Alster TS 1998 Complicationsof carbondioxide laser resurfacingAn evaluationof 500 patients Dermatologic Surgery24:31 5-320 FURTHERREADING Nanni CA, Alster TS 1999 Laserassisted hair removal:side effects of Q-switchedNd:YAG, long pulsedruby, and alexandrite Alam M, Dover JS, Arndt KA 2003 Treatment of facialtelangiecta- lasers Journalof the AmericanAcademy of Dermatology siawith variable-pulsehigh-fluence pulsed-dye laser: comparison 41;165171 of efficacywith fluencesimmediately above and below the Olbricht SM, Stern RS, Tang SC, Noe JM, Arndt KA 1987 purpura threshold DermatologicSurgery 29:681-684 Complicationsof cutaneouslaser surgery A survey Archivesof Alam M, PantanowitzL, Hartron AM, Arndt KA, Dover JS 2003 A Dermatology 123:345-349 prospectivetrial of fungalcolonization after laserresurfacing of RaglandHP, McBurney E 1996 Complicationsof resurfacing the face:correlation between culture positivity and symptoms Seminarsin Cutaneous Medicine and Surgery 15:200-207 pruritus ol DermatologicSurgery 29:255-260 Rendon-PelleranoMI, Lentini J, EaglsteriWE, Kirsner RS, Hanft K, Alster TS 1999 Cutaneousresurfacing with CO2 and Erbium:YAG Pardo RI 1999 Laserresurfacing: usual and unusualcomplica- lasers:preoperative, intraoperative and postoperativeconsider- tion DermatologicSurgery 25:360-366 ations Plastic and ReconstructiveSurgery 103:619 632 SchwartzRH, BurnsAJ, Rohrich RJ, Barton FE Jr, Byrd HS 1999 Alster TS, FernandezEM, Tanzi EL2007 Side effects and Long-termassessment of CO2 faciallaser resurfacing: aesthetic complicationsof fractionallaser photothermolysis: experience resultsand complicationsPlastic and ReconstructiveSurgery s'ith 961 treatments DermatologicSurgery (in pressJ I 03:592-601 Alster TS, Lupton JR 2000 Treatment of complicationsof laserskin SwinehartJM 1991 Hypertrophic scarringresulting from flashlamp- resurfacingArchives of FacialPlastic Surgery 7:279-284 pumped pulseddye lasersurgery Journalof the American Alster TS, Lupton JR 2002 Preventionand treatment of side effects Academy of Dermatology25:845-846 and complicationsof cutaneouslaser resurfacing Plastic and Tanzi EL, Alster TS 2003 Side effects and complicationso{ ReconstructiveSurgery I 09:308-316 variable-pulsederbium:yttrium-aluminum garnet laser skin Alster TS, Nanni CA 1999 Famciclovirprophylaxis of herpes resurfacing:extended experience with 50 patients Plasticand simplex virus reactivationafter laserskin resurfacingDermato- ReconstructiveSurgery 1 I I :1524-1529 logic Surgery25:242-716 Tanzi EL, Alster TS 2003 Single-passCO2 vs multiple-passEr:YAG Alster TS, Tanzi EL, LazarusM 2007 The use of fractionallaser laserskin resurfacingA comparisonof postoperativewound photothermolysisfor the treatment of atrophic scars Dermato- healingand side effect rates DermatologicSurgery 29:80-84 logic Surgery33:295 299 Wanner M, Tanzi EL, Alster TS 2007 Fractionalphotothermolysis: BeesonWH, RacherJD 2002 Valacyclovirprophylaxis for herpes treatment of facialand non-facialcutaneous photodamage with simplexvirus infection or infection recurrencefollowing laser a I 550 nm erbium-dopedfiber laser DermatologicSurgery skin resurfacingDermatologic Surgery 28:331-336 33:23-28 lndex

Note:Index entries in bold referto informationin tablesor anesthesia,36 boxes;index entries in ttalrcsrefer to figures fractionalresurfacing, 36 on hypopigmentation,14-15 A ntensepulsed light, 52 abdomen,radiofrequency treatment, 70, Z7 aserresurfacing, B, 25 ablativeskin resurfacing, 1 20, 21 22,25-27,29-41 mid-infraredlasers, 52 contralndicationof nonablativeskin resurfacing, 45 nonablativeskin resurfacing, 51 seeaso carbondioxide laser resurfacing, erbium:YAG plasmaskin resurfacing, 37 38 lasers radiofrequencytreatment, 64 65 ABNOM(Hort's macules),73,75, 76, 83 anguaton, erbium aser handPiece, 22 Accentradiofrequency device, 56, 58, 64-65 animalstudtes, radiofrequency treatment, 58 body treatment,70 anodethermography, cellulite, 92 cellulite,62, 71,96 98 anthropometry,cel ulite,91 92 clinicalfindings, 62 antibiotics safety,69 acne,101 techniques,63, 64, 66, 68-69 aserresurfacing, 16, 17,80, 103 aceticac d (vinegar)after CO. aserresurfacirg. 10. 11, 17 anthlstamines, for pruritus,1B acne antiseptics,17 1450-nmdiode aserfor, 48 antiviralagents, 80, 102-103 fractionallaser treatment, 40, 107 Aramislaser, 47, 52 linhl-em l inn clinclcq 50 arcing,radiofrequency systems, 69, 70 postoperative,18, 101 argonlaser, 107 acnescarring, 1 artichoke,94 COzlaser skln resurfacing, 9 10 ascorblcacld see vitaminC deepscars, 1, 2 attractrveappearance, success and, 29 erblumlaser, 22 atypicalmycobacteria, 17 ethnc skin,74, BO Aura laser,45 fractlonalresurfacing Ior, 33, 34,35 see alsoisotretinoin acquiredbilatera nevus of Ota-likemacules (ABNON/), 73 B 75, 76, 83 bacterialinfection, 16, 103 adiposetissue, 88 90 Baker'sphenol peels, herpes s mplexvirus, 16 reduclionby ullrasound.85 betamethasone,l3 adversee[[ects see cornplications:s'de effects biopsy,ce lulite,92 Affrm fractionalresurfacing devrces, 30, 31-32 bipolarradiofrequency devices, 56, 57-58 evauation, 33 clincal f indings, 62 afterglow(Lewis-Raleigh), 32 ethnrcskin, 78

o r nnnJinn'9' vr'oihnin 'v cL in a? with,56, 62, 63 " infraredlasers alexandritelasers bladderwrack,94 long-pulsed,veins, 108 b anching,nonabiat ve skinresurfacing, 52 Q-switched bleachingagents ABNOIV,83 melasmatreatment, B2 withCOz laser resurfacing, 22 postnflammatory hyperpigmentation, 80, 85 pigmentedesions, 110 bleeding allergicreactions, tattoo treatment, I10 alexandritelaser, 1lO S-aminolevulinicacid, 50 erbium:YAGlaser resurfac ng, 26 techniques,53 blistering eminnnhrrllina ^o I rita O? fractionalresurfacing, 40 analgesra mid-infraredlasers, 48 laserresurfacing, 25 nonablatlveskin resurfacing, 52 plasmaskin resurfacing, 36 b ood flow,cellulite and, 90, 92 Index

bluedye, fractional resurfacing, 36-37 complications,99-1 12 removal,39-40 CO2laser resurfacing,13-20 body mass index,91 intensepulsed light, 49-50, 108 body treatment,Accent radiofrequency device, 70 from melanin,73 bruising,laser treatment of cellulite,96 radlofrequencyskjn tightening, 69-70 bulk heating compressionhandpieces, 83 ethnicskin, 75 computers,in radiofrequencydevices, 56 fractionalresurfacing, 40 conductivity(electrical), cellulite, 92 burns consultationform, CO, laserresurfacing, 7-B radiofrequencytreatment, 61 consultations,99 sunburnsee Fitzpatrickskin types ethnicpatients, 80 butcher'sbroom, 94 fractionalresurfacing, 34, 36 nonablativeskin resurfacing, 50-51 C contactcooling, ethnic skin, 83 cAMP,cellulite and, 93 glasswater chamber, lentigines treatment, 83 candidainfection, 10, 16 hairadhesion, 84, B5 capacitatively-coupledelectrodes, 56, 5Z contactdermatitis, 17-18, 102 CaptainLED device, 50 continuous-wavelasers, 99, 109 carbondioxide laser resurfacing, 1-2O,21-22 see alsoquasi-continuous laser systems complications,99-106 Contourerbium:YAG laser,25-27 disadvantages,29 coolinqsystems erbium:YAGlaser with, 82 1540-nmerbium:glass laser, 48 fractionalresurfacing ys, 33 ethnicskin, 83 technique,B-10 hairadhesion, 84, 85 cefuroxime,B0 fractionalresurfacing, 36, 75 cellulite,87-98 glasswater chamber, lentigines treatment, 83 Accentdevice, 62, 71 lasertreatment of cellulite,95 VelaSmoothdevice, 62, 71,95-96, 97 nonablativeskin resurfacing, 45, 52 Centellaasiatica,94 vascutarrasers, 75 cheeks,radiofrequency treatment, 61-62, 66-69 see alsocryogen epidermal cooling chemicalpeels, contraindication of nonablativeskin Cooltouchlaser, 47, 52 resurfacing,45 corticosteroidssee steroids chest cosmeticssee maKe_uo erbium:YAGlaser, 20 couplinggel, 53, 65 fractionalresurfacing, 34 Cox eye shields,9 chickenpoxscarring, erbium:YAG laser,22 crusting,80 chofitol,94 preventionin CO, laserresurfacing, 11 ciprofloxacin,16, 17 cryogenepidermal cooling circumference,thigh, 92 1450-nmdiode laser,48 classifications(grading schemes), 3, 60 ethnicskin, 83 'cliff-drop' acne scarring,t hyperpigmentation,45,77 clobetasol,20 radiofrequencydevices, 56 closedwound treatment, 10, 100 vascutarrasers, 75 CO2lasers see carbondioxide laser resurfacing cryoinjury,52 coagulativemode, Contour erbium:YAG laser, 25 cyclesof treatment,radiofrequency devices, 56-57 cold compresses,13 cyclicAMP, cellulite and, 93 colagen cynergylaser, 46 fractionalresurfacing, 34 Cynosure,Inc see Affirmfractional resurfacing devices mid-infraredlasers on, 48 pulseddye laserson, 45-46 D radrofrequencytreatment on, 58-59 dark circlesaround eyes, treatment, 22 ultravioletlight on, 43 dark complexion collimation,erbium:YAG laser, 26 lasertreatment, 73-86 combinationtreatments nonablativeskin resurfacing and, 44, 46,s1 dark complexion,83*84 radiofrequencyin combinationtreatments, 59-61 radiofrequencyin,59-61 darkening,tattoos, 109, i10 EMLA(anesthesia), 64 debris CombinedApex Pulsetechnology, 31 CO2laser skin resurfacing, 9, i3 communrcatton erbium:yAclaser skin resurfacing, neck,20_21 instructionsto patient,CO2 laser resurfacing, 11 see alsodesiccated skin; microscopic epidermal necrotic see alsoconsultation debris !1f

Index de-epithelialization,management, 40 endpoints,COz laser resurfacing, 12 deep scars,acne scarring,1, 2 energysettings, fractional resurfacing, 37 demarcation,lines of epidermis avoidance,1 1 neck,20 fractionalresurfacing and plasmaresurfacing, 35 postoperativepeeling, CO2 laser resurfacing, 10 ^^^ ^t^^ 4^^+L^,:^^ JUV drOV rVdU rEr il rV temperature,1320-nm Nd:YAG laser, 48 densitysettings, fractional resurfacing, 37 epilation depressions,from radiofrequencyskin tightening, 69, Z0 complications,111 dermabrasion,1 ethnicskin, 74, BO,82,84 hypopigmentation,104-1 05 erbium-dopedmid-infrared lasers, fractional resurfacing, 55 see alsomicrodermabrasion erbiumfiber lasers,diode pumped,1550-nm, 29 oermts erbium:glasslaser, 1540-nm, 48 fractionalthermolysis, 31 fractionalresurfacing, 83 nanillarv naak )A erbiumIasers, hypopigmentation and, 14 temperature.1320-nm Nd:YAG laser, 48 erbium:YAGlasers, 25-27 desiccatedskin complications,99-106 as dressing,40 dark complexion,82 see alsodebris fractionalresurfacing, 31, 37 dicloxacillin,COz laser resurfacing, 17 neck photodamage, 20-21 .liot nollr rlito and O? Q-switchedalexandrite laser with, 22 diode lasers erosions,fractional laser treatment, 107 145O-nm,48,77 erythema hairremoval, ethnic skin, 80 CO2laser resurfacing, 13-14, 100, 101 radiofrequencywith, 56 erbium:YAGlaser treatment, 26, 100,101 diodepumped erbium fiber lasers, 1550-nm, 29 intensepulsed light, 53, 83 Diolitelaser, 45 plasmaskin resurfacing, 40 dicennoarinn lin O EsteluxlPL, Quantum IPL vs,78 double-passhigh-energy plasma skin resurfacing, 33-34 estrogen,cellulite, 87-88 dressings ethnicskin COzlaser resurfacing, 10, 77 lasertreatment, 73-86 desiccatedskin as, 40 techniques,82-85 lacor rocr rrfaninn l Ofl 'sv" iv! t vv see alsodark comPlexion dualmode erbium:YAGlasers, 25-27 examination oye cellulite,91 in flashlamp-pumpedpulsed dye laser,45 for fractionalresurfacing, 34, 36 fractionalresurfacing, 36-37 excimerlaser, hypopigmentation and, 15 removal,39-40 exercise,cellulite and, 93 dyschromia eye(sJ grading,60 dark circlesaround, treatment, 22 see alsohyperpigmentation; hypopigmentation postoperativecare, 11 protection,8, 9, 51, 52, 53 E see alsoperiorbital areas ectropion,laser resurfacing, 18, 105-106 eyebrows eoema intensepulsed light on, 53 lasertreatment, 100 tift,61 plasmaskin resurfacing, 40 eyelids radiofrequencytreatment, 63, 69 COzlaser resurfacing, 10, 12 elasticity,skin, 92 complications,18, 79 elastosis ectropion,18,'105-106 1540-nmerbium:glass laser and, 48 erbium:YAGlaser resurfacing, 26 grading,3, 60 eye shields(Cox), 9 electricalconductivity, cellulite, 92 electrodes,radiofrequency devices, 56, 5Z F electromagneticspectrum, 44 famciclovir,prophylaxis, 17, B0 electronmicroscopy, radiofrequency treatment studies, 58 fast treatmenttips, radiofrequencytreatment, 58 EMLA(anesthetic cream), B fat see adiposetissue combinationtreatments, 64 feathering ^n r^^^--^^..*^^'^^ hypopigmentationand, 14-15 UV2 lqDvl lvJUr laulllV, 12_13 emollients,dermatltis from, 1B plasmaskin resurfacing, 39 emulsification,cellullte, ultrasound, 98 ferricoxide, tattoos, 109 Endermologie,94-95 filters,intense pulsed light, 49,77-78, 1OB 176 Index

Fitzpatrickskin types, 3 herbaltreatments, cellulite, 94 fractionalresurfacing vs plasmaresurfacing, 36 herpessimplex virus, 16-17, 102-103 patientselection for laser resurfacing, 4 fractionalresurfacing, 36 flashlamp-pumpedpulsed dye laser (FLPDL), 45-46 nonablativeskin resurfacing, 106 techniques,51-52 high-energytreatments, plasma skin resurfacing, 33-34 telangiectasia,81-82 analgesia,36 flowmetry(perfusion), cellulite, 92 vs low-energytreatments, 37 fluconazole,16, 17 histology,cellulite, 92 fluenceadjustment history-taking,36, 99 1320-nmNd:YAG laser, 48, 52 hormonetreatment, cellulite, 93-94 Contourerbium:YAG laser, 25 horsechestnut, 94 fluorouracil,scar treatment, 20 Hort'smacules (ABNOM), 73,75, 76, 83 forehead,radiofrequency treatment side-effects, 69 hydration,plasma skin resurfacing, 38 fractional resurfacing, 29-37 , 38,39-41, 55 hydroquinone,15-16, 27, 36 complications,106-107 hydroxyzine,64 ethnicskln, 73, 74, 75, 80, 82, 83 hyperpigmentation(PlH), 103-104 Fraxellasers (Reliant), 29-31 1450-nmdiode laser, 77 coolingsystems, 36 bleachingagents, 80, 85 evaluation,33 afterCOz laser resurfacing, 15-16, 20 heatbuildup avoidance, 39 cryogenepidermal cooling, 45, 77 protocols,38 erbium:YAGlaser resurfacing, 27 frequency-doubledneodymium:YAG Iaser, 1 10-1 1 j ethnicskin, 73,74,75, 84-85 full-blowncellulite, 87 Fitzpatrlckskin types, 4 fungallnfections, 10, 16 fractionalresurfacing, prevention, 36 hairremoval, 111 G mid-infraredlasers, 48 Galaxyradiofrequency device, 56, 57-58 nonablativeskin resurfacing, 44, 52, 106 adverseevents, 69-70 topicalpreparations and, 15, 103-104 clinicalfindings, 62 hypoplgmentation,104-1 05 safety,69 1450-nmdiode laser, 48 techniques,63, 64, 66, 68 alexandritelaser, 110 gelcooling, 83 COzlaser, 14-15 gender,cellulite, 87-88 erbium:YAGlaser resurfacing, 27 ginkgo,94 ethnicskin, 75 glasswater chamber, lentigines treatment, 83 hairremoval, 111 glycolicacid, 51, 85, 103 KTPlaser, 108 gradingschemes, 3, 60 nonablativeskin resurfacing, 51, 52 granulomatousallergic reactions, tattoo treatment, 110 rubylaser, 109 grapes,94 groundivy, 94 I icepacks,83 H impedancemonitoring, ThermaCool radiofrequency device, hair 69 adhesionto coolingsystems, 84, 85 incipientcellulite, 87 intensepulsed light on, 53 indentatlons,from radiofrequency skin tightening, 69, Z0 paradoxicalgrowth, 1 1 1 Indianchestnut, 94 removal infection,10, 16-17, 102-103 complications,111 pruritus,18 ethnicskin, 74, 80, 82, 84 information(instructions to patient),CO2 laser resurfacing, handpieces 11 1320-nm Nd:YAG laser, 47-48 infrareddevices thermalsensor, 48, 52 fractionalthermolysis, 31 forcompression, 83 TiIan,71-72 radiofrequencydevices, 56 Velasmooth,58 STRefirme, 58 infraredlasers hands,fractional resurfacing, 34 bipolarradiofrequency devices with, 56, 62, 63 HarmonyPixel resurfacing devices, 30, 32 see also mid-infraredlasers; near infraredlasers healingsee wound healing injectabletherapy, cellulite, 93-94 heatingsee bulk heating inking,treatment grid, ThermaOool radiofrequency device, heatshock protein, radiofrequency treatment studies, 58 64 hemoglobin,absorption peaks, 49 instructionsto patient,CO2 laser resurfacing, 11 lndex intensepulsed light, 49-50 long-pulsedlasers bipolarradiofrequency and, 56 alexandrite,veins, 1 0B complications,49-50, 108 ethnicskin ar\/thamr 2ftar q? A? hairremoval, B0 ethnicskin, 77-78, 79 lentigines,83 hairremoval, B0 skinresurfacing, 82 vascularlesions, B1 leg veins,108-.109 techniques,52-53 long-wavelengthpulsed lasers, veins, 108 intradermotherapy,94 Iorazepam,radiofrequency treatment, 64 ironsalts, tattoos, 109 low-energyplasma skin resurfacing, 33 isotretinoin analgesia,36 lasertreatment and, 36, 74 evaluation,33-34 radiofrequencytreatment and, 61 vs high-energytreatments, 37 ivy, 94 lubrication,fractional resurfacing, 37 'lunch{ime'laser procedures, 44 I Luxfractional resurfacing devices, 30, 31 jawline evaluation,33 COzlaser resurfacing, 10 lymphaticdrainage, cellulite and, BB radiofrequencytreatment, 61-62, 66-69 see alsomandibular region M magneticresonance imaging K adiposetissue, 89, 90 keloids.treatment with pulseddye lasers.45 cellulite,97, 92 keratoses maKe-up grading,60 dermatitisfrom, lB seborrheic,ethnic skin, 73 intensepulsed light on, 53 kneading(Endermologie), 94-95 mandibularregion KTP lasers scarring,l9 nonablativeskin resurfacin g, 46,75-76 see alsojawline techniques,5l-52 massage,20 pigmentedand vascularlesions, 107-108 mattressphenomenon, 87, BB melanin,73 L absorptionspectrum, 49 lactatedehydrogenase, radiofrequency treatment studies, 58 hairremoval and, 111 laserDoppler flowmetry, cellulite, 92 pigment-specificlasers, 109 laxity,grading, 60 melasma,fractional resurfacing, 33, 74, 75,82 regs protocol,38 telangiectasias,75, 82 men,cellulite, B7-BB veins,l0B-109 MENDs(microscopic epidermal necrotic debris), 31, lentigines 40 ethnicskin, 73, 77,78,83 meperidine,radiofrequency treatment, 64 grading,60 mesotheraPY,94 Lewis-Raleighafterglow, 32 methoxsalen,I 05 lifestylemodif ication, cellulite, 93 microdermabrasion,53 light-emittingdiodes, 50 see alsodermabrasion

minrnlacar noalc e2A v' e,27 photomodulation,78 Hvviv' techniques,53 microprocessors,radiofrequency devices, 57 lightspectrum, 44 microscopicepidermal necrotic debris (MENDS)' 31, linesof demarcation 40 avoidance,1 1 microscopicthermal zones (MTZs), 29, 106-107 fractionalresurfacing and plasmaresurfacing, 35 microvascularcirculation, cellulite and, 88 cao rlcn foathorinn mid-infraredlasers lipiddistribution, cellulite, 90 erbium-doped,fractional resurfacing, 55 lipolysis,93 nonablativeskin resurfacing, 46-49 injectable,94 dark complexion,44 liposuction,95 techniques,52 lips mild vs severewrinkling, laser resurfacing, 3 riicennaarinn Q milia,18, 101 upper,erbium:YAG laser resurfacing, 26 monopolarradiofrequency devices, 55, 56-57 LMXcream (topical anesthetic), I cellulite,96-98 radiofrequencytreatment, 64 ethnicskin, 78 Index

multiplelasers,21-22 paradoxicalhair growth, 111 mupirocin,16 paranasalarea, nonablative skin resurfacing, 52 Mycobacterium fortuitum, 17 passes fractionalresurfacing, 37 N number near infraredlasers, ethnic skin, 75-76 Accenttreatment, 65 neck CO2laser treatment, I fractionalresurfacing, 34 ThermaCooltreatment, 65 photodamage,erbium:YAG laser, 20-21 patchtesting, nonablative skin resurfacing, 51 radiofrequencyskin tightening, 59, 61-62,66-69 patientsatisfaction, laser resurfacing, 4 neodymium:YAGlasers nrtiant eala.ti^n OO 532-nm carbondioxide laser resurfacing, 3-4 lentigines,83 ethnicskin, 73-74

telannitret2si2!v,siivrvvlsvrq, R1-R2 vr v fractionalresurfacing, 32-33 1064-nm,nonablative skin resurfacing, 46, 75-76 nonablativeskin resurfacin g, 44-45 1320-nm radiofrequencyskin tightening, 59-61 dark-skinnedpatients, 77 peeling,postoperative, CO, laserresurfacrng, 10 nonablativeskin resurfacing, 46-48, 52 penetrationenhancers, photodynamic therapy, 50 frequency-doubled,110-1 1 1 perfusionflowmetry, cellulite, 92 hairremoval, ethnic skin, B0 penorarareas long-pulsed,leg veins,108-109 improvementafter laser resurfacing, 4 Q-switched,110-1 11 plasmaskin resurfacing, 41 ABNOM,83 periorbitalareas pretreatmentfor fractionalresurfacing, 82 CO, laserresurfacing, 10 nerveblocks, radiofrequency treatment and, 64 improvementafter, 4 nevus of Ota, 73 fractionalresurfacing, 33 nitrogenplasma, 32 nonablativeskin resurfacing, 51-52 N Lite laser,45, 46 radiofrequencytreatment, 61, 65-66 nodules,from radiofrequencytreatmenl, 69, Z0 petechiae,CO, laserresurfacing, 14 nonablativeskin resurfacing, 43-54 petrolatum,postoperative care, 10 complications,106 phenolpeeling ethnic skin, 73-74, 82-83 herpessimplex virus, 16 KTPlasers, 46,75-76 hypopigmentation,104-105 techniques,51-52 phosphodiesteraseinhibition, for cellulite,93 treatmentchoice, 50-53 photoaging northernblot analysis,radiofrequency treatment studies, 59 ethnicskin, 73 pigmentation,75 o scale,8 occlusivedressings. CO, laserresurfacing, 10. 77 photodamage,1,43 Ohm'slaw, 56 CO2laser resurfacing, 3-4 open woundtreatment, postoperative care, 10, j0O neck,erbium:YAG laser, 20-21 opticalmultiplexing, Contour erbium:YAG laser, 25 types,43 opticaltracking, fractional resurfacing, 29-3.1 photodynamictherapy, 43, 50 OptiguideBlue, fractional resurfacing, 36-37 techniques,53 removal,39-40 photoepilationsee epilation oveflap photographs,34-35 ablativeskin resurfacing, 13, 15, 19 photomodulation,light-emitting diodes, 78 Contourerbium:YAG laser, 25, 26 photosensitivity,after photodynamictherapy, 50 fractionalresurfacing treatment passes, 37 physicaltherapy, cellulite, 94-95 prgmentation P ethnicskin, photoaging, 75 parn see alsohyperpigmentation; hypopigmentation postoperative,CO2 laser resurfacing, 10, 16 pigment-specific lasers radiofrequencytreatment, 6S duringCO2 laser sessions, 21-22 tolerance,63, 65-66 complications,109-1 1 1 PalomarMedical Technologies Inc see Lux fractional pinchtest, cellulite, 87, BB resurfacingdevices Pixelresurfacing devices, 30, 32 papaya, 94 plasmaskin resurfacing, 32, 33-34,35, 85 papillae adiposae, Bg analgesia,36 papillarydermis, neck, A^,,41^ ^^^^i^^ / { 20 uuuurv Pd-oil rg, + | papularelastosis, 3 indications,33 r79 lndex

postoperativecare, 39-40 R technique,37-39 radiofrequency treatment, 53 poikilodermaof Civatte,21 ethnicskin, 78 Polarishandpiece see Galaxyradiofrequency device tighteningof skin,55-72 polychromatlclight sources, intense pulsed light, 49 cellulite,96-98 port-winestains, 75 treatmentplanning, 62-63 postinflammatory hyperpigmentation see hyperpigmentation relaxationtime, thermal, 99 (PrH) ReliantTechnologies, lnc see Fraxellasers postoperativeacne, 18, 101 resurfacingof skin nnctnnoraii\/a aata lasers,1-27,2941 COzlaser resurfacing, 10, 11, 17 complications,99-106 laserresurfacing, 100 ethnicskin,73-75, 80-81, 82-85 plasmaskin resurfacing, 39-40 see alsofractional resurfacing; nonablative skin postoperativesun avoidance,84-85 resurfacing potassiumtitanyl phosphate lasers see KTP lasers retinoids prednisone,swelling after CO2 laser resurfacing, 13 contraindicationof nonablativeskin resurfacing, 45 preoperativeevaluation, laser resurfacing, B hypopigmentationprevention, nonablative skin preoperativesunblock, 104 resurfacing,51 pretreatment washout,36 CO2laser resurfacing, 15-16 retinol,cellulite and, 93 fractionalresurfacing, Q-switched neodymium:YAG returnpad, ThermaCoolradiofrequency device, 64 lasers,82 rhytidessee wrlnkling tretinoin,15-16 rollers,Endermologie, 94 vitaminC rosacea,intense Pulsed light, 53 CO2laser resurfacing, 15-16 roughness,grading,60 nonablatrveskin resurfacing, 51 ruby laser,109 Profilelaser, 52 technique,83 protoporphyrinlX, 50 pruritus,CO, laserresurfacing, 1B pseudofolliculitis,B0 s pseudohypopigmentation,carbon dioxlde laser resurfacing, safety '^^ ..^^'^^ 14,15 UV2 lduYl lvDul raurr rV' 10-13 Pseudomonas aerugi nosa, 21 nonablativeskin resurfacing, 51 PSR1,PSR2 and PSR3protocols, plasma skin resurfacing,39 radiofrequencydevices, 69 nr rlcod drro lacorc sapphirelens cooling system, 1540-nm erbium:glass laser, 48 5P5-nm fnr searrinn 1Q$ satisfactionsee patientsatisfaction duringCO, lasersessions, 21 scanningmode, laser therapy,74, 82 complications,108 erbium:YAGlaser resurfacing, 26 for complicationsof COzlaser resurfacing, 20 scarring,105 see alsoflashlamp-pumped pulsed dye laser assessment,stretching of skin,8 pulsedlight see intensepulsed light afterCO2 laser resurfacing, 1B-20 punchexcisions, acne scarring,1, 2 from erbium:YAGlaser resurfacing, 26 purpura fractionalresurfacing for,33, 34 cellulitetreatment, 96, 9Z hypopigmentationand, 14 pulseddye lasertreatment, 46, 47, 108 intensepulsed light, 49 pulseddye lasersfor, 45 a steroids,20, 101 Q-switchedlasers see alsoacne scarring alexandrite scattering,1320-nm light, nonablative skin resurfacing, 47 ABNOM,83 sebaceousglands, 1450-nm diode laser on, 48 withCO2 laser resurfacing, 22 seborrheickeratosis, ethnic skin, 73 ninmcntcdlesions 110 sedation,radiofrequency treatment, 64 complications,109-1 1 1 selectivephotothermolYsis, 99 Hort'smacules,75, 76 self-assessment,cellulite, 91 neodymium:YAc,110-1 1 1 septa,adipose tissue, BB, 89, 90 ABNOM,83 severevs mildwrinkling, laser resurfacing, 3 pretreatmentfor fractionalresurfacing, 82 side effects ruby,109 laserresurfacing, 5-7 technique,83 from melanin,73 QuantumlPL, Estelux IPL vs,78 radiofrequencyskin tightening, 69-70 quasi-continuouslaser systems, 107 see alsocomPlications Index

siliconemolding, fractional resurfacing, 34 testing(equipment), 11 Silonmask, 10, 77 tetracycline,74 single-passCO2 laser technique, 100 texture,grading, 60 single-passhigh-energy plasma skin resurfacing, 33-34 ThermaCoolradiofrequency device, 55, 56-57,63 skinsee Fitzpatrickskin types; resurfacing; tightening of skin clinicalfindings, 61 skinfoldthickness, 92 lowerface, 66-68 sleepingposition, after CO, laserresurfacing, 11 off{ace treatment,70 Smoothbeamlaser, 47, 52 periorbitalareas, 65-66 Spanishpatients, 1320-nm neodymium:YAG laser, 77 safety,69 spectra side-effects,69 lighI, 44 techniques,64, 65 melaninabsorption, 49 thermaldamage, COz laser resurfacing, 12 spot size thermalmaps, cellulite, 92 erbium:YAGlaser resurfacing, 26 thermalrelaxation time, 99 fractionalresurfacing, 74-75, 82 thermalsensor, 1320-nm Nd:YAG laser handpiece, 48,52 stackedpulses thigh,circumference, 92 fractionalresurfacing, 83 thyroidregion, 59 intensepulsed light, 49 tighteningof skin stampingmode, laser lhetapy,74, 82 infrareddevice,71-72 Staphylococcusaureus, laser resurfacing,16, 103 radiof requency treatment, 55-72 steroids cellulite,96-98 scarringafter laser resurfacing, 20, 101 treatmentplanning, 62-63 swellingafter C02 laserresurfacing, 13 time line,complications of C02 laserresurfacing, 20 ST Refirmehandpiece, 58 Titan device, infraredlighI, 7 1-72 stretchingof skin,assessing scarring, B tongueblades, equipment testing, 11 subcision,95 topicalanesthesia, B, 14 15,36, 52, 64, 65 success,attractive appearance and, 29 plasmaskin resurfacing, 37 38 sun avoidance,postoperative, +^^i^^t ^.^^^"^+i^^^ 84-85 ruPrudr Pr El,/dt aUvr t) sunblock S-aminolevulinicacid, 50, 53 postoperative,85 cellulite,93 preoperative,104 hyperpigmentationand, 15, 103-104 after ThermaCooltreatment, 68 vitaminC, 101 sunburnys tanningsee Fitzpatrickskin types see alsobleaching agents sweetclover, 94 toxicshock syndrome, CO, laserresurfacing, 16 swelling,after COz laser resurfacing, 13 tracking,optical, fractional resurfacing, 29-31 synechia,C02 laserresurfacing, 18, 7g treatmentcycles, radiofrequency devices, 56-57 treatmentgrid, ThermaOool radiofrequency T device,64 tretinoinpretreatment, CO: laserresurfacing, 15-16 tangentiallighting, cellulite, 9.1 , 92 Triactivesystem, 95,96, 97 tanning triamcinolone,scarring after CO, laserresurfacing, 20 lasertreatment ethnicskin, 74 U radiofrequencyand, 59-6i UltrapulseCO, laser,B, 9 vs sunburnsee Fitzpatnckskin types ultrasound,35 .10 targetedresurfacing, 7, cellulite,97, 92 tattoos,complications of treatment,109-1j 1 emulsification,98 tauteningof skin,ThermaCool treatment, 66 UltrathinDuoderm patch, synechia, 18, 19 telangiectasias ultravioletlight, effects, 43 ethnicskin, 74,75, 81-82, 83 see alsophotoaging: photodamage grading,60 unipolarradiofrequency devices see monopolar treatment radiof requency devices duringCO2 laser sessions, 21 urticarialplaques, from intensepulsed light, 52 intensepulsed light, 49, 52 temperatures,skin V 1320-nmNd:YAG laser, 48, 82 valacyclovir,prophylaxis, 17 mid-infraredlasers, 52 variable-pulsedye lasers,45 radiofrequencytreatment, SB, 63 vascularlasers, 45-46 temporalregion, radiofrequency treatment, 65 complications,107-1 09 tensioningof skin,ThermaCool treatment, 66 ethnicskin, 75 test areas,B0 for scarring,105 see also patchtesting techniques,5l-53 lndex

vascularleslons see telangiectasras watercontent, ce lulite,90 Vaseline,postoperative care, CO: laserresurfacing, 11 Wel Box,95 V-beamlaser, 45,46 woundhealing, 100 durng CO2laser sessions, 21 fractionallaser treatment, 107 veins,legs, 108 109 neck,20 VelaSmoothdevice, 58 woundtreatment, 10, 1OO cellulite,62, 71, 95 96,97 wrinkling vermilionborder, CO, lasertreatment and, B-9, 12 erbiumlaser, 22 Versapulselaser, 45 fractionalresurfacing, 33 vinegar,postoperative care, C02 aserresurfacing, 10, 11, grading,3, 60 17 intensepulsed light, 49 viralinfections, CO2 laser resurfacing, 16-17 ,,i+^-i^ ^ /^^^^.Ai^ ^^in\ vltd| iltI v \dJUU utu outu,/ n^at^nareli\/a naro 1fl1 Y pretreatment y-axiseffect, ThermaCool treatment, 68 COzlaser resurfacing, 15 16 yellow-browndiscoloration, COz laser resurfacing, 12 nonablativeskin resurfacrng, 51 yohimbe,94 V-starlaser, 45, 46 W z wans.after CO. aserresurfacing 17 z-axiseffect, ThermaCool treatment, 67-68 washout,retinoids, 36 Zimm* coolingsystem, fractional resurfacing, 36