Review Devices for Rejuvenation of the Aging Face P. Mark Neal, MD; Adrian Dobrescu, MD; John Chapman, MD; Mara Haseltine, MD Over the last 30 years, there has been a substantial increase in the number of ablative and nonablative devices that can be used to treat the signs of skin aging. Some devices have found new indications or new technology to refine older indications. In this article, we review the ablative and nonablative devices that are currently available for photorejuvenation of the aging face. Cosmet Dermatol. 2012;25:412-418. n the field of cosmetic dermatology, there are a vari- side effects, such as scarring and dyspigmentation. Patients ety of options to reverse the physical signs of aging. also experienced substantial downtime (approximately Many of these options include treatment with 2 weeks) following the procedure. Because of the need for devicesCOS that induce remodeling of the dermis andDERM more controlled ablation with less severe side effects, the epidermis, resulting in a more youthful appearance erbium:yttrium-aluminum-garnet (Er:YAG) laser as well I(Table). In the 1980s, the continuous wave CO2 laser was as the high-energy superpulsed and scanning CO2 lasers introduced with impressive results in reversing the signs were developed for cutaneous use. These newer devices of aging but also was associated with a high potential for help control the excess thermal injury that previously side effects and substantial downtime. Since then, many had led to unwanted side effects. The Er:YAG laser offers new devices have been made available to laser surgeons modes of variable long- and short-pulse durations to that Dooffer varying degrees of facial Notrejuvenation with fewer promote Copy more controlled ablation. Later, Manstein et al1 side effects and less downtime. In this article, we review introduced the concept of fractional photothermolysis, the ablative and nonablative devices that are currently which produces columns of treated tissue surrounded available for photorejuvenation of the aging face. by noninjured tissue, collectively known as microscopic treatment zones, in a process that allows the untreated tis- ABLATIVE RESURFACING sue to act as a reservoir for cells to heal the treated tissue CO2 and Erbium:Yttrium-Aluminum-Garnet Lasers more quickly. Many manufacturers have incorporated this Prior to the development of the continuous wave CO2 fractional photothermolysis technology into both ablative laser in the 1980s, dermabrasion and deep chemical (and nonablative) lasers, and the practitioner can now peels were the only tools available to the dermatologist choose from fractionated ablative lasers in a myriad of for treatment of deep static rhytides. The development spot sizes, shapes, and depths of ablation. Other advan- of the continuous wave CO2 laser allowed ablation of the tages of fractional ablative therapy include faster reepithe- dermis but was associated with high rates of unwanted lialization, less swelling, less erythema, and the option to treat multiple areas such as the neck, hands, and chest.2 Although the Er:YAG laser allows for more precise abla- From the Department of Dermatology, Tulane University School of tion, the cosmetic results achieved with the CO2 laser are Medicine, New Orleans, Louisiana. similar and perhaps better according to reports from the The authors report no conflicts of interest in relation to this article. few known head-to-head studies.3,4 Both lasers produce Correspondence: P. Mark Neal, MD, Tulane University School of their effects by varying degrees of ablation followed by Medicine, Department of Dermatology, 1430 Tulane Ave, #36, New reepithelialization, neocollagenesis, and wound contrac- Orleans, LA 70112 ([email protected]). ture. The superior results observed in CO2 resurfacing 412 Cosmetic Dermatology® • SEPTEMBER 2012 • VOL. 25 NO. 9 www.cosderm.com Copyright Cosmetic Dermatology 2012. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Photorejuvenation Devices Photorejuvenation Devices Device/Therapy Light Source Mechanism Uses Ablative lasers 10,600-nm CO2 laser, Energy is absorbed by water Mild to severe rhytides, 2940-nm Er:YAG laser as the chromophore, which dyspigmentation, solar results in tissue destruction elastosis, actinic cheilitis, and subsequent remodeling vascular changes, scars Vascular lasersa 532-nm KTP laser, 585- or Energy is absorbed Erythema, telangiectasia, 595-nm PDL by hemoglobin as the vascular malformations, chromophore, decreasing erythematous and telangiectasia and vascular hypertrophic scars photodamage Near-infrared lasers 1064-nm Nd:YAG Mainly vascular improvement Erythema, deeper (targeting hemoglobin) but telangiectasia, mild also some mild collagen heat- rhytides ing and subsequent new collagen formation Mid-infrared lasers 1320-nm Nd:YAG, 1450-nm Collagen heating causing Mild to moderate rhytides, diode laser, 1540-nm erbium subsequent remodeling and skin laxity, mild scars glass laser, fractionated neocollagenesis, fractionated 1550-nm erbium fiber laser treatment allows faster healing but may require more passes IPL COS500- to 1200-nm noncoherent DERM Wide range of wavelengths Fine rhytides, telangiectasia, flashlamp-pumped light covers a variety of chromo- pigmented lesions, source, cutoff filters allow phores, treating multiple poikiloderma, scar elimination of shorter components of photoaging modification wavelengths PDT Multiple light sources can PpIX is activated by the light Actinic keratoses, be used to activate topical source and releases reactive photoaging Dophotosensitizers Not 5-ALA and oxygen species,Copy causing an MAL: blue light (417 nm), inflammatory response red light (630 nm), and PDL LED Emits a narrow band of Unknown, but theories point Redness, fine lines and electromagnetic radiation, to an intracellular nonthermal wrinkles, acne, inflammation measured in milliwatts, effect mediated by mitochon- ranging from UV to visible drial cytochrome light absorp- and infrared wavelengths tion yielding increased fibroblast activity Radiofrequency Monopolar, bipolar, or Resistance of tissue results in Skin laxity, photodamage, tripolar devices create an heat production, which dena- rhytides electrical field that runs tures collagen and stimulates through the skin new collagen production Ultrasound devices Intense focused ultrasound Dermal and subcutaneous Rhytides, skin laxity waves transfer energy into heating result in collagen the skin, resulting in heat and tissue remodeling Abbreviations: Er:YAG, erbium:yttrium-aluminum-garnet; KTP, potassium titanyl phosphate; PDL, pulsed dye laser; IPL, intense pulsed light; PDT, photodynamic therapy; ALA, aminolevulinic acid; MAL, methyl aminolevulinate; PpIX, protoporphyrin IX; LED, light-emitting diode. aVascular lasers are not discussed in this article. www.cosderm.com VOL. 25 NO. 9 • SEPTEMBER 2012 • Cosmetic Dermatology® 413 Copyright Cosmetic Dermatology 2012. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Photorejuvenation Devices likely are a result of extra thermal damage, which leads reepithelialization occurs, while bio-occlusive dressings to greater remodeling in comparison to the Er:YAG are only used for the first few days secondary to increased laser4-6; however, the clinician can compensate by per- rates of infection with prolonged use.11 Following the forming more passes with the Er:YAG laser.4 procedure, the patient should adhere to strict sun pro- Patient selection depends on many factors. Patients tection measures, which should be continued for several with Fitzpatrick skin types I to IV are ideal candidates. months until erythema resolves to minimize the chances For cosmetic resurfacing, the dermatologist primarily will of hyperpigmentation. An acneiform eruption may occur treat only the face when using scanning or pulsed CO2 due to the occlusive dressings and petrolatum and typi- lasers. Treatment of the neck and chest areas with a scan- cally resolves on cessation. ning CO2 laser should only be performed by experienced Long-term complications consist of hypopimentation, laser surgeons using caution and lower energy levels. A hyperpigmentation, and scarring. Hyperpigmentation decreased proclivity to scarring with the Er:YAG and frac- is most commonly reported in darker skin types and is tional therapy allows the dermatologist to treat areas such treated with bleaching agents, topical tretinoin, and sun as the neck, hands, and chest with less risk for scarring.2 protection.12 Scarring is the result of excessive thermal Contraindications to ablative therapy include a history damage. High fluences, multiple passes, and more over- of keloids, collagen vascular disease, and recent surgical lap may provide greater cosmetic results but also may face-lifts or blepharoplasties, as well as a reduced number cause greater thermal damage and potential scarring. of adnexa (ie, from radiation dermatitis, morphea) to serve The Er:YAG and fractionated ablative lasers are safer as a reservoir for cutaneous stem cells. Relative contra- than the nonfractionated CO2 lasers to use on the face indications include diseases that can koebnerize such as (Figure 1), neck, chest, and hands for treatment of pho- psoriasis and vitiligo. Clinicians generally wait 6 months todamaged skin, as they are associated with a lower scar- to 1 year after the patient has finished an oral isotretinoin ring risk. Long-pulsed and