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What Is Nonablative Photorejuvenation of Human Skin?

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What Is Nonablative Photorejuvenation of Human Skin? What Is Nonablative Photorejuvenation of Human Skin? J. Stuart Nelson, MD, PhD,* Boris Majaron, PhD,* t and Kristen M. Kelly, MD* Nonablative photorejuvenation has become an in- Copyright 2002, Elsevier Science (USA). All rights tegral procedure in the emerging discipline of laser reserved. dermatologic surgery. The objective is to confine HE TREATMENT OF PHOTODAMAGE selectively, without any epidermal damage, ther- T and/or facial rhytides has been the concern mal injury to the papillary, and upper reticular der- of physicians and patients for many centuries. mis leading to fibroblast activation and synthesis of Popular approaches have historically included new collagen and extracellular matrix material. The procedure results in minimal patient morbidity, no dermabrasion and chemical peeling. Topical ap- interference with lifestyle, and a low risk of compli- plications of tretinoin (all-trans-retinoic acid), vi- cations, while providing a satisfying degree of rhyt. tamin C (ascorbic acid), and c~-hydroxy acids (eg, ides reduction. Multiple devices have been studied glycolic acid) are widely used. Although these and marketed for nonablative photorejuvenation of methods have been described and used, no single human skin. However, currently, nonablative pho- method has become the dominant one. More re- torejuvenation should not be considered an alterna- tive to laser skin resurfacing. The skin surface is not cently, laser skin resurfacing (LSR) has emerged removed or modified. What really occurs may be as a widely used aesthetic treatment modality that more accurately referred to as dermal "remodel- may have the advantages of improved reproduc- ing" or "toning" as a wound healing response is ibility and control when compared to dermabra- initiated and collagen regenerated. The narrow sion and chemical peeling.] "therapeutic window" of laser-induced dermal The carbon dioxide (CO 2) and erbium:yttrium- heating and epidermal cooling must still be opti- mized so that effective treatments can be obtained aluminum-garnet (Er:YAG) lasers are currently routinely. Clinical verification of effective treatment the devices of choice for human LSR. In practice, parameters (irradiation wavelength, pulse struc- superficial layers of human skin are removed ture, radiant exposure, cooling time) will be ob- through a primarily ablative process, driven by tained through further human studies. Most impor- intense infrared (IR) radiation. If used properly, tantly, understanding the relationship between the the procedure is clinically similar to dermabrasion degree of dermal thermal injury and synthesis of because the laser gradually removes cell layer after new collagen and extracellular matrix material will be fundamental to predicting the clinical efficacy cell layer through volatilization of water present and limitations of nonablative photorejuvenation. in human skin. Because IR radiation is absorbed so intensely by water, optical penetration depths are very shallow. Deposition of laser energy in a From the *Departments of Surgery, Dermatology and Biomed- shallow tissue layer produces a rapid rise in local ical Engineering, Beckman Laser Institute and Medical Clinic, University of California, Irvine, CA; and qcJozefStefan Institute, skin temperature. As more energy is added, water SI-1000 Ljubljana, Slovenia. is raised to its boiling point. Internal vapor pres- This work was supported by research granls from the Na- sure builds up until a microexplosion occurs. The tional Institutes of Health (AR-43419, GM-62177) toJ.S.N. B.M. rapid expansion created by this excitation gives was supported by the Slovenian Ministry of Education and Sci- rise to ejection of microscopic tissue fragments at ence. K.M.K. received support from the American Society,for La- ser Medicine and Surgery and the Dermatology Foundation. In- high velocities. Since most of the energy of the stitutional support from the Beckman Laser Institute and Medical laser pulse goes into the thermal phase change Clinic Endowment is also gratefully acknowledged. associated with tissue vaporization, ablated frag- Address reprint requests to J. Stuart Nelson, MD, PhD, Beck- ments ejected from the skin surface carry most of man Laser Institute and Medical Clinic, 1002 Health Sciences Rd the energy with them, leaving little energy in the East, Irvine, CA 92612; e-mail: [email protected]. Copyright 2002, Elsevier Science (USA). All rights reserved. form of heat to damage surrounding tissue. Be- 1085-5629/02/2104-0002535.00/0 cause of the significantly higher absorption of the doi: l O.l O53/sder.2002.367 64 Er:YAG wavelength (2.94 btm), as compared to 238 Seminars in Cutaneous Medicine and Surgery, Vol 21, No 4 (December). 2002: pp 238-250 NONABLATIVE SKIN PHOTOREJUVENATION 239 the CO 2 wavelength (10.6/,m), the depth of ther- A histologic study by Thomsen et al, 6 involving mal damage in subjacent tissue is much less polarization sensitive light microscopy of rodent (10-30/,m for the Er:YAG as opposed to 80-150 skin irradiated with parameters derived from hu- /xm for the CO2). 2 man CO 2 LSR, indicated thermal alteration of col- Although both the CO2 and Er:YAG lasers are lagen fibrils in the dermis at depths up to 300/xm. quite effective in terms of photodamage removal In another histological study, Cotton et al 7 noted and rhytides reduction, epidermal disruption and that reduction of human facial rhytides after CO2 removal results in an open wound that places the LSR corresponded to the formation of a new band patient at risk for bacterial, viral, and fungal infec- of dense, compact collagen bundles in the papil- tions. Patients also experience edema, drainage lary dermis. Moreover, the degree of thermally and burning discomfort during, typically, the first denatured dermal collagen strongly correlated week after LSR. The wound resolves with signifi- with bundle thickness. cant erythema, which often persists for several Long-term studies have documented that CO 2 months. Although erythema is of shorter duration and Er:YAG LSR results in acute dermal collagen when the Er:YAG laser is used, virtually all pa- denaturation.S-1 t During the first 3 days after LSR, tients undergoing LSR procedures experience this injured papillary dermal fibroblasts proliferate side effect. Finally, delayed or abnormal wound and migrate into the wound site where they are healing often results in complications such as dys- activated to synthesize type I procollagen (the pigmentation and/or scarring. most abundant dermal protein and synthetic pre- Although several details remain incompletely cursor to collagen I) and other matrix molecules. understood, 3 main processes are involved in LSR Partial collagen denaturation also stimulates a of human skin: 1) ablation of the epidermis and upper dermis; 2) acute shrinkage of dermal colla- wound healing reaction, accelerating collagen gen; and 3) long-term wound healing that leads to synthesis by fibroblasts and reabsorption of elas- dermal remodeling as new collagen and extracel- totic material. Thirty days after LSR, new deposi- lular matrix are synthesized over a period of tion of dense, compact, collagen fibers oriented months after treatment. parallel to the skin surface is visible in the papil- Epidermal and dermal ablation may be useful to lary dermis. Ninety days after treatment, there is remove superficial textural irregularities and the an even more highly organized network of colla- dyschromia associated with photodamage (and gen and elastic fibers in the upper dermis. acne scars), but may not be a major contributor to In conclusion, because these histologic changes rhytides reduction. Dermal collagen shrinkage in- occur primarily in the dermis, epidermal removal duced by LSR may contribute to acute wound may not be required to provoke a dermal wound contraction, but may be only incidental to long- healing response leading to remodeling and colla- term rhytides reduction. Therefore, it seems that gen and extracellular matrix synthesis. long-term wound healing, including dermal re- modeling and collagen and extracellular matrix WHAT IS NONABLATIVE synthesis, is the most likely process responsible PHOTOREJUVENATION? for rhytides reduction. Fisher et aP found that ultraviolet irradiation Nonablative photorejuvenation of human skin induces metalloproteinases in the skin including is a procedure designed to confine selectively, collagenase, gelatinase, and stromelysin, which without any epidermal damage, thermal injury to subsequently degrade dermal collagen. Free radi- the papillary, and upper reticular dermis leading cals, induced by ultraviolet radiation, further to fibroblast activation and synthesis of new col- damage collagen. Histologic evaluation of photo- lagen and extracellular matrix material. The skin damaged human skin shows increased glycosami- surface is not removed or modified. What really noglycans, which replace damaged and disorga- occurs may be more accurately referred to as der- nized collagen fibrils in the dermis. Elastic fibers mal '~remodeling" or "toning" as a wound healing are abundant, thickened, and tortuous (solar elas- response is initiated to regenerate subsurface col- tosis).4.5 lagen. Laser-induced thermal injury should be 240 NELSON, MAJARON, AND KELLY i confined to a zone 100 to 500/xm below the skin degree of rhytid reduction. To recapitulate, the surface where the majority of the aforementioned most important mechanism of rhytid improve- histologic changes associated with photoaging, ment after traditional LSR is believed
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